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Complex Cases
PEDIATRIC ORTHOPAEDICS
45

Complex Cases

A review of recent challenging cases

Orthopaedic surgeons Roger F. Widmann, MD, Daniel W. Green, MD, MS, and John S. Blanco, MD, present recent cases on deformity correction and limb lengthening after neonatal osteomyelitis, repair of severe osteochondritis dissecans and control of early-onset scoliosis.

Complex Deformity Correction and Limb Lengthening after Neonatal Osteomyelitis
PRESENTED BY ROGER F. WIDMANN, MD

A three-year-old patient presented to HSS with a prior history of neonatal osteomyelitis, which affected multiple bones and physes simultaneously. She was treated with eight weeks of intravenous antibiotics at an outside institution around the time of birth, and she presented about two and a half years later to HSS Lerner Children’s Pavilion with multiple developing orthopaedic problems. The prior infection was in both hips and knees, as well as her left shoulder, and had caused significant damage to multiple growth plates. The most pressing concerns were subluxation of the left hip and complete destruction of the left proximal femoral physis. The physes of the left proximal humerus and both distal femurs were damaged.

(Age 3-6) Pre-op: S/P Perinatal OM with multiple growth plate arrests and limb deformities. (Age 6.5) 2016: During TSF Tx (for correction of valgus + LLD). (Age 8) 2017: S/P hemiepiphysiodesis + Lt hip varus correction. (Age 11) 2020: On completion of PRECICE Tx.

Over the course of several years, the left distal femoral physis closed prematurely. This complete physeal arrest combined with her left proximal femur growth arrest resulted in a predicted 16cm limb length discrepancy at maturity. Additionally, both knees were growing into valgus.

The goal of treatment was to minimize the total number of interventions, control the deformities, and preserve her function as much as possible between surgical interventions. This began with a series of simple guided growth procedures, which worked initially while the growth plates were still open, until complete growth arrest occurred in the left knee.

THE GOAL OF THE TREATMENT WAS TO MINIMIZE THE TOTAL NUMBER OF INTERVENTIONS... and preserve her function as much as possible.

At the initial evaluation, prior to addressing the length discrepancy, David M. Scher, MD, performed an osteotomy of the left hip to stabilize the joint and prevent dislocation. The patient and the surgical team agreed upon a course of three staged femoral lengthening procedures. The first femur lengthening, performed when the patient was age five, was a traditional lengthening of 6cm using a Taylor spatial frame. By age nine years, the orthopaedic technology had advanced greatly and the patient underwent a 5cm femur lengthening using an intramedullary magnetically controlled lengthening rod. All the while she was closely monitored and underwent intermittent guided growth procedures to maintain limb alignment.

A final limb lengthening of 5cm is planned for the first half of 2021, when the patient is 11; an exchange nailing will be performed using a longer magnetically controlled lengthening rod in order to achieve equal limb length at maturity.

Repair of Severe Osteochondritis Dissecans with Particulated Juvenile Cartilage Implantation
PRESENTED BY DANIEL W. GREEN, MD, MS

A ten-year-old male who played competitive soccer presented with an unusually advanced case of osteochondritis of the knee. He came to HSS after elsewhere receiving a recommendation of activity modification to allow the injury to heal on its own. Based on the magnitude of the advanced degree of bone and cartilage disease associated with the lesion, the HSS team recommended cartilage restoration in order to restore anatomy and function so that the patient had the best chance possible to return to sport for many years to come.

In late 2018, the patient received an arthroscopic assisted particulated juvenile cartilage implantation to repair the articular cartilage damage. Juvenile allograft tissue has 10 times more chondrocyte density than adult tissue and does not elicit an allogeneic immune response. The graft is implanted in a single stage procedure with fibrin glue fixation.

The patient’s recovery plan included physical therapy along with one month on crutches and abstention from sports for six months. The patient has experienced restoration of function. MRI demonstrates impressive healing and restoration of the joint surface. Two years after the surgery the teenager reports zero pain and has returned to sports.

The patient has experienced restoration of function.… Two years after the surgery the teenager reports zero pain.
Control of Early-Onset Scoliosis with MAGEC Rods
PRESENTED BY JOHN S. BLANCO, MD

A three-year old male presented with an underlying diagnosis of congenital hypotonia along with failure to thrive and an early-onset scoliosis. At presentation his curve was 25 degrees. He was initially braced for his scoliosis and was always compliant with his full-time brace wear (16-20 hours a day). Brace management successfully prevented significant curve progression for several years, but by the age of nine his curve had worsened significantly and we were unable to effectively control his curve. Surgical intervention was necessary.

At this time, his height was in the 14th percentile and his weight was below the first percentile with a BMI of lower than first percentile. His thoracic curve was in the mid-60s.

The options were to 1) perform a formal fusion and instrumentation, which would correct the deformity with certainty but block any further growth in a significant part of his spine or 2) perform a growth-friendly procedure, which would provide internal control of his scoliosis while also allowing for ongoing growth. Given his young age and small stature, the team opted for the latter.

In November 2018, at age 10, he underwent insertion of MAGEC (MAGnetic Expansion Control) rods, a growth-sparing technique that entails the placement of two titanium magnetically controlled growing rods anchored proximally and distally at the ends of his curve.

single media

Since that time, his rods have been lengthened in the office every few months without sedation via a remote device mimicking the normal growth of the instrumented spinal segments. In the two years since insertion of the MAGEC rods his spine has grown 2 inches, his curve has been well controlled and he is brace free for the first time in years.

his spine has grown 2 inches, his curve has been well controlled and he is brace free for the first time in years.

At or near skeletal maturity, he will require conversion of the MAGEC rods to a formal instrumentation and fusion. But by that time we will have maximized his truncal height as well as his thoracic spine and pulmonary capacity.

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