Botulinum toxin type A injection in alleviating postoperative pain and improving quality of life in lower extremity limb lengthening and deformity correction: a pilot study.

BACKGROUND: The Ilizarov technique is commonly used for lengthening and deformity corrections of the lower limbs in children. Postoperative pain can be significant, affecting quality of life and functional mobility, and often requiring prolonged medication use. Several studies have investigated the antinociceptive actions of botulinum toxin type A (BtX-A), yet evidence for its use in this population is limited. The objectives were to (1) establish the feasibility of a randomized clinical trial in children undergoing limb lengthening or deformity correction and (2) provide preliminary evidence of the beneficial effects of BtX-A in this population. METHODS: Fifty-two patients with a mean age of 13.7 years (range, 5 to 21 y) were randomized to receive either BtX-A or an equivalent volume of sterile saline solution (placebo group), as a single dose during the surgical procedure. Pain, medication use, quality of life, and functional mobility outcomes were assessed in all patients. Adverse events were reported for all patients and classified as minor or major. RESULTS: Differences between groups did not reach statistical significance; however, pain at mid-distraction was found to be slightly lower in the BtX-A group, as compared with the placebo group. Patients in the BtX-A group used less parenteral pain medication in the first 4 days after the surgery, had higher quality of life scores at 3 of the 5 time points assessed, and slightly higher functional mobility scores. All adverse events were expected complications of the lengthening process. No event was considered to be a serious adverse event related to the BtX-A injection itself. There was a trend toward fewer major adverse events in the BtX-A group. CONCLUSIONS: This pilot study established the feasibility of a randomized controlled trial design for in this population. Its findings indicate that BtX-A injections appear to be safe and effective for reducing pain and improving the quality of life and functional mobility of children undergoing lengthening or deformity corrections of the lower limbs. A larger-scale study is currently underway to confirm these preliminary findings.

Transient monoparesis after blade plate removal in a Hutchinson-Gilford progeria syndrome patient: a case report.

Treatment of patients with Hutchinson-Gilford progeria syndrome (HGPS) is based on the abnormalities of accelerated aging that affect the healing processes, combined with a fragile cardiovascular status. A classic HGPS case, of Korean ancestry, previously treated for severe coxa valga with bilateral varus osteotomies using blade plate fixation is presented. Complications over the blade plate area required removal of the hardware, after which the patient showed right-sided hypertonicity--determined to be a cerebrovascular accident. Subsequently, the patient returned almost completely to her presurgical neurologic status. Perioperative planning for HGPS patients should include risks that are typically considered in the planning for geriatric patient care.

Precordial Doppler evaluation of simple bone cyst injection.

BACKGROUND: A randomized prospective trial of marrow-versus-steroids treatment of solitary bone cyst was ongoing. Protocol required contrast injection of the cyst. A subpopulation was noted to have large, rapid venous outflow of contrast material (omnipaque). Central embolization and resultant acute respiratory distress syndrome has been reported with bone marrow transplant. Particulate injection can result in bradycardia, low exhaled CO2, decreased SaO2 and voltage changes on electrocardiogram. METHODS: Precordial Doppler can measure flow and turbulence centrally after a peripheral cyst injection. Our cases were monitored with precordial Doppler as well as heart rate, ETCO2, blood pressure, electrocardiogram, and pulse oximetry. RESULTS: Five patients/7 injections were noted to have large and rapid outflow veins from solitary bone cyst. The Doppler showed increased signal in all 7 particulate injections (2 steroid injections, 5 bone marrow aspirates and cyst injections.) One marrow injection resulted in transient bradycardia and decreased blood pressure with no sequelae. One developed transient decrease in exhaled CO2. CONCLUSIONS: Rapid outflow has been reported in the past but precordial Doppler monitoring of injection into peripheral cysts is not reported. The potential for embolization with serious physiologic effects is a concern. Others have advocated injection of more particulate substances, such as calcium, sulfate, and demineralized bone matrix. This Doppler technique may be valuable for monitoring the potential harmful effects of these injections and lead to a better understanding of failure of cyst healing due to rapid outflow of material. LEVEL OF EVIDENCE: Level IV case series with poor reference standard.

Evidence-based analysis of removal of orthopaedic implants in the pediatric population.

BACKGROUND: Requested project of the Pediatric Orthopaedic Society of North America Evidenced-Based Medicine Committee. METHODS: The English literature was systematically reviewed for scientific evidence supporting or disputing the common practice of elective removal of implants in children. RESULTS: Several case series reported implant removal, but none contained a control group with retained implants. No articles reported long-term outcomes of retained implants in large numbers. Several small series describe complications associated with retained implants without evidence of causation. The existing literature was not amenable to a meta-analysis. By compiling data from the literature, it is possible to calculate a complication rate of 10% for implant removal surgery. The complication rate for removal of implants placed for slipped capital femoral epiphysis is 34%. Articles regarding postmarket implant surveillance and basic science were also reviewed. CONCLUSIONS: There is no evidence in the current literature to support or refute the practice of routine implant removal in children.

Trevor's disease: the clinical manifestations and treatment of dysplasia epiphysealis hemimelica.

Trevor's disease is a rare abnormality characterized by aberrant osteocartilaginous growth from an epiphysis. We describe six new cases from our institution. A patient with isolated tibial tuberosity involvement is described for the first time. Each patient was classified according to Azouz into localized (three), classical (two) and generalized (one) form. We recommend that parents be counseled regarding the progressive nature of this disorder owing to the chance of worsening deformity with surgical excision alone, and the need to be followed until skeletal maturity.

Cyst index: a nonpredictor of simple bone cyst fracture.

PURPOSE: Treatment is indicated for simple bone cysts (SBC) with high risk of fracture. The cyst index was described as a method to determine if a cyst is at high risk or low risk of fracture. STUDY DESIGN: The cyst index of 32 femoral and humeral SBCs was determined by 8 reviewers. The risk group cyst index was compared with whether a fracture took place. Sensitivities, specificities, and positive and negative predictive values were calculated across varying cutoff levels. Intraobserver and interobserver reliability testing for 10 cysts was made. RESULTS: Receiver operator curves demonstrate that no cutoff value gave an acceptable level of both sensitivity and specificity. The mean value for the cyst index was significantly different for different observers (P < 0.05). CONCLUSIONS: This study does not validate the cyst index to be an accurate predictor of fracture. The test has low intraobserver and interobserver reliability. CLINICAL RELEVANCE: The cyst index cannot reliably discriminate between the patients that will fracture and those that will not.

Pedicle rotation in scoliosis: a marker for occult intrathecal abnormalities.

STUDY DESIGN: The Perdriolle method was used to assess retrospectively radiographic pedicle rotation for association with occult intrathecal abnormalities in patients with scoliosis. OBJECTIVE: To determine if pedicle rotation can be predictive of underlying intrathecal abnormalities. SUMMARY OF BACKGROUND DATA: Scoliosis associated with intrathecal abnormalities is thought to produce less rotation than true idiopathic scoliosis. No supporting evidence was found in the literature. METHODS: A consecutive series of patients with a presenting diagnosis of idiopathic scoliosis were reviewed for anteroposterior radiographs and spinal magnetic resonance imaging (MRI). A blinded single examiner evaluated radiographic curve parameters. MRI reports were reviewed for the presence or absence of intrathecal abnormalities. RESULTS: A total of 78 MRIs included 15 intrathecal abnormalities and 63 normals. The abnormal MRI group had more males and apex left curves. Primary curve in the intrathecal abnormality group had a mean of 9.6 degrees of apical vertebrae rotation compared to 17.7 degrees in idiopathic curves (average 37 degrees and 40 degrees Cobb angles, respectively). Of angulation, 1 degrees correlated with 0.21 degrees and 0.34 degrees of rotation in intrathecal abnormality versus no abnormality groups, respectively. CONCLUSIONS: Curves with occult intrathecal pathology had significantly less rotation than those without. Pedicle rotation assessment is a useful adjuvant for identifying scoliosis with intrathecal abnormalities.

Chronic osteomyelitis in children: Shriners Hospital Honolulu experience.

Chronic osteomyelitis incidence and severity in 55 hospitalized Pacific Island children between 1990 and 2002 were compared with the expected incidence and reports in the literature. Of these 55 cases, 87% were from Polynesia/Micronesia. The average length of hospital stay was 104 days. Staphylococcus aureus was cultured in 64% of the cases with 43% of those being methicillin resistant S. aureus. A total of 111 bones were involved. Average antibiotic treatment was 135 days. Each case required an average of 1.3 irrigations/debridements and 45% required a sequestrectomy. Ninety-two percent had elevated erythrocyte sedimentation rate on admission. Sixty-nine percent of the cases involved metaphyseal, diaphyseal and epiphyseal segments of the bone and 29% were multifocal. Results indicate that Pacific Island children have a higher incidence and increased severity of osteomyelitis when compared with non-Pacific Island children in the literature, requiring a high suspicion for multifocal osteomyelitis, extensive bone involvement, S. aureus positive cultures and a longer period of antibiotic treatment.