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STUDY DESIGN: Case controlled study. OBJECTIVE: To explore the relative effects of body mass index (BMI) and the presence or absence of adolescent idiopathic scoliosis (AIS) on bone mineral density (BMD) as evidenced by Z-scores in adolescents. SUMMARY OF BACKGROUND DATA: Prior studies have identified adolescents with idiopathic scoliosis as having 'osteoporosis' or 'osteopenia,' when only a small percentage of subjects in these studies actually had bone density that was clinically abnormal. The terms osteoporosis and osteopenia as used in adults cannot be applied to adolescents and children, as fracture risk has not been well correlated to Z-scores. As we had noted that our scoliosis patients of normal and heavy weight had normal Z-scores, this study was undertaken to explore the relationship of bone mineral density to body mass index in adolescents with and without scoliosis. METHODS: Dual energy x-ray absorptiometry (DXA) scans of 49 adolescents with adolescent idiopathic scoliosis were compared to 40 normal control adolescents. Z-scores were compared to reduce variability when comparing subjects of varying age and genders. Student t test or simple linear regression was used to explore relationships between Z-scores and clinical and demographic variables. RESULTS: In both groups of subjects, Z-score was most strongly correlated with BMI (P < 0.001). The presence of scoliosis had the effect of lowering the Z-score as if the individual had 'lost' 3.4 BMI units. CONCLUSION: Z-scores in subjects with and without scoliosis were most strongly correlated to BMI: thin patients had lower bone density, heavy patients had higher. The presence of scoliosis had an effect similar to subtracting 3.4 'BMI units,' lowering the Z-score from what might otherwise be predicted. The 'scoliosis effect' may be noticeable in thin individuals, pushing them to the 'low for age' level, whereas in heavier individuals, the effect is negligible. No subjects in either group met the ISCD definition for osteoporosis. [ABSTRACT FROM AUTHOR]

Background: Talipes equinovarus is the most common congenital lower limb abnormality. Decreased calf size has been found to have negative impacts on patients' subjective appraisals of long-term outcomes. This study compares calf circumference ratios in 2 groups of patients with unilateral clubfoot, those treated according to the Ponseti method and those treated with extensive surgery, to determine whether the current standard of care achieves better anatomic outcomes., Methods: Patients >1 year after treatment for unilateral clubfoot were recruited during normal follow-up appointments and both calves were measured using a standardized protocol. A questionnaire concerning their treatment history was also completed. Data were analyzed by comparing calf circumference ratios between treatment modalities., Results: Thirty-five patients with unilateral clubfoot were recruited after satisfying inclusion criteria. Twenty-four (69%) were included in the Ponseti-managed group, and 11 (31%) were in the extensive surgery group. The affected legs were on average 3% to 10% smaller than the control legs across all groups. The surgery group's average calf ratio was significantly less at 90.8%±3.5% compared with 94.4%±3.3% in the Ponseti group., Conclusions: The calf circumference of limbs affected by clubfoot is significantly smaller in those treated with extensive surgery as compared with those treated with the Ponseti method alone, with or without percutaneous tenotomy. This supports the Ponseti method as the standard of care for achieving the most favorable anatomic outcome., Level of Evidence: Level I.

Pedal macrodactyly is a rare clinical entity that poses a challenge to practicing pediatric orthopedic surgeons. Many treatment options have been proposed. In 1967, Kenya Tsuge proposed a method to decrease the length, width, and circumference of a macrodactylous digit, while maintaining the cosmetic benefit of keeping the nail. We retrospectively reviewed our experience with using this technique in four children (six toes) over a 4-year period. The surgery is described and our results reviewed. We believe that the Tsuge procedure is a technically feasible, effective, single-stage reconstructive technique for pedal macrodactyly that pediatric orthopedic surgeons should have in their armamentarium.

Background: The Ponseti method has become the treatment standard for idiopathic clubfoot. Deformity recurrence is most commonly attributed to premature abandonment of the requisite abduction orthosis. A study in 2009 from our center revealed a high rate of deformity recurrence in our patient population. It was surmised that the importance of bracing to maintain correction had not been adequately communicated to some families, especially Native Americans. As a result, the principal investigator developed a different communication protocol for parents of infants., Methods: All children treated for clubfoot at the University of New Mexico Carrie Tingley Hospital, Albuquerque, NM, from 2008 to 2010 were reviewed. They were compared with a historical control group from this institution, the subjects of the 2009 study, and were analyzed for the rate of recurrence and Pirani score improvement., Results: Our study cohort comprised 69 infants (104 clubfeet), all of whom were treated with the new communication style. The recurrence rate for the new communication paradigm was 2.88% compared with 18.2% in the control group (P<0.001). The Pirani score improvement was 4.0 in the treatment group compared with 3.5 in the control group (P=0.001). Native American recurrence was zero in the treatment group and 41% in the control group (P=0.011)., Conclusions: A positive, rather than a negative communication style, emphasis on the brace as the most important aspect of treatment, and a more culturally sensitive family education paradigm, resulted in a lower rate of deformity recurrence when treating children with clubfeet using the Ponseti method., Level of Evidence: Level III.

Bisphosphonates (BPs) are used most commonly in children with osteogenesis imperfecta, resulting in increased trabeculae and cortical thickness, increased bone density as measured by DXA (Dual Energy X-ray Absorptiometry), and improved vertebral morphology. Less well documented in controlled trials are decrease in long bone fractures, improved strength and motor function, and decreased pain. Outside of children with osteogenesis imperfecta, use of bisphosphonates in children is increasing, all of which is off-label. This is seen in children with other chronic conditions resulting in pediatric osteoporosis and insufficiency fractures. Additional indications include steroid dependency with progressive loss of bone density, avascular necrosis of bone, and chronic regional pain syndrome. This review highlights the potential benefits and risks of the use of bisphosphonates in these unique children at risk for fracture or bone collapse.

Background: Lower extremity length inequality can be problematic in children and is often addressed surgically. Several techniques have traditionally been utilized for epiphysiodesis, the goal being physeal ablation. Recently, 8-plates, initially developed for hemiepiphysiodesis, have been extended to epiphysiodesis by placing the plates on both medial and lateral sides of the physis. No prior studies have compared 8-plates with physeal ablation techniques., Methods: Between January 2003 and August 2009, 27 patients underwent epiphysiodesis surgery using either physeal ablation or 8-plate technique. Sixteen patients had physeal ablation and 11 had dual 8-plates. A retrospective chart review sought demographic data, outcomes, and complications. Radiographs were reviewed to measure pretreatment and posttreatment limb lengths., Results: The median improvement in limb length discrepancy was 15.5 mm in the physeal ablation group and 4 mm in the 8-plate group (P<0.001). This difference was maintained following linear regression factoring out the effect of time (10.78 mm for ablation vs. 5.62 mm for 8-plates; P=0.016). There was no statistically significant difference in complication rate between the groups (P=0.112)., Conclusions: Our study demonstrated physeal ablation to be a significantly superior treatment compared with dual 8-plates for epiphysiodesis. Despite theoretical advantages of 8-plates to perform epiphysiodesis about the knee, this study does not recommend the use of medial and lateral 8-plates to effect epiphysiodesis., Level of Evidence: Therapeutic III.

Background: Postoperative bone mineral density (BMD) loss, especially after cast immobilization and/or non-weight-bearing, is a well-known phenomenon in children that can cause fracture. Children with marginal bone density are at greatest risk. This prospective randomized control trial compared the effect of single-dose intravenous (IV) pamidronate versus placebo to prevent postoperative BMD loss., Methods: Children between the ages of 4 and 18 were included in the study; inclusion criteria included a predisposition to low bone density and hip or lower extremity surgery that would require cast immobilization or non-weight-bearing for at least 4 weeks. Dual-energy x-ray absorptiometry (DXA) scans of the lumbar spine and bilateral distal femora were performed preoperatively and at least 4 weeks postoperatively. Subjects were randomized to receive either a single, low dose of IV pamidronate (1 mg/kg) or placebo, given during the immediate postoperative period. Changes in the BMD were compared using the Mann-Whitney test for significance in the lumbar spine. A multivariate general linear model was used to compare the effect of surgery, DXA region, and treatment on BMD., Results: A total of 24 subjects were included in the study, and 20 completed the protocol. Pamidronate-treated subjects showed a statistically significant difference with a median gain in BMD of 0.029 gm/cm in the lumbar spine compared with the control group, which showed a median loss of 0.025 gm/cm. Treatment did not have a statistically significant effect on BMD loss in the distal femur but trended toward decreased BMD loss (treatment=0.0331 gm/cm, control=0.0416 gm/cm). There were no complications or adverse reactions., Conclusions: This small pilot study shows that single-dose postoperative pamidronate mitigated postoperative BMD loss in at-risk children, which may in turn decrease postoperative fracture risk. Further investigation into the use of IV pamidronate in postoperative patients is warranted., Level of Evidence: Level 1 double-blinded randomized control trial.

Radiographic osteopenia is regularly observed after implant removal from a fracture or femoral osteotomy but has not been objectively quantified. Hardware removal is generally performed months to years after the index event (fracture or osteotomy) when full activity has been resumed. Objectively demonstrable bone mineral deficiency affects fracture risk. Hardware removal may facilitate the return to normal bone mineral density. Children who had dual-energy X-ray absorptiometry scans following femoral implant removal were retrospectively reviewed to assess the percent of change in bone mineral density and change in Z-scores. The femoral neck and the lateral distal femora were scanned, comparing the operated side with unaffected femur as a control. Sixteen children were included. Patients demonstrated up to 15.4% (average, 4.8%) less bone mineral density in the femoral neck region, up to 43% less (average, 16.5%) in the metabolically active distal metaphyseal region, and up to 18.1% less (average, 6.3%) in the transitional region. No statistical difference was noted in the diaphy-seal region. A statistically significant decrease in Z-score was noted when plate and screw constructs (average change, -0.97 SD) as compared with intramedullary nail constructs (average change, -0.33 SD) were used. Children can exhibit statistically significant decreases in bone mineral density in the femoral neck and distal femur following femoral implant removal, with plate and screw constructs demonstrating a greater effect than intramedullary (load sharing) devices. This has implications for return to activity and suggests that implant removal may be important in restoration of bone strength in children., (Copyright 2013, SLACK Incorporated.)

Background: Pediatric osteoporosis is uncommon but can result in painful and debilitating insufficiency fractures. Treatment options for osteoporosis in children are few. Bisphosphonate therapy for children has not been approved by the Food and Drug Administration (FDA) in the United States, but its use in that population has been increasing. Randomized controlled studies have not been done because of the small subject pool and the difficulty in randomizing a child with an insufficiency fracture to a placebo arm of a study. This retrospective case-control study of a population of children with primarily neuromuscular disease was done to review changes in bone mineral density as reflected by dual x-ray absorptiometry (DXA) scanning., Methods: Medical records and DXA scans were screened to identify children with low bone density who had been treated with alendronate as well as similar control subjects with low bone density for their age who had not received alendronate. Medication acquisition was confirmed by refill records, and cumulative exposure was calculated. Interval DXA scans were reviewed to correlate bone mineral density change in grams per square centimeter as well as the percent change and percent change over time for both alendronate-treated and control subjects., Results: Twenty-eight alendronate-treated subjects and thirty control subjects met the inclusion criteria. No significant improvement in bone mineral density was seen in the alendronate-treated subjects as compared with the control subjects. Some patients in both groups exhibited marked improvement, with improvement of >31% seen only in the alendronate-treated subjects., Conclusions: Alendronate does not reliably improve bone density in children and young adults with primarily neuromuscular disease and without osteogenesis imperfecta. Individual patients treated with bisphosphonates must be carefully followed to ensure medication compliance and appropriate response.

Background: Patients with spina bifida frequently sustain lower extremity fractures which may be difficult to diagnose because they feel little or no pain, although the relative contributions of low bone density to pain insensitivity are unclear. Routine dual-energy xray absorptiometry (DXA) scanning is unreliable because these patients lack bony elements in the spine, and many have joint contractures and/or implanted hardware., Questions/purposes: We asked (1) if the lateral distal femoral scan is useful in spina bifida; (2) whether nonambulatory children with spina bifida exhibit differences in bone mineral density (BMD) compared with an age-and-sex-matched population; and (3) whether Z-scores were related to extremity fracture incidence., Methods: We retrospectively reviewed 37 patients with spina bifida who had DXA scans and sufficient data. Z-scores were correlated with functional level, ambulatory status, body mass index, and fracture history., Results: The distal femoral scan could be performed in subjects for whom total body and/or lumbar scans could not be performed accurately. Twenty-four of 37 had Z-scores below -2 SD, defined as "low bone density for age." Ten of 35 patients (29%) with fracture information had experienced one or more fractures. Our sample size was too small to correlate Z-score with fracture., Conclusion: We believe BMD should be monitored in patients with spina bifida; nonambulatory patients with spina bifida and those with other risk factors are more likely to have low bone density for age than unaffected individuals. The LDF scan was useful in this population in whom lumbar and total body scans are often invalidated by contracture or artifact. Although lower extremity fractures occur regardless of ambulation or bone density, knowing an individual's bone health status may lead to interventions to improve bone health.

Background: Nonoperative management of clubfoot with the Ponseti method has proven to be effective, and it is the accepted initial form of treatment. Although several studies have shown that problems with compliance with the brace protocol are principally responsible for recurrence, no distinction has been made with regard to whether the distance from the site of care affects the early recurrence rate. We compared early recurrence after Ponseti treatment between rural and urban ethnically diverse North American populations to analyze whether distance from the site of care affects compliance and whether certain patient demographic characteristics predict recurrence., Methods: One hundred consecutive infants with a total of 138 clubfeet treated with the Ponseti method were followed prospectively for at least two years from the beginning of treatment. Early recurrence, defined as the need for subsequent cast treatment or surgical treatment, and compliance, defined as strict adherence to the brace protocol described by Ponseti, were analyzed with respect to the distance from the site of care, age at presentation, number of casts needed for the initial correction, need for tenotomy, and family demographic variables., Results: Of eighteen infants from a rural area who had early recurrence, fourteen were Native American. The families of these children, like those of all of the children with early recurrence, discontinued orthotic use earlier than was recommended by the physician. Discontinuation of orthotic use was related to recurrence, with an odds ratio of 120 (p < 0.0001), in patients living in a rural area. Native American ethnicity, unmarried parents, public or no insurance, parental education at the high-school level or less, and a family income of less than $20,000 were also significant risk factors for recurrence in patients living in a rural area. Intrinsic factors of the clubfoot deformity were not correlated with recurrence or discontinuation of bracing., Conclusions: Compliance with the orthotic regimen after cast treatment is imperative for the Ponseti method to succeed. The striking difference in outcome in rural Native American patients as compared with the outcomes in urban Native American patients and children of other ethnicities suggests particular problems in communicating to families in this subpopulation the importance of bracing to maintain correction. An examination of communication styles suggested that these communication failures may be culturally related.

Dual energy x-ray absorptiometry (DEXA) is the current standard for measuring bone mineral density (BMD) in children. The International Society for Clinical Densitometry recommends scanning the total body and spine in children. However, in orthopedics, the total-body and spine DEXA scans are often rendered useless by the presence of metallic hardware and/or contractures. The lateral distal femoral DEXA scan was developed as a scan mode for children such as those with cerebral palsy who have contractures or metallic implants, which make it impossible to do total-body or spine scans. Unlike other DEXA scans, a single scan of the lateral distal femoral illustrates the density of the metaphyseal cancellous (newer) bone, the transitional, and the cortical (older) bone in 1 image. Because of this, we hypothesized that an individual lateral distal femoral scan could provide a map of bone health over time. The lateral distal femoral scans of 40 children whose bone growth was tainted by distant chemotherapy (chemotherapy group) were compared to the lateral distal femoral scans of 40 children whose bone environment had remained relatively stable over time (control group). The hypothesis was not confirmed by the data. The "Z-score difference," the difference between the Z-scores of the cancellous and cortical bone, for the chemotherapy group (0.16) and the control group (0.32) were not statistically different. While these results did not confirm the hypothesis, the lateral distal femoral scan remains a reproducible and useful DEXA scan in pediatric orthopedic clinical practice.

Although bone mineral density (BMD) as related to T score (comparison with young adult) is well correlated with fracture risk in adults, no such correlation has been confirmed in children. Quadriparetic children have lower BMD than age-matched controls, as well as a higher rate of fragility fracture. This study examines a cohort of children with quadriparesis and other nonambulatory children to correlate BMD with fragility fractures.We hypothesize that fracture in these children is related to BMD as correlated with patient size and that age comparison (Z-score) is less important. Review of all children with a dual-energy x-ray absorptiometry scan from August 2003 to June 2005 identified 101 nonambulatory pediatric patients (excluding children with osteogenesis imperfecta or metabolic bone disease). Sixteen patients had insufficient data, leaving 85 patients, 26 of whom had experienced fragility fractures. Lateral femoral dual-energy x-ray absorptiometry scan was performed on one or both legs, then regions were averaged. Data was evaluated for statistical correlation between BMD and body size as evidenced by body mass index (BMI). Other factors, including age, Z-score, and height and weight independently were secondarily evaluated for correlation with fracture risk. Correlation was demonstrated between history of fracture and BMD when related to BMI (P = 0.002). In conclusion, in these nonambulatory children, the combination of the BMD of the distal femur and BMI correlates well with occurrence of fragility fracture and may relate to fracture risk. This relationship is independent of the child's chronological age and Z-score. This information may be helpful prognostically to define a treatment algorithm for low bone density on a case-by-case basis.

Osteoporosis and low bone density for age is increasingly recognized in children yet poorly understood and often overlooked. DXA scanning in children is problematic due to lack of guidelines and inexperience of most DXA practitioners. The International Society for Clinical Densitometry recommends spine or total body scans as the preferred skeletal sites for study in children, yet we find multiple regional scans to be far more useful in the clinical practice of pediatric DXA scanning, especially in a pediatric orthopaedic setting. DXA scans of 119 children are reviewed: 20% of the children had orthopaedic hardware or other artifact that would have rendered the whole body scan unusable. In 20 of 119 patients, the only scan that could be obtained, either due to contracture or patient cooperation, was the distal lateral femoral scan. Scanning multiple regions of interest including spine, hip, and/or distal lateral femora as indicated is the recommended protocol for assessment of BMD in the pediatric orthopaedic setting.

Slipped capital femoral epiphysis (SCFE) is a condition seen during the preadolescent growth spurt, often in obese children and in children with endocrine disorders. Given that endocrine factors also play a role in bone density, a link between low bone mineral density (BMD) and SCFE was proposed. Dual energy X-ray absorptiometry (DXA) scanning of the spine and hips was performed on 12 children with SCFE and on 5 overweight children without this hip disorder. All scans were performed by the same technician using a Hologic Delphi W densitometer and were interpreted by a pediatric orthopedic surgeon certified in clinical densitometry. Z-scores were obtained using a pediatric database. Mean and standard deviation of the Z-scores were calculated, and paired t tests were used to assess differences between these subjects and the expected norm. The SCFE patients' Z-scores at each of the skeletal sites assessed (spine, femoral neck, and total hip) were greater than the mean by an average of 1 standard deviation. The control subjects' BMD was also greater than the mean. The P values were less then 0.05. These results suggest that children with SCFE do not have low BMD, but show bone density significantly greater then expected for age and sex. Although BMD is endocrinologically driven and endocrinologic abnormalities are implicated in SCFE, there appears to be no correlation between low BMD and SCFE.

The diagnosis of childhood intervertebral disc space infection is often delayed. Establishment of the correct diagnosis is imperative to preclude unnecessary procedures and to exclude other, more serious, diagnoses that would require aggressive management. MRI is a noninvasive technique that is very sensitive for disc space infection in children.

A systematic approach to the injured shoulder includes careful history taking and sequential examination of all anatomic components of the shoulder girdle in each and every patient. High quality radiographs, with two views at 90 degrees to one another, are essential. A specific diagnosis can and must be made on every patient with an injured shoulder to enable referral for proper care and follow-up.

Patients with cerebral palsy and fixed hip extension are often unable to sit and therefore lose social and educational opportunities. At Texas Scottish Rite Hospital (Dallas, TX, U.S.A.), 29 patients had hip extension-abduction contractures. Eleven patients with mild involvement were managed with physical therapy. Six patients had moderate involvement and required wheelchair modification to maintain sitting. Twelve patients demonstrated severe contractures that required major soft tissue releases and often femoral shortening osteotomies to regain flexion. Patients with athetosis or rigidity were identified as those most likely to develop extension-abduction contractures either spontaneously or following adductor releases.

Myelodysplasia is a multisystem disease that requires a multidisciplinary approach. The orthopaedist is often the first to identify a changing neurologic picture or deformity and must work closely with neurosurgical colleagues to identify correctable neurologic lesions. The role of the orthopaedist begins at the birth of the child with spina bifida. At this time, the level of neurologic involvement can be determined. Education of the parents can then begin by outlining the expected ambulatory potential of the child, and predicting deformities or complications that might be anticipated depending on the level of neurologic involvement. The orthopaedist must also emphasize the extreme importance of neurosurgical care in preventing deterioration of neurologic function, so that goals for ambulation and musculoskeletal function can be achieved. As the child gets older, motor milestones paralleling those of a normal child should be sought with use of a corner chair or sitting device, followed by the use of a standing frame if needed. If appropriate, the child will then progress to full-control braces, with weaning as determined by neurologic level of involvement . Long-term mobility may be achieved by bracing or by the use of a wheelchair. A realistic approach must be taken in goal-setting, so that a child is not pressured to achieve unrealistic goals yet is enabled to achieve full functional capacity.

Diagnosis of disc space infection in childhood is often delayed and is usually made on the basis of multiple roentgenographic, laboratory, and nuclear imaging studies. Four cases of septic discitis in children are described. Special emphasis is placed on the diagnostic findings with magnetic resonance imaging. Magnetic resonance sensitivity for this entity and its role in comparison with other imaging modalities are discussed.

Intraoperative somatosensory evoked potentials in 50 patients were reviewed; each waveform was correlated with intraoperative surgical events and conditions. Twenty-two patients maintained reproducible waveforms and awoke without neurological deficit. Two patients had random waveform changes not correlated with a surgical event and awoke without deficit. Twelve patients showed waveform changes temporally related to circumstances that might endanger cord function; two of these awoke with transient neurological abnormality. Satisfactory waveforms were not obtained from 14 patients. Somatosensory evoked potential monitoring in scoliosis surgery appears to be sensitive, but may not be sufficiently specific; waveform changes do not necessarily indicate objective neurological damage.