James O. Sanders

Valgus deformity after reconstruction of the anterior cruciate ligament in a skeletally immature patient. A case report.

Whether acute or chronic, rupture of the anterior cruciate ligament is uncommon in children, most likely because the strength of the ligament is greater than that of bone or physes in children3,5. However, intrasubstance ruptures of the anterior cruciate ligament can occur in young patients1,2,4,6-8,11-17,19. A heightened awareness of injuries to the ligament and the fear of irreparable damage to the cartilage and menisci have created a trend toward operative treatment1,2,4,6-8,11-17,19. Intra-articular reconstruction of the anterior cruciate ligament has been successful in adults; however, drilling across an open growth plate is a cause of concern because it may lead to the formation of an osseous bridge, resulting in premature physeal closure, limb-length discrepancy, and angulation of the involved extremity10. We report on a fourteen-year-old boy who was managed with a transphyseal intra-articular reconstruction of the anterior cruciate ligament of the right knee. He subsequently had premature closure of the distal femoral physis that resulted in a valgus deformity of the lower extremity. A boy, fourteen years and four months old, sustained an injury of the right knee while playing football. The knee gave way and immediately swelled. The patient was evaluated in an emergency room, and he was referred to an orthopaedic surgeon. Physical examination revealed a large effusion in the right knee, positive Lachman and drawer signs, and a positive pivot-shift test. Knee flexion was limited to 90 degrees. Radiographic examination of the knee revealed no fractures. A rupture of the anterior cruciate ligament was diagnosed at that time. The patient began a rehabilitation program in an attempt to regain a …

Alendronate for the Treatment of Pediatric Osteogenesis Imperfecta: A Randomized Placebo-Controlled Study

CONTEXT Information on the use of oral bisphosphonate agents to treat pediatric osteogenesis imperfecta (OI) is limited. OBJECTIVE The objective of the investigation was to study the efficacy and safety of daily oral alendronate (ALN) in children with OI. DESIGN AND PARTICIPANTS We conducted a multicenter, double-blind, randomized, placebo-controlled study. One hundred thirty-nine children (aged 4-19 yr) with type I, III, or IV OI were randomized to either placebo (n = 30) or ALN (n = 109) for 2 yr. ALN doses were 5 mg/d in children less than 40 kg and 10 mg/d for those 40 kg and greater. MAIN OUTCOME MEASURES Spine areal bone mineral density (BMD) z-score, urinary N-telopeptide of collagen type I, extremity fracture incidence, vertebral area, iliac cortical width, bone pain, physical activity, and safety parameters were measured. RESULTS ALN increased spine areal BMD by 51% vs. a 12% increase with placebo (P < 0.001); the mean spine areal BMD z-score increased significantly from -4.6 to -3.3 (P < 0.001) with ALN, whereas the change in the placebo group (from -4.6 to -4.5) was insignificant. Urinary N-telopeptide of collagen type I decreased by 62% in the ALN-treated group, compared with 32% with placebo (P < 0.001). Long-bone fracture incidence, average midline vertebral height, iliac cortical width, bone pain, and physical activity were similar between groups. The incidences of clinical and laboratory adverse experiences were also similar between the treatment and placebo groups. CONCLUSIONS Oral ALN for 2 yr in pediatric patients with OI significantly decreased bone turnover and increased spine areal BMD but was not associated with improved fracture outcomes.

Maturity assessment and curve progression in girls with idiopathic scoliosis.

BACKGROUND Scoliosis progression during adolescence is closely related to patient maturity. Maturity has various indicators, including chronological age, height and weight changes, and skeletal and sexual maturation. It is not certain which of these indicators correlates most strongly with scoliosis progression. The purpose of the present study was to evaluate various maturity measurements and how they relate to scoliosis progression. METHODS Physically immature girls with idiopathic scoliosis were evaluated every six months through their growth spurt with serial spinal radiographs; hand skeletal ages; Oxford pelvic scores; Risser sign determinations; height; weight; sexual staging; and serologic studies of the levels of selected growth factors, estradiol, bone-specific alkaline phosphatase, and osteocalcin. These measurements were then correlated with the curve-acceleration phase. RESULTS The period and pattern of curve acceleration began during Risser stage 0 for all patients. Skeletal maturation scores derived with the use of the Tanner-Whitehouse-III RUS method, particularly those for the metacarpals and phalanges, were superior to all other indicators of maturity. Regression of the scores provided good estimates of maturity relative to the period of curve progression (Pearson r = 0.93). The initiation of this period occurred simultaneously with digital changes from Tanner-Whitehouse-III stage F to G. At this stage, curves also separated into rapid, moderate, and low-acceleration patterns, with specific curve types in the rapid and moderate-acceleration groups. The low-acceleration group was not confined to a specific curve type. CONCLUSIONS The curve-acceleration phase separates curves into various types of curve progression. The Tanner-Whitehouse-III RUS scores are highly correlated with timing relative to the curve-acceleration phase and provide better maturity determination and prognosis determination during adolescence than the other parameters tested. Accurate skeletal maturity determination should be used as the primary maturity measurement in girls with idiopathic scoliosis.

The American Academy of Orthopaedic Surgeons evidence-based guideline on: treatment of osteoarthritis of the knee, 2nd edition.

The AAOS Evidence-Based Guideline on Treatment of Osteoarthritis of the Knee, 2nd Edition, includes only less-invasive alternatives to knee replacement. This brief summary of the AAOS Clinical Practice Guideline contains a list of the recommendations and the rating of strength based on the quality of the supporting evidence. Discussion of how each recommendation was developed and the complete evidence report are contained in the full guideline at www.aaos.org/guidelines. ### Conservative Treatments: Recommendations 1-6 #### RECOMMENDATION 1 We recommend that patients with symptomatic osteoarthritis of the knee participate in self-management programs, strengthening, low-impact aerobic exercises, and neuromuscular education; and engage in physical activity consistent with national guidelines. Strength of Recommendation: Strong #### RECOMMENDATION 2 We suggest weight loss for patients with symptomatic osteoarthritis of the knee and a BMI ≥25. Strength of Recommendation: Moderate #### RECOMMENDATION 3A We cannot recommend using acupuncture in patients with symptomatic osteoarthritis of …

Treatment of femoral fractures in children by pediatric orthopedists: results of a 1998 survey.

This study aimed to determine treatment preference of various femoral fracture patterns in children by pediatric orthopedists and whether it is practice dependent. In September 1998, members of the Pediatric Orthopedic Society of North America were surveyed to determine their current preferences in treating each of four middle one-third femoral fracture patterns in four age groups. Forty-four percent (286/656) of those surveyed responded. For each fracture pattern, operative treatment was increasingly preferred over nonoperative as patient age increased, and the preferred treatments within the operative and nonoperative categories changed significantly as patient age increased. Fourteen specific cases of femoral head avascular necrosis were noted after rigid reamed and unreamed rodding. There is a statistically significant trend by pediatric orthopedists to treat older childrens femur fractures operatively and younger childrens nonoperatively. The consensus treatment is age dependent. The numerous cases of avascular necrosis after rigid rodding are a concern.

Posterior arthrodesis and instrumentation in the immature (Risser grade 0) spine in idiopathic scoliosis

We performed a retrospective study of the long-term results of posterior instrumentation and arthrodesis of the spine in forty-three patients who had idiopathic scoliosis and a Risser grade of 0 at the time of the operation. The average age of the patients was 12.4 years (range, 6.7 to 15.5 years) at the time of the operation. The triradiate cartilages were open in twenty-three patients and closed in twenty. At the time of the latest follow-up evaluation (average duration of follow-up, four years; range, two to eleven years), seventeen patients had a Risser grade of 5; twenty-two, 4; two, 3; one, 2; and one, 0. The crankshaft phenomenon, a progressive deformity resulting from continued growth of the anterior aspect of the spine after posterior arthrodesis, was seen in only one patient who had closed triradiate cartilages and in ten patients who had open triradiate cartilages (p = 0.004). The most common radiographic finding was a progressive rib-vertebra angle difference, which increased more than 10 degrees in seven of the eleven patients who had the crankshaft phenomenon. The mean increase in these eleven patients was 22 degrees, compared with no increase in the thirty-two other patients (p < 0.0001). Open triradiate cartilages (r = 0.58, p = 0.0001) and a younger age at the time of the operation (p < 0.0001) were predictive of the amount of progression as a result of the crankshaft phenomenon. In patients who had open triradiate cartilages, less skeletal maturity was also predictive of progression as a result of the crankshaft phenomenon (r = -0.72, p = 0.0002).

Comparing botulinum toxin A with casting for treatment of dynamic equinus in children with cerebral palsy

The purpose of this study was to compare the cumulative efficacy (three treatment sessions) of botulinum toxin A (BTX‐A) alone, casting alone, and the combination of BTX‐A and casting in the management of dynamic equinus in ambulatory children with spastic cerebral palsy (CP). Thirty‐nine children with spastic CP (mean age 5y 10mo, range 3 to 9y) were enrolled in the study. A multicenter, randomized, double blind, placebo‐controlled prospective study was used. Children were randomly assigned to one of three treatment groups: BTX‐A only (B), placebo injection plus casting (C), or BTX‐A plus casting (B+C). The dosage for the BTX‐A injections was 4U/kg per extremity. Assessments were performed at baseline, 3,6,7.5, and 12 months with a total of three treatments administered after the evaluations at baseline, 3, and 6 months. Primary outcome measures were ankle kinematics, velocity, and stride length. Secondary outcome measures were ankle spasticity, strength, range of motion, and ankle kinetics. Group B made no significant change in any variable at any time. Groups C and B+C demonstrated significant improvements in ankle kinematics, spasticity, passive range of motion, and dorsiflexor strength. Results of this 1‐year study indicate that BTX‐A alone provided no improvement in the parameters measured in this study, while casting and BTX‐A/casting were effective in the short‐ and long‐term management of dynamic equinus in children with spastic CP.

The minimum clinically important difference in Scoliosis Research Society-22 Appearance, Activity, And Pain domains after surgical correction of adolescent idiopathic scoliosis.

Study Design. Longitudinal cohort. Objective. To determine the minimum clinically important difference (MCID) of the Scoliosis Research Society (SRS)-22 Appearance, Activity, and Pain domains in patients with adolescent idiopathic scoliosis undergoing surgical correction of their spinal deformity. Summary of Background Data. The MCID, a threshold of improvement that is clinically relevant to the individual patient, is increasingly used to evaluate treatment effectiveness. MCID values for the SRS-22 domains have not been determined. Methods. Patients with adolescent idiopathic scoliosis who underwent surgical correction and had completed SRS-22 before operation and the SRS-30 and Scoliosis Appearance Questionnaire (SAQ) at 1 year after operation from a multicenter database for pediatric scoliosis were identified. The SAQ is a modification of the Walter Reed Visual Assessment Scale and is used to assess the patients perception of their spinal deformity. Paired sample t tests were used to compare preoperative and 1-year postoperative scores. Spearman correlations were used to evaluate associations between domain scores and summed responses to anchors for Appearance, Activity, and Pain. MCID values for the SRS-22 domains were determined using receiver operating characteristic curve analysis, with summed responses to anchor questions 23 to 30 of the SRS-30 and items 26 and 32 of the SAQ. Results. There were 735 women and 152 men with a mean age of 14.3 years and a mean Cobb angle of 53°. There was a statistically significant difference between paired preoperative and 1-year SRS domain scores. Analysis of variance showed a statistically significant difference between the summed responses to the anchors. The MCID was 0.20 for the Pain domain (area under the curve [AUC] = 0.723), 0.08 for Activity (AUC = 0.648), and 0.98 for Appearance (AUC = 0.629). The MCID for activity was less than the standard error of measurement. Conclusion. The MCID for the Pain domain was 0.20 and 0.98 for Appearance. Because these patients were generally in good health, a minimal though significant change in activity was observed, such that the calculated MCID was within the measurement error. As expected, the largest and most important change was in the Appearance domain. Future studies are needed to determine the MCID for the mental domain and the total SRS score and to further validate the MCID values in this study.

The Spinal Appearance Questionnaire: Results of reliability, validity, and responsiveness testing in patients with idiopathic scoliosis

Study Design. Prospective, sequential enrollment. Objective. We report the development and testing of the Spinal Appearance Questionnaire (SAQ) for reliability, validity, and responsiveness in patients with idiopathic scoliosis. Summary of Background Data. The SAQ was designed to measure patients’ and their parents’ perception of their spinal deformity’s appearance using standardized drawings and questions. This study was designed to test the instrument’s psychometric properties. Methods. The SAQ was administered as a test-retest to idiopathic scoliosis patients and parents for reliability and initial validity assessment (Group I). It was then administered to patients before surgery and 1 year after surgery (Group II) for responsiveness and further validity testing. Finally, both the SAQ and SRS instruments were administered to adolescent idiopathic patients before surgery and 1 year after surgery (Group III) for comparison of the 2 instruments. Results. Group I: The individual scale items had good to excellent reliability (Spearman’s rho, 0.57–0.99) and high internal scale consistency (Cronbach’s alpha >0.7). The mean scale scores differentiated between curves greater than 30° and lesser curves (P < 0.01). Surgery improved scores compared with those with “surgery recommended.” Group II: The domains correlated with clinical and radiographic aspects of the deformity before surgery. All of the domains showed significant difference after surgery (P < 0.0001) and large effect size for all domains except for the patient chest domain. Group III: Both the SAQ and the SRS instruments had significant improvement in all of their domains except for the SRS Activity scale. The relative efficiency of the SAQ domains to the SRS appearance domain (the most responsive SRS domain) was greater for 5 SAQ domains. Conclusion. The SAQ is reliable, responsive to curve improvement, and shows strong evidence of validity. It provides more detail than the SRS in the appearance domain, and provides explanation of spinal deformity’s concerns and improvements.

Predicting Scoliosis Progression from Skeletal Maturity: A Simplified Classification During Adolescence

BACKGROUND Both the Tanner-Whitehouse-III RUS score, which is based on the radiographic appearance of the epiphyses of the distal part of the radius, the distal part of the ulna, and small bones of the hand, and the digital skeletal age skeletal maturity scoring system, which is based on just the metacarpals and phalanges, correlate highly with the curve acceleration phase in girls with idiopathic scoliosis. However, these systems require an atlas and access to the scoring system, making their use impractical in a busy clinical setting. We sought to develop a simplified system that would correlate highly with scoliosis behavior but that would also be rapid and reliable for clinical practice. METHODS A simplified staging system involving the use of the Tanner-Whitehouse-III descriptors was developed. It was tested for intraobserver and interobserver reliability by six individuals on thirty skeletal age radiographs. The system was compared with the timing of the curve acceleration phase in a cohort of twenty-two girls with idiopathic scoliosis. RESULTS The average intraobserver unweighted kappa value was 0.88, and the average weighted kappa value was 0.96. The percentage of exact matches between readings for each rater was 89%, and 100% of the differences were within one unit. The average interobserver unweighted kappa value was 0.71, and the average weighted kappa value was 0.89. The percentage of exact matches between two reviewers was 71%, and 97% of the interobserver differences were within one stage or matched. The agreement was highest between the most experienced raters. Interobserver reliability was not improved by the use of a classification-specific atlas. The correlation of the staging system with the curve acceleration phase was 0.91. CONCLUSIONS The simplified skeletal maturity scoring system is reliable and correlates more strongly with the behavior of idiopathic scoliosis than the Risser sign or Greulich and Pyle skeletal ages do. The system has a modest learning curve but is easily used in a clinical setting and, in conjunction with curve type and magnitude, appears to be strongly prognostic of future scoliosis curve behavior.