Orthopedic devices in the growing child

During middle childhood, many orthopedic appliances are frequently used to treat skeletal trauma or to correct a variety of deformities. Device use in this age group should take into account the ongoing physical growth of these children, as well as their high energy level and active lifestyle. Long-bone fractures occur frequently and are different from those seen in adulthood. The healing and remodeling abilities of developing bones in children are greater, and care must be taken to avoid long-term growth problems. Problems with non-union are rare, and some non-displaced fractures may need only minimal intervention, either simple splinting or casting. However, there may be separation or damage to the epiphysis (growth plate) and these fractures require open surgical reduction with device fixation and pinning. Device technology has evolved and flexible plastic nails are now commonly used to treat many fractures, but overly active and often non-compliant children may still be at risk for re-fracture of these mended bones.

Adverse fracture sequelae may manifest as different types of growth disturbances, including: premature partial closure of the growth plate, leading to angular deformity; complete interruption of the growth plate, resulting in the affected leg being shorter than the other; or, conversely, as the fracture heals there may be increased blood supply and overgrowth of the affectedbone. Femoral fractures pose a particular challenge when they occur in the school-aged child. Very different from young pre-school children who are treated with spica casts, school-aged children are not skeletally mature, need to be mobile, must attend school, and have higher risk for problems associated with prolonged bed rest. These factors have led to an increased use of internal and external fixation devices in this age group [36-38]. Rigid intramedullary nails inserted into growing young children may be used; however, according to the results of a 1998 survey of pediatric orthopedists, avascular necrosis of the femoral head may rarely occur, and intramedullary rods are not recommended in children initially treated with external fixation because of an increased risk of infection [39,40]. Elastic nails are increasingly being used to treat closed femoral fractures and have the advantages of being minimal invasive, resulting in good callus formation with little scarring, showing very low rates of re-fracture and infection, and allowing the child's early return to activities [41].

Long-term follow-up success for most musculoskeletal repairs really should not be judged until after skeletal maturity and 'injury to a growing bone is always prone to long-term complications that may influence the patient's entire life' [42]. Mechanisms of injury, healing, and complications are also different for childhood spinal injuries involving the thoracic and lumbar areas [43]. An increasing number of case series reports of late-onset infections in pediatric spinal surgeries is of concern, with varying incidence rates of 1-7% [44]. One ofthe largest case series (n = 937) found a 5% incidence of late-onset infections up to 8 years following spinal surgeries to correct spinal deformities of congenital, neuromuscular, and idiopathic types of scoliosis [45]. The etiology of late-onset infections (greater than 1 year postoperative posterior fusion for idiopathic adolescent scoliosis and congenital scoliosis types) has been thought to relate to the bulk of the implant materials, reaction to metal components, and possible contamination at the time of surgery. These severe complications pose additional challenges for surgeons regarding reimplantation, so as not to lose the spinal curve correction. They highlight the need for longer-term follow-up studies.

Recently there has been much interest in evaluating outcomes for children undergoing spinal and other musculoskeletal instrumentation for various orthopedic conditions of childhood, especially spinal disorders (congenital scoliosis, idiopathic scoliosis, and kyphosis). A special survey instrument, the Pediatric Outcomes Data Collection Instrument (PODCI) questionnaire, has recently been shown to be reliable and valid in the assessment of function, disability, and patient satisfaction for children aged 2-18 years with different musculoskeletal conditions, and is used to compare endpoints with normal same-age children [46]. This instrument includes interview information from both the child and parent, with assessment of efficacy and child satisfaction related to their medical conditions and orthopedic interventions with regards to comfort, pain, function including participation in sports and other activities, and overall satisfaction. It importantly aims to better understand both functional and emotional outcomes for children [47].

Advances and innovations in device technology have led to the use of newer implants, including bio-absorbable fracture fixation devices and mechanical growth plates, but these have not been well studied and for the most part are off-label devices for children. Resorbable fixation devices are increasingly being used in the repair and construction of craniofacial defects and injuries, which pose unique challenges for restoration of growth and function. While enthusiasm for their use continues, with a recent large cohort study (1883 pediatric patients) reporting a lower rate of reoperation than for metal implants [48], an earlier retrospective study of 100 very young pediatric patients who received resorbable plates with metal screws for bony craniofacial abnormalities and defects emphasized the need for further study of potential problems and long-term complications, such as stability, possible foreign body reactions, and infection [49].

Certain spinal disorders unique to childhood, such as severe congenital scoliosis, have led to the development of devices, such as spinal growing rods and the Vertical Expandable Prosthetic Titanium Rib implant (VEPTR), that aim to address special problems of spine fusion procedures performed during childhood. Recent studies suggest that early spinal fusion results in loss of thoracic volume with restricted lung growth and sometimes may result in significant pulmonary morbidity [50]. Other growing rods and the use of anterior spinal stapling are currently being studied. Much of the rationale for newer orthopedic devices has emerged from anecdotal clinical experience, device improvisation, and expert opinion, rather than through an evidence-based approach and conduct of pediatric clinical trials. Further survey and cross-sectional studies of young children are desperately needed.

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