Postoperative shoulder-spine spica cast for young children

Immobilization of the young child after spinal surgery is an important component of the surgical plan. This study reviews the authors' experience with postoperative immobilization in a shoulder-body spica cast and provides a detailed description of the technique. Twenty-two children with an average age of 31 months at the time of surgery were placed in the shoulder-spine spica cast after hemivertebra excision. There was no loss of correction in any of the 22 children during the period of postoperative immobilization. All patients were able to be ambulatory in the shoulder-spine spica cast while immobilized. Patients experienced the minor complications of prolonged cast wear, with one cast becoming loose and three casts causing skin rash. One patient required removal of the cast 6 weeks after surgery for unrelated nausea and vomiting. The shoulder-spine spica cast has been used at the authors' institution with great success and allows children to be ambulatory after hemivertebra resection.

Discoid lateral meniscus: prevalence of peripheral rim instability

The purpose of this study was to determine the prevalence of peripheral rim instability in discoid lateral meniscus. A consecutive series of 112 patients (128 knees) (mean age 10.0 years [range 1 month to 22 years]) who underwent arthroscopic evaluation and treatment of a discoid lateral meniscus between 1993 and 2001 was reviewed. Of those discoid menisci classified intraoperatively (n = 87), 62.1% (n = 54) were complete discoid lateral menisci and 37.9% (n = 33) were incomplete discoid lateral menisci. An associated meniscal tear was present in 69.5% (n = 89) of all knees studied. Overall, 28.1% (n = 36) of discoid lateral menisci had peripheral rim instability: 47.2% (n = 17) were unstable at the anterior-third peripheral attachment, 11.1% (n = 4) at the middle-third peripheral attachment, and 38.9% (n = 14) at the posterior-third peripheral attachment. Thirty-one of the 36 unstable discoid menisci underwent repair of the peripheral meniscal rim attachment. One patient underwent a complete, open meniscectomy. Peripheral rim instability was significantly more common in complete discoid lateral menisci (38.9% vs. 18.2%; P = 0.043) and in younger patients (8.2 vs. 10.7 years; P = 0.002). The frequency of peripheral instability mandates a thorough assessment of meniscal stability at all peripheral attachments during the arthroscopic evaluation and treatment of discoid lateral meniscus, particularly in complete variants and in younger children.

Delay in diagnosis of slipped capital femoral epiphysis

OBJECTIVE

Delay in diagnosis of slipped capital femoral epiphysis (SCFE) has important implications in terms of slip severity and long-term hip outcome. The purpose of this study was to identify predictors of delay in the diagnosis of SCFE.

METHODS

A review of 196 patients with SCFE was performed. The primary outcome measure was delay from onset of symptoms to diagnosis. Covariates included age, gender, side, weight, pain location, insurance status, family income, slip severity, and slip stability. Delay in diagnosis was not normal in distribution; therefore, nonparametric univariate and multivariate analyses were performed.

RESULTS

The median delay in diagnosis was 8.0 weeks. There was a significant relationship between delay in diagnosis and slip severity (<30 degrees : 10.0 weeks; 30 degrees to 50 degrees : 14.4 weeks; >50 degrees : 20.6 weeks). There were no significant associations between delay in diagnosis and covariates of age, gender, side, and weight. There were significant associations between longer delay in diagnosis and covariates of knee/distal-thigh pain versus hip/proximal-thigh pain (6.0 vs 15.0 weeks), Medicaid coverage versus private insurance (12.0 vs 7.5 weeks), lower family income, and stable slips versus unstable slips (8.0 vs 6.5 weeks). Controlling for the other covariates, knee/distal-thigh pain, Medicaid insurance, and stable slips remained significant independent multivariate predictors of delay in diagnosis.

CONCLUSIONS

Patients who present with primarily knee or distal-thigh pain, patients with Medicaid coverage, and patients with stable slips have longer delays in diagnosis of SCFE. Focused intervention programs to reduce the delay in diagnosis of SCFE should emphasize patients with knee/thigh pain and patients with Medicaid coverage.

Tibial eminence fractures in children: prevalence of meniscal entrapment

BACKGROUND

Meniscal entrapment under a displaced tibial eminence fragment may be a rationale for arthroscopic or open reduction in type 2 and 3 tibial eminence fractures.

PURPOSE

To determine the prevalence of meniscal entrapment in children with type 2 and 3 tibial eminence fractures.

STUDY DESIGN

Case series.

METHODS

Records of a consecutive series of 80 skeletally immature patients (mean age, 11.6 years; range, 5 to 16) who underwent arthroscopic (71), open (5), or combined arthroscopic and open (4) reduction and internal fixation of type 3 tibial eminence fractures (57) or type 2 fractures that did not reduce in extension (23) from 1993 to 2001 were reviewed.

RESULTS

Entrapment of the anterior horn of the medial meniscus (36), intermeniscal ligament (6), or anterior horn of the lateral meniscus (1) was seen in 26% (6 of 23) of type 2 fractures and 65% (37 of 57) of type 3 fractures. An associated meniscal tear was seen in 3.8% of patients (3 of 80).

CONCLUSIONS

Meniscal entrapment is common in patients with type 2 and 3 tibial eminence fractures. Arthroscopic or open reduction should be considered for type 3 fractures and for type 2 fractures that do not reduce in extension to remove the incarcerated meniscus, allowing for anatomic reduction.

Prospective reevaluation of the association between thrombotic diathesis and legg-perthes disease

BACKGROUND

Legg-Perthes disease is associated with ischemia of the capital femoral epiphysis in children. Thrombophilia has been implicated as a potential cause of the condition, and screening of patients with Legg-Perthes disease for thrombophilia has been recommended. We analyzed the value of screening for inherited thrombophilia in patients with Legg-Perthes disease by examining the association between Legg-Perthes disease and abnormalities in the thrombotic pathway.

METHODS

A random series of consecutive patients with Legg-Perthes disease were prospectively enrolled in this study. Assays for the detection of factor-V Leiden mutation and the plasma concentrations of protein C, protein S, antithrombin III, and lipoprotein (a) were performed on plasma samples from children with Legg-Perthes disease, and the results were compared with those for pooled plasma from normal controls. Plasma concentrations below the 95% midrange of the control values were classified as protein deficiencies. The estimated population frequency of each coagulation abnormality was compared with the proportion of the study group with the corresponding abnormality.

RESULTS

The proportion of abnormalities observed in the study group did not differ from the estimated population frequency for protein C, protein S, antithrombin III, or factor-V Leiden mutation. A lipoprotein (a) level of >30 mg/dL (>1.07 micro mol/L) was found in 16% of the study group.

CONCLUSIONS

Our data do not suggest that thrombotic diatheses due to deficiency of protein C, protein S, or antithrombin III or due to factor-V Leiden mutation are major causes of Legg-Perthes disease. The elevated levels of lipoprotein (a) in children with Legg-Perthes disease suggest that they may be at risk for atherosclerosis as adults.

Surgical treatment of congenital kyphosis

STUDY DESIGN

In this study, 26 cases of congenital kyphosis and kyphoscoliosis treated surgically were retrospectively reviewed.

OBJECTIVE

To assess the clinical outcomes and surgical indications for posterior only versus anteroposterior surgery in the child.

SUMMARY OF BACKGROUND DATA

Congenital kyphosis usually is progressive without surgical intervention. Current recommended treatment includes posterior arthrodesis for deformities of less than 50 degrees to 60 degrees, and anterior release or decompression, anterior fusion, and posterior instrumented arthrodesis for large deformities and cord compression.

METHODS

Cases involving myelodysplasia, spinal dysgenesis, and skeletal dysplasia were excluded from the study. Kyphoscoliosis was included if the kyphotic deformity was greater than the scoliotic deformity. Patients were grouped by age and surgical technique. The patients in group P1 underwent posterior arthrodesis at an age younger than 3 years, and those in group P2 underwent the procedure at an age older than 3 years. The patients in group AP1 underwent anterior and posterior procedures at an age younger than 3 years, and those in group AP2 underwent the procedures at an age older than 3 years. The preoperative deformity, complications, and postoperative deformity correction were analyzed. There were nine Type 1 (failure of formation), nine Type 2 (failure of segmentation), and eight Type 3 (mixed) deformities. Four patients had associated spinal dysraphism. Three patients with Type 1 deformities had clinical or radiographic evidence of cord compression.

RESULTS

In Group P1, five patients at an average age of 16 months underwent posterior arthrodesis alone for an average kyphotic deformity of 49 degrees. The immediate postoperative correction improved over a period of 6 years and 9 months by an additional 10 degrees, resulting in a final deformity of 26 degrees. Pseudarthrosis developed in two patients, requiring fusion mass augmentation or anterior arthrodesis. Neither patient was instrumented. In Group P2, five patients at an average age of 13 years and 7 months underwent posterior arthrodesis with instrumentation for kyphotic deformity of 59 degrees. Approximately 30 degrees of intraoperative correction was achieved safely using compression instrumentation and positioning. No further correction occurred with growth. The final residual kyphotic deformity was 29 degrees after a follow-up period of 4 years and 5 months. In Group AP1, seven patients underwent anterior release or vertebra resection for deformity correction and posterior arthrodesis for an average kyphotic deformity of 48 degrees at the age of 16 months. There were no iatrogenic neurologic injuries. The final residual kyphotic deformity was 22 degrees after a follow-up period of 6 years and 3 months. In Group AP2, nine patients underwent anterior release or decompression with posterior arthrodesis for kyphotic deformity of 77 degrees at the age of 11 years and 6 months. The deformity was corrected to 37 degrees, with no significant loss over a follow-up period of 5 years and 2 months. There were two postoperative neurologic complications.

CONCLUSIONS

After reviewing their experience, the authors made the following observations: 1) The pseudarthrosis rate was low even without routine augmentation of fusion mass if instrumentation was used; 2) gradual correction of kyphosis may occur with growth in patients younger than 3 years with Types 2 and 3 deformities after posterior fusion, but appears to be unpredictable; 3) the risk of neurologic injury with anterior and posterior fusion for kyphotic deformity was associated with greater age, more severe deformity, and preexisting spinal cord compromise.

Osteonecrosis of the femoral head associated with slipped capital femoral epiphysis

We performed a retrospective analysis of 212 patients (299 hips) with slipped capital femoral epiphysis (SCFE) over a 9-year period to assess the incidence of osteonecrosis of the femoral head. Risk factors for the occurrence of osteonecrosis and the influence of treatment on the development of osteonecrosis were determined. Osteonecrosis occurred in 4 hips with unstable SCFE (4/27) and did not occur in hips with stable SCFE (0/272). The proportion of hips in which osteonecrosis developed was significantly higher among the unstable hips (4/27 vs. 0/272, p < 0.0001). Among those with an unstable hip, younger age at presentation was a predictor of a poorer outcome. Magnitude of the slip, magnitude of reduction, and chronicity of the slip were not predictive of a poorer outcome in the unstable group. In situ fixation of the minimally or moderately displaced "unstable" SCFE demonstrated a favorable outcome. We have identified the hip at risk as an unstable SCFE. The classification of hips as unstable if the epiphysis is displaced from the metaphysis or if the patient is unable to walk is most useful in predicting a hip at risk for osteonecrosis.

Wagner multiple K-wire osteosynthesis to correct coxa vara in the young child: experience with a versatile 'tailor-made' high angle blade plate equivalent

In 1978, Wagner described a technique using multiple Kirschner wires (K-wires) to stabilize an intertrochanteric osteotomy performed for the correction of coxa vara in small children. Multiple K-wires are used to create a custom high-angle blade plate for valgus osteotomy. The authors have evaluated a retrospective series of 17 Wagner intertrochanteric osteotomies that were performed in 10 children with coxa vara between the ages of 1 year and 8 years. The neck-shaft angle was corrected from 93.5 degrees to 129.5 degrees at long-term follow-up, and the Hilgenreiner epiphyseal angle was corrected from 71 degrees to 37.6 degrees at long-term follow-up. Revision surgery was performed on five hips with inadequate initial surgical correction. Complications included a single broken K-wire, a femur fracture after hardware removal, and one hip developed avascular necrosis postoperatively.

Extrapleural thoracoscopic anterior spinal fusion: a modified video-assisted thoracoscopic surgery approach to the pediatric spine

Video assisted thoracoscopic surgery (VATS) has recently been developed as an alternative to thoracotomy for anterior spinal surgery. We report a case in which an extrapleural dissection was combined with VATS to further improve this approach.

Comparison of single- and dual-rod techniques for posterior spinal instrumentation in the treatment of adolescent idiopathic scoliosis

STUDY DESIGN

Two groups of patients undergoing posterior spinal instrumentation and arthrodesis for treatment of adolescent idiopathic scoliosis were reviewed retrospectively.

OBJECTIVE

To compare intraoperative concerns (operative time and blood loss), complications, and outcome in patients undergoing single or double posterior rod instrumentation for treatment of adolescent idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

The current treatment of idiopathic scoliosis includes posterior spinal instrumentation and arthrodesis. The standard configuration is a rectangular construct of dual rods connected by cross-links. Use of a single rod with multiple fixation points has been proposed as an alternative method to decrease operative time and blood loss, and to avoid late deep infections.

METHODS

In this study, 21 patients underwent posterior instrumentation using a standard dual-rod construct, and 25 patients underwent posterior instrumentation using a solitary rod with multiple fixation points. Patients were assessed after a minimum 2-year follow-up period.

RESULTS

No significant differences were found in blood loss, operative time, or overall frequency of long-term complications. Although not statistically significant, the trend was toward implant prominence in the double-rod group and implant failure in the single-rod group. Implant failure occurred only in instrumentations extending into the lumbar spine. There was no statistical difference in curve progression.

CONCLUSIONS

Single-rod instrumentation and dual-rod constructs offered similar curve correction, blood loss, and operative time. However, single-rod instrumentation may be more prone to implant failure when extended into the lumbar spine.

Occipitocervical fusions in children. Retrospective analysis and technical considerations

This report presents a retrospective analysis of the authors' experience with occipitocervical fusions in children and adolescents during the last 2 decades. A description of an operative technique devised by the senior author (JEH), and a comparison of the results using this and other methods of fusion are given. Twenty-three patients underwent occipitocervical fusion. Fifteen of the patients were operated on using the authors' technique. To achieve stable fixation of the distal cervical vertebra a threaded Kirschner wire was passed transversely through the spinous process; occipital fixation was achieved by the traditional method of wiring corticocancellous bone graft to the skull through burr holes. The occipital wires then were wrapped around the Kirschner wire and the graft was cradled in the resulting nest. Halo immobilization was used in 10 patients for an average of 12.5 weeks (range, 6-24 weeks). Twenty-two patients achieved successful fusion at an average followup of 5.8 years (range, 1-14.33 years). Several complications, including transient quadriplegia in one patient, pseudarthrosis in two (one of which persists), hardware fixation failure in one, unintended distal extension of the fusion, pneumonia, wound infection, halo pin infection, skin breakdown under the halo vest, hydrocephalus, cerebrospinal fluid leak, and traumatic fusion fracture were encountered. Results using the technique described herein are comparable with or better than the results reported in the previous literature, and the results of the patients in this series in whom the technique was not used.

Lumbosacral fusion in children and adolescents using the modified sacral bar technique

Between 1986 and 1995 10 patients who were 9 to 18 years of age underwent posterior spinal fusion and instrumentation to the pelvis for correction of spinal deformity using the modified sacral bar technique at the authors' institution. Etiologies of the spinal deformity included congenital scoliosis, cerebral palsy, myelomeningocele, neurofibromatosis, and postlaminectomy kyphosis. Indications for pelvic instrumentation were progressive scoliosis of the lower lumbar spine, pelvic obliquity greater than 15 degrees, and dysraphic posterior elements. Five of the patients had prior spinal surgery. Five patients had a prior or a planned pelvic osteotomy. Nine of the patients achieved lumbosacral fusion without an additional procedure. Major complications included loss of pelvic fixation in two patients, and a dural leak and a wound infection in another patient with myelomeningocele. Mean scoliotic curve correction was from 71.9 degrees to 34.5 degrees at final followup. Lumbar lordosis essentially was unchanged. Pelvic obliquity was corrected from a mean of 20.5 degrees preoperatively to a mean of 7.6 degrees at final followup. The modified sacral bar technique was selected for fusion to the sacrum because of planned or prior pelvic osteotomies, prior posterior spinal fusion and instrumentation, sacral dysraphism, or local anatomic anomalies. The modified sacral bar technique proved to be an effective technique in these patients.

Excision of the radial head in patients younger than 18 years

We evaluated the results of an excision of the radial head in 25 patients (27 operated-on elbows) younger than 18 years with stiff painful radiocapitellar joints. The mean age was 14.2 years (range, 4.6-17.8 years) with average follow-up of 7.8 years. Analysis of the results with a postoperative elbow score revealed excellent or good results in 19 of the 27 elbows of patients. Skeletal maturity of the patient did not alter the results based on the rating scale. Revision surgery to remove appositional bone growth was needed in six of the 12 posttraumatic cases and one of 15 developmental elbows. Cubitus valgus, wrist pain, and ulnar neuropathy were not clinical problems at follow-up examination. Excision of the radial head was beneficial for 70% of patients younger than 18 years with stiff, painful radiocapitellar joints. Results were not improved in patients who had reached skeletal maturity.

MRI demonstration of occult purely chondral fractures of the tibia: a potential mimic of meniscal tears

We report the case of a 12-year-old boy with bilateral, purely chondral fractures of the tibia. The patient had Crohn's disease treated with systemic corticosteroids. MR images of the knee were initially interpreted to show a bucket-handle tear of the lateral meniscus. However, arthroscopic evaluation revealed purely chondral fractures of the tibial plateau without meniscal damage. Re-evaluation of the MR study identified the chondral fracture of the lateral tibial articular cartilage detected arthroscopically. This purely chondral fracture of the tibial plateau represented a rare finding in the symptomatic knee that mimicked a meniscal tear by history, physical exam, and MR imaging.

Segmental spinal dysgenesis: early neurologic deterioration and treatment

Segmental spinal dysgenesis is a rare congenital condition of the lumbar or thoracolumbar spine that can be associated with significant progressive or permanent neurologic defects, including paraplegia. In the past, both bracing and surgery have been recommended. Of the seven children we have seen with this problem, three have lost motor function between presentation and the time of surgery. Our experience suggests that to prevent catastrophic neurologic deterioration, surgery is indicated once the diagnosis is made.

Patellar sleeve fracture: demonstration with MR imaging

PURPOSE

To demonstrate the magnetic resonance (MR) imaging characteristics of patellar sleeve fracture, a cartilaginous avulsion from the lower pole of the patella occurring during forceful contraction of the quadriceps muscle against a partially flexed knee.

MATERIALS AND METHODS

The authors evaluated radiographs and MR images from three children with suspected sleeve fractures.

RESULTS

Radiographs showed small bone fragments avulsed from the lower patella in two children and no bone abnormality in one. MR imaging demonstrated separation of most of the cartilaginous lower patella in all children, definite intraarticular extension in one, and possible intraarticular extension in another.

CONCLUSION

MR imaging can help determine the need for surgery by depicting the extent of cartilaginous injury and displacement of fracture fragments.

Burst fractures of the fifth lumbar vertebra

Eleven patients with burst fractures of the fifth lumbar vertebra were reviewed. The results of nonoperative treatment were compared with that of immediate surgery and stabilization with pedicle screw fixation. Five patients were treated nonoperatively and six patients underwent pedicle screw instrumentation and spinal fusion. Five patients had neurologic injury associated with their L5 burst fracture. Nonoperative treatment yielded excellent results in young patients with minimal canal compromise. Neurologic deficits responded more predictably to surgical decompression than to conservative treatment and internal fixation with pedicle screws restores spinal stability and allows early mobilization.

Hip disease in adults with Down syndrome

The life expectancy of patients with Down syndrome has increased significantly in recent years. Hip abnormalities occur in children with this syndrome but little is known about their natural history in later life. In 65 adults with Down syndrome we found hip abnormalities in 28%, and this was statistically correlated with walking ability. A subgroup of 18 patients was followed by serial examination; this showed that hip instability occurred in adulthood and became worse with time. In some patients, hip instability started after skeletal maturity.

Latent psoas abscess after anterior spinal fusion

This case is presented to emphasize that late infection should be considered in all postoperative patients as a cause of pain. A psoas abscess may remain dormant for many years after an anterior spinal procedure. It should be considered in the differential diagnosis of back pain and lumbar radiculopathy after anterior spinal fusion. The lumbar nerve plexus lies within the psoas muscle, and referred pain patterns may occur in the lumbar nerve distribution. In this case, dysesthesias occurred in the distribution of the genitofemoral nerve. The diagnosis and treatment of a psoas abscess has been greatly aided by use of CT and ultrasound. Either of these modalities may be used for directed percutaneous drainage of the abscess. The presence of metal fixation devices necessitates removal of the hardware in order to ensure eradication of the infection.

Physeal arrest about the knee associated with non-physeal fractures in the lower extremity

The cases of seven patients who had a physeal arrest about the knee in association with nonphyseal fractures in the lower extremity were reviewed. The patients were between ten and twelve and one-half years old at the time of injury, and the physeal arrest involved either the posterolateral part of the distal femoral physis or the anterior part of the proximal tibial physis. There was no evidence of iatrogenic trauma to the physis. Recognition of the physeal injury was delayed for an average of one year and ten months until a gross angular deformity appeared. Adolescents who have fractures of the lower extremities that do not appear to involve a physeal plate should nevertheless be evaluated and followed for possible physeal injury about the knee that can be detected only after additional growth has taken place.

Unicameral bone cyst in the scapula of an adolescent

Unicameral bone cysts of the scapula have been reported mainly in adult patients. The atypical location of the unicameral bone cyst in a 12-year-old girl presented a diagnostic dilemma. Curettage proved to be an effective method for both diagnosis and treatment of this benign lesion.