Abstract: Serial casting is successful in avoiding extensive posteromedial release (PMR) in only 11% to 58% of patients with idiopathic congenital clubfoot. Extensive open surgery is commonly associated with long-term stiffness and weakness. Ponseti claims to avoid PMR in 89% of cases by using his specific technique of manipulation, casting, and limited surgery. The authors report their first 27 patients undergoing the Ponseti technique (34 feet) with a group of 27 matched control patients (34 feet). All patients underwent serial casting, begun within the first 3 months of life. The parameter studied was the need to perform PMR within the first year of life. In the Ponseti group, only 1 (3%) of 34 feet required PMR. In 31 (91%) of 34 feet, percutaneous Achilles tenotomy was performed at age 2 to 3 months. The average duration of casting was 2 months. In the control group, 32 (94%) of 34 feet required PMR within the first year of life, despite a longer casting period. Based on the authors' initial success with the Ponseti method, they no longer believe that PMR is required for most cases of idiopathic clubfoot. Foot abduction splints are crucial to avoid recurrence. Longer follow-up will determine whether the authors can continue to match Ponseti's reported outcomes.

Abstract: Supracondylar humerus fractures are a common childhood occurrence. Displaced fractures are typically treated with closed reduction and percutaneous pinning. Controversy continues over the appropriateness of various pinning techniques. The most common include crossed or lateral pins. A biomechanical comparison of crossed pins, "parallel" lateral pins, and "divergent" lateral pins was performed using a pediatric synthetic bone model. Mechanical testing of each pin configuration was performed in extension, varus, valgus, internal rotation, and external rotation. The divergent configuration provided statistically greater stability than parallel pins under varus and valgus loading. Divergent pins had similar stability compared with crossed pins in extension, varus, and valgus testing. In axial rotation testing, crossed pins were more stable. If the surgeon feels confident in the ability of lateral pins to provide satisfactory fracture stability, divergent lateral pins provide greater stability than parallel lateral pins while avoiding ulnar nerve injury (associated with crossed pins).

Abstract: The purpose of this study was to evaluate the long-term effects of the femoral derotation osteotomy (FDO) in the ambulatory patient with cerebral palsy (CP). The effectiveness of the FDOs were evaluated using three-dimensional gait analysis just before surgery (P0), 1 year after surgery (P1), and 5 years after surgery (P2). A total of 20 patients (27 sides) with CP were evaluated. Related physical examination and motion measures showed significant improvements at P1 that were maintained at P2. Mean maximum internal hip rotation at P0 of 77 degrees +/- 9 degrees decreased to 53 degrees +/- 8 degrees at P1 and was maintained at 58 degrees +/- 11 degrees at P2. Mean maximum external hip rotation at P0 of 21 degrees +/- 11 degrees increased to 35 degrees +/- 15 degrees at P1 and was maintained at 32 degrees +/- 13 degrees at P2. Mean femoral anteversion at P0 of 63 degrees +/- 9 degrees was reduced to 26 degrees +/- 15 degrees and was maintained at 31 degrees +/- 13 degrees at P2. During gait, mean hip rotation in stance at P0 of 20 degrees +/- 8 degrees was decreased to 2 degrees +/- 10 degrees at P1 and was maintained at 4 degrees +/- 5 degrees at P2. There were associated significant foot progression changes from an internal progression mean of 5 degrees +/- 17 degrees at P0 to -11 degrees +/- 17 degrees at P1 that were maintained at -12 degrees +/- 5 degrees at P2. The findings suggest that the FDO is a viable and lasting treatment option for the correction of anteversion and associated internal hip rotation during gait in children with CP.

Abstract: A retrospective review of 158 type 3 supracondylar humerus fractures was undertaken to determine whether any correlation exists between an increased time from injury to surgery and four unfavorable results: a longer operative time, an increase in hospital stay, an increase in the need to open the fracture, or an increase in unsatisfactory outcomes. The average age of the patients was 5.0 years. Five children had nerve injury on initial examination, and no arm was poorly perfused. The average time from injury to evaluation in the emergency department was 9.8 hours and the average time from the emergency department to surgery was 11.5 hours. The average total time from injury to surgical treatment was 21.3 hours. The patients were in the hospital between 1 to 6 days. The average operative time was 53 minutes. Thirty patients had unsatisfactory results, defined as a pin infection, more than 15 degrees loss of motion in any plane, loss of normal carrying angle, neuropraxia, or retained hardware. There was no correlation between an increase in time to surgical intervention and longer operative time or need to open the fracture site, nor was there an indication that the delay to surgical treatment resulted in a longer hospital stay or an increase in unsatisfactory results.

Abstract: Gait improvement surgery was performed on 25 ambulatory children with the diplegic type of cerebral palsy. Multiple soft tissue and bony procedures were performed (mean 8.2 procedures) according to criteria defined on the basis of physical examination and gait analysis. Relevant physical examination findings and kinematic and kinetic data in the sagittal plane were evaluated before surgery and at least 3 years after surgery. Physical examination showed a reduction in the ankle plantar-flexor power and in the range of hip flexion and ankle plantarflexion after surgery. Analysis of gait data showed significant improvements in the sagittal plane kinematics and the power generation at the hip and the ankle. At the knee joint there was maintenance of power of the flexor and extensor group of muscles on physical examination, with significant improvements in the kinematics after surgery. The authors conclude that well-selected surgery improves function of the spastic muscle. The importance of assessing clinical, kinematic, and kinetic data together for proper evaluation of gait is stressed.

Abstract: Radiologic measures of migration percentage (MP) and acetabular index (AI) taken from plain radiographs of the pelvis are the most commonly used tools for determining hip displacement and management options in children with cerebral palsy and spastic hip disease This study determined interrater and intrarater reliability of MP and AI on pelvic radiographs chosen to represent a wide range of age (11 months to 8 years 5 months), MP (0%-56%), and AI (9 degrees -33 degrees ) The study demonstrated that an experienced rater would be expected to measure MP on a single radiograph to within +/-58% of the true value and a change in MP between two radiographs taken at different times to within +/-83% of the true value Similarly for AI, the measurement error for a typical rater would be within +/-26 degrees on a single reading and +/-37 degrees if recording change between two occasions The authors believe that the results indicating true change are acceptable in clinical practice, provided treatment decisions are based on a series of radiographs taken at 6-month intervals, methods and training are standardized, and consistent raters are used

Abstract: Kinematic and kinetic data were obtained from 36 normal children who walked at five different clinically relevant speeds, which were mostly slower than normal speed. Speed groups were normalized for body height. Speed significantly affected most of the stride parameters, joint angles, joint moments, and the ground reaction force in all three planes of motion. The effects of speed were not always the same over the whole range of speeds studied. The clinical relevance of these findings is that when comparing pathologic gait characteristics with those of normal children, these should be derived from the same walking speed. This may help to differentiate between effects caused by speed and underlying pathology.

Abstract: Fifteen elbows (3 congenital, 12 traumatic) in 14 children (mean age 9.5 years) with chronic radial head dislocation for at least 3 months (range 3-180 months) underwent radial head-sparing reconstructive surgery and were followed up at an average of 43.5 months postoperatively (range 12-105 months). At follow-up, the patients were evaluated radiographically and clinically using range-of-motion measurements and an elbow performance score based on four parameters (deformity, pain, motion, function). Ten cases had excellent results, two had good results, two had fair results, and one case had poor results. Scores at follow-up were evaluated with seven preoperative factors. Among those, the degree of preoperative carrying angle asymmetry associated with flexion contracture correlated significantly with the elbow scores. The most common complication was loss of pronation. The authors advocate radial head reduction and reconstruction in chronic radial head dislocations in children after obtaining informed consent from patient and parents.

Abstract: Femoral fractures resulting from birth injuries are rare. The authors undertook a study to assess their incidence and outcome. Seven patients from a total of 55,296 live births suffered 8 femoral fractures (incidence 0.13 per 1,000 live births). Twin pregnancies, breech presentations, prematurity, and disuse osteoporosis were associated with the occurrence of a fracture. The typical injury pattern was a spiral fracture of the proximal half of the femur, which was held in an extended position. A variety of treatment modalities were used, including gallows traction, spica cast, and Pavlik harness. All patients in this study, regardless of treatment, had a satisfactory clinical outcome, with no evidence of limb length discrepancy or angular deformity on follow-up.

Abstract: Although benign bone neoplasms are relatively uncommon in children and adolescents, their discovery can produce great angst among providers and parents. In most but not all instances, imaging studies can indicate the likely benign nature of the tumor and allay fears. The clinical presentation, imaging, and contemporary management of five common types of tumor or tumor-like conditions of bone commonly seen in children and adolescents are reviewed: nonossifying fibroma, unicameral bone cyst, aneurysmal bone cyst, fibrous dysplasia, and exostosis.

Abstract: The pathologic changes in 15 elbows of 14 children (2 bilateral congenital, 12 unilateral posttraumatic, mean age 9.5 years) with radial head dislocation unreduced for at least 3 months (range 3-180 months) and their open treatment were reviewed. Common dysplastic changes observed in both congenital and posttraumatic groups included large deformed radial heads, slender radial necks, and ulnar bowing. Changes were bilateral and symmetrical in the congenital group. In traumatic dislocations, patients with more severe deformities had longer delays from time of injury to time of reduction. Persistent pain, limitation of motion, and deformity were unacceptable symptoms to both patients and their parents, prompting surgical intervention. To produce a smooth rotational arc for the radius and maintain it in stable reduction, restoration of the congruency of the capitello-radioulnar joint and correction of the various dysplastic changes were mandatory during open reduction.

Abstract: Objective documentation of dynamic varus and valgus deformities of the hindfoot is still a clinical dilemma. In a review of spastic foot deformities, clinical, radiographic, and foot pressure data were collected in 108 children with cerebral palsy. According to the clinical assessment, five categories of foot deformities were defined: severe varus, varus, neutral, valgus, and severe valgus. A coronal index of the pedobarograph was determined by comparing the pressure/time integral under the medial column to that under the lateral column of the foot. Coronal index is highly correlated with clinical assessment and offers better information than radiographic measurements in differentiating the clinical categories. The authors recommend the pedobarograph as the primary evaluation tool to measure the severity of deformity for patients with varus and valgus foot dysfunction. The severity of the deformity can be monitored with a single measurement, which has the best correlation with the clinical assessment. The clinical assessment is still the primary tool to determine general patterns, but it is difficult to apply an objective measurement. Radiographic study is most useful for the preoperative assessment when surgery is indicated.

Abstract: The efficacy of psoas surgery for the treatment of hip flexor dysfunction in cerebral palsy has long been a subject of debate. A retrospective, repeated-measures analysis was performed to examine the effect of psoas surgery based on gait and clinical and functional measures. The results of this study show that intramuscular psoas lengthening over the pelvic brim is a safe and effective way to improve the hip function of independently ambulatory children with cerebral palsy while maintaining hip flexor power. The data also support the use of the multivariate hip flexor index as an overall measure of hip function.

Abstract: Thirty-four consecutive patients with displaced supracondylar humerus fractures were treated with reduction and percutaneous pinning. The precise location of the ulnar nerve to the medial pin was determined by intraoperative nerve stimulation. In 22 of the 34 patients, the authors attempted to predict the location of the ulnar nerve by palpation and placing a mark on the skin. They also recorded the ability to feel the anatomic landmarks for pin fixation, including the medial epicondyle and ulnar nerve. The average distance from the medial pin to the predicted location was 9.3 mm, whereas the actual distance measured 7.6 mm, for a significant difference of 1.7 mm. Statistically, the authors could not accurately predict the location of the ulnar nerve prior to blind percutaneous crossed K-wire fixation of supracondylar humerus fractures. However, clinically they were fairly close in their prediction and documented safe insertion and distance from the nerve. Intraoperative nerve stimulation may assist in localizing the nerve prior to placement of the medial pin. Stimulation of the pin itself following insertion is another technique to ensure safe pin placement and decrease the risk of injury.

Abstract: Clinical assessment of femoral anteversion (FA) in children with cerebral palsy (CP) is frequently determined by the trochanteric prominence angle test (TPAT). Limited three-dimensional volumetric imaging by axial tomography of the femur was performed before surgery for 35 hips in 20 children with CP. The TPAT was performed before the imaging study for 31 hips in 18 children. The TPAT angle was within 10 degrees of the FA as determined from the computed tomography scans (Murphy technique) for 17 femurs (55%). The most prominent portion of the greater trochanter was located anterior to the femoral neck axis (mean 27 degrees, range 0 degrees-52 degrees) on the three-dimensional images in 34 of 35 hips. A simulated TPAT, measured from the imaging studies, consistently underestimated the FA as determined by the Murphy technique (mean 10 degrees, range 0 degrees-18 degrees). Accurate clinical assessment of FA by the TPAT in children with CP presumes that the prominence of the greater trochanter lies perpendicular to the axis of the femoral neck. Three-dimensional imaging showed the prominence to be anterior, to a variable degree, to the femoral neck axis, which in addition to clinical factors such as obesity compromises the accuracy of this clinical maneuver.

Abstract: The purpose of this study was to review longitudinally the clinical features, method of treatment, and recurrence rates of 40 cases of aneurysmal bone cyst in children treated at one institution. Twenty-nine patients with histologic confirmation of the diagnosis and minimum follow-up of 2 years were included. Thirteen patients were less than 10 years of age, and 16 were in the second decade of life. The most frequent location of the lesion was the tibia (seven cases). Patients were treated with curettage, curettage and bone grafting, or resection. The overall recurrence rate was 27.5%. Five lesions recurred once, and three recurred twice. The average time before recurrence was 18.7 months. Complications occurred in six cases, three of them with physeal arrest. The lesion occurred more commonly in females in the second decade of life and was not associated with a pre-existing tumor. The recurrence rate dropped after the use of a high-speed bur.

Abstract: Osteoporosis has been recognized in nonambulatory boys with Duchenne's muscular dystrophy. In this study, the hips and spines of 10 ambulatory children with Duchenne's muscular dystrophy were examined. The study group comprised 10 boys with a mean age of 8 years (range 6-11). All patients were scanned by dual-energy x-ray absorptiometry (DEXA) using a DPX LUNAR Corporation scanner (Madison, WI, U.S.A.). Manual muscle testing of the major muscle groups of the upper and lower extremities was performed on all patients. Pubertal development status was determined using the Tanner scale. Although they were still ambulatory, boys diagnosed with Duchenne's muscular dystrophy experienced weakness in the lower extremity musculature, as well as proximal femur and lumbar spine osteoporosis or osteopenia.

Abstract: Sixteen consecutive cases of unstable slipped capital femoral epiphysis treated with urgent reduction and pinning during a 7-year period are presented. In 2 of the 16 patients, avascular necrosis of the femoral head developed. Ten of the 16 patients were treated within 24 hours after the onset of acute symptoms by reduction, arthrotomy, and cannulated screw fixation of the hip using two screws. In none of these patients did avascular necrosis of the femoral head develop. Two patients required hardware removal for persistent pain, and one required a revision pinning after a nondisplaced femoral neck fracture. Chondrolysis did not develop in any patient, and no hip progressed after fixation. At last follow-up (mean 27 months after surgery), two patients walked with a moderate limp. Three reported persistent mild pain in the affected hip. Early reduction of unstable hips with arthrotomy and pinning using two cannulated screws to minimize the risk of avascular necrosis is recommended.

Abstract: Chronic recurrent multifocal osteomyelitis (CRMO) is a childhood, bone disorder causing bone pain, swelling, malaise, and fever. A study of 22 children with CRMO, treated at the Royal Children's Hospital, Melbourne, was reported previously. This present study reviews 8 of these, together with 4 additional patients. The patients were interviewed and examined by the first two authors, who had not been involved in their management. The patients were 9 females and 3 males, with a mean age of 22 years (16-31 years). Age at onset of symptoms was between 4 and 11 years and duration 2.5-20 years. Only 1 patient experienced difficulties in school and in maintaining a job. However, only 2 patients experienced complete resolution of symptoms. The number of affected sites was 2-9, most commonly ankle, knee, and clavicle. Seven patients have noticeable deformity. Five had leg-length inequality of at least 1.5 cm, one of whom, with shortening of 5.5 cm, has undergone a lengthening procedure. CRMO is not a benign condition and if not followed to maturity can have disabling sequelae.

Abstract: There is no one large study on pediatric shoulder instability. The purposes of this study were to characterize patients with shoulder subluxation or dislocation, the treatments provided, outcomes, and the predictors of good outcomes. Seventy shoulders in 66 patients were retrospectively reviewed, all with follow-up >2 years. The authors defined characteristics, treatment, outcomes, and associations between patient and treatment variables and outcome measures. Instability was associated with boys, adolescents, and trauma. Forty-two shoulders received physical therapy, and 28 required surgery. At follow-up, 54 of 70 described their shoulders as "better" or "much better," and 90% were performing at the same or higher levels of sports and work. Surgically treated patients were less likely to have recurrent instability or to report limitations. The current study is a large study of pediatric shoulder instability. Surgery improved stability, but overall, stability improved over time, with few patients having limitations at moderate- to long-term follow-up.

Abstract: The purpose of this study was to evaluate the problems associated with hip dislocation in adults with cerebral palsy. Twenty-nine subjects with dislocated hips and no prior hip surgery were identified. There were a total of 38 dislocated hips. Age range was 21 to 52 years (average 34). Seven dislocated hips (18%) were definitely painful and four hips (11%) produced only mild or intermittent pain. Twenty-seven hips (71%) were not painful. The seven painful hips underwent proximal femoral resection, resulting in excellent range of motion and no pain. In conclusion, for established nonpainful hip dislocation in the severely involved spastic quadriplegic patient, aggressive surgical treatment should be undertaken only after careful consideration of the natural history. If a dislocated hip becomes painful in adulthood or develops an adduction contracture interfering with perineal care, a proximal femoral resection can be performed with reliably good success.

Abstract: The purpose of this study was to determine the role of magnetic resonance imaging (MRI) in the evaluation of children with suspected cervical spine injury (CSI). The authors studied 237 consecutive children, 74 of whom were evaluated by MRI based on a trauma protocol of the authors' institution. The criteria for MRI were: (1) an obtunded or nonverbal child suspected of having CSI, (2) equivocal plain films, (3) neurologic symptoms without radiographic findings, or (4) an inability to clear the cervical spine within 3 days, based on testing. The average age of the evaluated children was 8 years. MRI confirmed the plain radiography diagnosis in 66% of children and altered the diagnosis in 34%. MRI is valuable in the evaluation of potential CSI, especially in obtunded children or children with equivocal plain radiographs.

Abstract: Thirty-three cases of acute hematogenous bone or joint infection in children were randomly treated with short-term (7 days for joint infection, 10 days for bone infection) or long-term (14 days and 21 days, respectively) intravenous antibiotics after surgical drainage. The treatment outcome was measured through a detailed scoring system that included the ability to eradicate infection, the functional status of the limb, and the radiographic appearance of the bone and joint. The results were similar in both groups, showing the added benefit of a shorter hospital stay for children with blood-borne musculoskeletal infection. The use of this scoring system in choosing the route of antibiotic administration is recommended.

Abstract: Physeal fractures and the formation of physeal bars can pose significant problems in skeletal development for the injured, growing child. Regrettably, little experimental attention has been directed toward this clinical disturbance. The current study documents early histologic changes (days 2-6) and subsequent alterations (day 21) following a physeal fracture in the rat proximal tibia model. The fracture plane was usually contained within the physis but could involve many regions of the physis. In some instances, the fracture plane extended to the physeal epiphyseal border. When the fracture was contained within the physis, healing was uneventful. However, when the fracture extended through the physis to the epiphyseal physeal border, there was greater physeal disorganization and formation of vertical septa leading to physeal bars. Physeal bars appeared to form at sites of vertical fibrotic septa into which marrow cells, osteoclasts, and osteoblasts had migrated. Bar formation mediated by primary osteogenesis (rather than by endochondral bone formation) followed. This study examines the changes in the histologic features of the rat proximal tibial physis, epiphysis, and metaphysis after a physeal fracture and identifies key factors associated with physeal bar formation.

Abstract: Magnetic resonance imaging (MRI) was performed on 73 hips in 59 children aged 3 to 16 months after surgical reduction of developmental dislocation of the hip. Twenty-seven hips in 22 children had repeat MRI 6 weeks after reduction, and 20 hips in 16 patients had further MRI at least 1 year later. Only 38% of hips appeared concentrically reduced on the initial MRI scan, but this increased to 90% by 1 year later, without intervention. The authors measured coronal plane acetabular index and transverse plane anterior, posterior, and axial acetabular indices, as well as acetabular version and anteversion. Persistent difference could be shown in the coronal plane acetabular index between the dysplastic and normal sides for the cartilaginous anlage and the bony model of the acetabulum in scans performed at least 1 year after reduction. However, 40% of cartilaginous coronal plane acetabular indices fell within the "normal" range at 1 year. No other parameters could be shown to be persistently different.

Abstract: The authors reviewed 21 patients who underwent triple pelvic osteotomy for severe Legg-Calve-Perthes disease to evaluate their clinical, functional, and radiologic results. The mean age at presentation was 7 years 7 months (range 5-11 years). Seventeen hips were Herring group C and 5 were group B. All of them had "at risk" radiologic signs. A new technique of interlocking iliac osteotomy was used to provide extra stability, allow early weight bearing, and prevent inadvertent retroversion. The average period of follow-up was 30 months (range 1-5 years). The average gain in Harris score was 34.3 (range 4-55). The average gain in acetabular head index was 18% and that in center-edge angle was 22 degrees, more than reported for any other single surgical procedure for containment of the subluxed femoral head. Average gains in abduction, internal rotation, and flexion were 17 degrees, 12 degrees, and 28 degrees respectively. Longer follow-up is required to see the results at maturity, but the early results are promising.

Abstract: External fixation of pediatric femoral shaft fractures has the advantages of minimal dissection and early weight bearing. However, it is associated with slow healing and potential for refracture. Some surgeons have proposed that axial dynamization may improve the speed and strength of callus formation. to test this hypothesis, we performed a randomized controlled trial using 53 femur fractures in 52 patients between 1995 and 1999. Patients were randomized to receive dynamic or static fixation. Average time until early callus formation was 23.2 days for dynamic fixation and 24.9 days for static fixation (P = 0.627). Average time until complete radiographic healing was 70.1 days for dynamic fixation and 63.1 days for static fixation (P = 0.370). Similarly, the differences in time to fixator removal and to full weight bearing did not reach statistical significance. The conclusion was that axial dynamization of external fixation for pediatric femur fractures has no significant effect on time to healing or frequency of complications.

Abstract: The authors report the results of the management of five consecutive children with McCune-Albright syndrome. These children were treated with a combination of drug treatment (bisphosphonates) and surgical treatment with elongating intramedullary rods (Sheffield) for management of femoral and tibial lesions. This treatment was successful in all patients, as judged by improvement in their quality of life and in clinical parameters, such as decreased bone pain and fracture rate, and improved walking ability. Two of the five children had been wheelchair-bound before treatment. All children are now community ambulators. In 5 of 10 hips, there was a significant decrease in the neck-shaft angle over time compared with the immediate postoperative angle.

Abstract: In a retrospective review of 74 tibial osteotomies performed for Blount disease, the patients were divided into three groups based on age and treatment. Group A (26 osteotomies), 4 years old or younger, and group B (34 osteotomies), older than 4 years, were treated the same with osteotomy and crossed pins. Group C (14 osteotomies), older than 4 years, was treated with osteotomy and external fixator. At 6 years of follow-up, the recurrence of varus deformity was 46%, 94%, and 72% in groups A, B, and C, respectively. There was no correlation between recurrence of varus deformity and preoperative deformity angle or degree of surgical correction. Fixation with crossed pins or external fixator was not a factor. Surgery at 4 years old or younger and correction of the postoperative deformity angle in valgus may obviate recurrence of varus deformity in Blount disease at long-term follow-up.