Clinical practice. Static, axial, and rotational deformities of the lower extremities in children.

Static, axial, and rotational deformities of the lower extremities are very frequent in children and often a reason for clinic visits. It is important to make a difference between physiological, usually spontaneously healing conditions, and real pathology. Flatfeet and less frequently cavus feet are the main foot problems. Special attention should be paid to the cavovarus foot that often has an underlying neurological disorder. Localized foot pain has usually a very specific cause and needs further investigation. Genua valga and genua vara are typical for a given age group and correct usually spontaneously. Toeing in and toeing out are mainly cosmetic problems and can be caused by tibial or femoral rotation, very rarely by a foot deformity. Leg length discrepancy is also frequent and in most patients limited to less than 2 cm, causing no further problems. Follow-up is, however, needed because of possible increasing discrepancy during growth.

Clinical practice: the hip from birth to adolescence.

Hip problems in children are relatively rare but usually serious, potentially causing lifelong disability. Early diagnosis and treatment is, therefore, mandatory. The aim of this review is to discuss the most frequent diseases of the hip from birth to adolescence. The different affections are relatively closely related to age periods. After birth and in infancy, developmental dislocation of the hip (DDH) and septic arthritis are more prominent. DDH is not always present at birth and should regularly be checked for in the first 6 months of life. Septic arthritis is an emergency and should be adequately treated within 4 days of the beginning of the infection with open drainage of the hip. Transient synovitis and Legg-Calvé-Perthes disease (LCPD) are mostly found between 4 and 10 years of age. Transient synovitis is the most frequent hip disorder in that age group. It is a self-limiting noninfectious effusion in the joint without serious consequences. Differential diagnosis with septic arthritis should, however, be made. LCPD is an idiopathic avascular necrosis of the hip causing flattening and deformity of the femoral head, depending on the extent of the necrosis. Treatment by containment is aimed at favoring the remodeling of the deformed femoral head. Finally, between the age of 10 and 15 years, slipped capital femoral epiphysis (SCFE) should be the preferential diagnosis, especially in the limping obese boy. SCFE is an inferior and posterior displacement of the proximal epiphysis of the femur in the growth plate. It should be treated as an emergency with a screw fixation.

Clinical practice: the spine from birth to adolescence.

The spine in children can be affected by different bone pathologies such as trauma, infection, and tumoral processes. Most typical however are postural deformities, of which the evolution is mainly influenced by growth. An overview will be given of the most frequent problems encountered in children. Back pain is not infrequent and should always be taken seriously. In recent years, however, there has been an increase in functional complaints, mainly due to stress-related problems. Improving imaging techniques allows more and more accurate diagnoses and should be used judiciously. Postural deformities should be divided into functional and structural entities. Functional hyperkyphosis, hyperlordosis, and scoliosis should be identified by a thorough clinical evaluation and certainly not be overtreated. A structural scoliosis has the most potential of creating cardiovascular or pain problems in later life. Not all curves however have a bad prognosis. It is the task of the clinician to identify the children needing special attention, based on their knowledge of the underlying pathology as in congenital scoliosis and of the physiological age or maturity of the child, especially in the adolescent idiopathic scoliosis. Treatment should be initiated according to the prognosis regardless of the age of the child.

Thrombophilia and Legg-Calvé-Perthes disease: is it a causative factor and does it affect the severity of the disease?

Coagulation parameters were studied in a population of 118 children with Perthes disease in order to determine the possible role of thrombophilia as a causative factor for the disease and to determine if thrombophilia could affect its course. We found 27 children presenting one or more coagulation disorders. The statistical analysis concurs with previous findings of a relationship between Legg-Calvé-Perthes disease and an increased liability to thrombosis; however, no significant effect of thrombophilia on the severity of the disease could be demonstrated.

Reliability of serial bone scintigraphy classification according to Conway in Legg-Calvé-Perthes disease.

Serial bone scintigraphy in Legg-Calvé-Perthes disease (LCP) has a good early prognostic value. So far, no intra- and inter-observer reliability study on this classification has been published. Serial technetium scintigraphy of the hips was performed in 40 children with LCP disease, and the hips were classified based on their scintigraphic patterns according to Conway. Forty hips were classified twice by six observers. The two assessments were made in a different order, with a minimum time interval of one month. Unweighted kappa coefficients were calculated. Only moderate reliability was measured: intra-observer reliability: kappa = 0.573 and inter-observer reliability: kappa = 0.525. Serial bone scintigraphy in LCP has an inter- and intra-observer reliability that is only moderate. The reliability is better than that observed for the radiological Catterall classification and head-at-risk factors, but worse than the reliability of the radiological Herring classification.

Motor function following multilevel botulinum toxin type A treatment in children with cerebral palsy.

This study evaluated the effects of multilevel botulinum toxin type A (BTX-A) treatments on the gait pattern of children with spastic cerebral palsy (Gross Motor Function Classification System Levels I-III). In this nested case-control design, 30 children (mean age 6y 11mo [SD 1y 5mo]; 21 males, nine females; 19 with hemiplegia, 11 with diplegia) were treated according to best practice guidelines in paediatric orthopaedics, including BTX-A injections. A matched control group of 30 children (mean age 7y 8mo [SD 1y 10mo]; 13 males, 17 females; 19 with hemiplegia, 11 with diplegia) were treated identically, but without BTX-A. Motor development status at 5 to 10 years of age was assessed by means of three-dimensional gait analysis at a mean time of 1 year 10 months (SD 10mo) after the last BTX-A treatment. The control group showed a significantly more pronounced pathological gait pattern than the BTX-A group. Major differences were found for pelvic anterior tilt, maximum hip and knee extension, and internal hip rotation. These results provide evidence for a prolonged effect of BTX-A and suggest that BTX-A injections, in combination with common conservative treatment options, result in a gait pattern that is less defined by secondary problems (e.g. bony deformities) at 5 to 10 years of age, minimizing the need for complex surgery at a later age and enhancing quality of life.

Epiphysiodesis of the greater trochanter in Legg-Calvé-Perthes disease: The importance of timing.

Patients with Legg-Calvé-Perthes disease (LCP) often exhibit relative overgrowth of the greater trochanter and shortening of the femoral neck. Biomechanically, this corresponds to a shorter lever arm and a decreased muscle tension which may result in a Trendelenburg gait and pelvic instability. This is a retrospective study of 31 patients (32 hips) with LCP disease and relative overgrowth of the greater trochanter who were treated with an epiphyseodesis. The average age at operation was 10 years and 6 months. We evaluated the patients clinically with the Trendelenburg sign and analysed on radiographs the growth of the greater trochanter and the neck-shaft angle of the normal hip and the pre- and postoperative growth and angle of the involved hip. We did not find any significant differences between the pre- and postoperative values. After a mean follow-up of 4 years and 2 months, however, 27 patients presented with a negative Trendelenburg sign (versus 14 patients preoperatively).

Evaluation of wound healing after total knee arthroplasty in a randomized prospective trial comparing fondaparinux with enoxaparin.

BACKGROUND: Fondaparinux, a new synthetic pentasaccharide has proven to be a more potent thromboprophylactic drug compared to enoxaparin after major orthopaedic surgery. However, the safety of fondaparinux regarding wound healing has not yet been investigated. METHODS: We performed a single-centre prospective clinical trial, in which patients undergoing total knee arthroplasty or revision of at least one of the components of a previous knee arthroplasty were randomly assigned to thromboprophylaxis with fondaparinux or enoxaparin. The trial included 109 patients and wound discharge was compared. Secondary outcome measures were the amount of blood in the suction drain, postoperative transfusion rate, change in haemoglobin levels, haematocrit, intervention rate, time to regain flexion and rate of symptomatic thromboembolic events. RESULTS: 55 patients were treated with fondaparinux and 54 with enoxaparin. Base-line characteristics were similar. In both groups wound dressings remained dry after five (5.17+/-2.5 and 5.19+/-3) days postoperatively. There were no significant differences in any of our outcome measures. CONCLUSIONS: We did not find any significant difference in wound healing with fondaparinux after major knee surgery. Post hoc analyses suggested the study should have had a sample size of 155 in each group. We believe this trial should be used as a pilot study for further investigations concerning the safety of thromboprophylaxis.

The effects of quantitative gait assessment and botulinum toxin a on musculoskeletal surgery in children with cerebral palsy.

BACKGROUND: The limits of nonoperative treatment for children with cerebral palsy, including physical therapy and orthotics, commonly lead to orthopaedic surgical intervention. The purpose of the present study was to evaluate the influence of gait analysis and botulinum toxin type-A injections on the timing, prevalence, and frequency of orthopaedic surgery. METHODS: We performed a retrospective review of 424 children with cerebral palsy who had been born between 1976 and 1994. The children were divided into three groups: Group 1 comprised 122 patients who were managed throughout the entire study period according to best-practice guidelines in orthopaedics, Group 2 comprised 170 patients who were similarly managed but with input from gait analysis, and Group 3 comprised 132 patients who had gait analysis and also received botulinum toxin type-A injections. We analyzed the prevalence of orthopaedic surgical procedures at different ages (three to nine years) and the time to the first surgical procedure. RESULTS: The progression to orthopaedic surgery was significantly different among the three groups (p < 0.0001). The proportion of patients who had undergone at least one surgical procedure by the age of seven years was 52% (sixty-four of 122) for Group 1, 27% (forty-six of 170) for Group 2, and 10% (thirteen of 132) for Group 3. There was a delay in surgery in Group 2 as compared with Group 1 (p < 0.00001 at seven, eight, and nine years of age) and a significant decrease in the prevalence of orthopaedic surgical procedures for Group 3 as compared with Group 1 (p < 0.00001 at four to eight years of age) and Group 2 (p < 0.0025 at four to nine years of age). CONCLUSIONS: In the treatment of children who have cerebral palsy, the introduction of gait analysis increases the age of the first orthopaedic surgical procedure and botulinum toxin type-A treatment delays and reduces the frequency of surgical procedures.

Serial bone scintigraphy in Legg-Calvé-Perthes disease: correlation with the Catterall and Herring classification.

Radiographic classifications in Legg-Calvé-Perthes disease are difficult to use in the early stage of the disease. Changes on bone scintigraphy (revascularization versus recanalization pathway) precede the radiographic changes. Our purpose was to study the correlation between serial bone scintigraphy and radiographic classifications in Legg-Calvé-Perthes disease. In 86 patients, 95 hips that presented with Legg-Calvé-Perthes disease in the early stage were followed with serial bone scintigraphy and radiographs. Forty-four hips showed recanalization: pathway A on bone scintigraphy. Of these hips 96% were classified as Herring A or B and 66% as Catterall 2. Thirty-five hips showed revascularization: pathway B on bone scintigraphy. Of this group 82.8% were classified as Herring C and 17.1% as Herring B. All pathway B hips have Catterall 3 or 4. Sixteen hips showed pathway C: regression from pathway A to pathway B. They presented in 56% of cases with Herring B, 44% with Herring C, and in 81% with Catterall 3 or 4 classifications. We can conclude that there is a significant correlation between the vascularization pattern and the radiographic classification of Herring and Catterall.

Treatment of high-grade spondylolisthesis by posterior lumbosacral transfixation with transdiscal screws: surgical technique and preliminary results in four cases.

In high-grade spondylolisthesis, the surgical treatment should be aimed at achieving good stability to allow solid fusion in the face of high biomechanical forces at the lumbosacral junction. A 360 degrees fusion seems to be able to provide this stability. This is however extensive surgery and many problems and complications have been reported. In order to overcome these difficulties, various new procedures have been published. Most of these techniques aim for a good anterior column support, allowing primary stability and a large bony surface area for fusion. Transfixation of the lumbosacral disc space using a fibular strut graft was published decades ago. Several modifications have been reported since, including the use of threaded cages filled with bone graft. In contrast to the number of these surgical techniques, only few biomechanical test results and small-size clinical studies have been reported in the literature. An interesting technique of lumbosacral transfixation includes the use of transdiscal pedicle screws, described by Abdu et al in 1994. This allows for the use of standard instruments and implants, while biomechanical testing recently has shown improved stability equal to classic PLIF constructs by providing three-column support. Moreover, in high-grade slips this technique is easier to perform than other methods. We have treated four consecutive patients according to this technique with good clinical and radiographic results. The surgical technique is described in detail and a review of the literature is provided.

Factors determining the final outcome of treatment of idiopathic scoliosis with the Boston brace: a longitudinal study.

This study tries to determine factors influencing the final outcome of treatment of idiopathic scoliosis with the Boston brace and to compare the results with the natural history. One hundred and fifty-one patients, 130 girls and 21 boys, treated between 1982 and 1991, were reviewed. A series of continuous and categorical variables were measured, allowing for the construction of a multiple regression equation. Continuous variables were age at discovery of the curve, time of interval between discovery and treatment and age at the beginning of treatment. Furthermore age of menarche, duration of treatment, duration of weaning and age and time of follow-up were noted. Continuous numerical variables were the Cobb angle, the apical vertebral rotation, and the Risser stage. Categorical variables consisted of the results of a questionnaire and the King's classification of the curve. Good results are achieved in older children, with low Cobb angles and advanced maturity, who are, however, the very ones not expected to progress, as also indicated in studies on natural history. Brace treatment seems not to alter the natural history in general, and especially not in the older child; this is the case from age 12 years and Risser stage 2 onwards. In the younger child, a brace is probably still indicated, because it has been proved that a scoliosis is more prone to progress and that a possible positive result can still not be ruled out, as long as randomized control trials are not conducted.

Lateral shelf acetabuloplasty in the early stage of Legg-Calvé-Perthes disease with special emphasis on the remaining growth of the acetabulum: a preliminary report.

This study reports on the preliminary results in 43 patients with an early stage of unilateral Legg-Calvé-Perthes disease, treated with a shelf acetabuloplasty. The mean postoperative follow-up was 3.7 years (1.3-6.2 years). The results suggest an improved outcome in children older than 5 years of age at onset. According to the Stulberg classification, 16 hips were classified as Stulberg 2, 19 hips as Stulberg 3 and eight hips as Stulberg 4. The acetabular size, which is a measurement of the length of the acetabulum relative to the size of the shelf, increased from 48.86 to 69.13%. This reflects an incorporation of the shelf-graft into the pelvis as a result of continued growth of the lateral acetabular structures. The coverage of the femoral head by the bony acetabulum increased from 68.51 to 73.83%. The acetabular cover increases in children younger than 8 years of age and decreases in patients older than 8 years. We suggest that shelf acetabuloplasty can be considered as an appropriate surgical treatment for children older than 5 years of age, with severe Legg-Calvé-Perthes disease.

Juvenile spondylodiscitis: the value of magnetic resonance imaging: a report of two cases.

Two boys presenting with reluctance to sit straight and stand were diagnosed with spondylodiscitis of the lumbar spine. After confirmation of the diagnosis on plain radiographs, computed tomography and magnetic resonance imaging, they were successfully treated with antibiotics and in one case a lumbar orthosis. The use of magnetic resonance imaging is discussed and compared to the other radiological techniques. Magnetic resonance imaging seems to be the most sensitive and specific imaging technique used in the diagnostic process of spondylodiscitis. Computed tomography and technetium bone scan both play a specific part in the process of diagnosis and follow-up.

Temporary epiphysiodesis with Blount stapling for treatment of idiopathic genua valga in children.

Not all idiopathic genua valga in children show an innocuous evolution. If the deformity persists or increases, it can cause a long-term cosmetic or functional problem. The problem can easily be corrected, with only limited risks for complications, with temporary medial hemi-epiphysiodesis of the growth plates around the knees. This retrospective study considers the pre- and postoperative evolution of 44 patients who underwent temporary stapling of the medial femoral and tibial physes following Blount's technique. Ninety percent were satisfied and showed good correction of the knee alignment. Four patients were not satisfied with the result, owing to recurrence of the valgus deformity; two of them had a good result after revision surgery. The condition was assessed by measuring clinically the intermalleolar distance and the radiological hip-knee-ankle angle. Average age at the time of surgery was 12 years six months for girls and 13 years eight months for boys. Pre-operative evaluation of skeletal age on radiographs of the hand is advised. There is a rebound phenomenon after hardware removal, with an average recurrence of the valgus deformity of 4 degrees. Blount stapling appears as a reliable method for treatment of idiopathic genua valga in children, with satisfactory results and few complications.

Legg-Calvé-Perthes disease in patients under 5 years of age does not always result in a good outcome. Personal experience and meta-analysis of the literature.

This study attempted to analyze objectively the long-standing impression that children under 5 years of age, who have Legg-Calvé-Perthes disease, generally do well. Thirty patients, with 36 hips and onset of disease prior to their fifth birthday were reviewed at skeletal maturity. More than 50% of the hips were classified in Catterall group 3 or 4, and Herring group C. The end evaluation by the Stulberg classification showed 44.5% good, 22.2% fair and 33.3% poor results. By the Mose rating the results were respectively 27.8% good, 30.6% fair and 41.6% poor.A meta-analysis of the literature showed a very broad spectrum of results, leading to the conclusion, first, that comparison is difficult and, second, that young age is not a free ticket to a good result.

Percutaneous epiphysiodesis for leg length discrepancy.

This study presents a retrospective evaluation of 57 patients who underwent a percutaneous epiphysiodesis for leg length discrepancy. Of these patients, 68.5% presented with a good result with a final leg length discrepancy of less than 1.5 cm, 14% with a fair result with a discrepancy of between 1.5 and 2 cm, and 17.5% showed a poor result with a leg length discrepancy of more than 2 cm. The percutaneous epiphysiodesis was found to be a safe and reliable technique. There were very few technical errors. The causes of failure were analyzed and compared with a previous study from the same department. Error in timing remains the main problem.

Avascular necrosis of the talus in children with haemophilia.

Patients who have haemophilia often present with joint problems. Haemarthrosis can occur spontaneously or after minor trauma. Later, degenerative changes can cause pain and loss of motion. Avascular necrosis of the talus has a high incidence after serious trauma. Furthermore, avascular necrosis of the talus has been associated with multiple systemic conditions. The association of haemophilia and avascular necrosis of the femoral head has been described. This study reports three cases (four ankles) where we suspect an avascular necrosis of the talus in children with haemophilia. To the authors' knowledge, the possible association of haemophilia and avascular necrosis of the talus has not yet been described in children.