Before Surgery in Pediatric Orthopedics

Operative Indications

Operative procedures are the most definitive mode of treatment in pediatric orthopedics. The outcome of the procedure is largely determined by the judgment and skill of the surgeon. Children have both greater healing potential and fewer complications than adult patients, increasing the chances for a successful outcome.

Indications for operations include alleviating pain, limited function, and unsatisfactory appearance, as well as a means of preventing future disability. Prophylactic operations are appropriate only when the natural history is known and serious disability is relatively certain. In some, the need for surgery is well accepted; in others, persisting deformity is unexpected.

Management options Orthopedists can choose from among a wide range of treatment options. First, try a nonoperative treatment, if there is a reasonable chance of success. If the patient has a tarsal coalition and pain, immobilize the foot in a cast for several weeks as a trial. If the pain recurs, excise the bar. If the family is seeking multiple consultations, it is often wise to start with an nonoperative approach. If the family is uncertain, and waiting will not jeopardize the outcome, simply delay the needed operative correction until the family is ready to make a decision.

Conservative management Sometimes an operation is the most conservative of the treatment options. If so, proceed with this treatment first. This approach benefits both the family and child. There are a number of classic examples in which delay in operative correction has harmed the child. A 12-year-old girl with a 50-degree right thoracic scoliosis was given a trial treatment with a brace and physical therapy for several years, only to have the 60-degree curve instrumented and fused at age 15. This unfortunate girl experienced the hardships of 3 years of unnecessary brace treatment. Long-term brace treatment is not a benign option; it is often a psychologically damaging experience. In another case, a child with cerebral palsy and a subluxation of the hip was managed by physical therapy. Subluxation progressed to dislocation. An early adductor lengthening or transfer would have been the conservative approach.

Cosmetic disability A cosmetic disability may justify operative correction. Unsightly genu varum or valgum may be corrected by a hemiepiphysiodesis. An abductor lurch may be corrected with a trochanteric transfer. A severe kyphotic deformity may justify instrumentation, correction, and fusion. Each treatment carries risks. Weighing the risks and benefits is often difficult.

Family’s Role Provide factual information regarding risks and benefits of each alternative, and then allow the family to choose among the medically acceptable options. Be aware that issues concerning body image peak during early adolescence. What is bothersome at age 14 may become acceptable at age 17. Delay the correction of marginally disabling deformities until it is clear that the concern is lasting. Performing an unnecessary operation just because the parent wishes to do something is not appropriate. First and foremost, the orthopedist is the advocate of the child.

Preoperative Planning

During the final preoperative evaluation, think through each step of the procedure to make certain that the preoperative planning is complete. Be certain that special tools or implants will be available.

Anticipate Possible Complications Look for problems that may complicate the procedure. The most common problems are respiratory infections and skin lesions. Check the temperature, evaluate the ears, throat, and lungs. Examine the skin about the operative site for inflammation. The decision regarding respiratory status is generally made by the anesthesiologist. It is usually wise to reschedule the procedure if the child has an unexplained fever, a respiratory infection, infected or inflamed skin lesions in the operative area, or documented exposure to a contagious disease, such as chicken pox or measles. Make certain the family understands the procedure and follow-up plans. Use a model or a skeleton to explain the operation to the family.

Discharge Plans Make discharge plans at this time. Arrange for adaptive equipment necessary for home care. If the child will be using crutches or splints after the procedure, make fittings before the operation. Plan transportation home and anticipate special needs. Plan for home teaching if the child will be away from school for more than two weeks. Make certain someone will be available to care for the child at all times.

Preparing the Child Prepare the child for the operation with a simple and honest explanation. Describe the procedures in terms appropriate to the child’s or adolescent’s age, and detail what he or she is likely to experience. Use the material in the reference section of this book and use models. A teddy bear in a spica cast is a useful model for young patients. Let the child make choices wherever it is possible; for example, let the child choose the color of the cast. Arrange for the child to tour the hospital. All of these measures will help to reduce fear and to build a positive attitude toward the experience and the doctor.

Special Operative Needs Be certain fixation, bank bone graft, special tools, or implants will be available.

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