The Rib Vertebra Angle Difference and its Measurement in 3D for the evaluation of early onset scoliosis.

The Rib Vertebra Angle Difference (RVAD) as defined by Mehta (1972) is used to predict the progression of early onset scoliosis. No clear physical significance has been established for this measurement. The purpose of this study was to evaluate the RVAD along the thoracic spine and the equivalent measurement on 3D reconstructions of the spine and rib cage of early onset scoliosis patients in order to determine their relationship with the geometry of the chest wall and evolution along the spine. The RVAD was measured on PA radiographs of 42 infantile scoliotic patients (Cobb >20°) from T4 to T10 according to the method described by Mehta. The RVAD 3D was computed using the same landmarks from the 3D reconstruction generated from the calibrated biplanar radiographs. Cases were divided into Phase I and Phase II using Mehta's classification based on the rib head overlap with the apical vertebral body on coronal plane radiographs. A linear relationship exists between the Metha (2D) and 3D RVAD for both Phase I (r = 0.87) and Phase II (r = 0.78) patients. For more severe deformities (RVAD 3D ≥ 35°), a relationship was found between RVAD 3D and the axial rotation of the thoracic vertebrae (r = 0.51) in Phase II patients. However, no significant relationship exists between axial rotation and RVAD 3D for Phase I patients as well as Mehta's RVAD. Maximal RVAD measurements were located 2 ½ levels above the apical vertebra. Results indicated that RVAD 3D provides additional information to Mehta's RVAD on the torsional nature of the deformity. Considering the importance of clinical indices to assess the progression of early onset scoliosis, this study raises some questions on looking solely at the RVAD measured on radiographs at the apical vertebra of Phase I patients and suggests considering also levels above the apex of the scoliotic curve and 3D measurements. Further investigation is required to fully understand the 3D nature of the spine and rib cage deformities.

Alendronate for the treatment of pediatric osteogenesis imperfecta: a randomized placebo-controlled study.

CONTEXT: Information on the use of oral bisphosphonate agents to treat pediatric osteogenesis imperfecta (OI) is limited. OBJECTIVE: The objective of the investigation was to study the efficacy and safety of daily oral alendronate (ALN) in children with OI. DESIGN AND PARTICIPANTS: We conducted a multicenter, double-blind, randomized, placebo-controlled study. One hundred thirty-nine children (aged 4-19 yr) with type I, III, or IV OI were randomized to either placebo (n = 30) or ALN (n = 109) for 2 yr. ALN doses were 5 mg/d in children less than 40 kg and 10 mg/d for those 40 kg and greater. MAIN OUTCOME MEASURES: Spine areal bone mineral density (BMD) z-score, urinary N-telopeptide of collagen type I, extremity fracture incidence, vertebral area, iliac cortical width, bone pain, physical activity, and safety parameters were measured. RESULTS: ALN increased spine areal BMD by 51% vs. a 12% increase with placebo (P < 0.001); the mean spine areal BMD z-score increased significantly from -4.6 to -3.3 (P < 0.001) with ALN, whereas the change in the placebo group (from -4.6 to -4.5) was insignificant. Urinary N-telopeptide of collagen type I decreased by 62% in the ALN-treated group, compared with 32% with placebo (P < 0.001). Long-bone fracture incidence, average midline vertebral height, iliac cortical width, bone pain, and physical activity were similar between groups. The incidences of clinical and laboratory adverse experiences were also similar between the treatment and placebo groups. CONCLUSIONS: Oral ALN for 2 yr in pediatric patients with OI significantly decreased bone turnover and increased spine areal BMD but was not associated with improved fracture outcomes.

Gross Motor Function Classification System and outcome tools for assessing ambulatory cerebral palsy: a multicenter study.

The relationships between different levels of severity of ambulatory cerebral palsy, defined by the Gross Motor Function Classification System (GMFCS), and several pediatric outcome instruments were examined. Data from the Gross Motor Function Measure (GMFM), Pediatric Orthopaedic Data Collection Instrument (PODCI), temporal-spatial gait parameters, and oxygen cost were collected from six sites. The sample size for each assessment tool ranged from 226 to 1047 participants. There were significant differences among GMFCS levels I, II, and III for many of the outcome tools assessed in this study. Strong correlations were seen between GMFCS level and each of the GMFM sections D and E scores, the PODCI measures of Transfer and Mobility, and Sports and Physical Function, Gait Velocity, and Oxygen Cost. Correlations among tools demonstrated that the GMFM sections D and E scores correlated with the largest number of other tools. Logistic regression showed GMFM section E score to be a significant predictor of GMFCS level. GMFM section E score can be used to predict GMFCS level relatively accurately (76.6%). Study data indicate that the assessed outcome tools can distinguish between children with different GMFCS levels. This study establishes justification for using the GMFCS as a classification system in clinical studies.

Masked rotatory subluxation of the atlas associated with fracture of the clavicle: a clinical and biomechanical analysis.

We report on two children who developed a fixed rotatory subluxation of the atlantoaxial joint due to torticollis being attributed to a fractured clavicle. Appropriate treatment was delayed for weeks to months; only after the fractured clavicle had healed and the torticollis persisted was the problem identified. Persisting rotatory subluxation also predisposes to further anterior displacement of C-1 due to an increased moment arm created by the forward displacement of the center of gravity of the head. The association of atlantoaxial subluxation should always be considered in children presenting with a clavicular fracture and an acute torticollis.

The influence of desmopressin on blood loss during spinal fusion surgery in neuromuscular patients.

STUDY DESIGN: A double-blind study comparing the effects of desmopressin and a placebo (normal saline) on blood loss during spinal instrumentation for neuromuscular scoliosis. OBJECTIVE: To determine the effectiveness of desmopressin acetate (DDAVP) in reducing operative blood loss in hemostatically normal patients undergoing spinal fusion surgery for neuromuscular scoliosis. SUMMARY OF BACKGROUND DATA: Desmopressin acetate has been shown to improve bleeding times and to provide surgical hemostasis in patients with platelet disorders. Its effect in reducing bleeding times in normal patients has been the subject of debate in several surgical specialties. Recent observations that DDAVP seems to reduce bleeding times and blood loss in patients undergoing spinal surgery for neuromuscular scoliosis warranted a more focused analysis on its role in this surgical procedure. METHODS: Patients undergoing surgery for neuromuscular scoliosis were randomly assigned to receive DDAVP or placebo. Bleeding times and plasma clotting factors were measured before the administration of the DDAVP or placebo and 60 minutes after. Operative blood loss was carefully measured. RESULTS: Although the administration of DDAVP decreased overall blood loss by an average of 19% compared with blood loss in the placebo group and blood loss per vertebra fused by an average of 15%, these results were not statistically significant. CONCLUSIONS: Bleeding time and blood loss seem to respond better to DDAVP in some patients, in whom significant decreases were observed, than they do in others. The problem is in identifying those patients in whom a decrease in bleeding time will be elicited after administration of DDAVP. Preoperative administration of DDAVP to such patients should significantly decrease operative blood loss.

Fractures of the capitellum in adolescents.

Fractures of the capitellum are rare in children. The treatment of these injuries has been controversial. At a major pediatric trauma center, seven capitellar fractures were seen in children between 1988 and 1994. The average age of the children was 14.7 years (range, 11-17). Six of these fractures were type I injuries, with large anterosuperior fragments that required operative reduction and internal fixation in five cases. Internal fixation methods used were K wires in three patients, Herbert screws in one patient, and cannulated screws in one patient. The remaining type I fracture was treated with a closed reduction. The seventh fracture was a type II fracture, treated nonoperatively. Five children did well with their respective treatments, but one required reoperation to remove an exostosis block to flexion. Accurate open reduction and internal fixation for the displaced capitellar fracture in children is an effective treatment to restore normal elbow function.

Poststreptococcal reactive arthritis mimicking acute septic arthritis: a hospital-based study.

Poststreptococcal reactive arthritis (PSRA) is an inflammatory arthritis that follows group A streptococcal pharyngitis. The clinical presentation of PSRA can mimic acute septic arthritis. We present 12 children with PSRA seen between December 1991 and September 1993. Most children had only mild pharyngitis by history. The pattern of arthritis was variable and included migratory polyarthritis, additive polyarthritis, and monoarthritis, and was accompanied by fever in seven children. In four patients, the presentation of fever and acute onset of painful monoarthritis mimicked septic arthritis, and synovial fluid cultures were negative in all four cases. All 12 patients demonstrated an immune response to group A streptococcus. PSRA should be in the differential diagnosis of any child presenting with acute onset of painful arthritis, including those cases of presumed septic arthritis with negative synovial fluid cultures.

Postoperative heterotopic ossification in children: a comparison of children with spina bifida and with cerebral palsy.

The authors reviewed 250 consecutive myotomies and tenotomies performed on the hips of 186 children. Two groups were studied: 162 children with cerebral palsy and 24 children with spina bifida. In total 19 children were found to have heterotopic ossification postoperatively. The incidence of heterotopic ossification was 21% in the spina bifida group and 8.6% in the cerebral palsy group. The most severe cases were in children with thoracic myelomeningocele. Only one child with lumbar myelomeningocele had ossification, and it was mild. This difference was statistically significant. Two children with thoracic spina bifida had severe ossification and abduction contractures requiring resection of the bony mass. Recurrence was successfully prevented by a course of radiotherapy.

Simple bone cysts. The effects of methylprednisolone on synovial cells in culture.

Ten years ago, a protocol using Depo-Medrol injections was developed for the treatment of unicameral bone cysts. This concept, designed by tumor surgeons and based on theory, has been cautiously approached. However, reproducible results have gradually increased clinical acceptance. Understanding the healing process has been restricted because of the lack of an experimental model. In an attempt to elucidate this mechanism of healing, a cell culture model was used to investigate the effects of methylprednisolone on synovial cells. Initially, three doses of the drug were tested and maximal changes were noted with the concentration of 40 mg/ml. Changes were then quantified by morphology, DNA assay, cell protein analysis, and electron microscopy. Results suggest that methylprednisolone may have a direct effect on the cellular component of unicameral bone cysts.

Oral morphine versus injected meperidine (Demerol) for pain relief in children after orthopedic surgery.

This study provides a comparison of two clinical regimens for controlling pain in children for the first 48 h after orthopedic surgery: oral morphine, every 4 h, and injected meperidine (Demerol), every 3-4 h pro re nata. Using Visual Analogue Scale, 25 children between the ages of 7 and 17 years of age, who were randomly divided into two groups, rated the severity of their pain every 1-3 h from 8 a.m. to 8 p.m. Each child's parents and attending nurse also rated the child's pain. The morphine group had a significantly higher number of pain-free children on both day 1 and day 2.

Proximal femoral resection-interposition arthroplasty: salvage hip surgery for the severely disabled child with cerebral palsy.

The treatment of spastic hip dislocation by proximal femoral resection-interposition arthroplasty (PFRIA) has not been popular because of previous unfavorable experience with Girdlestone-type resections. Since 1979, four severely disabled patients with cerebral palsy having five painful, spastic hip dislocations have undergone PFRIA at the Children's Hospital of Eastern Ontario (Ottawa, Ontario, Canada) by the technique described by Castle and Schneider. The preliminary follow-up shows no significant loss of motion, no bony ankylosis or impingement, no myositis ossificans, and no recurrence of pain. A comfortable sitting status was achieved within 3-6 weeks postoperatively. For a carefully selected group of severely disabled, spastic, nonambulatory patients with painful hip dislocation, we recommend this procedure over more complicated reconstructive procedures or arthrodesis.

Bilateral fracture of the pedicle of the second cervical vertebra in the young child.

We report the cases of five children, six to eighteen months old, who had bilateral fracture of the pedicles of the second cervical vertebra. The children were treated with gentle cervical traction in mild extension or were maintained in near-anatomical reduction in a Minerva jacket or halo cast. The fractures united in four patients. One patient underwent fusion to stabilize the spine.

The pediatric T-supracondylar fracture.

T-supracondylar fractures of the humerus occur rarely in children compared with the adult variety. Sixteen such fractures treated at the Children's Hospital of Eastern Ontario between 1975 and 1983 are described. There were nine male and seven female patients, 7-17 years old. All fractures were displaced, two were open, and one patient had an associated radial nerve palsy. All cases were managed by open reduction, internal fixation, and early mobilization. Follow-up revealed no cases of functional disability despite significant loss of motion in two patients. The conservative approach should be abandoned in these intraarticular injuries, and good operative results can be anticipated.