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Paediatric orthopaedic surgery: a worrying future?

Manuel Cassiano Neves
1 July, 2006  

Manuel Cassiano Neves MD
Head
Orthopaedic Department
Lisbon Children’s Hospital
Portugal
Chairman
Education and Events
The European Federation of the National Associations of Orthopaedics and Traumatology
W: www.efort.org

It is commonly thought that children are like adults – they just come in a smaller size. But because children are still growing, their anatomy differs from that of adults. As a consequence their response to injuries, infections and deformities may also be quite different.

This distinction is particularly important in relation to children’s bones and joints, and all other conditions affecting the musculoskeletal system (eg, certain neurological diseases). It is therefore crucial that orthopaedic surgeons be trained to deal with these conditions. They need to gain experience in dealing with anxious parents and grandparents, and working in a child-friendly environment.

Over the past years, orthopaedic surgery has become a very attractive field for the young surgeon due to recent innovations – mainly in the fields of joint replacement, sports medicine and spine surgery. This was not the case in paediatrics. For this reason we have recently seen a fall in the number of young surgeons applying for fellowships in paediatric orthopaedics, not only in the US but also in Europe. This is a frightening prospect.

Advances in paediatric orthopaedics
Paediatric orthopaedic surgeons have been dealing with practically the same conditions since 1741, when Parisian paediatrician Nicholas Andry established the discipline with L’Orthopaedie, his treatise on the art of correcting and preventing deformities in children. In recent years we have seen several developments in paediatric orthopaedics, due to a more comprehensive knowledge of different conditions and to innovations in the hardware.
 
With the development of the internet, information has become available in an easier and faster way. Parents are now assuming a more direct role in planning their children’s treatment. This was the case with treatment for clubfoot, which is now moving towards a more conservative approach under the guidelines of the Ponseti method (Figure 1), outlined almost 50 years ago. This is only being accepted now due to pressure from parents who have learned about this treatment on the internet.

[[HHE06_fig1_T10]]

Neurological conditions that involve the musculoskeletal system, such as cerebral palsy and spina bifida, have in recent years been affected by major improvements in orthopaedic treatment. The development of new laboratories for gait analysis has permitted a better understanding of different issues and has, more relevantly, validated the surgical results.  Moreover, the introduction of medicaments like botulin toxin or baclofen pumps in the last decade has improved the quality of life for patients affected by these conditions.

In the hardware field we have seen new developments dedicated to treating deformities that develop during growth – not only deformities of the long bones but also those of the spine. Scoliosis was identified a long time ago – and the first surgery to correct this deformity was described by Hibbs and Albee in 1911. Arthrodesis has been the correct approach for idiopathic scoliosis, but when dealing with a congenital deformity it is more difficult to implement due to its effects on a growing spine. Recent innovations in spine hardware have made the hardware systems smaller while maintaining their mechanical properties, which allows earlier surgery. Furthermore, such innovations have also made hardware systems dynamic, which allows for extending the construction during growth. This represents a major benefit for children suffering from the condition.

Additionally, new advances in the design of external fixations have been made since the innovative techniques outlined by Ilizarov in 1951 for treating deformity of the long bones – heralding a better knowledge of bone biology and growth. The new generation of external fixators, such as the Taylor Frame, use sophisticated computer programs to preoperatively analyse the deformities, helping to design the frame construction that could correct the problem and also give the settings to obtain an anatomical axis of the long bone. The involvement of bioengineers is becoming more vital for evaluating certain children’s orthopaedic conditions and planning correct treatment. This is particularly true also for the application of prostheses; for example in tumours where, due to the growth of the child, the prostheses need to increase with age.

Arthroscopy in children and adolescents is becoming more popular. In the past, meniscal tears and cruciate ligament injuries were seen as typical of the adult population. With the increase of sports activities and better devices for arthroscopy in children these lesions are now seen frequently in young patients. As a result, new techniques have been developed to treat these conditions in this group. In order to avoid disturbing the normal growing process, reconstructive surgery of the ligaments protecting the growth plates and meniscal are used.

Training
The intervention of the paediatric orthopaedic surgeon will be increasingly necessary in the future. It is fundamental to launch a training programme in paediatrics that will be attractive to the general orthopaedic surgeon. Most conditions in children can and should be treated by the general orthopaedic surgeon, but cases involving congenital deformities, genetic or metabolic disorders should be treated by a specialist. Although the Union European de Médecins Specialisés (UEMS) does not recognise paediatric orthopaedics as a subspecialisation of orthopaedics, training in this field is mandatory to treat these conditions and their specific effect on growing children.
 
Orthopaedic training varies from one country to another within Europe; the way orthopaedic care is provided in each country also varies accordingly. When uniform rules within the EU are being established, it is vital to establish training programmes that will meet the requirements of each country as well as requirements to practise all over Europe. In 2000 the first European Board of Orthopaedics and Traumatology (EBOT) exam was established in Greece with the goal of creating a uniform method of evaluation in Europe. But it is first necessary to provide the applicants with material to study and enhance their knowledge so that they can prepare for the examination.

EFORT’s role
The European Federation of the National Associations of Orthopaedics and Traumatology (EFORT) is responsible for looking into these problems and works to standardise the different teaching programmes, while assuring the feasibility of national programmes. It is also important to launch specialised courses in the different branches of orthopaedics and, in particular, paediatric orthopaedics.

This is why EFORT is working with the “pyramid concept”: it consists of a series of events, starting from the basic principles directed at residents and operating room personnel, and ending with the experts. This concept relies on the experience of the instructors for each level of teaching and it should be practically oriented. The cooperation of specialty associations is fundamental to the success of such a teaching programme. They represent the highest scientific knowledge in every subspecialty, and can offer the most valuable contribution towards designing and producing the programme.

Next year EFORT is launching a programme in collaboration with UEMS with the aim of providing residents throughout Europe with the right material for preparing for the final EBOT exam, particularly in the children’s field. These courses can be repeated in different regions of Europe, with the aim of spreading information as much as possible.

European orthopaedic surgeons must be aware that we have to prepare orthopaedic surgeons to deal with special children’s conditions. It is becoming increasingly difficult to find the right surgeon for each specific problem. The European Paediatric Orthopaedic Society (EPOS) will be called upon to provide resources for launching the “ExMex” (Experts meet the Expert) programme. These courses will be designed for a small group of participants, focusing on clinical aspects and hands-on exercises.  With these courses we hope to have highly educated surgeons in the field of paediatric orthopaedics in the years to come.

Further reading

  1. Wenger DR, Rang M. Art and practice of children’s orthopaedics. New York: Raven Press; 1992
  2. Fazzi E, Maraucci I, Torrielli S, Motta F, Lanzi G. Factors predicting the efficacy of botulinum toxin-A treatment of the lower limb in children with cerebral palsy. J Child Neurol 2005;20:661-6.
  3. Hell AK, Campbell RM, Hefti F. The vertical expandable prosthetic titanium rib implant for the treatment of thoracic insufficiency syndrome associated with congenital and neuromuscular scoliosis in young children. J Pediatr Orthop B 2005;14:287-93.
  4. Feldman DS, Madan SS, Koval KJ, van Bosse HJ, Bazzi J, Lehman WB. Correction of tibia vara with six-axis deformity analysis and the Taylor Spatial Frame. J Pediatr Orthop 2003;23:387-91.