Kit M. Song

The Effect of Limb-Length Discrepancy on Gait*

We evaluated the gait of thirty-five neurologically normal children who had a limb-length discrepancy of the lower extremities that ranged from 0.8 to 15.8 per cent of the length of the long extremity (0.6 to 11.1 centimeters). The twenty-two boys and thirteen girls had an average age of thirteen years (range, eight to seventeen years). No patient had a substantial angular or rotational deformity of the lower extremities. We found no correlation between the actual discrepancy or the per cent discrepancy and any of the dependent kinematic or kinetic variables, including pelvic obliquity. Discrepancies of less than 3 per cent of the length of the long extremity were not associated with compensatory strategies. When a discrepancy was 5.5 per cent or more, more mechanical work was performed by the long extremity and there was a greater vertical displacement of the center of body mass. Clinically, this degree of discrepancy was manifested by the use of toe-walking as a compensatory strategy. Children who had less of a discrepancy were able to use a combination of compensatory strategies to normalize the mechanical work performed by the lower extremities.

Plate fixation of femoral shaft fractures in multiply injured children

A study was done of twelve patients (seven boys and five girls) who, because of multiple injuries or a head injury, had been managed with compression plating of a unilateral or bilateral femoral-shaft fracture at a level-I trauma center from 1986 through 1990. The patients had a total of fifteen fractures. The average age at the time of the injuries was eight years (range, five years to nine years and eleven months). There were nine closed fractures and six open fractures; three of the open fractures were Grade I; two, Grade II; and one, Grade IIIA, according to the criteria of Gustilo et al. Each patient had an average of three associated injuries. All fifteen fractures had healed clinically and radiographically at an average of eight weeks (range, six to twelve weeks) after the operation. There were no infections. Anatomical alignment was obtained in fourteen limbs. One fracture healed with 13 degrees of anterior angulation. The compression plates were removed at an average of ten months (range, three to twenty-four months) after the index operation. At the latest follow-up evaluation (average, twenty-six months; range, eleven to fifty-seven months), no patient had restriction of activities due to the femoral fracture. Scanograms revealed overgrowth of the injured femur averaging 0.9 centimeter (range, 0.3 to 1.4 centimeters) in seven patients who had an uninjured contralateral femur. We believe that plate fixation of the femur is a good treatment option for children who have a femoral shaft fracture and a major head injury or multiple injuries, or both.

Determining treatment of flatfeet in children

Infants are born with flexible flatfeet, and the normal arch develops in the first decade of life. Flexible flatfeet rarely cause disability, and asymptomatic children should not be burdened with orthotics or corrective shoes. Flexible flatfeet with tight heelcords may become symptomatic and can be addressed with a stretching program. Surgical intervention for flexible flatfeet is reserved for patients who have persistent localized symptoms despite conservative care. Rigid or pathologic flatfeet have multiple etiologies and many will require treatment to alleviate symptoms or improve function.

Peak height velocity as a maturity indicator for males with idiopathic scoliosis.

We retrospectively studied 43 adolescent boys treated with orthoses for idiopathic scoliosis to assess the usefulness of the timing of peak height velocity for predicting growth remaining and the likelihood of curve progression when compared with Risser sign, closure of the triradiate cartilage, and chronologic age. We compared the peak height velocity data in boys to our previous work for girls with adolescent idiopathic scoliosis. We found the median height velocity plots showed a similar high peak and sharp decline as is found in girls. All 13 patients with a curve magnitude > 30 degrees at the time of peak height velocity had progression of their scoliosis to > 45 degrees despite bracing. Four of 29 patients (14%) with curves < or = 30 degrees at peak height velocity progressed to 45 degrees. These values generate a sensitivity of 76%, specificity of 100% and accuracy of 91% in predicting progression to 45 degrees. Similar values have been found in female patients. The use of peak height velocity to predict the length of time for remaining growth was superior to Risser sign and chronologic age for boys with idiopathic scoliosis. Closure of the triradiate cartilage approximated the timing of peak height velocity in boys.

Acute hematogenous osteomyelitis in children.

&NA; Acute hematogenous osteomyelitis in children is a relatively uncommon but potentially serious disease. Improvements in radiologic imaging, most notably magnetic resonance imaging, and a heightened awareness of this condition have led to earlier detection and resultant marked decreases in morbidity and mortality. Staphylococcus aureus, which has the ability to bind to cartilage, produce a protective glycocalyx, and stimulate the release of endotoxins, accounts for 90% of infections in all age groups. Infections with Haemophilus influenzae have become rare in immunized children. A careful history and a thorough physical examination remain important. Positive cultures are obtained in only 50% to 80% of cases; the yield is improved by the use of blood cultures and evolving molecular techniques. Improvements in antibiotic treatment have lessened the role of surgery in managing these infections. Sequential intravenous and high‐dose oral antibiotic therapy is now an accepted modality. Evaluation of response to treatment by monitoring C‐reactive protein levels has decreased the average duration of therapy to 3 to 4 weeks with few relapses. The emergence of antibiotic resistance, particularly resistance to methicillin and vancomycin by S aureus organisms, is of increasing concern. Long‐term sequelae and morbidity are primarily due to delays in diagnosis and inadequate treatment.

Open fractures of the tibia in children.

We treated 38 patients from 4 to 15 years old and with open growth plates for open fractures of the tibia. The average follow-up was 33 months (range, 9-122). All patients had repeated operative debridement, parenteral antibiotics, and immobilization by cast or fixation. Outcomes were analyzed with respect to age at the time of injury, grade of injury, and type of immobilization. The time to union was prolonged and averaged 21 weeks (range, 6-82). No patients younger than 11 years required bone grafting for union. The deep infection and nonunion rate was 8%, with all of these occurring in patients older than 11 years. Clinically significant leg-length discrepancy or functional limitation was encountered only in patients with an ipsilateral femur fracture or with deep infection requiring osseous debridement. Our data suggest that open tibia fractures in children older than 11 years have nonunion and infection rates that parallel those of adult patients, but that younger children have a more benign course. With aggressive wound care and adequate stabilization, few complications or sequelae should occur in open tibial shaft fractures in younger patients.

Health-Related Quality of Life in Children With Thoracic Insufficiency Syndrome

Background: The traditional techniques to treat thoracic insufficiency syndrome (TIS) are not able to stabilize or improve chest wall size or pulmonary function while allowing spine growth. To this end, vertical expandable prosthetic titanium rib (VEPTR) was specifically designed to treat TIS by allowing growth of the thoracic cavity and control/correction of spine deformity. The purpose of this study was to determine quality of life (QOL) of children with TIS and its impact on their parents before and after implantation of the VEPTR and also compare these results to those of healthy children. Methods: As part of the original multicenter evaluation of the VEPTR, a Child Health Questionnaire (CHQ) was collected preoperatively on 45 patients who were subsequently treated with expansion thoracoplasty using the VEPTR. The average age was 8.2 ± 2.6 years, and the parent form of the CHQ was filled out by the primary caretaker. Patients were divided into 3 diagnostic categories: rib fusion (n = 15), hypoplastic thorax syndromes (n = 17), and progressive spinal deformity (n = 13). Results: There were significant differences between the study patients and healthy children in physical domains. Compared with parents of healthy children, parents of children with TIS experienced more limitations on their time and emotional lives due to their childrens health problems. There were no significant differences in CHQ before and after the surgery except for a significant decrease in the self-esteem among a subgroup of patients with hypoplastic thorax syndromes. There were no significant differences in postoperative QOL between patients who had VEPTR-related complications and patients who did not have the complications. Conclusions: The children with TIS had lower physical scores and higher caregiver burden scores than healthy children. However, the scores in psychosocial domains were similar to those in healthy children. Our study demonstrated that QOL of children and burden of care in their parents remained the same after VEPTR instrumentation. Childrens QOL seemed to be not affected by whether they had VEPTR-related complications or not.

Ankle-foot orthoses for preambulatory children with spastic diplegia

We evaluated the effect of articulating and solid ankle-foot orthoses (AFOs) on the transitional movement of sit-to-stand for 15 children aged 2-5 years with spastic diplegia and dynamic equinus. Kinematic and kinetic data were collected for each child. The time to reach stable standing was determined by using a force plate. Seven children were comparable to age-matched normals while barefoot and were slowed by the use of AFOs. Eight patients were more than 1 standard deviation slower than normals while barefoot. All were significantly (p < 0.003) improved by the use of articulating AFOs. The clinical difference between these groups was the presence of equinus during stable standing while barefoot for patients aided by AFOs, whereas the second group remained plantigrade barefoot. We conclude that children with spastic diplegia with uncontrolled dynamic equinus benefit from the use of articulating AFOs for the movement of sit-to-stand.

Use of the StepWatch activity monitor for characterization of normal activity levels of children.

Abstract: Clinical and research measures for walking activity measure capacity and performance. Existing tools such as 3-dimensional gait analysis and validated gross motor instruments examine capacity but do not measure performance. We defined normal activity levels for 20 children ages 5-7 and 9-11 years using the StepWatch Activity Monitor (SAM). Average daily step counts varied widely by age and sex (mean 7604 ± 2485), but the percent time spent at high, medium, and low levels of activity was very consistent regardless of age or sex of the child.

Retrospective review of multilevel spinal fusion combined with spinal cord transection for treatment of kyphoscoliosis in pediatric myelomeningocele patients

Study Design. Retrospective review of cases at a single institution from 1998 to 2005. Objective. The authors present their surgical experience, complications, and learned insight in 9 myelomeningocele children with kyphoscoliosis treated with combined spinal cord transection and spinal fusion. Summary of Background Data. Complication rates in spinal fusion for treatment of kyphoscoliosis in myelomeningocele patients are high. Spinal cord transection in combination with fusion can be an appropriate strategy in selected patients, but changes in cerebrospinal fluid (CSF) dynamics that may accompany ligation of the distal CSF circulation are not well characterized. Methods. Demographic, clinical, and radiologic data were examined in 9 children with myelomeningocele level at or above T12 and no residual urologic function treated at our institution with spinal cord detethering and transection, and multilevel spinal fusion. Seven children underwent kyphectomy with posterior fusion only for severe gibbus deformities, while 2 had anterior and posterior fusions for severe kyphoscoliosis. Results. Follow-up of patients ranged from 4 to 92 months (mean, 37.8 months). Eight children (89%) experienced postoperative complications involving wound infection or skin breakdown. One child presented with a CSF leak. Two children (22%) required revision of their ventriculoperitoneal shunts. The average angle of kyphosis before surgery was 122.3 (range, 48°–180°), and the average postoperative angle was 38.2 (range, 4°–113°), with average correction being 81.9° (range, 29°–124). Average correction of scoliosis, if present, was 59.5° (range, 35°–92°). Conclusion. Combined spinal cord transection and spinal fusion allowed an average correction of kyphosis by 81.9°. The complication rate was 89%, with wound concerns being the most significant. Additionally, 22% of patients required shunt revision within 6 weeks of surgery. We attribute this to alteration of CSF dynamics resulting from loss of CSF absorption and flow-buffering capacity below the level of the spinal cord transection.