Slipped capital femoral epiphysis and associated hypothyroidism. A review of the literature with two classic case examples.

Slipped capital femoral epiphysis (SCFE) is a relatively common hip disorder often seen in overweight, peripubertal children. Although the exact etiology is uncertain, it is generally accepted that underlying endocrinopathies play a role in the pathogenesis. Hypothyroidism is the endocrine disorder cited most commonly in association with SCFE, and patients often have no history of thyroid dysfunction at the time of presentation. Despite being a well-recognized risk factor, recommendations for screening thyroid function in patients with typical presentations of SCFE have not been deemed cost-effective; however, there is data to support screening for hypothyroidism in patients with atypical presentations of SCFE or short stature. Hypothyroidism may have a significant impact on healing and bone union after surgical management of SCFE and there is a paucity of case reports in the literature describing potential peri- and postoperative complications. We performed a systematic review of the literature of all reported cases of SCFE with associated hypothyroidism using the search terms, which demonstrated a physiologic relationship between hypothyroidism and SCFE. Two case reports of SCFE in patients with hypothyroidism and associated complications are presented with the literature review. There is a physiologic relationship between thyroid dysfunction and SCFE, and we postulate that profound hypothyroidism may contribute to delayed healing or nonunion in patients undergoing operative management. We support the recommendation to screen patients with short stature, atypical presentation of SCFE, or perisistent nonunion after surgery. In cases of hypothyroidism, we recommend thyroid hormone replacement and laboratory confirmation of return to euthyroid state prior to operative intervention.

MW construct in fusion for neuromuscular scoliosis.

A retrospective case control review was conducted to determine if the MW construct offers a superior means of correction of Cobb angles and pelvic obliquity in neuromuscular scoliosis. Posterior spinal fusion (PSF) in patients with neuromuscular scoliosis presents a surgical challenge. Particularly difficult is the correction of pelvic obliquity. Numerous instrumentation techniques have sought to address these difficulties. Most recently Arlet et al have introduced the MW construct. (in Eur Spine 8(3):229-231, 1999). They theorize that this construct may allow for superior spinopelvic fixation. Six patients with neuromuscular scoliosis who underwent PSF with the MW construct were compared with six subjects undergoing PSF utilizing the Galveston technique. Subjects were matched on the basis of preoperative Cobb angles and similar amounts of preoperative pelvic obliquity. Individuals who underwent PSF utilizing the MW construct obtained nearly 30% better correction of pelvic obliquity than did those who received a Galveston construct. A trend toward superior correction of Cobb angles with the MW construct was also observed. The MW construct may be a superior construct for curve correction in PSF for neuromuscular scoliosis, particularly those cases with excessive pelvic obliquity.

Role of vacuum-assisted closure in the treatment of pediatric lawnmower injuries.

Lawnmower injuries in children often present treatment challenges due to complex soft tissue damage. Vacuum-assisted closure (VAC), the application of controlled subatmospheric pressure to a wound surface, has been used to treat complex lacerations in many patients and has been shown to be safe and effective in children. However, VAC treatment of lawnmower injuries in children has not been reported. This study analyzes the outcomes of treatment following the use of VAC in children with lawnmower injuries and compares the results of VAC treatment to historical controls who were treated before VAC was available for wound treatment. The use of VAC demonstrated a trend toward a decrease in revision amputations and an improvement in function after treatment. There were no complications or adverse reactions related to VAC treatment. The VAC system is a safe and effective method of treating soft tissue injuries resulting from lawnmower accidents in children.

Clinical usefulness of botulinum toxin in the lower extremity.

As the literature that pertains to botulinum toxin expands, the scope of treatment options broadens. Although initial uses of botulinum toxin focused around the head and neck, there are many uses for the toxin in the area of the foot and ankle; more possibilities are under investigation every day. We review the uses and techniques for botulinum toxin in the foot and ankle and present results of botulinum toxin treatment in 10 idiopathic toe walkers.

Cost impact of botulinum toxin use in Medicaid-enrolled children with cerebral palsy.

The use of botulinum toxin type A (BTX) in the management of spasticity in childhood cerebral palsy (CP) is increasing. This study examined annual health care service utilization and costs associated with BTX therapy for spastic CP in Medicaid-enrolled children receiving complete health care coverage (1997 to 1999). We used pair matching as well as recent statistical technique improvements (bootstrap method) to work with limited samples. The introduction of BTX was associated with an increase of approximately $62 per month in prescription costs for the patient. However, these costs were made up by reductions in hospitalization. When each year was examined individually, reimbursements for BTX users were not different from those for pair-matched non-BTX users. These data suggest that BTX therapy does not significantly add to the costs of treating Medicaid-enrolled children with CP.