A Current Review in the Orthopedic Management of Osteonecrosis of the knee Secondary to Treatment of Pediatric Hematologic Malignancy.

Acute Lymphoblastic Leukemia is the most prevalent pediatric hematologic malignancy. The treatment for this illness has advanced significantly, now touting a 90% cure rate. Although these patients often become disease free, treatment can leave devastating effects that last long after their disease burden is alleviated. A commonly experienced result of treatment is osteonecrosis (ON), often occurring in weight bearing joints. Uncertainty exists in the optimal treatment of this cohort of patients. In this review, we describe the etiology and suspected pathogenesis of ON, as well as treatment options described in the literature.

Management of Calcaneal Cysts in the Pediatric Population: A Review.

Cysts of the bone are a common pathology that, although benign, are frequently treated because of their tendency to compromise the integrity of affected bone. Two common entities are unicameral bone cysts and aneurysmal bone cysts. Although these are two distinct pathologies, they are treated similarly and thus will be discussed in tandem. The optimal treatment of calcaneal bone cysts in pediatric patients has long been debated among orthopaedic surgeons because of the relatively small number of cases and varied results within the literature. Currently, there are three lines of thought regarding treatment: observation, injection, and surgical intervention. When considering which course of treatment is best for an individual patient, the surgeon must consider the fracture risk without treatment, the risk of complications with treatment, and the recurrence rate with each treatment approach. There are limited data on pediatric calcaneal cysts specifically. Still, there are much data concerning simple bone cysts of long bones in the pediatric population and calcaneal cysts in the adult population. Because of the lack of literature on the subject, there is a need for a review of the available literature and a consensus on the approach to treating calcaneal cysts in the pediatric population.

Ponseti Casting vs. Soft Tissue Release for the Initial Treatment of Non-idiopathic Clubfoot.

Purpose: Ponseti casting has universally been accepted as the gold standard for treatment of idiopathic clubfoot. Conversely, primary treatment for non-idiopathic clubfoot has not been established. The purpose of this study is to compare treatment outcomes following primary soft tissue release (STR) and Ponseti casting of non-idiopathic clubfoot. Methods: An IRB-approved retrospective study of patients treated for non-idiopathic clubfoot between 2005 and 2020 was conducted. Patients were included if they began treatment before the age of 2 and had at least 1 year of follow up. Patients were placed into either the STR group or Ponseti group and variables of interest were documented including reoccurrence of deformity, number of surgeries performed, type of surgeries performed, anesthesia time, and surgery time. Data was analyzed using Mann-Whitney U test for continuous variables. Results: A total of 33 children with 57 neuromuscular/syndromic clubfoot were identified of which 9 (15 feet) were treated with STR and 24 (42 feet) were treated with Ponseti casting. Average anesthesia and surgery time were found to be 291 and 179 min, respectively, for the STR group, and 113 and 67 min for the Ponseti group. The difference in operating time was determined to be significant (p = 0.02, p = 0.01). Patients treated with STR were found to have significantly more surgeries performed over the course of treatment than those treated with Ponseti casting (p = 0.001) with an average of 4.2 surgeries in the STR group and 1.5 surgeries in the Ponseti group. Extracapsular procedures were performed in 100% of the STR group and 97.6% of the Ponseti group (p = 0.55). Intracapsular procedures were performed in 100% of the STR group and 50% of the Ponseti group (p = 0.001). Conclusion: The Ponseti method should serve as the primary approach in the initial treatment of non-idiopathic clubfoot as it can reduce the risk of future invasive intracapsular surgery and shorten anesthesia and surgery times when surgical treatment is necessary. Level of Evidence: Level III retrospective case control study.

Preoperative Angiography Can Guide Treatment of Post-Femoral Neck Fracture Capital Femoral Physeal Separation and Displacement: A Case Report.

CASE: A 13-year, 6-month-old boy sustained a Delbet type III femoral neck fracture with postoperative femoral head avascular necrosis (AVN) and subsequent capital femoral physeal separation (CFPS). Preoperative angiography revealed a patent artery of the ligamentum teres to the femoral head epiphysis, allowing our patient to undergo a modified Dunn procedure to maintain this artery and preserve his native hip. CONCLUSION: Preoperative angiography allows for real-time identification of femoral head epiphyseal blood supply in patients with femoral head AVN complicated by CFPS and guides surgical treatment for hip preservation.

Surgical Correction of Torticollis Due to Agenesis of the Sternocleidomastoid: Case Study and Review.

Unilateral agenesis of the sternocleidomastoid (SCM) muscle is a rare phenomenon known to cause torticollis. There have been around 12 reported instances of SCM agenesis in the literature; in almost every case, torticollis was easily resolved nonsurgically with stretching and physical therapy. We report the case of a 6-year-old boy with severe torticollis due to unilateral SCM absence who underwent the surgical release of the contralateral SCM. To our knowledge, this is the first time a surgical release of the SCM was performed to correct torticollis associated with agenesis of the SCM.

Reliability of radiographic measures for infantile idiopathic scoliosis.

BACKGROUND: Radiographic measures such as the rib vertebral angle difference (RVAD), Cobb angle, and space available for the lung (SAL) help to guide treatment and measure treatment effects in patients with infantile idiopathic scoliosis. This study aimed to evaluate the intraobserver and interobserver reliability of these radiographic measures. METHODS: Forty-five spine radiographs of skeletally immature patients (age, two months to four years) with infantile idiopathic scoliosis were measured with use of Surgimap software. Three pediatric orthopaedic surgeons and a pediatric orthopaedic fellow identified the major curve apex, rib-vertebra phase, Cobb angle, and end vertebrae and calculated the RVAD and SAL values at two separate time points. Interobserver and intraobserver reliability of the RVAD, Cobb angle, and SAL values were assessed with use of intraclass correlation coefficients (ICCs). Fleiss kappa coefficients were calculated for categorical variables. RESULTS: The RVAD (ICC = 0.86 to 0.92) and Cobb angle (ICC = 0.99) measurements had high reliability. The SAL value had substantial interobserver reliability (ICC = 0.66) and moderate intraobserver reliability (ICC = 0.73). Despite the high agreement for the Cobb angle, the choice of the major curve vertebrae (kappa = 0.19 to 0.39) and apical vertebra varied (kappa = 0.57 to 0.62). Observers were more likely to choose the same apical vertebra in large curves (r = 0.483, p = 0.001). The agreement for the apical rib-vertebra phase was substantial (kappa = 0.67). Paired RVAD measurements fell within ≤ 10° of each other in 82% of cases, but the remaining 18% of the RVAD measurements showed >10° of variation. CONCLUSIONS: Measurements used to guide treatment of infantile idiopathic scoliosis curves were reliable despite standard radiographic measurement error and the difficulty in obtaining quality images in young patients. Clinicians are dependent on seemingly objective radiographic data. The reliability of the Cobb angle and RVAD measurements in infantile scoliosis was high but not devoid of variability that could skew the ability to accurately and reliably suggest the best course of treatment. The SAL value was a less reliable measure. Treatment recommendations for infantile idiopathic scoliosis should rely on the synthesis of objective and clinically subjective data, as variations in radiographic measurements can lead to inconsistencies in management and to inconsistent treatment outcomes.

The role of posterior spinal osteotomies in pediatric spinal deformity surgery: indications and operative technique.

The primary goals of spinal deformity surgery are to prevent the progression of further deformity and to improve sagittal and coronal balance. Although increasingly powerful instrumentation has greatly facilitated these treatment goals, osteotomy of the spine is sometimes necessary to address more significant deformity. This review provides a detailed overview of posterior spinal osteotomies, which have gained increased attention as an adjunct to the treatment of complex pediatric spine deformity. The indications, operative technique, and advantages and disadvantages of the Smith-Petersen, pedicle subtraction and vertebral column resection osteotomies will be discussed, as well as operative considerations generally applicable to spinal deformity surgery involving correction with osteotomies.

Radiofrequency application to the growth plate in the rabbit: a new potential approach to epiphysiodesis.

BACKGROUND: Radiofrequency energy is being used more and more frequently in orthopaedics, mainly in the treatment of bone tumors. We postulated that radiofrequency ablation may produce growth plate lesions similar to those observed in the bone and conducted this study to see whether radiofrequency may be used as a technique for producing epiphysiodesis. METHODS: We randomized 60 8-week-old female New Zealand white rabbits into 3 groups. Group A was destined for a total epiphysiodesis at 60 degrees C, group B was destined for a total epiphysiodesis at 90 degrees C, and group C for a lateral hemiepiphysiodesis at 90 degrees C. Radiofrequency energy was delivered in 1 minute in all 3 groups. Using fluoroscopic imaging, radiofrequency was applied percutaneously to the left proximal tibial physis whereas the right growth plate received a sham procedure. A bicortical pin was used to evaluate the longitudinal growth rate at every monthly radiologic control, beginning 8 weeks after the procedure. Comparisons between the right and left side and between groups A and B were achieved using a paired t test. A histopathologic study was conducted in parallel to the radiographic study. RESULTS: In a radiograph at the 8-week point, pin migration was 4.74 mm on the left side compared with 9.72 mm on the right (P<0.0001), in group A. In group B, pin migration on the left was 1.37 mm compared with 5.49 mm on the right (P<0.0001). In group C, mean angular deviation was 11.6 degrees on the left compared with 1.9 degrees on the right (P=0.0001). These differences were maintained until the end of growth. Pathology specimens revealed cellular anarchy, loss of columnar stratification, and height of the physis on the left side, which occurred earlier and were more pronounced in group B than in group A. In group C, these changes involved only the lateral half of the left physis whereas its medial counterpart remained normal. There was no evidence of articular cartilage damage. CONCLUSIONS: This experimental study shows that radiofrequency can efficiently and rapidly achieve epiphysiodesis. It is one of many methods that can be used for this purpose. The development of new electrodes suitable for use on human growth plates and the elaboration of specific utilization protocols may lead to its use in children. Its simplicity and precision may lead to a quick and efficient growth arrest with little pain and postoperative disability in addition to reduced costs. CLINICAL RELEVANCE: Radiofrequency has proved to be effective in producing growth arrest in rabbits with no complications. Technical improvements and adaptations may allow its use for pediatric limb inequalities or angular deformities in the near future.