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1.  Effects of ankle–foot braces on medial gastrocnemius morphometrics and gait in children with cerebral palsy 
In children with cerebral palsy (CP), braces are used to counteract progressive joint and muscle contracture and improve function. We examined the effects of positional ankle–foot braces on contracture of the medial gastrocnemius (MG) and gait in children with CP while referencing to typically developing children.
Seventeen independently ambulant children with CP and calf muscle contracture (age 10.4 ± 3.0y) and 17 untreated typically developing peers (age 9.5 ± 2.6y) participated. Children with CP were analysed before and 16 ± 4 weeks after ankle–foot bracing. MG muscle belly length and thickness, tendon and fascicle length, as well as their extensibility were captured by 2D ultrasound and 3D motion capturing during passive, manually applied stretches. In addition, 3D gait analysis was conducted.
Prior to bracing, the MG muscle–tendon unit in children with CP was 22 % less extensible. At matched amounts of muscle–tendon unit stretch, the muscle belly and fascicles in CP were 7 % and 14 % shorter while the tendon was 11 % longer. Spastic fascicles displayed 32 % less extensibility than controls. Brace wear increased passive dorsiflexion primarily with the knees flexed. During gait, children walked faster and foot lift in swing improved. MG muscle belly and tendon length showed little change, but fascicles further shortened (−11 %) and muscle thickness (−8 %) decreased.
Use of ankle–foot braces improves function but may lead to a loss of sarcomeres in series, which could explain the shortened fascicles. To potentially induce gastrocnemius muscle growth, braces may also need to extend the knee or complementary training may be necessary to offset the immobilizing effects of braces.
PMCID: PMC4486505  PMID: 26108740
Cerebral Palsy; Ankle–foot bracing; Ultrasound; Gastrocnemius; Muscle contracture; Equinus
2.  Dega osteotomy for the management of developmental dysplasia of the hip in children aged 2–8 years: results of 58 consecutive osteotomies after 13–25 years of follow-up 
Developmental dysplasia of the hip (DDH) is a term used to cover a broad spectrum of anomalies ranging from mild dysplasia to high-riding dislocations. We report the management of DDH in children using the Dega osteotomy and their long-term follow-up.
Fifty-eight hips from 48 children younger than 8 years treated using the Dega osteotomy between January 1988 and October 2000 were included in this multcenter study. Both prospective (41 hips) and retrospective (17 hips) cases were included, and follow-up was for a minimum of 13 years. Radiographs were made preoperatively, immediately postoperatively, after 6 weeks or at removal of the spica cast if any, at 6-month intervals and/or as indicated for 3 years postoperatively and then on annual basis until the last follow-up. A single-cut computed tomographic scan was performed for all prospective patients. Special attention was paid to the predictive measures of hip arthrosis and the survival of the hip after Dega osteotomy.
The final clinical outcome was favorable in 44 hips (75.9 %). Eleven hips needed a second surgery (acetabuloplasty and/or arthroplasty) during the follow-up period.
In our pediatric patient population the Dega osteotomy proved to be an adequate measure for the management of this complex condition. The worst complication was avascular necrosis, and all of the affected hips ended with failure (pain, another surgery, or both).
PMCID: PMC4486499  PMID: 26099459
Dega; Pelvic osteotomy; Femoral osteotomy; Developmental dysplasia of the hip; Dysplasia
3.  Prolonged use of foot abduction brace reduces the rate of surgery in Ponseti-treated idiopathic club feet 
There is conflicting evidence related to factors affecting the rates of recurrence of idiopathic club feet using the Ponseti method. We attempt to evaluate the predictors of success and failure in our physiotherapy-led Ponseti club foot clinic.
We evaluated 189 children with 279 club feet with a mean follow-up of 6.3 years for the following: Pirani score at presentation, number of casts for correction, indication for Achilles tenotomy, and the duration of foot abduction brace (FAB) use, in relation to outcome. Outcome measures were the need for additional surgery and functional scores. Based on the pattern and rate of ossification of the tarsal bones in idiopathic club foot, a much longer FAB weaning protocol was designed and practiced since 2000. The objective of this study was to answer the question of whether a prolonged period of FAB use reduces the need for surgery in Ponseti-treated idiopathic club foot.
Thirty-six feet (12.9 %) underwent additional surgery. The Pirani score and the number of cast changes had no influence on the rate of surgery. The duration of FAB use had a significant effect on the outcome, i.e., the rate of surgery and functional scoring. Operated children used the FAB for 28 months versus 33 months in the non-operated group (p < 0.05). Only a minor delay in the attainment of walking age was noted (average 15 months).
The duration of FAB treatment was found to be the most influential on the functional results and on rate of surgery. Close follow-up and longer FAB weaning program reduced the rates of recurrence.
PMCID: PMC4486506  PMID: 26091918
Club foot; Foot abduction brace; Ponseti; Delayed ossification; Cartilaginous anlagen; Ossific nuclei of tarsal bones
4.  Characterization of knee alignment in children with mucopolysaccharidosis types I and II and outcome of treatment with guided growth 
To describe knee alignment in children of different ages with severe mucopolysaccharidosis (MPS) I and II and the outcome of treatment with guided growth in a patient subgroup.
This is a retrospective observational study of 58 knees in 29 children with severe MPS I and II. Long-leg standing radiographs were evaluated to determine mechanical axis deviation, mechanical lateral distal femoral angle and medial proximal tibial angle at different ages throughout childhood. The change in deformity in individual children over time is reported. 20 knees in 10 patients were treated with guided growth using eight-plates. Radiographic measurements were recorded at the time of plate insertion, at plate removal and at 1 year following removal.
At 8 years of age, all MPS I children and three-quarters of MPS II children had valgus knee alignment. There was deformity progression in two-thirds of MPS I knees and half of MPS II knees. Guided growth corrected the deformities. There was recurrence in most cases 1 year after plate removal.
Knee deformity is common in children with severe MPS I and II. Guided growth can be considered where there is significant and/or or progressive deformity with the aim of halting progression and correcting existing deformity and thus minimizing the risk of gross deformity. Patients should be aware of the high rate of recurrence and the need for repeat surgery.
PMCID: PMC4486501  PMID: 26076735
Mucopolysaccharidoses; Knee alignment; Guided growth
5.  Mid-term results of a physiotherapist-led Ponseti service for the management of non-idiopathic and idiopathic clubfoot 
The Ponseti method is the preferred treatment for idiopathic clubfoot. Although popularised by orthopaedic surgeons it has expanded to physiotherapists and other health practitioners. This study reviews the results of a physiotherapist-led Ponseti service for idiopathic and non-idiopathic clubfeet and compares these results with those reported by other groups.
A prospective cohort of clubfeet (2005–2012) with a minimum 2-year follow-up after correction was reviewed. Physiotherapists treated 91 children—41 patients (69 feet) had non-idiopathic deformities and 50 children (77 feet) were idiopathic. Objective outcomes were evaluated and compared to results from other groups managing similar patient cohorts.
The mean follow-up was 4.6 years (range 2–8.3 years) for both groups. The non-idiopathic group required a median of 7 casts to correct the clubfoot deformity with an 83 % tenotomy rate compared to a median of 5 casts for the idiopathic group with a 63 % tenotomy rate. Initial correction was achieved in 96 % of non-idiopathic feet and in 100 % of idiopathic feet. Recurrence requiring additional treatment was higher in the non-idiopathic group with 40 % of patients (36 % of feet) sustaining a relapse as opposed to 8 % (6 % feet) in the idiopathic group. Surgery was required in 26 % of relapsed non-idiopathic feet and 6 % of idiopathic.
Although Ponseti treatment was not as successful in non-idiopathic feet as in idiopathic feet, deformity correction was achieved and maintained in the mid-term for the majority of feet. These results compare favourably to other specialist orthopaedic-based services for Ponseti management of non-idiopathic clubfeet.
Level of evidence
Prognostic Level III.
PMCID: PMC4486504  PMID: 26072327
Non-idiopathic; Clubfoot; Ponseti; Physiotherapist
6.  A modified surgical approach of the hip in children: is it safe and reliable in patients with developmental hip dysplasia? 
Treatment is easier and complications are less likely to occur if developmental dysplasia of the hip (DDH) is diagnosed early. In this study, we examined the early results of open reduction using a medial approach which we had modified for DDH and analyzed the success of this technique and the associated complication rates, with a focus on avascular necrosis (AVN).
This is an Institutional Review Board-approved retrospective review of all patients diagnosed with DDH and treated with a modified medial approach at a single institution from July 1999 to December 2010. The patients' charts were analyzed for clinical and radiographic features.
Fifty-five hips of 41 patients, all of whom were treated by open reduction using a modified medial approach due to DDH, were evaluated retrospectively. The mean age of the patients at surgery was 19 (range 11–28) months, and the average follow-up was 5.5 (range 3–9.5) years. AVN was the most important complication in terms of radiological outcomes as assessed according to the Kalamchi–McEwen classification. Radiologic results were excellent or good in 51 hips (92.7 %) and fair–plus in four (7.3 %). Type 1 temporary AVN was detected in only two hips (3.6 %), and the lesions had disappeared completely in the final control graphs of these two patients. A secondary intervention was needed for two hips (3.6 %) of the same patients who were operated on due to bilateral DDH. No other complications, such as infection, re-dislocation, or subluxation, were seen in the operated patients.
We believe that treatment for DDH using a modified medial approach during early childhood is an effective and reliable method with low AVN rates. As shown here, this method achieves great success in radiological and clinical outcomes after a minimum 3-year follow-up.
PMCID: PMC4486503  PMID: 26058855
Surgical approach; Medial open reduction; Developmental hip dysplasia; Avascular necrosis
7.  A radiographic study of the distal femoral epiphysis 
Previous studies have described the complex undulation pattern in the distal femoral physis. We investigated whether standard radiographs can visualize these landmarks, in order to guide hardware placement in the distal immature femur.
We studied 36 cadaveric immature femora in specimens 3 to 18 years of age. Anteroposterior (AP) and lateral radiographs were obtained with and without flexible radiodense markers placed on the major undulations and were analyzed to determine the relative height or depth of each topographical landmark. Intraclass correlation coefficients (ICCs) were calculated between measurements taken with and without markers for each undulation on each view.
Examination of the specimens confirmed a central peak and anteromedial and posterolateral valleys as the major physeal structures. AP radiographs without markers correlated well with marked AP radiographs for all three landmarks (ICC = 0.92, 0.92, 0.91), but the lateral radiographs had lower correlations for the posterolateral valley (ICC = 0.36). The correlation between AP and lateral radiographs without markers on the posterolateral valley was also decreased compared to the other two landmarks (ICC = 0.28 versus 0.57 for the central ridge and 0.62 for the anteromedial valley).
This is the first study to rigorously evaluate radiographic visibility of the distal femur physeal undulations. The position of the central ridge, anteromedial valley, and posterolateral valley are reliably seen on AP radiographs, while the lateral view is less consistent, especially for the posterolateral valley. We recommend that caution should be taken when placing screws near the posterolateral aspect of the epiphysis, as lateral views do not visualize those undulations well.
PMCID: PMC4486502  PMID: 26044995
Distal femur; Epiphysis; Physis; Radiographs
8.  Cervical fractures with associated spinal cord injury in children and adolescents: epidemiology, costs, and in-hospital mortality rates in 4418 patients 
Cervical spine fractures with spinal cord injury (CFSCI) can be devastating. We describe the epidemiology of children and adolescents with CFSCI.
Using the Nationwide Inpatient Sample (NIS) database, we identified 4418 patients (≤18 years old) who had CFSCI from 2000 through 2010. Outcomes of interest were patient characteristics (age, sex), injury characteristics [fracture location, spinal cord injury (SCI) pattern], economic variables (duration of hospital stay, total hospital charges), and mortality.
Upper cervical fractures (UCFs) occurred half as often (31.4 %) as lower cervical fractures (LCFs; 68.8 %). Among patients <8 years old, 73.6 % had UCFs; among patients ≥8 years old, 72.3 % had LCFs. Overall, 68.7 % had incomplete SCI, 22.4 % had complete SCI, 6.6 % had central cord syndrome, and 2.3 % had anterior cord syndrome. Patients with complete SCI had the longest hospital stays and highest hospital charges. The overall in-hospital mortality rate was 7.3 %, with a sixfold higher rate in patients <8 (30.6 %) vs. those ≥8 (5.1 %) years old (p < 0.001). There was a threefold higher mortality rate in patients with upper (13.5 %) vs. lower (4.3 %) cervical fractures (p < 0.001). Patients with complete SCI had a 1.85-fold higher mortality rate than patients with other cord syndromes (p < 0.001).
Patients <8 years old were more likely than older patients to sustain UCFs. Patients with UCFs had a significantly higher mortality rate than those with LCFs. Patients with complete SCI had the longest duration of hospital stay and highest hospital charges and in-hospital mortality rate.
PMCID: PMC4486498  PMID: 25953413
Cervical spine; Children; Death; Spinal cord injury; Trauma
9.  Hip reconstruction is more painful than spine fusion in children with cerebral palsy 
Concerns about pain control in patients with cerebral palsy (CP) are especially anxiety provoking for parents, given the fact that spasticity, communication issues, and postoperative muscle spasms are significant problems that make pain control difficult in these patients. A better understanding of the magnitude and quality of the pain these patients experience after our surgical procedures would better prepare the patients and their families. The purpose of this study is to quantify the amount of postoperative pain in children with CP undergoing hip reconstruction and spinal fusion. Specifically, the study will compare pain scores and the amount of narcotics used between the two groups.
Materials and methods
This is a retrospective chart review of a consecutive series of children with CP (GMFCS levels IV and V) over a 5-year period undergoing hip reconstruction (femoral osteotomy, pelvic osteotomy, or both) and posterior spinal fusion (PSF) at a tertiary-care pediatric hospital. The primary end point was the total opioid used by the patient during the hospitalization, by converting all forms of narcotics to morphine equivalents. The secondary end point was the documentation of pain with standard pain scores at standard time points postoperatively. Adverse effects related to pain management were documented for both groups. Student’s t-tests were utilized to statistically compare differences between the groups, with significance determined at p < 0.05.
Forty-two patients with CP who underwent hip reconstruction (mean age 8.8 years) were compared to 26 patients who underwent PSF (mean age 15.4 years). The total opioid used, normalized by body weight and by days length of stay (DLOS), in the hip group was 0.49 mg morphine/kg/DLOS, compared to 0.24 for the spine group (p = 0.014). The mean pain score for the hip group was 1.52, compared to 0.72 for the spine group (p = 0.013). There were no significant differences in the occurrence of adverse effects related to pain management between the two groups.
Patients with CP undergoing hip reconstruction surgery had significantly more pain, as exhibited by requiring more narcotics and having higher pain scores, than those patients undergoing PSF. The knowledge that hip reconstruction is more painful than PSF for patients with CP will better prepare families about what to expect in the postoperative period and will alert providers to supply better postoperative pain control in these patients.
Level of evidence
III (case control series).
PMCID: PMC4486500  PMID: 25944242
Cerebral palsy; Hip reconstruction; Hip dysplasia; Scoliosis; Spine fusion; Pain control; Pain assessment
10.  EPOS 34th Annual Meeting 
Journal of Children's Orthopaedics  2015;9(Suppl 1):11-56.
PMCID: PMC4353816  PMID: 25754189
11.  EPOS 34th Annual Meeting 
Journal of Children's Orthopaedics  2015;9(Suppl 1):67-119.
PMCID: PMC4353813  PMID: 25716893
12.  Author Index EPOS, 2015, France 
Journal of Children's Orthopaedics  2015;9(Suppl 1):1-7.
PMCID: PMC4353818  PMID: 25716894
13.  IFPOS 34th Annual Meeting 
Journal of Children's Orthopaedics  2015;9(Suppl 1):133-138.
PMCID: PMC4353812  PMID: 25711755
14.  IFPOS 34th Annual Meeting 
Journal of Children's Orthopaedics  2015;9(Suppl 1):121-132.
PMCID: PMC4353814  PMID: 25711754
15.  EPOS 34th Annual Meeting 
Journal of Children's Orthopaedics  2015;9(Suppl 1):57-65.
PMCID: PMC4353815  PMID: 25711753
16.  Author Index IFPOS, 2015, France 
Journal of Children's Orthopaedics  2015;9(Suppl 1):9-10.
PMCID: PMC4353817  PMID: 25711756
17.  Clinical and radiographic outcomes of supracondylar humerus fractures treated surgically by pediatric and non-pediatric orthopedic surgeons 
This study compares clinical and radiographic outcomes of operatively managed pediatric supracondylar humerus fractures between patients treated by pediatric orthopedists (POs) and patients treated by non-pediatric orthopedists (NPOs).
Patients and methods
A retrospective cohort study of pediatric patients with surgically managed supracondylar humerus fractures was conducted. For clinical outcomes analyses, 3 months of clinical follow-up were required, resulting in a sample size of 90 patients (33 treated by NPOs, 57 by POs). For radiographic outcomes analyses, 3 months of both clinical and radiographic follow-up were required, resulting in a sample size of 57 patients (23 treated by NPOs, 34 by POs).
The rate of inadequate fracture fixation was higher for patients treated by NPOs (43.5 %) than for patients treated by POs (14.7 %; p = 0.030), but rates of clinical complications, malreduction, and postoperative loss of reduction did not differ. Treatment with open reduction was more common for patients treated by NPOs (33.3 %) than for patients treated by POs (3.5 %; p < 0.001). Total operating room time was longer for patients treated by NPOs (110.9 min) than for patients treated by POs (82.9 min; p < 0.001).
While patients treated by POs differed from patients treated by NPOs with respect to several intermediate outcomes, including having a lower rate of open reduction and a lower rate of inadequate fracture fixation, there were no differences between POs and NPOs in the rates of the more meaningful and definitive outcomes, including clinical complications, malreduction, and postoperative loss of reduction.
PMCID: PMC4340853  PMID: 25701426
Supracondylar humerus fracture
18.  Surgical management for displaced pediatric proximal humeral fractures: a cost analysis 
The purpose of this investigation was to determine which of the following methods of fixation, percutaneous pinning (PP) or intramedullary nailing (IMN), was more cost-effective in the treatment of displaced pediatric proximal humeral fractures (PPHF).
A retrospective cohort of surgically treated PPHF over a 12-year period at a single institution was performed. A decision analysis model was constructed to compare three surgical strategies: IMN versus percutaneous pinning leaving the pins exposed (PPE) versus leaving the pins buried (PPB). Finally, sensitivity analyses were performed, assessing the cost-effectiveness of each technique when infection rates and cost of deep infections were varied.
A total of 84 patients with displaced PPHF underwent surgical stabilization. A total of 35 cases were treated with IMN, 32 with PPE, and 17 with PPB. The age, sex, and preoperative fracture angulation were similar across all groups. A greater percentage of open reduction was seen in the IMN and PPB groups (p = 0.03), while a higher proportion of physeal injury was seen in the PPE group (p = 0.02). Surgical time and estimated blood loss was higher in the IMN group (p < 0.001 and p = 0.01, respectively). The decision analysis revealed that the PPE technique resulted in an average cost saving of $4,502 per patient compared to IMN and $2,066 compared to PPB. This strategy remained cost-effective even when the complication rates with exposed implants approached 55 %.
Leaving pins exposed after surgical fixation of PPHF is more cost-effective than either burying pins or using intramedullary fixation.
PMCID: PMC4340855  PMID: 25697469
Pediatric proximal humerus fractures; Decision analysis; Cost analysis
19.  The demographics of developmental hip dysplasia in the Midwestern United States (Indiana) 
Today’s society is much more mobile than in the past. This increased mobility has resulted in different marriage/parenting groups. We wished to study the demographics of developmental dysplasia of the hip (DDH) in our area and compare/contrast our findings with those in the literature and specifically look for new findings compared to previous studies.
A retrospective review of all children with DDH from 2003 through 2012 was performed. The age at first visit, gestational age, pregnancy number, gender, race, and family history of DDH was collected. Statistical significance was a p-value < 0.05.
There were 424 children (363 girls, 61 boys). Ethnicity was White in 80.8 %, Hispanic in 13.8 %, Black in 4.0 %, and Indo-Malay and Indo-Mediterranean in 0.7 % each; 66.8 % were unilateral; 14.2 % had a positive family history. The average gestational age was 38.1 weeks; 94.4 % were full term. The child was vertex presentation in 67.6 % and breech in 32.4 %; 52.8 % were delivered vaginally and 47.2 % by Cesarean section. The child was the first-born in 48.3 %. When compared to the birth statistics of our state, there was a higher proportion of Whites and Hispanics with DDH, and a lower, but not inconsequential, proportion of Blacks (p = 0.0018).
Mixing of gene pools and infant carrying methods (lack of swaddling or marked abduction) occurring with societal change likely explains the higher than expected proportion of DDH amongst those of Hispanic ethnicity and a lower than expected, but not rare, proportion in those of African ancestry.
Level of evidence
Level IV—retrospective case series.
PMCID: PMC4340845  PMID: 25690337
Developmental hip dysplasia; Demographics; Gender; Race; Laterality; Birth presentation
20.  Panner’s disease: literature review and treatment recommendations 
To determine the most up-to-date theory on the aetiology of Panner’s disease, to form a consensus on the assessment of radiographs and to evaluate clinical outcome in order to summarise the best available evidence for diagnosis and treatment.
A review of studies to date on Panner’s disease. Studies were eligible if: (1) the study provided criteria for defining Panner’s disease in order to eliminate confounding data on other radiographic entities that were mistakenly grouped and presented as Panner’s disease; (2) original data of at least one patient was presented; (3) manuscripts were written in English, German or Dutch; and (4) a full-text article was available. Animal studies, reviews and expert opinions were not included. Because the majority of the studies were case reports, we did not use an overall scoring system to evaluate methodological quality.
Twenty-three articles reporting on Panner’s disease were included. Most cases of Panner’s disease were unilateral in distribution and occurred in boys during the first decade of life. In general, conservative treatment is advised for Panner’s disease. Panner’s disease is a self-limiting disease and the majority of patients heal without clinical impairment.
Based on the results of this review, Panner’s disease should be treated conservatively. Uniform names and descriptions of signs on radiographs would help to make the correct diagnosis. Since Panner’s disease is very rare, higher quality studies are not likely to be performed and, thus, this review provides the best level of evidence on the current knowledge about Panner’s disease.
PMCID: PMC4340849  PMID: 25663360
Osteochondrosis; Panner’s disease; Elbow pain
21.  Short-term pelvic fracture outcomes in adolescents differ from children and adults in the National Trauma Data Bank 
Pediatric pelvic fractures are associated with high-energy trauma and injury to other systems, leading to an increased incidence of complication and mortality. Previous studies analyzed the pediatric population as a whole, including both children and adolescents. The purpose of this study was to examine whether adolescents with pelvic fracture have different complication and mortality rates compared to younger children and adults.
Using the National Trauma Data Bank, 37,784 patients below the age of 55 years with pelvic fractures were identified and divided into children (age <13 years), adolescents (age 13–17 years), and adults (age >17 years). Descriptive statistics and bivariate and multivariate analyses were performed.
Children had an increased odds of death [odds ratio (OR) 2.29, 95 % confidence interval (CI) 1.96–2.67] and complications (OR 1.36, 95 % CI 1.20–1.55), whereas adolescents had a decrease in odds of death (OR 0.89, 95 % CI 0.74–1.06) and complications (OR 0.70, 95 % CI 0.61–0.81) compared to the adult population.
Adolescents with pelvic fractures exhibit a different physiologic response to the children and adult populations. This emphasizes the need to distinguish these subpopulations in future epidemiological research and treatment planning.
PMCID: PMC4340850  PMID: 25648432
Pelvic fractures; Adolescents; Children; Pediatric; Outcomes; National Trauma Data Bank
22.  Early ultrasonographic evaluation of idiopathic clubfeet treated with manipulations, casts, and Botox®: a double-blind randomized control trial 
The manipulations, casts, and Botox® method for treating idiopathic clubfoot is an alternative non-surgical treatment method. Botox®-induced reversible muscle paralysis of the gastrocsoleus enables a physician to manipulate and cast the clubfoot in greater dorsiflexion. Ultrasound is incorporated during the early treatment stages to monitor the underlying physiology of the muscle–tendon unit following Botox®.
Ultrasonographic evaluation was performed parallel to a double-blind randomized control trial administering Botox® or placebo to correct clubfoot. Patients underwent two-dimensional ultrasound to monitor the length changes to the gastrocsoleus and Achilles tendon unit at two time points: pre-injection (baseline) and 6 weeks post-blinded injection. Gastrocsoleus and Achilles tendon length measurements were analyzed among placebo, Botox® and contralateral controls using repeated measures ANOVA.
The baseline gastrocsoleus length of the clubfoot (322.4 pixels) before blinded injection appears shorter than controls (337.5 pixels), but fails to reach significance (p = 0.05). The complex length within each of the three treatment groups displayed no significant change between baseline and 6 weeks. The complex–tendon ratio and muscle–tendon ratio of the Botox® treatment group was significantly decreased compared to controls (p = 0.049 and 0.042, respectively). Briefly, when expressed as a proportion, an increase in Achilles tendon length and decrease in gastrocsoleus is observed when clubfeet are treated with Botox®.
Only in the Botox® treatment cohort did the muscle shrink to uncover tendon (seen as a decreased complex–tendon ratio and muscle–tendon ratio) over the 6-week interval to effectively increase tendon length with respect to the unit as a whole.
Electronic supplementary material
The online version of this article (doi:10.1007/s11832-015-0633-4) contains supplementary material, which is available to authorized users.
PMCID: PMC4340848  PMID: 25609054
Clubfoot; Ultrasound; Achilles tendon; Gastrocsoleus; Botox; Onabotulinumtoxin A
23.  Spinal deformity progression after posterior segmental instrumentation and fusion for idiopathic scoliosis 
Study design
Retrospective chart and radiographic review.
To assess the incidence of and variables associated with spinal deformity progression after posterior segmental instrumentation and fusion at a single institution. Progression of the scoliotic deformity after posterior instrumented spinal fusion has been described. Recent studies have concluded that segmental pedicle screw constructs are better able to control deformity progression.
Retrospective review of a consecutive series of idiopathic scoliosis patients (n = 89) with major thoracic curves (Lenke types 1–4) treated with posterior segmental instrumentation and fusion. Deformity progression was defined as a 10° increase in Cobb angle between the first-erect and 2-year post-operative radiographs. Clinical and radiographic data between the two cohorts (deformity progression versus stable) were analyzed to determine the variables associated with deformity progression.
Patients in the deformity progression group (n = 13) tended to be younger (median 13.7 vs. 14.7 years) and experienced a significant change in height (p = 0.01) during the post-operative period compared to the stable group (n = 76). At 2-years post-op, the patients in the deformity progression group had experienced a significantly greater change in upper instrumented vertebra (UIV) angulation, lower instrumented vertebra (LIV) angulation, and apical vertebral translation (AVT). Two-year post-op Scoliosis Research Society questionnaire (SRS-22) scores in the appearance domain were also significantly worse in the deformity progression group. Patients in the deformity progression group had a significantly greater difference between the lowest instrumented vertebra and stable vertebra compared to patients in the stable group (p = 0.001).
Deformity progression after posterior spinal fusion does occur after modern segmental instrumentation. Segmental pedicle screw constructs do not prevent deformity progression. Skeletally immature patients with a significant growth potential are at the highest risk for deformity progression. In immature patients, extending the fusion distally to the stable vertebra may minimize deformity progression.
Level of evidence
Level III.
PMCID: PMC4340851  PMID: 25599928
Spinal deformity; Spinal deformity progression; Posterior segmental instrumentation and fusion; Idiopathic scoliosis
24.  Local and systemic metal ion release occurs intraoperatively during correction and instrumented spinal fusion for scoliosis 
Study design
Prospective pilot study.
The aim of this study was to measure titanium, niobium and aluminium levels in various intraoperative and postoperative samples to determine patterns of metal ion release that occur within the first month following instrumented spinal fusion.
Summary of background data
Raised serum metal ion levels are reported following instrumented spinal fusion in adolescent idiopathic scoliosis. The exact topological origin and chronology of metal ion release remains conjectural. Recent literature suggests an immediate rise in serum metal levels within the first postoperative week.
Titanium, niobium and aluminium levels were measured before, during and after surgery in serum and local intraoperative fluid samples obtained from two pediatric patients undergoing posterior correction and instrumentation for scoliosis.
Measurable metal ion levels were detected in all local samples obtained from wound irrigation fluid, cell saver blood, and fluid that immersed metal universal reduction screw tabs. Postoperative serum metal ion levels were elevated compared to baseline preoperative levels. In general, metal ion levels were considerably higher in the intraoperative fluid samples compared to those observed in the serum levels.
Our findings of contextually high metal ion concentrations in intraoperative and early postoperative samples provide further empirical support of a ‘putting-in’ phenomenon of metal ion release following instrumented spinal fusion. This challenges existing beliefs that metal ion release occurs during an intermediate ‘wearing-in’ phase. We recommend thorough irrigation of the operative site prior to wound closure to dilute and remove intraoperative metal ion debris. Possibilities of filtering trace metal ions from cell saver content may be considered.
PMCID: PMC4340846  PMID: 25589286
Spinal deformity; Pediatric; Metal; Wear; Titanium
25.  SAPHO syndrome: a review 
Synovitis–acne–pustulosis–hyperostosis–osteitis (SAPHO) is an acronym for various osteoarticular and dermatological manifestations that can appear in the same patient. It is a rare syndrome, but since its awareness has increased, there have been more and more such reports in the literature.
The objectives of this review are to summarize the current state of knowledge on pediatric and adult-onset SAPHO syndrome, and to discuss treatment strategies that should be considered.
The SAPHO syndrome can affect patients of any age, and its etiology is still not known. The syndrome has its cognizable radiological characteristics that are most important in making the diagnosis. There are several diagnostic criteria as well, but they need further validation. No standard treatment protocols are available and current treatment options are not evidenced-based due to the rarity of the syndrome. Therapy is empirical and aimed at easing pain and modifying the inflammatory process. It includes nonsteroidal anti-inflammatory drugs (NSAIDs) as the first-line agents. Antibiotics, corticosteroids, disease-modifying anti-rheumatic drugs, biologicals targeting tumor necrosis factor alpha or interleukin-1, and bisphosphonates have all been used with variable success. Surgery is reserved to treat complications. Even though it is a disease with good long-term prognosis, its treatment remains a challenge and the results are known to be disappointing, especially with the skin component of the disease.
It is expected that these patients present at the time of diagnosis and the treatment should be as early, effective, and safe as possible in order to prevent osteoarticular progression and to limit the adverse events associated with pharmacological drugs.
PMCID: PMC4340847  PMID: 25585872
SAPHO; CRMO; Hyperostosis; Osteitis; Arthritis

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