Outcomes of growing rod surgery for severe compared with moderate early-onset scoliosis: a matched comparative study.

Aims: The aim of this study was to compare the outcomes of surgery using growing rods in patients with severe versus moderate early-onset scoliosis (EOS). Patients and Methods: A review of a multicentre EOS database identified 107 children with severe EOS (major curve ≥ 90°) treated with growing rods before the age of ten years with a minimum follow-up of two years and three or more lengthening procedures. From the same database, 107 matched controls with moderate EOS were identified. Results: The mean preoperative major curve was 101° (90 to 139) in the severe group and 67° (33° to 88°) in the moderate group (p < 0.001), which was corrected at final follow-up to 57° (10° to 96°) in the severe group and 40° (3° to 85°) in the moderate group (p < 0.001). T1-S1 height increased by a mean of 54 mm (-8 to 131) in the severe group and 27 mm (-4 to 131) in the moderate group at the initial surgery (p < 0.001), and by 50 mm (-17 to 200) and 54 mm (-11 to 212), respectively, during distraction (p = 0.84). The mean number of complications per patient was 2.6 (0 to 14) in the severe group and 1.9 (0 to 10) in the moderate group (p = 0.040). Five patients (4.7%) in the severe group and three (2.8%) in the moderate group developed a neurological deficit postoperatively (p = 0.47). Conclusion: Severe EOS can be treated effectively using growing rods, but the risk of complications is high. Cite this article: Bone Joint J 2018;100-B:772-9.

Submuscular Isola rod with or without limited apical fusion in the management of severe spinal deformities in young children: preliminary report.

STUDY DESIGN: Retrospective review of the results of submuscular rod placement with and without limited apical fusion for the treatment of severe spinal deformities in young children. OBJECTIVES: To determine the success of this method for controlling severe deformities while allowing for spinal growth and to compare this method with previously reported results. SUMMARY OF BACKGROUND DATA: A variety of methods for controlling scoliosis in young children have been reported, but complications including spontaneous fusion, loss of correction, instrumentation failure, and limited spinal growth are common. METHODS: The cases of 29 young children with progressive scoliosis or kyphoscoliosis as a result of a variety of diagnoses treated with a submuscular Isola rod and a postoperative orthosis were retrospectively reviewed. Eleven patients also had a short anterior and posterior apical fusion or convex hemiepiphysiodesis to aid in correction and stabilization of their deformity. The remaining 18 patients had a submuscular rod only. RESULTS: The mean age at surgery was 6.7 years (range, 1-11 years). The initial preoperative mean magnitude of the major curve was 66 degrees (range, 42-112 degrees ). After surgery this decreased to a mean of 38 degrees (range, 16-70 degrees ). The most recent radiographs demonstrated a mean 47 degrees curve (range, 28-79 degrees ). The mean number of lengthenings per patient has been two (range, 0-5). Nine patients have reached a suitable age and have been converted to a posterior spinal fusion and segmental spinal instrumentation. Nine complications have occurred in seven patients (24%). These included five hook displacements and three rod breakages. These were treated by hook reinsertion and rod exchange or sleeve and a repeat lengthening. There was one superficial infection treated medically. CONCLUSION: This technique is useful in the management of severe spinal deformities in young children who have either failed, or have a contraindication to, orthotic management. Complications are relatively frequent but well tolerated.

A three-dimensional study of calcaneonavicular tarsal coalitions.

The authors studied 37 presumed calcaneonavicular tarsal coalitions from the Hamann-Todd Osteological Collection at the Cleveland Museum of Natural History. The anatomy of the coalitions and the associated subtalar and transverse tarsal joints was quite variable. The coalitions in 8 specimens completely spared the anterior facet of the calcaneus and in 7 specimens it was partially replaced by the navicular portion of the coalition, whereas in 22 specimens the anterior calcaneal facet was completely replaced by the navicular portion of the coalition. The authors suggest that the pathoanatomy of calcaneonavicular coalitions is not uniform and may involve the subtalar and transverse tarsal joints. This may have clinical relevance and contribute to the unsatisfactory results in feet undergoing coalition resection and soft tissue interposition.

Child and family functioning 6 and 12 months after a serious pediatric fracture.

BACKGROUND: Previous findings indicate that pediatric fractures can have adverse consequences for child adjustment and family functioning immediately after injury. However, longer term effects of the fractures are unknown. The purposes of the present prospective study were to examine the child and family outcomes of pediatric traumatic fractures at 6 months and 1 year after injury, and to identify injury and treatment factors associated with these outcomes. METHODS: We evaluated 57 children 6 to 12 years of age with traumatic fractures requiring hospitalization. Using standardized measures and parent interview, we obtained measures of pre- and postinjury child and family functioning. RESULTS: Although outcomes were primarily positive at 1 year after injury, child functional limitations and family stress were observed up to 6 months after injury. Lower extremity fractures had a more negative impact on families across all three assessment points. Children with fracture interventions that involved prolonged immobilization had more functional limitations at 6 months than children who were ambulatory. Family burden was higher at 1 month for the immobilized children, but not at later follow-up. CONCLUSION: Some children and families experience adverse effects during the year after a serious pediatric fracture, especially if sustained in a lower extremity. Fracture stabilization that allows for greater ambulation may offer some benefits related to functional outcomes and family impact.

The Effect of epsilon-aminocaproic acid on perioperative blood loss in patients with idiopathic scoliosis undergoing posterior spinal fusion: a preliminary prospective study.

STUDY DESIGN: A prospective study evaluating the efficacy of epsilon-aminocaproic acid (EACA) in decreasing perioperative blood loss in idiopathic scoliosis. OBJECTIVES: To compare the perioperative blood loss and need for blood replacement in two groups of patients undergoing surgery for idiopathic scoliosis. One group received intraoperative EACA; the other did not and served as controls. SUMMARY OF BACKGROUND DATA: Excessive blood loss increases the operative time, risk for blood product disease transmission, postoperative complications, and costs associated with posterior spinal fusion and instrumentation. EACA is an antifibrinolytic agent that has been shown to be effective in reducing perioperative blood loss during pediatric cardiothoracic surgical procedures. We hypothesized that it would also be effective in lowering blood loss during posterior spinal fusion for idiopathic scoliosis. METHODS: We compared the perioperative blood loss of 28 consecutive pediatric patients with idiopathic scoliosis who underwent posterior spinal fusion and received intraoperative EACA with 31 consecutive patients who did not receive this medication and served as a control group. RESULTS: The patients in both groups were similar. Patients in the EACA group demonstrated statistically significant decreases in total estimated perioperative blood loss and the need for autologous blood transfusion. The patients in the EACA group had no intraoperative or postoperative complications related to the use of this medication. CONCLUSIONS: Based on these preliminary findings, we believe that EACA is helpful in decreasing blood loss in patients undergoing posterior spinal fusion and instrumentation, and may decrease the number of autologous units needed to maintain safe perioperative hemoglobin levels, thereby improving safety and lowering cost associated with scoliosis surgery.

Salter-Harris type II fractures of the capital femoral epiphysis.

Salter-Harris type II fractures of the capital femoral epiphysis have not been previously documented. The authors have treated three patients who sustained four such fractures. One child had a recurrent fracture two years after the first had healed satisfactorily. Two fractures were treated by spica cast immobilization, one fracture by closed reduction and internal fixation, and the other fracture healed without treatment. No patient developed avascular necrosis or other complications. Two of the children had an association with idiopathic slipped capital femoral epiphysis. An etiologic relationship with slipped capital femoral epiphysis, if any, is uncertain.

The rigid flatfoot. Tarsal coalitions.

Tarsal coalitions are the major cause of painful rigid flatfoot deformity in children and adolescents. Talocalcaneal and calcaneonavicular coalitions are the most common sites. They are often bilateral and may be asymptomatic. They represent a failure of fetal mesenchymal differentiation, and onset of symptoms in children often corresponds to the time of ossification of the fibrous or cartilaginous coalition. The most common presenting symptom is pain, and diagnosis is aided by plain radiographs and computerized tomography. Some patients respond to conservative measures, but surgical treatment is often required. Resection and interposition of fat or tendon (talocalcaneal) or muscle (calcaneonavicular) are the most common operative treatments, with arthrodesis reserved for symptomatic recurrences, patients with degenerative changes, and those with multiple coalitions.

Compartment syndrome in ipsilateral humerus and forearm fractures in children.

Ipsilateral fractures of the humerus and forearm are uncommon injuries in children. The incidence of compartment syndrome in association with these fractures is controversial. The authors reviewed 978 consecutive children admitted to the hospital with upper extremity long bone fractures during a 13-year period. Forty-three children with ipsilateral fractures of the humerus and forearm were identified. Of 33 children with a supracondylar humerus fracture and ipsilateral forearm fracture, three children (7%) had compartment syndrome develop and required forearm fasciotomies. All three cases of compartment syndrome occurred among nine children with ipsilateral displaced extension supracondylar humerus and displaced forearm fractures; the incidence of compartment syndrome was 33% in this group. These findings suggest that children who sustain a displaced extension supracondylar humerus fracture and displaced forearm fracture are at significant risk for compartment syndrome. These children should be monitored closely during the perioperative period for signs and symptoms of increasing intracompartmental pressures in the forearm.

The floating knee in the pediatric patient. Nonoperative versus operative stabilization.

The results of nonoperative and operative or rigid stabilization of ipsilateral femur and tibia fractures in children and adolescents were evaluated. Twenty-nine consecutive patients with open physes (30 affected extremities) were reviewed. Their mean followup was 8.6 years (range, 1.1-18.6 years). The nonoperative group consisted of 16 patients and 16 extremities treated by skeletal traction of the femoral fracture, closed reduction and splinting or casting of the tibia fractures, and eventual immobilization in a hip spica cast. The operative group, was comprised of 13 patients and 14 extremities in which one or both fractures were treated by open reduction and internal fixation, intramedullary fixation, or external fixation. Despite higher modified injury severity scores and skeletal injury scores, the patients who were treated operatively had a significantly reduced hospital stay, 20.1 days versus 34.9 days, respectively; decreased time to unsupported weightbearing, 16.8 weeks compared with 22.3 weeks, respectively; and fewer complications. Operative stabilization of the femur had a significant effect on decreasing the length of hospital stay and the time to unassisted weightbearing. The patients also were analyzed according to their age at the time of injury: 9 years of age or younger and 10 years of age and older. The younger children who were treated nonoperatively had an increased rate of lower extremity length discrepancy, angular malunion, and need for a secondary surgical procedure as compared with younger children who were treated operatively with rigid fixation. Based on the results of the current study, operative stabilization of at least the femur fracture and, preferably, both fractures in the treatment of a child with a floating knee is recommended, even for younger children.

Radiographic evaluation of children and adolescents with a spinal deformity.

Accurate and reproducible measurement of radiographs of children and adolescents with spinal deformities by radiologists is important. It provides useful information for treating physicians. Standing posteroanterior (PA) and lateral radiographs of the entire spine are the preferred views. Common radiographic measurements include the Cobb angle for curve magnitude, the center sacral line for trunk shift, and the Risser sign for maturity. A vocabulary of standard spinal deformity terminology is presented to be utilized on radiographic reports to improve communication. Correctly measuring spinal deformity and determining skeletal maturity enables the treating physician to evaluate the status of their patients' deformity, determine if treatment is necessary, and assess the stability of the spine during orthotic treatment and after surgery.

Interposition of the split flexor hallucis longus tendon after resection of a coalition of the middle facet of the talocalcaneal joint.

Ten consecutive patients (fourteen feet) who had a painful coalition of the middle facet of the talocalcaneal joint with restricted motion of that joint were managed with a resection of the coalition and interposition of a split flexor hallucis longus tendon in 1992, 1993, or 1994. Initial nonoperative treatment of all of the feet had failed. According to the ankle-hindfoot clinical rating system of the American Orthopaedic Foot and Ankle Society, there were eleven excellent results and one good, one fair, and one poor result at a mean of fifty-one months (range, thirty-two to sixty months) after the procedure. Thirteen of the fourteen procedures resulted in considerable relief of pain, an improved range of motion of the talocalcaneal joint, and improved function of the foot. No patient had symptoms or functional impairment of the great toe secondary to the interposition of the split flexor hallucis longus tendon. On the basis of these early results, tendon interposition appears to be an excellent procedure for the treatment of a symptomatic coalition of the middle facet of the talocalcaneal joint after initial nonoperative treatment has failed. The presence of degenerative osteoarthritis in the other facets of the talocalcaneal joint is a contraindication to this procedure. The long-term results have yet to be determined. However, the standardized rating system used in the present study will allow accurate comparison of our results with those of subsequent studies.

Acute psychosocial impact of pediatric orthopedic trauma with and without accompanying brain injuries.

BACKGROUND: The acute psychosocial effects of orthopedic injuries on children and their families are poorly understood. Previous studies have relied on retrospective reports or failed to take into account accompanying brain injuries. The purpose of the present study was to examine prospectively the psychosocial impact of pediatric orthopedic traumatic fractures with and without accompanying brain injuries. METHODS: Participants were 108 children 6 to 12 years old with orthopedic injuries requiring hospitalization: group 1 (n=80) had fractures only, group 2 (n=28) also had moderate or severe brain injuries. Using standardized measures and parent interviews, we obtained preinjury estimates of family functioning and child behavior problems and postinjury measures of parental distress, family stresses, and child behavior. RESULTS: Parents reported significant clinical distress (35% in group 1, 57% in group 2), family burdens (group 2 > group 1), and child behavioral changes (41% in group 1, 89% in group 2). Multiple regression analyses indicated that preinjury family status and brain injuries predicted postinjury parental and family distress. CONCLUSION: Pediatric orthopedic injuries have greater social effects on children with accompanying brain injuries and poorer preinjury family functioning.

Nicotine replacement therapy.

OBJECTIVE: To review the literature on nicotine dependence, nicotine pharmacology, health consequences associated with the use of nicotine, and nicotine replacement therapies used to aid smokers who are nicotine dependent. DATA SOURCES: A review of articles, book bibliographies, and published studies identified by a search of the MEDLINE database from 1982 to 1996 on nicotine dependence, nicotine addiction, nicotine withdrawal, smoking, smoking cessation, smoking intervention, nicotine pharmacology, nicotine pharmacokinetics, nicotine pharmacodynamics, and nicotine replacement therapies. STUDY SELECTION AND DATA EXTRACTION: Inclusion criteria were published randomized, double-blind trials of at least 12 weeks' duration, meta-analyses, and panel consensus guidelines. DATA SYNTHESIS: Cigarette smoking and tobacco use have met the surgeon general's primary criteria as well as additional criteria for drug dependence. Drug dependence requires that the drug produce psychoactive effects. Nicotine has been identified as the cause of tobacco dependence. First, nicotine provides positive reinforcement by stimulating nicotinic receptors to promote high self-administration rates. Second, nicotine causes a negative reinforcement in the form of withdrawal symptoms when nicotine is withheld after chronic use. Nicotine replacement therapy reduces the severity of withdrawal symptoms in smokers abstaining from tobacco. Nicotine replacement therapy allows the smoker to focus on psychosocial aspects of tobacco abstinence while receiving relief from withdrawal symptoms. The long-term effectiveness and health benefits of nicotine replacement therapy coupled with nonpharmacologic approaches have been clearly established. Smoking cessation has received wide attention from the public and medical communities; it is complex and has several interwoven factors to be considered. The psychological, behavioral, and physical components have to be understood before designing a treatment plan. The most successful approaches to smoking cessation involve multicomponent, multisession behavioral treatment programs as a foundation coupled with pharmacologic intervention. Pharmacists can play a key role in initiating behavior change and ensuring the safe and proper use of nicotine replacement in order to produce the desired outcome. CONCLUSIONS: The optimum choice in nicotine replacement depends on the individual's needs and coping abilities. Individualized nicotine replacement coupled with nonpharmacologic interventions produces the highest rate of success for abstinence from nicotine.

Imaging the child with a limp.

A great many pathologic conditions can cause a child to limp. Prior to imaging, it is necessary to complete a thorough history and physical examination in order to limit the differential diagnosis to a few possible causes. The selection of imaging modalities should then be guided by the history and physical examination findings. Because of their sensitivity and specificity for detecting a wide range of bone pathology, radiographs should be obtained first. Plain radiographs often are diagnostic. The choice of sonography, CT, bone scintigraphy, or MR imaging is made while keeping in mind the strengths of each imaging modality.

Proposed curriculum model for resident education in pediatric orthopaedic surgery.

A curriculum developed for pediatric orthopaedic residency training is described. The curriculum is practice based, emphasizing those components thought to be necessary for orthopaedic practice. Highly technical or esoteric topics are deemphasized, because they are not relevant to practice capabilities at the end of residency training. The curriculum is designed to serve as a guide for educational direction in pediatric orthopaedic residency training, and not as a description of competency. Resource materials are being developed to provide the educator with relevant clinical material, objectives, and bibliography. The advantages of a practice based curriculum warrant further development of this model for other orthopaedic subspecialties.

Comparative tolerability profiles of the inhaled anaesthetics.

Improved understanding of the structure/activity relationship of inhaled anaesthetics has resulted in the synthesis of fluorinated compounds which are more potent and less toxic than their unfluorinated antecedents. The toxic effects of inhaled anaesthetics on the liver and kidney are complex but, in general, are related to the extent to which individual inhaled agents are metabolised. Halothane hepatotoxicity is a rare, idiosyncratic reaction which typically occurs in obese women having more than one exposure to the drug within a short time interval. All currently available volatile anaesthetic drugs have depressant effects on the cardiovascular and respiratory systems; arrhythmias are more likely with halothane than with the fluorinated ethers. Cerebral blood flow tends to increase during inhalation anaesthesia, especially with halothane and in the presence of hypercarbia; isoflurane may be given sparingly during neurosurgical procedures whilst monitoring its end-tidal concentration. Although the volatile agents tend to cause uterine relaxation they may be given safely in low concentration to avoid awareness during Caesarean section. In general, young children require rather higher concentrations of volatile agents than adults and seem to be less susceptible to organ toxicity. Two relatively new volatile agents, sevoflurane and desflurane, offer some advantages over isoflurane but neither is an "ideal drug'. Sevoflurane interacts with soda-lime to produce a series of degradation products, the most important of which is compound A. Production is greatest during low-flow, closed circuit anaesthesia using high inspired concentrations of the drug. Compound A has nephrotoxic potential in rats but the clinical significance of the interaction between sevoflurane and soda-lime is unclear. Nitrous oxide when given for prolonged periods may cause irreversible bone marrow depression.

Emergence of diabetes mellitus in a Mexican-origin population: a multiple cause-of-death analysis.

The "New World syndrome" is comprised of disorders that are hypothesized to have resulted from an interaction of the Amerindian genotype with an environment that includes marked changes in lifestyle and diet. The principal component of the syndrome is adult-onset (noninsulin dependent) diabetes mellitus. The purpose of this paper is to describe the emergence of diabetes in a Mexican-origin population. Using a unique file of multiple-cause mortality data, we have computed standardized mortality ratios and relative standardized mortality ratios for Mexican-origin individuals and for other white persons age 30 and over from the 1930's through the middle 1980's. Results for the study population residing in Bexar County (San Antonio), Texas, show that diabetes mortality for Mexican-origin individuals did indeed increase in a pattern consistent with the New World syndrome hypothesis. This study is the first description of the emergence of diabetes using a data set with consistently defined causes of death and demographic characteristics.