Journal of Children's Orthopaedics

The purpose of this review is to clarify the role of botulinum toxin serotype A (BTX-A) in the treatment of children with cerebral palsy (CP), with a special focus on the lower limb.

The treatment of spasticity is central in the clinical management of children with CP. BTX-A blocks the release of acetylcholine at the motor end plate, causing a temporary muscular denervation and, in an indirect way, a reduced spasticity. Children with increased tone develop secondary problems over time, such as muscle contractures and bony deformities, which impair their function and which need orthopaedic surgery. However in these younger children, delaying surgery is crucial because the results of early surgical interventions are less predictable and have a higher risk of failure and relapse. As BTX-A treatment reduces tone in a selective way, it allows a better motor control and muscle balance across joints, resulting in an improved range of motion and potential to strengthen antagonist muscles, when started at a young age. The effects are even more obvious when the correct BTX-A application is combined with other conservative therapies, such as physiotherapy, orthotic management and casts. There is now clear evidence that the consequences of persistent increased muscle tone can be limited by applying an integrated multi-level BTX-A treatment approach. Nevertheless, important challenges such as patient selection, defining appropriate individual goals, timing, dosing and dilution, accuracy of injection technique and how to measure outcomes will be questioned. Therefore, “reflection is more important than injection” remains an actual statement.

The safety and feasibility of posterior screw fixation of the cervical spine in children has not been well documented in the orthopedic literature. We performed a retrospective review of our experience using posterior cervical screw fixation in children.

The medical records and radiologic records of 36 children at a mean age of 10 years (range 3–16 years) were reviewed. Diagnoses included: ten instability, 11 deformity, seven trauma, five tumor, and three congenital abnormalities. Operative reports and postoperative computed tomography (CT) scans were reviewed to determine the technical feasibility of screw placement, any screw-related complications, and to assess for correct screw position. In this series, there were no neurologic complications, no vertebral artery injuries, and no screw-related complications.

Thirty patients (141 screws) had screws evaluated postoperatively and were shown to be completely contained on postoperative CT scans. There were no revisions due to screw failure or dislodgement. There were no vascular or neurologic complications.

Posterior screw fixation in the pediatric population may be done safely and greatly enhances fixation strength for a variety of disorders requiring instrumentation and fusion.

Spinal deformity in neurofibromatosis, when associated with dystrophic change, is a major treatment challenge. Early anterior and posterior spinal fusion is the accepted treatment plan for severe progressive kyphoscoliosis. Resection of the vertebral body as an additional step in correction and fusion has not been previously investigated. Information on the functional status of the neurofibromatous curves is also scarce in the literature. The purpose of this study is to report an experience with corpectomy and circumferential fusion in dystrophic spines of neurofibromatosis.

Among 16 patients with dystrophic spinal curves, nine cases who had undergone anterior and posterior fusion with 6.7 years (range 2–11.9) average follow-up were evaluated clinically, radiographically, and functionally (SRS-22).

Nine cases with a mean age of 11.8 years (range 7.8–17) at surgery consisted of seven kyphoscoliotic patients, who had received one or two levels of cord decompression and corpectomy, and two cases of scoliosis with hypokyphosis. Surgery improved the mean preoperative scoliosis of 87 (range 60–110) and local kyphosis of 69.3° (range 50–100) to 49 (range 15–85) and 49° (range 35–70), respectively. Loss of correction of 5° in the scoliosis and 13° in the kyphosis angles was observed in the final follow-up. One surgery resulted in an immediate postoperative mortality. Fusion was achieved in all cases. The average SRS-22 score of 4.1 (range 3–4.6) was obtained.

Simultaneous anterior and posterior fusion with corpectomy for dystrophic neurofibromatous spinal deformities is associated with a high fusion rate, good correction, and also good functional outcome.

Dynamic SpineCor was designed to overcome the disadvantages of rigid orthoses—bulkiness, physical constraint and warming—and to improve the acceptance and compliance as limiting factors of brace treatment. Those theoretical benefits have not been proved by compliance studies yet.

SpineCor braces of 12 adolescent scoliotic girls were equipped with flexible temperature loggers, which were sandwiched between gel foam and the brace's pelvic base. Patients and parents were blinded for the observation period of 14 days and gave post-hoc consent. The logger yielded 672 time-stamped values at 30-min intervals. Pilot testing revealed values beyond the 30°C threshold as indicative for brace wear.

The average overall compliance (% wearing hours/prescribed 23 h) was 54% ± 22.3 (range, 11.8–95.8%). The youngest patients (aged 10–12 years) were significantly more compliant than the others (P < 0.05). Most patients had a scattered wearing pattern: one was a day-wearer, one a night-wearer and only the two high adherers showed a consistent daily pattern. There was no significant difference between weekdays, weekdays and weekends, nor between day and night wear.

The current study showed that the compliance of patients in a dynamic SpineCor is as limited as in a conventional brace. This is in line with earlier data on patients’ SpineCor and rigid brace acceptance evaluated by a questionnaire and on temperature logging in rigid braces.

Brace treatment is the gold standard for patients with mild adolescent idiopathic scoliosis (Cobb angle 20°–40°). However, negative psychosocial impacts, physical constraints and incompliance cause many patients and parents to seek for so-called holistic and apparently less harmful approaches within the field of complementary and alternative medicine (CAM). Osteopathy—manual interventions on the viscera and locomotor system—is widely used for scoliosis. There is, however, a complete lack of evidence regarding its efficacy. We, therefore, tested the hypothesis that osteopathy alters trunk morphology, a prerequisite to unload the concave side of the scoliosis, and that it halts curve progression.

This was a prospective, controlled trial of 20 post-pubertal young women (20°–40° idiopathic scoliosis) randomly allocated to an observation (group 0) or osteopathic treatment (group 1). The latter comprised three sessions (5 weeks). Trunk morphology (clinical examination, video rasterstereography) and spine flexibility (MediMouse^®) were assessed at a pre- and post-intervention with a 3-month interval (blinded examiner). We chose scoliometer measurement (rib hump, lumbar prominence) as the main outcome parameter.

Two patients in the treatment group refused further treatment and the final examination, as they felt no benefit after two osteopathic treatments. Regression analysis for repeat measurements (independent statistician) revealed no therapeutic effect on rib hump, lumbar prominence, plumb line, sagittal profile and global spinal flexibility.

We found no evidence to support osteopathy in the treatment of mild adolescent idiopathic scoliosis. Therefore, we caution against abandoning the conventional standard of care for mild idiopathic scoliosis. As for other CAM therapies, the use of osteopathy as a treatment option for scoliosis still needs to be clearly defined.

Neglected congenital muscular torticollis (CMT) is a common presentation in developing countries like India, with the primary concern of the patients being cosmesis. Little has been published regarding the management of such patients. The aim of our study was to evaluate the results of bipolar release in this age group.

Over a period of five years, 14 patients older than ten years (range 10–19 years) with neglected CMT were operated on with bipolar release of sternocleidomastoid muscle and z-plasty lengthening of the sternal end. Postoperative protocol included head halter traction for three weeks followed by intensive physical therapy. Results were evaluated using a modified version of the system of Lee et al.

At an average follow-up of around three years (range 1–5 years), excellent results were noted in three patients, good in seven, fair in two, and poor in two. Postoperative improvements in range of motion, head tilt, chin deviation and cosmesis were noted in all patients, and these improvements were statistically significant. No surgery-related complications or recurrences requiring surgery occurred in any of the patients.

This study concluded that patients with CMT presenting after ten years of age definitely benefit from surgery, and that bipolar release is an adequate and complication-free method for such patients.

Long arm cast is the method of immobilization after closed reduction of the fracture of the distal third of the forearm, although short arm cast has been used to immobilize the forearm by some orthopedic surgeons. We conducted this study to evaluate the rate of displacement, union time, complication, and cost of treatment between the above-elbow and below-elbow plaster cast groups.

We designed a prospective randomized controlled trial to compare above- and below-elbow casts for patients of distal forearm fracture aged 4–12 years. One hundred and one patients were presented to our institution during the period from 1st June 2007 to 31st May 2008. Twelve patients were excluded from the study. Eighty-nine patients were randomized into two groups. Four patients were lost to follow up. Hence, 85 patients, 42 in the above-elbow group and 43 in the below-elbow group, were analyzed. Informed consent was obtained prior to participation in the trial. The parameters to be studied were defined before treatment and noted in the pilot-tested pro forma and follow up was done.

Among the 85 patients analyzed, randomization was successful. Pain and swelling on the next day and at one week following cast application was significantly higher (P = 0.000) in the above-elbow group. Three cases in the above-elbow group needed slitting of the plaster cast. Remanipulation was needed more often in the above-elbow group (9.5%). Although the cast index was not statistically significant (P = 0.054) between the groups, those who needed remanipulation had a larger cast index (0.80). The total cost of the treatment and the number of school days lost was significantly higher (P = 0.000) in the above-elbow group.

Below-elbow cast treatment was comparable in terms of redisplacement, union time, and movement of the wrist to the above-elbow treatment. The complications rate and total cost was higher in the above-elbow plaster group, which could be a cost benefit if a below-elbow cast is used.

In situ fixation for mild to moderate slipped capital femoral epiphysis (SCFE) remains an acceptable treatment methodology in most centers. Satisfactory fixation results have been reported with the procedure using either the fracture table or radiolucent table, both of which allow the hip to be imaged during the procedure. The position of the pin within the center of the femoral head is important to secure adequate fixation of the capital femoral epiphysis and prevent further slippage with minimal risk for articular penetration and avascular necrosis (AVN) or chondrolysis.

We describe a pre-operative planning technique to determine the pin-entry point for percutaneous pinning of SCFE on a radiolucent operating table. A retrospective review of patients who underwent in situ screw fixation with the usage of a cannulated screw on a radiolucent table or fracture table over a 6-year period was conducted.

The pin-entry point with this technique was reliable in 92% of procedures and comparable in both accuracy and complications to in situ screw fixation on a fracture table. In situ screw fixation on a regular radiolucent table was straightforward and required significantly less surgical time than on the fracture table (P = 0.01). It was also more efficient during a bilateral procedure, as it required only a single preparation and draping of the patient.

This pre-operative planning technique for deciding the starting point on the proximal femur is helpful in executing an accurate in situ screw fixation of hips with SCFE.

The purpose of the study was to assess the validity of surgical interference with elastic nailing in treating pediatric femur fractures in comparison with the traditional treatment method—hip spica casting.

Sixteen consecutive femur fractures in children 5–15 years of age were recruited prospectively over 13 months. An equal number of age-matched children treated by spica casting were recruited retrospectively. Subtrochanteric, supracondylar femur fractures were excluded.

Fracture union occurred earlier in the surgical group (6 weeks) than in the spica group (8 weeks) (P = 0.001). Spica casting caused higher coronal plane angulation (P = 0.001), higher rotational malalignment (P < 0.001), higher limb length discrepancy at 1-year follow-up (P < 0.001), longer duration of immobilization (P < 0.001), later full weight-bearing (P < 0.001), and greater absence from school (P < 0.001). Flynn outcome scores were better with titanium elastic nailing than with hip spica casting.

Titanium elastic nailing led to better outcomes compared to hip spica casting in terms of earlier union, lower rates of malunion, shorter rehabilitation milestones, and better functional outcome scores.

The outcomes movement has emphasized the importance of the patient in evaluating treatment outcome. However, concern has been raised about the ability of children, particularly those with multisystem disease, to evaluate their disability.

To determine whether children with spina bifida and muscular dystrophy and their parents agree when asked about the relative difficulty of daily activities and the severity of symptoms experienced by the child.

First, a list of symptoms and activity restrictions was generated from the literature, clinicians, and interviews with families with spina bifida and muscular dystrophy. Second, another group of parents and children with spina bifida (with hip dislocation or scoliosis) and with muscular dystrophy (with scoliosis), including those before and after surgery, independently rated the severity and importance of their objective and subjective complaints.

The correlation between parents and their children was high for both objective (median Spearman's = 0.70; standard deviation [SD] = ±0.17; range = −0.05–1.00) and subjective (median Spearman's = 0.76; SD = ±0.14; range = 0.13–1.00) complaints, with an overall excellent level of agreement (Kappa = 0.75; 95% confidence interval [CI]: 0.73, 0.76).

Children with spina bifida and muscular dystrophy are capable of understanding and assessing their disability.

The Ilizarov hip reconstruction is a well accepted but complication-prone operative salvage procedure in chronically dislocated hips, not least due to the long-term application of external fixation. Although the advantages of fully implantable devices are well known in limb lengthening and are described consistently, until now, external fixation has been used exclusively to perform the Ilizarov hip reconstruction procedure. We present a new technique of Ilizarov hip reconstruction with purely internal implants.

A 14-year-old girl with a history of spina bifida presented with a 4-cm-short right leg, a Trendelenburg gait and a complex neurological disease expression. Because of refusal of external fixation by the patient and significantly lower complication rates, an Ilizarov hip reconstruction without external fixation was performed. A locking compression plate was applied to fix the proximal femoral valgus-extension osteotomy and a motorised intramedullary distraction nail was used for the distal, lengthening–varisation osteotomy.

A healing index of 33 days/cm and full weight bearing after 6 months were noted. At the 1 year follow-up, the patient showed an improvement of the Trendelenburg gait, as well as successful leg equalisation. Satisfaction to a high degree was additionally noted by factors such as reduced pain, the ability to wear workaday clothes and cosmetically appealing scars. No complications were recorded.

The exclusive use of internal implants for Ilizarov hip reconstruction is a feasible and patient-friendly alternative to traditional methods. Their use, however, may be restricted by geometric preconditions.

The evaluation of a construction that allows the exchange of circular and unilateral external fixators on the same fixation pins to the bone in outpatient circumstances during bone lengthening and alignment procedures.

Nine children were treated with this concept. After bone lengthening and alignment, the circular fixators were exchanged for unilateral fixators in the outpatient clinic to hold the position of the bony parts during the consolidation phase.

The decrease of time needed to use the circular fixator during the treatment was considered to be an improvement in comfort.

The concept of using both a circular and a unilateral external fixator in a construction that allows the exchange of the external fixators in outpatient circumstances combines the advantages of both systems, and creates more options in the different stages of bone deformity correction. Patient comfort is increased by the decrease of time needed to use the circular fixator.