Treating Complex Orthopedic Disorders

CCH pediatric orthopedists are expert in hip dysplasia and childhood scoliosis

 

By Sean Early, MD and Michael Maguire, MD

 

The team-oriented, subspecialty care required to properly treat children with complex orthopedic pathology is rarely found in community hospitals. Cottage Children’s Hospital has a breadth of pediatric subspecialists and institutional experience that allows for optimal outcomes, while minimizing the risk of complications, for children with orthopedic disorders.

 

Patients with acute traumatic injuries are a large part of our pediatric orthopedic surgery practice, yet we also care for a multitude of extremely complex disorders. Children present weekly to our office with limping or refusal to bear weight. Within the past six months alone, we have diagnosed infection, rheumatoid arthritis, cerebral palsy, muscular dystrophy and leukemia in children whose only presentation was a limp.

 

Sean Early, MD

Children with leg length inequality, angular and rotational deformities of the lower extremities, foot deformities, torticollis, and upper extremity pathology such as Erbs palsy and trigger finger, are also commonly seen. Two of the more common disorders that are almost exclusively treated by pediatric orthopedists are hip dysplasia and childhood scoliosis.

 

Hip Dysplasia

Developmental dysplasia of the hip (DDH) occurs in 1 of 100 births. Risk factors include breech position, positive family history, first child, female gender, and any intrauterine “crowding” disorders such as oligohydramnios or twin birth. The left hip is involved 3:1. Critical parts of the newborn examination are the Ortolani maneuver (hip clunks and reduces into place with abduction) and Barlow maneuver (hip dislocates with gentle posterior pressure), which allow definitive diagnosis of hip dysplasia.

 

Michael Maguire, MD

 

Pavlik harness treatment gently relocates and maintains the hip in the acetabulum. If the hip remains unstable, it is repositioned into the acetabulum under general anesthetic and held in place with a spica cast (closed reduction). Children of walking age at presentation require a surgical or open reduction, one of the more difficult orthopedic procedures.

 

In children with long-standing dislocation, femoral and / or pelvic osteotomy is necessary to maintain stability of the reduced hip. Although remodeling of the acetabulum is expected over time, if the socket remains shallow, a pelvic osteotomy provides proper coverage of the femoral head and prevents early degenerative arthritis. Adolescent or young-adult patients with undiagnosed hip dysplasia present with a limp or pain after modest activity. In these patients, a much larger procedure, the periacetabular osteotomy, is performed. This requires cuts in three different pelvic bones to allow free rotation of the socket into proper position.

 

Childhood Scoliosis

Spinal pathology in children and adolescents is most commonly treated by pediatric orthopedists with specialized spinal deformity training. These disorders include kyphosis, congenital anomalies, spinal infections and trauma, but most often involve scoliosis. Scoliosis may be secondary to underlying pathology, such as congenital vertebral anomaly, neuromuscular disease or connective tissue disorders, but the vast majority of patients are otherwise healthy and have idiopathic scoliosis.

 

The occurrence rate for idiopathic scoliosis is as high as 3 percent, with the vast majority of patients never needing formal intervention. With curves approaching 20 degrees, referral to a pediatric orthopedist is imperative. Patients with curves greater than 20-25 degrees and significant growth remaining are usually treated with bracing to prevent further progression. Children with scoliosis that approaches 40-45 degrees, with significant growth remaining, are candidates for corrective surgery due to the very high incidence of continued deformity if untreated. Patients with curves greater than 45-50 degrees will have their curves progress throughout life, possibly resulting in pulmonary and cardiac sequelae; thus, corrective surgery is indicated.

 

The goal of surgery is to obtain bone fusion, thereby arresting curve progression by correcting the deformity with metallic anchors to the spine that are connected to straightening rods. Successful outcomes in these complex patients require not only specialized surgical training, but an entire team of specialized care providers. This includes pediatric orthopedic surgeons, anesthesiologists, pediatric critical care physicians, pediatric hospitalists, nurses, surgical scrub technicians, and respiratory, physical and occupational therapists who are uniquely trained and experienced in managing all facets of pre-operative, intra-operative, and postoperative care.

 

Cottage Children’s Hospital has a breadth of pediatric subspecialists and institutional experience that allows for optimal outcomes, while minimizing the risk of complications, for children with orthopedic disorders.


Hip Dysplasia: The pre-operative X-ray (left) shows a 4-year-old patient with a dislocated right hip and a subluxated left hip. The X-ray below at right shows the same patient after open reduction and pelvic osteotomy on the right hip and femoral osteotomy on the left hip.

 

 

Childhood Scoliosis: The pre-operative X-ray (below) is of a 14-year-old patient with 75 degree scoliosis. The X-ray on the right shows the same patient after surgical correction.

 

 


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