Prof. Dr. Nurullah Ermiş
Pediatric Orthopedics
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Pediatric orthopedics is a subspecialty that encompasses the diagnosis, treatment, and long-term follow-up of congenital and developmental disorders of the musculoskeletal system — bones, joints, muscles, and nerves — in children from birth through adolescence. The pediatric skeleton differs fundamentally from the adult skeleton: growth plates (physes) are active and vulnerable, bone modeling and remodeling are ongoing, and the appropriate treatment for the same pathology may differ dramatically by age. These characteristics make dedicated pediatric orthopedic expertise indispensable in both diagnosis and treatment. Early identification and timely intervention prevent many congenital conditions from causing major disability later in life and lay the foundation for the child to lead a healthy, active, and independent life.
Developmental dysplasia of the hip (DDH), clubfoot (pes equinovarus), adolescent idiopathic scoliosis, limb length discrepancies, congenital bone deformities, osteogenesis imperfecta, Perthes disease, and childhood fractures are among the primary treatment areas in pediatric orthopedics. Detecting hip instability on newborn examination, interpreting hip ultrasonography in infancy, and reading school-age spinal screening results illustrate how early in a child's life the pediatric orthopedic surgeon's role begins.
Prof. Dr. Ermiş's pediatric orthopedic practice includes DDH management across all stages from Pavlik harness to open surgical reduction, clubfoot treated with the Ponseti method, early-onset scoliosis managed with VBT and growing-rod systems, limb-lengthening surgery using the Ilizarov external fixator, Taylor Spatial Frame (TSF), and the PRECICE magnetic intramedullary nail, correction of rotational deformities, genu valgum and varum correction, and the care of childhood fractures.
The defining feature of pediatric orthopedics is that treatment is aimed not only at correcting the current deformity, but also at predicting how the growing skeleton will develop over time. For this reason, pediatric orthopedic evaluation must include growth plate status, gait pattern, muscle balance, family history, and developmental milestones, with long-term follow-up planning established from the beginning whenever needed.
Pediatric orthopedic decision-making also depends heavily on age-specific timing. A condition that can be managed with a harness, cast, or guided-growth technique in infancy or early childhood may later require a much more extensive procedure if diagnosis is delayed. For that reason, regular follow-up, parental awareness, and early specialist evaluation are central not only to treatment success, but also to reducing the need for major surgery in the future.
Another essential feature of pediatric orthopedics is close communication with the family. Treatment often includes long-term brace use, serial casting, rehabilitation, growth monitoring, and repeated imaging over time. When families understand the condition, the treatment stages, and the importance of adherence, outcomes improve significantly and the child is more likely to maintain healthy growth, gait, and functional independence.
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- Asymmetric leg skin folds or apparent leg length discrepancy in infants
- Limping, a wide-based gait, or difficulty climbing stairs in a child
- Feet turning inward (metatarsus adductus, tibial torsion) or outward
- Visible leg length inequality and pelvic obliquity
- Spinal curvature — particularly scoliosis that accelerates during adolescence and causes asymmetric clothing fit
- Marked slowing, stagnation, or deviation from the expected percentile in height growth
- Pain, swelling, and deformity following a fracture
Tedavi Yöntemleri
Developmental Dysplasia of the Hip (DDH)
Developmental dysplasia of the hip (DDH) describes a spectrum of conditions in which the acetabulum and femoral head are in an incompatible relationship during development; the incidence in newborns is approximately 1 to 2 per 1,000 live births. In infants aged 0 to 6 months, treatment with a Pavlik harness achieves success in over 90% of cases by maintaining the hip in a stable abduction-flexion position that allows the femoral head to seat concentrically within the acetabulum and stimulates normal joint development. Between 6 and 18 months, closed reduction under general anesthesia and spica cast immobilization are used, with progressive cast changes to maintain the corrected position. In children over 18 months and in failed closed reduction cases, open surgical reduction is required, often combined with femoral or pelvic osteotomy to achieve and maintain stable reduction. The most critical determinant in DDH treatment is the time window: treatment initiated within the first 3 to 6 months of life offers success rates of 90 to 95%, while late diagnosis leads to significantly more complex treatment and poorer long-term outcomes.
Clubfoot — Ponseti Method
Congenital clubfoot (pes equinovarus) is a complex three-dimensional foot deformity composed of equinus (plantar flexion), varus (inward rotation), adduction, and cavus (elevated arch) components. Early diagnosis and application of the Ponseti method successfully treat the vast majority of cases. The method consists of serial casting — applied weekly from birth, typically for 5 to 7 applications — in which each component of the deformity is corrected in a specific sequence. This is followed by a minor procedure: percutaneous Achilles tendon lengthening (tenotomy) to eliminate the equinus component. In the final phase, a Denis Browne bar and boot orthosis is used full-time until 3 months of age, and then only at night until age 3. When this protocol is applied in full, over 90% of cases are successfully treated without major surgery; the principal determinant of success is family education and adherence to the orthosis-wearing regimen.
Limb Lengthening Surgery
Controlled bone lengthening, or distraction osteogenesis, exploits the ability of bone-forming cells to generate new bone in response to gradual mechanical tension. It is indicated for leg length discrepancy, short stature secondary to achondroplasia or other skeletal dysplasias, Ollier disease, and growth plate injuries from trauma. The Ilizarov external fixator or Taylor Spatial Frame (TSF) — a ring-and-wire construct placed around the bone — enables both lengthening and three-dimensional correction of rotational and angular deformities simultaneously. The PRECICE magnetic intramedullary nail is a modern alternative in which lengthening is driven by an external remote controller without any hardware on the skin surface, substantially improving patient comfort. The standard distraction rate is 1 mm per day; approximately 2 months are calculated for each 1 cm of length gained — 1 month of active distraction followed by 1 month of consolidation. Concurrent physical therapy and rehabilitation are integral to the process.
Sıkça Sorulan Sorular
How can hip dislocation be recognized in babies?
Newborn DDH screening involves two complementary approaches: the Ortolani and Barlow clinical maneuvers test for hip instability on physical examination; hip ultrasonography is recommended for all infants within the first 4 to 6 weeks after birth to confirm the diagnosis. The Galeazzi sign (asymmetric knee heights), asymmetric thigh skin folds, resistance to hip abduction, and an apparently shorter limb are findings that raise suspicion on examination. Risk factors — female sex, swaddling, breech presentation, and family history — heighten the importance of screening.
Can clubfoot be treated without major surgery?
Yes. When the Ponseti method is applied correctly and family compliance with the orthosis protocol is maintained, over 90% of clubfoot cases can be successfully treated without major surgery. Only a minor Achilles tenotomy — a short procedure performed under local anesthesia — may be needed and is not considered major surgery. The single most important factor determining treatment success is family education and strict adherence to brace wearing.
How long does limb lengthening take?
The duration depends on the amount of lengthening planned, the bone being lengthened (tibia vs. femur), and the patient's overall health. As a practical estimate, approximately 2 months are allocated for each 1 cm gained: 1 month of active distraction and 1 month of bone consolidation. For example, a planned 5 cm lengthening would require approximately 10 months in total. Regular radiological monitoring and physical therapy support throughout this period are mandatory.
When does scoliosis in children require surgery?
In growing children, observation is recommended for Cobb angles below 25 degrees, and bracing (TLSO) is recommended between 25 and 45 degrees during active growth. When the curve continues to progress despite bracing and the Cobb angle exceeds 45 degrees, surgery is indicated. In adolescents with growth potential (Risser 0 to 2), VBT offers fusionless correction; in patients who have completed growth, posterior spinal fusion is preferred. In neuromuscular scoliosis, surgical indications are assessed at lower thresholds.
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