Search

The Netherlands has well-organized school health services, and children are assessed on a regular basis for scoliosis among other disturbances and pathologies. The purpose of this study was to assess the benefits of an annual screening programme for scoliosis in the Netherlands. Three cohorts of 10,000 children sampled at 10, 12 and 14 years of age, respectively, were followed for 3 years. Children with a positive bending sign were referred to a second screening stage, in which external asymmetry was quantified. Children diagnosed via the programme (group 1) were compared with those children who had been referred for treatment independently of the screening (group 2). The total number of children in these groups combined was then compared with the number that would have been expected on the basis of accepted prevalence figures for idiopathic scoliosis given in current literature. Over 30,000 children were screened. Although the programme established a total of 57 cases of definite scoliosis (0.18%), the 34 cases (0.11%) already known, mainly detected by previous school health checks, were more severe regarding the risk of progression and treatment. The annual screening programme did not detect a single case that needed surgery. These figures provide the basis on which to decide for or against adopting an annual screening programme for scoliosis; the decision is a socio-political one. Based on this study, we expect all scoliotic patients needing treatment should be detected in time if periodic health checks will be maintained biennially. On medical grounds, it is our view, that screening for scoliosis should not be performed in the Netherlands annually.

We studied retrospectively gross motor development and the impact of intramedullary rodding in 10 children with type III osteogenesis imperfecta (OI). There was a pronounced delay in motor development and the order in achieving gross motor milestones differed from the normal developmental sequence. Static milestones developed at an earlier stage than dynamic milestones. Intramedullary rodding of the lower extremities prior to the age of 3.5 years enhanced neuromotor development, especially regarding the milestones supported standing, rolling from prone to supine and crawling with abdomen on the floor. The different sequence in achieving gross motor milestones should have implications for future rehabilitation programs and for orthopedic surgery.

Ground reaction forces from two force plates are used to determine the cyclic oscillations of the body center of mass while walking at preferred speed. Good approximations to the oscillations may be obtained from formulae containing just the first- and second-order Fourier coefficients of the combined left-right ground reaction forces taken over a complete walking cycle. The symmetric components of the oscillations have consistent mutual phase relations for normal subjects, so that the amplitudes alone can be used as sufficient parameters to characterize the body center of mass oscillations. The analytical technique enables detection of small but consistent gait asymmetries.

Quantification of the bending test became necessary within a large school screening for scoliosis, which started in 1983 in the central part of the Netherlands. Measurement of the angle of trunk rotation appeared to be the easiest method for the school doctors involved. Since at that time no device was commercially available, a device was developed to permit an easy and reliable angle measurement. Methodological qualities of the device in the measurement of the Cobb angle on radiographs are reported. The results of interobserver variation in measurement of the angle of trunk rotation and in the determination of the Cobb angle on radiographs using this device are compared with data from other studies reported in the literature. We did not find important differences in interobserver variation. Measurements of the Cobb angle with the new device could not be distinguished from the Cobb angle determination using conventional techniques. Therefore, we conclude that the spinal rotation meter described here is a reliable device for the measurement of scoliosis parameters.

The reliability of scoliosis parameters such as the Cobb angle, the angle of trunk rotation and moir e topography is known from several publications. These studies concern intra- and interobserver variations; they are in general of transversal nature, which means the measurements were performed on the same subject within a short time period. From clinical experience it appears that these variations may be greater when scoliosis patients are followed over several years. In order to determine the parameter variation in the follow-up of children with scoliosis, a retrospective study was undertaken. From among our outpatient population, 41 children with stable scoliosis over a period of at least 2 years were selected. Stable scoliosis was defined as a spinal deformity which, in retrospect, had not deteriorated during at least a 2-year period prior to the end of growth. Hence no indication for treatment was found for this group. The measurements of the angle of external trunk rotation, moiré topography and Cobb angle of these children during the follow-up period were submitted to statistical computations using one-way analysis of variance. Variations in the results of Cobb angle measurement and the measurement of the angle of trunk rotation were found to be no different to the variations in intra- and interobserver measurements as reported mainly from transversal studies. The variation found in moiré topography, in moiré contour lines and in angle moiré determination, was, however, considered too great for measurements to be reliable. In conclusion, only Cobb angle determination and external measurement of trunk rotation can be accepted as valid follow-up parameters from a methodological viewpoint.

Several studies advocate quantification of the bending test or performing surface topography to reduce the referral rate and to increase the specificity of the bending test in screening for scoliosis. Within the framework of a school screening project all children with a positive bending test were reexamined with measurement of rib hump height, angle of trunk rotation and moiré topography. In the period 1983-1986, out of three cohorts of 10,000 children of 10, 12 and 14 years of age, 3,069 were reexamined, of whom 1931 again tested positive (63%). The value of the three techniques in terms of sensitivity and specificity within the reexamined group was evaluated with regard to the Cobb angle on a spinal radiograph, which was made in 671 cases. A reduction in referrals of 37% was found. No significant difference in the ability to detect scoliosis was found between the three techniques mentioned. It is concluded that measurement techniques are valuable in school screening programmes. In particular, if instead of a single cut-off value, a range within which the examination should be repeated is chosen, high sensitivity and high specificity can be combined. Angle of trunk rotation measurement seems to be the easiest method of screening.

2 boys had unilateral Perthes' disease at the age of 5 years. After 6 and 7 years, respectively, both patients developed contralateral femoral head necrosis with rapid destruction leading to ankylosis of the hip. Histology of the synovium showed nonspecific synovitis. Both patients fulfilled criteria for oligo-articular juvenile chronic arthritis (JCA). The association with Perthes' disease suggests a common etiology.

In order to determine the reliability of the Cobb angle measurement as it is used in the clinical management of scoliosis, a methodological survey was carried out. In the measurement of a Cobb angle two phases can be distinguished: (a) the production of a spinal radiograph and (b) the measurement of the angle itself. In respect of the first phase, the variation in production of the radiographs was calculated on Cobb angle measurements made by one investigator on serial radiographs of patients who underwent spinal fusion for scoliosis and therefore had a fixed spinal curvature. For the second phase, the accuracy of Cobb angle measurement was investigated by comparing measurements on the same radiographs of 46 scoliosis patients obtained by three investigators, namely two orthopaedic surgeons and an orthopaedic fellow who was assigned to a school screening project. Results were expressed as a Spearman correlation coefficient and a standard deviation of the differences. The Spearman correlation coefficient was 0.98 for the repeated radiographs (production variation) and also 0.98 for the repeated measurements on one radiograph (interobserver measurement variation). The standard deviation of the differences in Cobb angle for the repeated radiographs amounted to 3.2 degrees and for the repeated measurements on one radiograph it was 2.0 degrees. Although there is a good reproducibility of the Cobb angle measurement between different investigators, the variation in production of a spinal radiograph is an important source of error. This should be taken into account when making decisions in scoliosis management.

Objective: To determine the results and complications of the Cotrel-Dubousset (CD) operation in idiopathic scoliosis., Design: Retrospective., Setting: Wilhelmina Children's Hospital, Utrecht, and University Hospital, Leiden., Method: Of the first 22 patients with idiopathic scoliosis operated on with CD instrumentation the results were determined: the Cobb angle, the percentage of rotational correction achieved, duration of the operation, amount of blood loss, complications and duration of the postoperative hospital stay., Results: Compared with the Harrington technique, there were fewer complications resulting from instrumental failure (three in all), while the correction of the scoliosis was the same and in some cases even better. Advantages of the CD operation for the patient were rapid mobilization, short postoperative hospital stay and short duration of the after-treatment with use of a removable light plastic corset., Conclusion: The Cotrel-Dubousset operation appears to be a promising method for the treatment of patients with idiopathic scoliosis.

The childhood form of discitis was diagnosed in a 2-year-old girl and a 5-year-old boy. They presented with an antalgic posture, muscular defense and a positive Gowers sign. Characteristic symptoms of this childhood discitis form the triad: unexplained fever, increased erythrocyte sedimentation rate and symptomatic narrowing of an intervertebral space.

The cases are described of three adolescents in whom hip pain was found to be due to chondrolysis. Arthroscopy revealed chronic synovitis in all three cases. It is stated that the synovitis is probably the cause of the articular damage and that the disorder should be regarded as juvenile chronic arthritis of the oligoarticular type. Treatment with intra-articular triamcinolone acetonide and in two patients with an anti-inflammatory agent as well resulted in almost complete recovery of hip function.

Correction of spinal deformities in patients with myelomeningoceles (mmc) is notoriously complicated. To identify the deformity, frequency, gravity and complications of treatment a retrospective study was carried out on 61 patients from four hospitals. 45 patients had neurological defect above L3 and were wheelchair-bound. The indications for surgery were progressive disturbance in sitting balance, pain and pressure sores. Two types of spinal deformity were identified; scoliosis (often thoraco-lumbar or double major curves) and kyphosis (usually angular and lumbar). The mean age at operation was 12 years 8 months (2y 6m-19y 7m). Several operative procedures were used; posterior, anterior and circumferential fusion, and resection of the kyphosis. 52 solid fusions were achieved with variable correction at the cost of many complications such as excessive blood loss (2), post-operative pressure sores (15), failure of instrumentation (15), deep infection (11), and death following a CSF leak (1). 4 patients died from unrelated causes. Only 16 patients had no complications. The type and severity of scoliosis and kyphosis, operative technique, results and complications were correlated to identify the risks and define the optimal surgical technique for each type of spinal deformity in mmc.

As the result of an inquiry among Dutch orthopaedic surgeons a consensus is formulated on the treatment of congenital talipes equinovarus in the first year of life. From this, the following general directives emerge: Treatment should start early and consist of repeated redressing followed by immobilisation; In more severe cases often surgical release is necessary, this should be performed preferably between the 4th and 9th months of life, in order to make normal motor development possible.

In order to determine the applicability of school screening techniques for scoliosis, a methodologic survey was carried out within the framework of a school screening project. The accuracy of the measurements of rib hump height, angle of trunk rotation, and of moiré topography was investigated by assessing the intraobserver and interobserver variation. The validity of these techniques was tested by comparing their outcome to the Cobb angle. Intraobserver variation was measured over both short and long time intervals. The interobserver variation was determined among two orthopaedic surgeons and among a group of six doctors. Results are expressed in a Spearman correlation coefficient and a standard deviation. The Spearman correlation ranges from 0.46 (moiré) to 0.75 (rib hump height) in intraobserver variation, and from 0.60 (rib hump height) to 0.70 (angle of trunk rotation) in interobserver variation. The standard deviations illustrate the interobserver range of the measurements, for rib hump height, 3.7 mm, for rotation, 2.3 degrees, and for moiré, 0.7 lines. The validity of the three methods varied from 0.40 to 0.53 as correlated with the angle of Cobb. The conclusion is that these methods can be applied in school screening techniques, but that they do not allow a sharp distinction between normal and pathologic cases. Instead, it is preferable to define the borderline in terms of a danger zone rather than a strict single value. The danger zone for the rib hump height should be 5-10 mm, for the rotation 3-7 degrees, and for the moiré topography 1-3 lines. Recordings in these zones should be repeated within a few months.

Defects in proprioceptive postural control have been linked to the etiology of idiopathic scoliosis. In particular, a rearrangement of the internal representation of the body has been proposed in these cases. In this study, upper-extremity proprioceptive accuracy was compared among the following groups: 1) patients with idiopathic scoliosis (n = 25); 2) subjects with nonprogressive spinal asymmetry detected by screening in school (n = 23); 3) subjects undergoing behavioral training for nocturnal enuresis (n = 17); and 4) normal subjects (n = 134). A significant inaccuracy was found among the right-handed subjects of the scoliosis and spinal asymmetry groups as compared to the normal group. It is postulated that proprioceptive dysfunction, or borderline function, is a causative factor of spinal asymmetry, which is often observed in early adolescence and which in some cases may be progressive.

The management of juvenile chronic arthritis requires a multidisciplinary approach. Treatment is based on knowledge of the pathogenetic factors playing a role in the disintegration of joints due to the chronic synovitis and consist of non-operative and operative methods. These therapeutic modalities are used in close coherence with each other. Preservation of ambulation and hand function has a priority in the treatment program. Early intervention, in order to prevent joint destruction is one of the cornerstones in the treatment of juvenile chronic arthritis.

The results and complications of 46 leg-lengthening procedures in 28 consecutive patients were analyzed retrospectively. There were 24 femoral and 22 tibial lengthenings, performed for short stature (5 patients) and limb-length discrepancy (23 patients). Three methods were used: diaphyseal osteotomy, metaphyseal corticotomy, and distraction physiolysis. In the second group a satisfactory result was obtained more often and a lower complication rate was observed. The overall complication rate was high: 45 substantial problems occurred. We conclude that leg lengthening is difficult, requiring good preoperative examination and planning, and should be carried out only in specialized centers.

In Juvenile Chronic Arthritis the wrist often is involved. Synovitis of this joint gives rise to several types of disintegration, which can lead to serious deformities and loss of function. Therapeutical considerations should be based upon knowledge of these types of disintegration and the natural history.

Equinovarus foot deformity as seen in neurologic disease is often caused by imbalance in muscle tone. One of the possible operative procedures to correct this deformity is transposition of the posterior tibial tendon. The effect of this intervention is disputed in the orthopaedic literature. The results of this procedure are presented in a retrospective study of 9 children (11 feet). The mean follow-up period was 19 months (8-40). In all cases but one the results were satisfactory. The indications and complications of this operation are discussed.

Physical and psychic vulnerability in children performing competitive sports may turn an accidental injury into a starting-point for chronic pain. This pain may give rise to serious physical and social restraints. The case histories of two fourteen years old girls are presented. Both patients suffered from overburdening. This phenomenon had not been recognized, or was not explicitly stated at least. Probably, too high expectations from medical help by parents and child played a crucial role. Expectations were twofold: the chronic pain should fit a specific defect caused by the injury, or it should be due to a (serious) disease. Both types of expectations led to disappointments, repeated diagnostic procedures and ineffective therapies. A comprehensive assessment without delay by a multidisciplinary pediatric team is recommended.

The pathomechanism of low-back pain generation is not understood very well. Functional disturbances of motion at the individual segmental level appear to play a role in many cases. In this study a technique of numeric analysis of radiographic observations of the lumbar spine is developed by which the authors are able to assess the displacement of the two components of the L5-S1 motion segment in the sagittal plane when the subject assumes three specified standard postural positions.

The causes of late diagnosis of congenital dislocation of the hip were examined retrospectively in a group of 49 children (56 hips affected). It appears that at neonatal examination as well as a further screening during the first year of life, the classical symptoms of this condition are not infrequently missed. The classical tests for the early diagnosis are described and the consequences of late diagnosis are studied. In spite of late detection, the final result of the treatment in most cases is quite favourable. However, this result can only be achieved by prolonged and intensive treatment, including hospitalization and surgery.

From 1979-1985 seventeen children with twenty-six club-feet were treated. Thirty-four operations have been carried out, divided in three surgical procedures. The heel cord was lengthened in eight feet, a posterior release was done in thirteen feet and a posteromedial release according to Turco was done thirteen times as well. Lengthening of the heel cord seemed to be an insufficient procedure, because six out of eight feet showed a recurrent deformity. The posterior release has given in half of the cases a good result. After posteromedial release we saw in 70% a good or excellent result, when this procedure has been performed between the age of six to twelve months.

Slow arm movements were made over a smooth horizontal table at shoulder height. With visual cues excluded, target position was indicated by the index finger of the nonmoving arm touching the underside of the table. 134 subjects (including 26 left-handed subjects) in the age range 8.0 to 24.6 yr. were examined to see if the results were age-related. Accuracy slightly but significantly increased with age. The younger subjects showed a greater accuracy with the dominant hand--a situation which tended to be reversed in the older subjects.