Winter 2005

Alternatives for Children with Scoliosis, Hip Dysplasia

Mohammad Diab, M.D.

Innovative procedures are offering children and young adults more options for treating developmental malformations of the hip and spine. Although some of the procedures are technically complex, they offer pediatric patients treatments that may be more effective and less traumatic, UCSF pediatric orthopedic surgeons say. Uncorrected spinal deformities like scoliosis need to be addressed when children are young, so that the spine can grow into a more normal position. If untreated, spinal deformities may worsen as the child grows, impairing physical activity or, in severe cases, affecting cardiopulmonary and spinal cord function.

Traditionally, scoliosis is treated with an external brace or, if severe enough, with surgical fusion of vertebrae in the proper position. UCSF orthopedic surgeons are now evaluating the use of novel instrumentation techniques without fusion for severe scoliosis in the very young and growing spine. This is done by placing implants that correct the curvature but do not stop growth. Correction is made by periodic small lengthening procedures until the child is sufficiently mature to undergo traditional spinal fusion surgery. The advantage of this approach is that it allows for spinal growth while controlling the curvature, thereby enabling more normal development of the heart and lungs.

UCSF orthopedic surgeons are also using a surgical stapling technique for older children (up to about 15 years) with scoliosis who are not willing or able to undergo bracing. In this procedure, vertebrae are bound together with surgical staples on the side where they most diverge. This stabilizes the spine, preventing curve progression, and may lead to reversal of the scoliosis as the child grows and the unstapled side expands.

UCSF Benioff Children's Hospital is a leading national center for developmental spinal deformities, where approximately 100 children undergo operations per year, according to UCSF surgeon Mohammad Diab, M.D., Adult and mature teenage patients suffering from developmental dysplasia of the hip now have a joint-conserving procedure as an alternative to joint replacement surgery.

Periacetabular osteotomy involves carving the acetabulum out of the surrounding pelvis and rotating it into better alignment with the femoral head, explains Diab, who is one of the few West Coast orthopedic surgeons who perform the procedure. "If the hip joint has dysplasia without significant degenerative changes, the best treatment is periacetabular osteotomy, as this preserves the patient's own hip, which is always better than replacement," says Diab, chief of Pediatric Orthopedics at UCSF Benioff Children's Hospital.

The incidence of developmental dysplasia of the hip is about one in 1,000, but most cases are detected in childhood and successfully treated with bracing. Approximately 10 percent will require surgical treatment. Some patients, however, aren't diagnosed until they are physically mature and begin to experience hip pain, often in the groin, in their teens and early adulthood.

Periacetabular osteotomy, devised in the 1980s by Dr. Reinhold Ganz of Bern, Switzerland, is gaining popularity in the United States, although it has been done on thousands of European patients. Diab says the procedure is a demanding one for the surgeon. It requires four principal cuts — including two "blind" cuts in which the surgeon can't actually see directly where he or she is cutting — to restore the normal location of the hip socket. "The surgeon has to understand the complex three-dimensional geometry of the pelvis to do this," says Diab, who has performed dozens of these procedures. "But the results have been gratifying, with excellent patient outcomes in the mature teenager and young and active adult."

Prior to the Ganz procedure, the available surgical options included so-called "salvage" pelvic osteotomies — in which the femoral head is covered with raw bone obtained from the adjacent pelvis — and ablative procedures. The latter include total hip arthroplasty, which is effective in relieving pain, but requires significant activity restriction to avoid accelerated loosening of the artificial components. Young arthroplasty patients also require at least one repeat operation because the components either wear out or loosen with time, no matter how careful the patient is.

On the other hand, the Ganz procedure is durable and should last for the patient's lifetime without restricting activity or requiring a subsequent operation. Diab adds that UCSF recently completed a study that indicates that the Ganz procedure is more cost-effective and beneficial to the skeletally mature teenager and young adult without advanced osteoarthritis than total hip arthroplasty. Although Diab and colleagues at UCSF have a particular interest in such specialty areas, they also offer the full spectrum of other orthopedic services, Diab says.

For more information, contact Dr. Diab at (415) 353-9384.

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