Change in Sagittal Plane Alignment Following Surgery for Scheuermann's Kyphosis.

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: To evaluate changes in sagittal plane alignment in patients with Scheuermann's kyphosis after spinal fusion. SUMMARY OF BACKGROUND DATA: Although surgery is commonly undertaken in patients with severe Scheuermann's kyphosis for deformity correction, there are limited data regarding the response of spinopelvic parameters and sagittal plane alignment of the spine to surgical treatment. METHODS: Eighteen consecutive surgical Scheuermann's kyphosis patients were retrospectively reviewed (mean preoperative kyphosis, 76°). Full-length spine films were evaluated for maximal sagittal Cobb angle, thoracic kyphosis, cervical and lumbar lordosis, pelvic parameters, and sagittal plane alignment. Findings were compared with reported literature values in normal patients. RESULTS: After surgery, thoracic kyphosis improved significantly, with mean maximum kyphosis improving from 76° to 56° (p = .001). Preoperative cervical lordosis was increased compared with reported normal adolescent values (-35° vs. -5°) and did not significantly change after surgery. Lumbar lordosis decreased significantly after surgery, from -77° to -57° (p = .023). No change was noted in pelvic tilt, sacral slope, or pelvic incidence. Furthermore, there was little improvement in sagittal plane alignment. Preoperatively, 12 of the 18 patients had deviation in sagittal plane alignment greater than 2 cm (5 positive and 7 negative); postoperatively, 11 patients had persistent sagittal imbalance (6 positive and 5 negative). Five patients were noted to have proximal junctional kyphosis and 3 underwent revision surgery for malpositioned screw (1) and loss of distal fixation (2). CONCLUSIONS: Surgical management of Scheuermann's kyphosis resulted in normalization of thoracic kyphosis and lumbar lordosis. Compared with reported values in unaffected adolescents, cervical lordosis remained increased and most patients had residual sagittal plane imbalance greater than 2 cm on imaging.

Hemiepiphysiodesis for correction of angular deformity in pediatric amputees.

BACKGROUND: Angular deformities at the knee are common in children with congenital or acquired below-knee or Syme amputations. These deformities can be well compensated and accommodated with prosthetic modifications. However, as children grow, these prosthetic modifications become more difficult and mechanical axis correction becomes necessary. These deformities have previously been treated with osteotomies and internal or external fixation devices, which necessitate prolonged periods without use of their prosthesis. This study examines the results of hemiepiphysiodesis to correct the mechanical axis and improve prosthetic fitting in a pediatric amputee population. METHODS: Mechanical axis correction using hemiepiphysiodesis in 22 pediatric Symes or transtibial amputees with 22 involved limbs were retrospectively reviewed. Hemiepiphysiodesis was performed with 8-plates (10), staples (6), or drilling and curetting (6). Postoperatively, children were allowed to resume prosthetic use after their wounds healed and they indicated no pain while wearing their prosthesis. Seventeen patients presented with valgus and 5 with varus deformity of their residual limb. Mean age at time of surgery was 11 years and 11 months (range, 7 y and 11 mo to 15 y and 8 mo). Mechanical axis deviation (MAD) was measured before initial surgery and again after hardware removal or physis closure. RESULTS: The mean preoperative MAD was -29.6 mm for the valgus deformities and +10.6 mm for the varus deformities. The mean postoperative MAD was +3.1 mm for the varus knees and -6.0 mm for the valgus knees The mean total mechanical axis correction was 21.8 mm. One patient failed to achieve any mechanical axis correction and 1 hardware failure (broken 8-plate) occurred. Most patients had the staples or 8-plates removed, either after correction was achieved and physes were still open, or due to hardware prominence after physeal closure. CONCLUSIONS: Hemiepiphysiodesis provides reliable correction of angular deformity in pediatric amputees. Surgical intervention while skeletally immature allows for correction using guided growth, without the need for osteotomy with internal or external fixation and the resultant disruptions in prosthetic wear. LEVEL OF EVIDENCE: Case Series, Level IV.

Spinal stenosis frequent in children with multiple hereditary exostoses.

PURPOSE: Children with multiple hereditary exostoses (MHE) have numerous osteochondromas, with the most prominent lesions typically over the appendicular skeleton. A recent report noted a high rate of intracanal lesions in this patient population and recommended preventative spinal screening with magnetic resonance imaging (MRI) or computed tomography (CT). We sought to evaluate the prevalence of spinal stenosis from intracanal osteochondromas at our pediatric orthopedic center in order to evaluate if routine screening is warranted. METHODS: All pediatric patients treated for MHE were retrospectively identified. Records were reviewed to determine demographics, previous orthopedic surgery, and indication and results of axial spine imaging (CT or MRI). Imaging studies were reviewed to evaluate the presence of intracanal and compressive spinal lesions. RESULTS: Between 1990 and 2011, axial imaging was performed in nine patients with MHE due to concerns of pain, weakness, and/or dizziness. These patients had moderate disease involvement, with a mean of 4.9 previous orthopedic surgeries to address skeletal osteochondromas. Two patients with MHE had cervical spinal stenosis secondary to intracanal osteochondromas. Both children successfully underwent spinal decompression. Thus, of our MHE population undergoing axial imaging, 22 % were noted to have intracanal lesions. CONCLUSIONS: Our experience reveals a >20 % rate of compressive intracanal osteochondromas in MHE patients undergoing spinal imaging. These two patients represent 5 % of the MHE patients treated at our center. These lesions may be slow growing, and significant consequences can occur if not identified promptly. Thus, we confer that routine axial screening of the spinal canal may be warranted in these children.

Financial and employment problems in families of children with special health care needs: implications for research and practice.

INTRODUCTION: The purpose of this study was to identify factors related to financial burden among families of children with special needs and to identify specific provider-level activities associated with decreased risk for such burden. METHOD: Data for secondary analysis are from the National Survey of Children with Special Health Care Needs (CSHCN). Logistic regression analysis of state-level data was conducted to identify significant predictors of financial and employment problems among families of children with SHCN in Minnesota. RESULTS: Children with more severe conditions and whose family members provided health care at home were more likely to have parents report financial and employment problems due to the child's condition. On the other hand, families whose health care providers communicated well with other service providers and who helped them feel like partners in their child's care were significantly less likely to report financial and employment problems. DISCUSSION: Pediatric nurses and nurse practitioners can use these findings as they work with families for optimal family outcomes. Advocacy and policy implications at state and federal levels also are discussed.