317 C OPYRIGHT Ó 2016
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Specialty Update
What’s New in Pediatric Orthopaedics Jeffrey E. Martus, MD, MS, Norman M. Otsuka, MD, and Derek M. Kelly, MD Investigation performed at the Division of Pediatric Orthopaedics, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
Over the past year, a substantial number of high-quality studies were published that are relevant to the clinical practice of pediatric orthopaedics. Additionally, in an effort to improve the care of pediatric patients, the American Academy of Orthopaedic Surgeons (AAOS) updated and reissued the 2009 Clinical Practice Guideline on the treatment of pediatric diaphyseal femoral fractures1. The AAOS also recently adopted Appropriate Use Criteria for pediatric supracondylar humeral fractures with vascular injury2. Spine Multiple database studies demonstrated trends in the management of pediatric spinal deformity. Martin et al. reviewed the Nationwide Inpatient Sample (NIS) from 2001 to 2011 and found that spinal fusion rates for adolescent idiopathic scoliosis have remained stable, but anterior fusion declined by 80%3. The mean hospital charges increased by 113%, from $72,780 in 2001 to $155,278 in 2011. The mean annual increase in hospital charges to treat adolescent idiopathic scoliosis was 11.3%; in comparison, charges for nonspine conditions increased 4.5% to 6% annually. Martin et al. suggested that spinal implant costs may be a substantial driver of increased charges. Vigneswaran et al. performed a similar study with the Kids’ Inpatient Database (KID) and estimated that the incidence of surgical procedures to treat adolescent idiopathic scoliosis had increased from 0.58 admission per 10,000 individuals per year in 1997 to 0.74 admission per 10,000 individuals per year in 20124. From 1997 to 2012, the mean hospital length of stay had decreased from 6.5 to 5.6 days. Similar to these studies of adolescent idiopathic scoliosis, in their study Jain et al. reviewed the NIS and noted that the utilization of spinal fusion for Scheuermann kyphosis increased by 2.9 times from 2000 to 20085. As noted for adolescent idiopathic scoliosis, treatment Specialty Update has been developed in collaboration with the Board of Specialty Societies (BOS) of the American Academy of Orthopaedic Surgeons.
has shifted toward posterior spinal fusion, but anterior-posterior fusion rates declined by 7% per year. Lower complication rates and shorter hospitalizations were noted with posterior spinal fusion compared with anterior-posterior fusion. There have been substantial efforts at quality improvement for the surgical procedure to treat spinal deformity. In an attempt to minimize neurologic complications during this procedure, a combined Scoliosis Research Society and Pediatric Orthopaedic Society of North America task force led the development of an intraoperative checklist to optimize the response to neuromonitoring changes and created a best practice guideline6. Risk factors for surgical site infection after a pediatric spine surgical procedure were also investigated. Croft et al. performed a matched case control study and found that neuromuscular scoliosis, weight for age at the ‡95th percentile, American Society of Anesthesiologists score of ‡3, and prolonged operative time were associated with a higher risk of surgical site infection7. In a retrospective series, LaGreca et al. found that the rate of delayed surgical site infection following instrumented spinal fusion was six times higher in patients with stainless steel implants compared with patients with titanium implants8. Propionibacterium acnes was the most common organism in the delayed group; this pathogen was not cultured in any of the patients with titanium implants. Further research is required to determine if titanium implants are protective against infection with this organism. Martin et al. evaluated readmissions after the surgical procedure to treat pediatric spinal deformity utilizing the National Surgical Quality Improvement Program (NSQIP) pediatric database in 20129. The rate of unplanned thirty-day readmission was 4.0% and was highest in patients with neuromuscular deformity (6.8%) and those with congenital deformity (6.3%). Surgical complexity and medical comorbidities were associated with readmission. The most common reasons for readmission were wound complications (73.3%) and gastrointestinal complications (13.3%), suggesting that
Disclosure: The authors received a stipend for this work from JBJS; the authors donated this stipend to the Pediatric Orthopaedic Society of North America (POSNA). On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author (or the author’s institution) had a relevant financial relationship in the biomedical arena outside the submitted work.
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What’s New in Pediatric Orthopaedics quality improvement programs should target these areas to minimize the risk of readmission. A definition of early-onset scoliosis as “scoliosis with onset less than the age of ten years, regardless of etiology” has been endorsed by the Growing Spine Study Group, the Children’s Spine Study Group, the Scoliosis Research Society, and the Pediatric Orthopaedic Society of North America10,11. Additionally, a group of experienced surgeons developed and provided initial validation of the Classification of Early-Onset Scoliosis (C-EOS)12. Hip The modified Dunn osteotomy is a powerful procedure for correction of slipped capital femoral epiphysis; however, there are substantial potential complications. Upasani et al. reviewed the results of modified Dunn osteotomy for twenty-six unstable and seventeen stable slipped capital femoral epiphyses13. There were twenty-two complications in sixteen patients, including osteonecrosis (23%), femoral neck nonunion (9%), and postoperative hip dislocation (5%). Because of the high complication rate and an inverse relationship between surgeon volume and patient outcomes, the authors’ practice was modified such that the operation is considered only for patients with acute slipped capital femoral epiphysis with severe displacement (>50°) of the epiphysis and when treatment can proceed within twenty-four hours of the slip with a high-volume surgeon present during the procedure. Novais et al. compared the outcomes of patients with severe stable slipped capital femoral epiphysis treated with in situ fixation (n = 15) or a modified Dunn realignment (n = 15) with a mean follow-up of 2.5 years14. Good or excellent results were achieved in a higher proportion of the modified Dunn cohort. The complication rate was similar between cohorts and each had a case of osteonecrosis; however, the reoperation rate was greater in the in situ fixation cohort because of subsequent reconstructive procedures, including intertrochanteric osteotomy and/or surgical hip dislocation with osteochondroplasty. Multiple studies investigated risk factors for complications following periacetabular osteotomy for acetabular dysplasia. In a prospective multicenter study, Zaltz et al. analyzed complications graded with the modified Clavien-Dindo grading scheme15. Major complications (grade III or IV) were noted in 5.9% of 205 patients with a mean age of 25.4 years. There was a nonsignificant trend associating complications with male sex and obesity. Novais et al. conducted a multicenter review of eighty-four adolescents (mean age, 16.5 years) following periacetabular osteotomy and found that the odds of a complication were ten times higher for an obese patient (body mass index [BMI] of >95th percentile) than for a non-obese patient16. A similar study in 280 adult patients found that obesity (BMI of >30 kg/m2) was an independent risk factor for greaterseverity complications after periacetabular osteotomy17. A higher frequency of comorbidities such as attentiondeficit hyperactivity disorder and adult cardiovascular disease has been reported for Legg-Calv´e-Perthes disease. Hailer and Nilsson identified 4057 patients with Legg-Calv´e-Perthes disease in the
Swedish Patient Registry from 1964 to 201118. In comparison with matched controls, patients with Legg-Calv´e-Perthes disease had an elevated hazard ratio of 1.5 for attention-deficit hyperactivity disorder, 1.3 for depression, and 1.2 for mortality. The mortality risk was 2.9 times greater from suicide and 1.2 times greater from vascular disease for patients with Legg-Calv´ePerthes disease. These findings are concerning; however, it is unclear if patients with Legg-Calv´e-Perthes disease would benefit from routine psychiatric or cardiovascular screening. Management of the infant with clinically stable hips with sonographic abnormalities has been controversial. Pruszczynski et al. reviewed a retrospective cohort with prospectively collected data to determine the natural history of clinically stable hips (negative Barlow and Ortolani signs) with sonographic instability by the Harcke method in infants younger than two months of age19. Sonographic acetabular dysplasia on the basis of femoral head coverage or acetabular inclination (Graf a angle) was variably present. Patients were not treated, swaddling was not permitted, and patients were followed until normalization of the acetabular index to £25°. All patients’ radiographs normalized by the age of three years without treatment. Breech presentation and cesarean delivery correlated with delayed normalization. Neuromuscular Conditions Prevention of hip dislocation may avoid pain and the need for a salvage surgical procedure in patients with cerebral palsy. H¨agglund et al. reported the twenty-year follow-up on a populationbased hip surveillance program from southern Sweden 20 . In comparison with a historical cohort in whom the rate of dislocation was 8%, the Cerebral Palsy Follow-Up Programme (CPUP) reduced the rate of dislocation to 0.5% among 258 children born from 1992 to 1997 and 0% among 431 children born from 1998 to 2007. However, a preventative surgical procedure was utilized in 13% of the study population. Koch et al. investigated the incidence of and risk factors for osteonecrosis after treatment of complete hip dislocations with open reduction, proximal femoral osteotomies, and Dega pelvic osteotomies21. Among 115 hip dislocations, there was evidence of osteonecrosis in 68.7%; risk factors include high dislocation, preoperative femoral head deformity, and age older than eight years. Davids et al. reported on a prospective series of 255 patients with spastic diplegia to describe the relationship of strength, weight, and age to walking function22. Lowerextremity strength normalized to weight (STR-N) decreased over time at a rate of 0.84 N/kg/year, irrespective of Gross Motor Function Classification System (GMFCS) level. For patients who were classified as GMFCS level I or II, the chance of independent walking was 90% if STR-N was 21 N/kg (49% of predicted relative to typical developing children). That study supported the common clinical observation that strength decreases relative to the child’s weight result in a decline in walking status. This information may be utilized in the development of guidelines and parental shared decision-making for appropriate interventions within this population.
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What’s New in Pediatric Orthopaedics Spina bifida remains a common cause of disability worldwide. Sawin et al. reported the baseline cross-sectional data of the U.S. National Spina Bifida Patient Registry (NSBPR) enrollments from 2009 to 201223. The mean age was 10.1 years, with 85% of patients younger than eighteen years of age. The primary diagnosis was myelomeningocele in 81% of patients, and the remainder of patients had meningocele, lipomyelomeningocele, or fatty filum. Within the 2172 patients, the functional level was thoracic (15.2%), high-lumbar (9.7%), midlumbar (26.7%), low-lumbar (18.1%), or sacral (30.2%). The majority had impaired function of the bowel (87.1%) or bladder (91.6%). Health outcomes assessed included prevalence of a pressure ulcer in the past year (13.9%) and daytime continence of the bowel (29.7%) and bladder (30.1%). The goal of the NSBPR is to provide a foundation for ongoing research and to improve health outcomes for people living with spina bifida. Sports Medicine Increased participation in youth sports and earlier sports specialization have been associated with an increased incidence of overuse injuries. Jayanthi et al. performed a case control study comparing 822 injured athletes seen in sports medicine clinics with 368 uninjured athletes undergoing sports physicals24. Overuse injuries were frequent, representing 67.4% of all injuries. Serious overuse injuries such as spondylolysis, osteochondritis dissecans, overuse elbow or ligament injuries, and stress fractures were 15.8% of all injuries. Injured athletes reported a greater number of hours of weekly sports participation, and the risk of serious overuse injury was two times greater if the hours of participation were greater than the athlete’s age in years. Sports-specialized training was an independent risk factor for injury and serious overuse injury. An epidemiologic analysis of the National High School SportsRelated Injury Surveillance System from 2006 to 2012 noted overuse injuries at a rate of 1.50 per 10,000 athletic exposures, where an exposure was defined as a participation in one practice or competition25. Girls’ field hockey and track and field had the highest rates of overuse injury. Tenforde et al. investigated factors associated with low bone mineral density in 136 adolescent runners26. Among male runners, a belief that “thin is faster” and a BMI of £17.5 kg/m2 were associated with low bone mass (bone mineral density Z-score of £21). Low bone mass in female runners was associated with a BMI of £17.5 kg/m2 or both menstrual irregularity and a history of fracture. There is increasing evidence that associates a delay in reconstruction of anterior cruciate ligament (ACL) tears in children and adolescents with greater meniscal and articular cartilage injury. Newman et al. studied sixty-six patients who were fourteen years of age and younger; the time to an ACL surgical procedure was associated with more severe chondral injuries, and a delay of longer than three months predicted a five times greater risk of an additional injury requiring operative treatment27. Anderson and Anderson found greater-severity chondral injuries and medial meniscal tears to be associated with an
increased time to ACL reconstruction among 130 pediatric patients with a median age of fourteen years (range, eleven to seventeen years)28. Ramski et al. conducted a meta-analysis of initial nonoperative treatment compared with operative treatment of ACL tears in children and adolescents29. Eleven studies were identified; five compared early reconstruction with delayed reconstruction (353 patients), and six compared operative treatment with nonoperative treatment (217 patients). Instability and pathologic laxity were noted in 75% of patients with nonoperative treatment compared with 13.6% of patients following reconstruction. A medial meniscal tear was twelve times more likely after nonoperative treatment. A return to the previous level of activity was noted in 85.7% of patients after reconstruction, but no patients with nonoperative management returned to full activity. Trauma There were multiple publications of interest in the management of pediatric supracondylar humeral fractures. Kao et al. performed a prospective study of sixty-one children with supracondylar humeral fractures comparing daily pin-site care with no pin-site care30. In the group with daily pin care, both the infection rate and the number of postoperative phone consultations were significantly higher, suggesting no benefit to pin care. Muchow et al. found that a supracondylar humeral fracture with an ipsilateral forearm fracture had almost twice the rate of neurologic injury (14.7%) compared with an isolated supracondylar humeral fracture (7.8%), without an increase in the rate of vascular compromise31. Within the floating elbow cohort, a higher rate of neurologic injury was associated with injuries that required reduction of the forearm fracture (18.9%) compared with those injuries that did not require reduction (7.3%). Compartment syndrome was not observed in either cohort. Barrett et al. reviewed 4409 supracondylar humeral fractures with isolated anterior interosseous nerve palsies from multiple centers, without sensory nerve injury, dysvascularity, or ipsilateral forearm fractures, and found no evidence that urgent treatment was required32. Delayed treatment up to twenty-four hours did not delay neurologic recovery and all deficits resolved. Pennock et al. investigated risk factors for loss of reduction of supracondylar humeral fractures after pin fixation33. Decreased pin spread at the level of the fracture was associated with loss of reduction, and the authors recommended a goal of pin spread of at least 13 mm or one-third the width of the humerus at the level of the fracture. Bear et al. performed a prospective study comparing hematoma blocks and conscious sedation for reduction of pediatric distal radial fractures34. Satisfaction was excellent for both groups and pain scores were similar; however, the length of emergency department visit was significantly shorter for the hematoma block group by a mean of 2.2 hours. After the reduction, 38% of the sedation group had nausea requiring antiemetic therapy compared with 4% of the hematoma block group.
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What’s New in Pediatric Orthopaedics In the treatment of dysvascular-extremity trauma, the availability of a vascular surgeon is critical to avoid revascularization delay, muscle necrosis, and the potential need for amputation. Gans et al. described the development of a lowerextremity musculoskeletal and vascular trauma protocol incorporating a team of microvascular surgeons35. Initiation of the protocol improved the time from admission to revascularization and eliminated delays beyond eight hours. Additionally, the protocol reduced the use of preoperative radiographic vascular studies, which are often unnecessary and may delay revascularization. Heffernan et al. performed a multicenter retrospective review of 215 patients who were two to six years of age treated for a femoral shaft fracture with immediate spica casting (n = 141) or elastic nails (n = 74)36. The nail group had a shorter time to independent walking and return to full activities, although this was likely influenced by the duration of casting. There was a significantly greater rate of leg-length discrepancies of 2 cm. The burden of treatment on the caregivers was not assessed. Riley et al. reviewed fortyfour pediatric femoral neck fractures and found an overall rate of osteonecrosis of 20%; the rates by Delbet type were similar to those in prior studies37. Displacement, time to reduction, and performance of capsular decompression did not impact the rates of osteonecrosis; however, age was a factor as osteonecrosis was not observed in the fourteen patients younger than eleven years of age. Temporary internal fixation is commonly utilized in pediatric orthopaedic procedures. Tosti et al. reviewed all procedures utilizing smooth wire fixation over a seventeen-year period and found serious infections in 1.4%38. Missed appointments or wet dressings were noted in 60% of the cases and 42% required operative treatment of an abscess, septic arthritis, or osteomyelitis. The authors presented an algorithm for the treatment of pin-related infections and emphasized that patient education on the importance of follow-up, wound care, and cast care may reduce the rate of this complication. Foot and Ankle Recurrent clubfoot deformity after Ponseti treatment has been attributed to poor compliance with the foot abduction orthosis. Gelfer et al. reviewed sixty-seven patients with clubfeet who had a minimum two-year follow-up39. Compliance with use of the foot abduction orthosis was reported in 90%. At a mean follow-up of thirty-one months, recurrence was noted in 15.8% of the idiopathic deformities and 48.3% of the non-idiopathic deformities. Recurrence was not associated with initial severity, age at initiation of treatment, number of casts required, or caregiver-reported foot abduction orthosis compliance. However, a significant correlation was identified between poor peroneal tendon activity and recurrence in both groups. Awareness of this risk factor will allow clinicians to closely monitor patients with poor evertor
function and to consider adjunctive treatment to prevent recurrence. After failure of nonoperative measures, calcaneal lengthening osteotomy may be considered for painful planovalgus foot deformity; however, there has been concern for iatrogenic calcaneocuboid joint subluxation with this procedure. Ahn et al. reviewed forty-four feet in twenty-four patients with mean age of 9.7 years following calcaneal lengthening osteotomy40. The procedure was combined with Achilles tendon lengthening or a Strayer procedure, lengthening of the peroneus brevis, and pin fixation across the calcaneocuboid joint prior to distraction of the osteotomy. All feet demonstrated dorsal calcaneocuboid joint subluxation immediately postoperatively (median, 26% [range, 10% to 67%]), which was improved at the time of the final follow-up (median, 11% [range, 2% to 30%]). No evidence of calcaneocuboid joint arthritis was observed at a mean follow-up of twenty-five months. Lee et al. explored risk factors for the failure of allograft bone after calcaneal lengthening osteotomy41. The authors identified 304 feet in 176 patients with a mean age of 11.3 years (range, 5.4 to twenty years) and a minimum of six months of postoperative clinical and radiographic follow-up (mean, 1.5 years). As above, the procedure was combined with appropriate tendon lengthenings. Eleven feet (4%) were noted to have radiographic allograft failure; four of those feet underwent reoperation with iliac crest autograft because of pain and loss of correction. Multivariate analysis demonstrated a lower risk of failure with tricortical iliac crest allograft compared with patellar allograft. Additionally, the risk of radiographic graft failure increased with patient age. Subtalar arthroereisis is an alternative procedure for the symptomatic planovalgus feet. Chong et al. performed a prospective, nonrandomized study comparing subtalar arthroereisis (thirteen feet) with lateral column lengthening (eleven feet) in fifteen patients with a mean age of 12.8 years42. Outcomes were assessed at a one-year follow-up with the Oxford Ankle and Foot Questionnaire (OAFQ), kinematic motion analysis, pedobarometry, and radiographs. Both groups demonstrated postoperative improvements in OAFQ scores and radiographic measures, decreased hindfoot valgus, and lateralization of center-of-pressure measurements. The frequency of complications was similar between groups. The authors concluded that subtalar arthroereisis is a less invasive procedure that warrants additional investigation with long-term outcome studies. Hand and Upper Extremity Several studies described long-term outcomes after treatment of congenital hand anomalies. Ekblom et al. evaluated twenty individuals with Bayne type-II to V radial longitudinal deficiency who were eighteen to sixty years of age43. Grip strength, key pinch, forearm length, and elbow and digital motion seem to be more important for the individual’s activity and participation than the radial angulation of the wrist. Vuillermin et al.
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What’s New in Pediatric Orthopaedics reported the results of soft-tissue release and a bilobed flap for severe radial longitudinal deficiency with a mean follow-up of 9.2 years44. Patients and caregivers were satisfied with appearance and function. Useful active motion was maintained; however, partial recurrence of radial deviation had occurred. Stutz et al. evaluated the long-term outcomes of forty-three reconstructed thumbs in forty-one patients with radial polydactyly at a mean follow-up of seventeen years45. Compared with the unaffected side, key pinch strength was 96%, tripod pinch strength was 86%, and tip pinch strength was 92%. The functional results assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure and Pediatric Quality of Life (PedsQL) scores were excellent; however, 20% of patients required a revision surgical procedure at a mean of eight years after the index procedure, with five patients undergoing interphalangeal joint arthrodesis. Musculoskeletal Infection Differentiating between benign inflammation (transient synovitis) and septic arthritis of the hip remains a diagnostic challenge. Kingella kingae infection is particularly difficult to identify because of the mild clinical picture and near-normal levels of acute-phase reactants. Yagupsky et al. performed a retrospective, multicenter review of culture-proven K. kingae infection of the hip among thirty-four children who were six to twenty-seven months of age46. Among the twenty-eight children with sufficient data, the Kocher algorithm would have predicted £40% probability of septic arthritis and 3% risk of infection in seven of the twenty-eight children. The sensitivity of the individual variables of the algorithm was determined: refusal to bear weight (88%), leukocytosis (65%), fever (48%), and elevated erythrocyte sedimentation rate (ESR) (32%). Only seven patients in the series had synovial fluid analysis performed; of those, five had >50,000 white blood cells (WBCs)/mm3 (71% sensitivity). The authors recommended inoculation of blood culture bottles with joint fluid aspirates to maximize detection of K. kingae and to consider nucleic acid amplification assays. The necessity of anaerobic, fungal, and acid-fast bacteria cultures in suspected pediatric musculoskeletal infection was investigated in a cohort of 869 children with osteomyelitis, septic arthritis, pyomyositis, or abscess47. The authors found that only 2.5% of anaerobic cultures, 2.0% of fungal cultures, and 0.9% of acid-fast bacteria cultures were positive. As all patients with true-positive cultures had a history of penetrating injury, immunocompromise, or failure of primary treatment, the authors recommended not routinely obtaining specimens for these cultures unless one of these risk factors is present. During the treatment of acute hematogenous osteomyelitis, some children fail to respond to treatment and ultimately require multiple operative debridements with a prolonged length of stay. Tuason et al. performed a retrospective comparative study to identify factors associated with multiple
interventions among fifty-seven children treated for acute hematogenous osteomyelitis in 200948. Repeated surgical intervention was associated with four or more febrile days despite antibiotics and with C-reactive protein (CRP) of >19.8 mg/dL at admission, >21.5 mg/dL at forty-eight hours after the initial operation, and >15.3 mg/dL at ninety-six hours after the initial operation. The authors concluded that patients with acute hematogenous osteomyelitis should be carefully assessed for additional operative intervention if there is persistent fever and CRP is elevated at ninety-six hours postoperatively. Weeks of post-discharge antibiotic therapy are required following inpatient treatment of acute hematogenous osteomyelitis in children. Keren et al. performed a retrospective cohort study of 2060 patients with pediatric osteomyelitis utilizing the Pediatric Health Information System from 2009 to 201249. Post-discharge oral antibiotics were compared with intravenous antibiotics administered with a peripherally inserted central catheter. The primary outcome was treatment failure and was similar between groups (5% oral and 6% peripherally inserted central catheter). Adverse drug reactions were
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Specialty Update
What’s New in Pediatric Orthopaedics Jeffrey E. Martus, MD, MS, Norman M. Otsuka, MD, and Derek M. Kelly, MD Investigation performed at the Division of Pediatric Orthopaedics, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
Over the past year, a substantial number of high-quality studies were published that are relevant to the clinical practice of pediatric orthopaedics. Additionally, in an effort to improve the care of pediatric patients, the American Academy of Orthopaedic Surgeons (AAOS) updated and reissued the 2009 Clinical Practice Guideline on the treatment of pediatric diaphyseal femoral fractures1. The AAOS also recently adopted Appropriate Use Criteria for pediatric supracondylar humeral fractures with vascular injury2. Spine Multiple database studies demonstrated trends in the management of pediatric spinal deformity. Martin et al. reviewed the Nationwide Inpatient Sample (NIS) from 2001 to 2011 and found that spinal fusion rates for adolescent idiopathic scoliosis have remained stable, but anterior fusion declined by 80%3. The mean hospital charges increased by 113%, from $72,780 in 2001 to $155,278 in 2011. The mean annual increase in hospital charges to treat adolescent idiopathic scoliosis was 11.3%; in comparison, charges for nonspine conditions increased 4.5% to 6% annually. Martin et al. suggested that spinal implant costs may be a substantial driver of increased charges. Vigneswaran et al. performed a similar study with the Kids’ Inpatient Database (KID) and estimated that the incidence of surgical procedures to treat adolescent idiopathic scoliosis had increased from 0.58 admission per 10,000 individuals per year in 1997 to 0.74 admission per 10,000 individuals per year in 20124. From 1997 to 2012, the mean hospital length of stay had decreased from 6.5 to 5.6 days. Similar to these studies of adolescent idiopathic scoliosis, in their study Jain et al. reviewed the NIS and noted that the utilization of spinal fusion for Scheuermann kyphosis increased by 2.9 times from 2000 to 20085. As noted for adolescent idiopathic scoliosis, treatment Specialty Update has been developed in collaboration with the Board of Specialty Societies (BOS) of the American Academy of Orthopaedic Surgeons.
has shifted toward posterior spinal fusion, but anterior-posterior fusion rates declined by 7% per year. Lower complication rates and shorter hospitalizations were noted with posterior spinal fusion compared with anterior-posterior fusion. There have been substantial efforts at quality improvement for the surgical procedure to treat spinal deformity. In an attempt to minimize neurologic complications during this procedure, a combined Scoliosis Research Society and Pediatric Orthopaedic Society of North America task force led the development of an intraoperative checklist to optimize the response to neuromonitoring changes and created a best practice guideline6. Risk factors for surgical site infection after a pediatric spine surgical procedure were also investigated. Croft et al. performed a matched case control study and found that neuromuscular scoliosis, weight for age at the ‡95th percentile, American Society of Anesthesiologists score of ‡3, and prolonged operative time were associated with a higher risk of surgical site infection7. In a retrospective series, LaGreca et al. found that the rate of delayed surgical site infection following instrumented spinal fusion was six times higher in patients with stainless steel implants compared with patients with titanium implants8. Propionibacterium acnes was the most common organism in the delayed group; this pathogen was not cultured in any of the patients with titanium implants. Further research is required to determine if titanium implants are protective against infection with this organism. Martin et al. evaluated readmissions after the surgical procedure to treat pediatric spinal deformity utilizing the National Surgical Quality Improvement Program (NSQIP) pediatric database in 20129. The rate of unplanned thirty-day readmission was 4.0% and was highest in patients with neuromuscular deformity (6.8%) and those with congenital deformity (6.3%). Surgical complexity and medical comorbidities were associated with readmission. The most common reasons for readmission were wound complications (73.3%) and gastrointestinal complications (13.3%), suggesting that
Disclosure: The authors received a stipend for this work from JBJS; the authors donated this stipend to the Pediatric Orthopaedic Society of North America (POSNA). On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author (or the author’s institution) had a relevant financial relationship in the biomedical arena outside the submitted work.
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http://dx.doi.org/10.2106/JBJS.15.01236
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What’s New in Pediatric Orthopaedics quality improvement programs should target these areas to minimize the risk of readmission. A definition of early-onset scoliosis as “scoliosis with onset less than the age of ten years, regardless of etiology” has been endorsed by the Growing Spine Study Group, the Children’s Spine Study Group, the Scoliosis Research Society, and the Pediatric Orthopaedic Society of North America10,11. Additionally, a group of experienced surgeons developed and provided initial validation of the Classification of Early-Onset Scoliosis (C-EOS)12. Hip The modified Dunn osteotomy is a powerful procedure for correction of slipped capital femoral epiphysis; however, there are substantial potential complications. Upasani et al. reviewed the results of modified Dunn osteotomy for twenty-six unstable and seventeen stable slipped capital femoral epiphyses13. There were twenty-two complications in sixteen patients, including osteonecrosis (23%), femoral neck nonunion (9%), and postoperative hip dislocation (5%). Because of the high complication rate and an inverse relationship between surgeon volume and patient outcomes, the authors’ practice was modified such that the operation is considered only for patients with acute slipped capital femoral epiphysis with severe displacement (>50°) of the epiphysis and when treatment can proceed within twenty-four hours of the slip with a high-volume surgeon present during the procedure. Novais et al. compared the outcomes of patients with severe stable slipped capital femoral epiphysis treated with in situ fixation (n = 15) or a modified Dunn realignment (n = 15) with a mean follow-up of 2.5 years14. Good or excellent results were achieved in a higher proportion of the modified Dunn cohort. The complication rate was similar between cohorts and each had a case of osteonecrosis; however, the reoperation rate was greater in the in situ fixation cohort because of subsequent reconstructive procedures, including intertrochanteric osteotomy and/or surgical hip dislocation with osteochondroplasty. Multiple studies investigated risk factors for complications following periacetabular osteotomy for acetabular dysplasia. In a prospective multicenter study, Zaltz et al. analyzed complications graded with the modified Clavien-Dindo grading scheme15. Major complications (grade III or IV) were noted in 5.9% of 205 patients with a mean age of 25.4 years. There was a nonsignificant trend associating complications with male sex and obesity. Novais et al. conducted a multicenter review of eighty-four adolescents (mean age, 16.5 years) following periacetabular osteotomy and found that the odds of a complication were ten times higher for an obese patient (body mass index [BMI] of >95th percentile) than for a non-obese patient16. A similar study in 280 adult patients found that obesity (BMI of >30 kg/m2) was an independent risk factor for greaterseverity complications after periacetabular osteotomy17. A higher frequency of comorbidities such as attentiondeficit hyperactivity disorder and adult cardiovascular disease has been reported for Legg-Calv´e-Perthes disease. Hailer and Nilsson identified 4057 patients with Legg-Calv´e-Perthes disease in the
Swedish Patient Registry from 1964 to 201118. In comparison with matched controls, patients with Legg-Calv´e-Perthes disease had an elevated hazard ratio of 1.5 for attention-deficit hyperactivity disorder, 1.3 for depression, and 1.2 for mortality. The mortality risk was 2.9 times greater from suicide and 1.2 times greater from vascular disease for patients with Legg-Calv´ePerthes disease. These findings are concerning; however, it is unclear if patients with Legg-Calv´e-Perthes disease would benefit from routine psychiatric or cardiovascular screening. Management of the infant with clinically stable hips with sonographic abnormalities has been controversial. Pruszczynski et al. reviewed a retrospective cohort with prospectively collected data to determine the natural history of clinically stable hips (negative Barlow and Ortolani signs) with sonographic instability by the Harcke method in infants younger than two months of age19. Sonographic acetabular dysplasia on the basis of femoral head coverage or acetabular inclination (Graf a angle) was variably present. Patients were not treated, swaddling was not permitted, and patients were followed until normalization of the acetabular index to £25°. All patients’ radiographs normalized by the age of three years without treatment. Breech presentation and cesarean delivery correlated with delayed normalization. Neuromuscular Conditions Prevention of hip dislocation may avoid pain and the need for a salvage surgical procedure in patients with cerebral palsy. H¨agglund et al. reported the twenty-year follow-up on a populationbased hip surveillance program from southern Sweden 20 . In comparison with a historical cohort in whom the rate of dislocation was 8%, the Cerebral Palsy Follow-Up Programme (CPUP) reduced the rate of dislocation to 0.5% among 258 children born from 1992 to 1997 and 0% among 431 children born from 1998 to 2007. However, a preventative surgical procedure was utilized in 13% of the study population. Koch et al. investigated the incidence of and risk factors for osteonecrosis after treatment of complete hip dislocations with open reduction, proximal femoral osteotomies, and Dega pelvic osteotomies21. Among 115 hip dislocations, there was evidence of osteonecrosis in 68.7%; risk factors include high dislocation, preoperative femoral head deformity, and age older than eight years. Davids et al. reported on a prospective series of 255 patients with spastic diplegia to describe the relationship of strength, weight, and age to walking function22. Lowerextremity strength normalized to weight (STR-N) decreased over time at a rate of 0.84 N/kg/year, irrespective of Gross Motor Function Classification System (GMFCS) level. For patients who were classified as GMFCS level I or II, the chance of independent walking was 90% if STR-N was 21 N/kg (49% of predicted relative to typical developing children). That study supported the common clinical observation that strength decreases relative to the child’s weight result in a decline in walking status. This information may be utilized in the development of guidelines and parental shared decision-making for appropriate interventions within this population.
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What’s New in Pediatric Orthopaedics Spina bifida remains a common cause of disability worldwide. Sawin et al. reported the baseline cross-sectional data of the U.S. National Spina Bifida Patient Registry (NSBPR) enrollments from 2009 to 201223. The mean age was 10.1 years, with 85% of patients younger than eighteen years of age. The primary diagnosis was myelomeningocele in 81% of patients, and the remainder of patients had meningocele, lipomyelomeningocele, or fatty filum. Within the 2172 patients, the functional level was thoracic (15.2%), high-lumbar (9.7%), midlumbar (26.7%), low-lumbar (18.1%), or sacral (30.2%). The majority had impaired function of the bowel (87.1%) or bladder (91.6%). Health outcomes assessed included prevalence of a pressure ulcer in the past year (13.9%) and daytime continence of the bowel (29.7%) and bladder (30.1%). The goal of the NSBPR is to provide a foundation for ongoing research and to improve health outcomes for people living with spina bifida. Sports Medicine Increased participation in youth sports and earlier sports specialization have been associated with an increased incidence of overuse injuries. Jayanthi et al. performed a case control study comparing 822 injured athletes seen in sports medicine clinics with 368 uninjured athletes undergoing sports physicals24. Overuse injuries were frequent, representing 67.4% of all injuries. Serious overuse injuries such as spondylolysis, osteochondritis dissecans, overuse elbow or ligament injuries, and stress fractures were 15.8% of all injuries. Injured athletes reported a greater number of hours of weekly sports participation, and the risk of serious overuse injury was two times greater if the hours of participation were greater than the athlete’s age in years. Sports-specialized training was an independent risk factor for injury and serious overuse injury. An epidemiologic analysis of the National High School SportsRelated Injury Surveillance System from 2006 to 2012 noted overuse injuries at a rate of 1.50 per 10,000 athletic exposures, where an exposure was defined as a participation in one practice or competition25. Girls’ field hockey and track and field had the highest rates of overuse injury. Tenforde et al. investigated factors associated with low bone mineral density in 136 adolescent runners26. Among male runners, a belief that “thin is faster” and a BMI of £17.5 kg/m2 were associated with low bone mass (bone mineral density Z-score of £21). Low bone mass in female runners was associated with a BMI of £17.5 kg/m2 or both menstrual irregularity and a history of fracture. There is increasing evidence that associates a delay in reconstruction of anterior cruciate ligament (ACL) tears in children and adolescents with greater meniscal and articular cartilage injury. Newman et al. studied sixty-six patients who were fourteen years of age and younger; the time to an ACL surgical procedure was associated with more severe chondral injuries, and a delay of longer than three months predicted a five times greater risk of an additional injury requiring operative treatment27. Anderson and Anderson found greater-severity chondral injuries and medial meniscal tears to be associated with an
increased time to ACL reconstruction among 130 pediatric patients with a median age of fourteen years (range, eleven to seventeen years)28. Ramski et al. conducted a meta-analysis of initial nonoperative treatment compared with operative treatment of ACL tears in children and adolescents29. Eleven studies were identified; five compared early reconstruction with delayed reconstruction (353 patients), and six compared operative treatment with nonoperative treatment (217 patients). Instability and pathologic laxity were noted in 75% of patients with nonoperative treatment compared with 13.6% of patients following reconstruction. A medial meniscal tear was twelve times more likely after nonoperative treatment. A return to the previous level of activity was noted in 85.7% of patients after reconstruction, but no patients with nonoperative management returned to full activity. Trauma There were multiple publications of interest in the management of pediatric supracondylar humeral fractures. Kao et al. performed a prospective study of sixty-one children with supracondylar humeral fractures comparing daily pin-site care with no pin-site care30. In the group with daily pin care, both the infection rate and the number of postoperative phone consultations were significantly higher, suggesting no benefit to pin care. Muchow et al. found that a supracondylar humeral fracture with an ipsilateral forearm fracture had almost twice the rate of neurologic injury (14.7%) compared with an isolated supracondylar humeral fracture (7.8%), without an increase in the rate of vascular compromise31. Within the floating elbow cohort, a higher rate of neurologic injury was associated with injuries that required reduction of the forearm fracture (18.9%) compared with those injuries that did not require reduction (7.3%). Compartment syndrome was not observed in either cohort. Barrett et al. reviewed 4409 supracondylar humeral fractures with isolated anterior interosseous nerve palsies from multiple centers, without sensory nerve injury, dysvascularity, or ipsilateral forearm fractures, and found no evidence that urgent treatment was required32. Delayed treatment up to twenty-four hours did not delay neurologic recovery and all deficits resolved. Pennock et al. investigated risk factors for loss of reduction of supracondylar humeral fractures after pin fixation33. Decreased pin spread at the level of the fracture was associated with loss of reduction, and the authors recommended a goal of pin spread of at least 13 mm or one-third the width of the humerus at the level of the fracture. Bear et al. performed a prospective study comparing hematoma blocks and conscious sedation for reduction of pediatric distal radial fractures34. Satisfaction was excellent for both groups and pain scores were similar; however, the length of emergency department visit was significantly shorter for the hematoma block group by a mean of 2.2 hours. After the reduction, 38% of the sedation group had nausea requiring antiemetic therapy compared with 4% of the hematoma block group.
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What’s New in Pediatric Orthopaedics In the treatment of dysvascular-extremity trauma, the availability of a vascular surgeon is critical to avoid revascularization delay, muscle necrosis, and the potential need for amputation. Gans et al. described the development of a lowerextremity musculoskeletal and vascular trauma protocol incorporating a team of microvascular surgeons35. Initiation of the protocol improved the time from admission to revascularization and eliminated delays beyond eight hours. Additionally, the protocol reduced the use of preoperative radiographic vascular studies, which are often unnecessary and may delay revascularization. Heffernan et al. performed a multicenter retrospective review of 215 patients who were two to six years of age treated for a femoral shaft fracture with immediate spica casting (n = 141) or elastic nails (n = 74)36. The nail group had a shorter time to independent walking and return to full activities, although this was likely influenced by the duration of casting. There was a significantly greater rate of leg-length discrepancies of 2 cm. The burden of treatment on the caregivers was not assessed. Riley et al. reviewed fortyfour pediatric femoral neck fractures and found an overall rate of osteonecrosis of 20%; the rates by Delbet type were similar to those in prior studies37. Displacement, time to reduction, and performance of capsular decompression did not impact the rates of osteonecrosis; however, age was a factor as osteonecrosis was not observed in the fourteen patients younger than eleven years of age. Temporary internal fixation is commonly utilized in pediatric orthopaedic procedures. Tosti et al. reviewed all procedures utilizing smooth wire fixation over a seventeen-year period and found serious infections in 1.4%38. Missed appointments or wet dressings were noted in 60% of the cases and 42% required operative treatment of an abscess, septic arthritis, or osteomyelitis. The authors presented an algorithm for the treatment of pin-related infections and emphasized that patient education on the importance of follow-up, wound care, and cast care may reduce the rate of this complication. Foot and Ankle Recurrent clubfoot deformity after Ponseti treatment has been attributed to poor compliance with the foot abduction orthosis. Gelfer et al. reviewed sixty-seven patients with clubfeet who had a minimum two-year follow-up39. Compliance with use of the foot abduction orthosis was reported in 90%. At a mean follow-up of thirty-one months, recurrence was noted in 15.8% of the idiopathic deformities and 48.3% of the non-idiopathic deformities. Recurrence was not associated with initial severity, age at initiation of treatment, number of casts required, or caregiver-reported foot abduction orthosis compliance. However, a significant correlation was identified between poor peroneal tendon activity and recurrence in both groups. Awareness of this risk factor will allow clinicians to closely monitor patients with poor evertor
function and to consider adjunctive treatment to prevent recurrence. After failure of nonoperative measures, calcaneal lengthening osteotomy may be considered for painful planovalgus foot deformity; however, there has been concern for iatrogenic calcaneocuboid joint subluxation with this procedure. Ahn et al. reviewed forty-four feet in twenty-four patients with mean age of 9.7 years following calcaneal lengthening osteotomy40. The procedure was combined with Achilles tendon lengthening or a Strayer procedure, lengthening of the peroneus brevis, and pin fixation across the calcaneocuboid joint prior to distraction of the osteotomy. All feet demonstrated dorsal calcaneocuboid joint subluxation immediately postoperatively (median, 26% [range, 10% to 67%]), which was improved at the time of the final follow-up (median, 11% [range, 2% to 30%]). No evidence of calcaneocuboid joint arthritis was observed at a mean follow-up of twenty-five months. Lee et al. explored risk factors for the failure of allograft bone after calcaneal lengthening osteotomy41. The authors identified 304 feet in 176 patients with a mean age of 11.3 years (range, 5.4 to twenty years) and a minimum of six months of postoperative clinical and radiographic follow-up (mean, 1.5 years). As above, the procedure was combined with appropriate tendon lengthenings. Eleven feet (4%) were noted to have radiographic allograft failure; four of those feet underwent reoperation with iliac crest autograft because of pain and loss of correction. Multivariate analysis demonstrated a lower risk of failure with tricortical iliac crest allograft compared with patellar allograft. Additionally, the risk of radiographic graft failure increased with patient age. Subtalar arthroereisis is an alternative procedure for the symptomatic planovalgus feet. Chong et al. performed a prospective, nonrandomized study comparing subtalar arthroereisis (thirteen feet) with lateral column lengthening (eleven feet) in fifteen patients with a mean age of 12.8 years42. Outcomes were assessed at a one-year follow-up with the Oxford Ankle and Foot Questionnaire (OAFQ), kinematic motion analysis, pedobarometry, and radiographs. Both groups demonstrated postoperative improvements in OAFQ scores and radiographic measures, decreased hindfoot valgus, and lateralization of center-of-pressure measurements. The frequency of complications was similar between groups. The authors concluded that subtalar arthroereisis is a less invasive procedure that warrants additional investigation with long-term outcome studies. Hand and Upper Extremity Several studies described long-term outcomes after treatment of congenital hand anomalies. Ekblom et al. evaluated twenty individuals with Bayne type-II to V radial longitudinal deficiency who were eighteen to sixty years of age43. Grip strength, key pinch, forearm length, and elbow and digital motion seem to be more important for the individual’s activity and participation than the radial angulation of the wrist. Vuillermin et al.
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What’s New in Pediatric Orthopaedics reported the results of soft-tissue release and a bilobed flap for severe radial longitudinal deficiency with a mean follow-up of 9.2 years44. Patients and caregivers were satisfied with appearance and function. Useful active motion was maintained; however, partial recurrence of radial deviation had occurred. Stutz et al. evaluated the long-term outcomes of forty-three reconstructed thumbs in forty-one patients with radial polydactyly at a mean follow-up of seventeen years45. Compared with the unaffected side, key pinch strength was 96%, tripod pinch strength was 86%, and tip pinch strength was 92%. The functional results assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure and Pediatric Quality of Life (PedsQL) scores were excellent; however, 20% of patients required a revision surgical procedure at a mean of eight years after the index procedure, with five patients undergoing interphalangeal joint arthrodesis. Musculoskeletal Infection Differentiating between benign inflammation (transient synovitis) and septic arthritis of the hip remains a diagnostic challenge. Kingella kingae infection is particularly difficult to identify because of the mild clinical picture and near-normal levels of acute-phase reactants. Yagupsky et al. performed a retrospective, multicenter review of culture-proven K. kingae infection of the hip among thirty-four children who were six to twenty-seven months of age46. Among the twenty-eight children with sufficient data, the Kocher algorithm would have predicted £40% probability of septic arthritis and 3% risk of infection in seven of the twenty-eight children. The sensitivity of the individual variables of the algorithm was determined: refusal to bear weight (88%), leukocytosis (65%), fever (48%), and elevated erythrocyte sedimentation rate (ESR) (32%). Only seven patients in the series had synovial fluid analysis performed; of those, five had >50,000 white blood cells (WBCs)/mm3 (71% sensitivity). The authors recommended inoculation of blood culture bottles with joint fluid aspirates to maximize detection of K. kingae and to consider nucleic acid amplification assays. The necessity of anaerobic, fungal, and acid-fast bacteria cultures in suspected pediatric musculoskeletal infection was investigated in a cohort of 869 children with osteomyelitis, septic arthritis, pyomyositis, or abscess47. The authors found that only 2.5% of anaerobic cultures, 2.0% of fungal cultures, and 0.9% of acid-fast bacteria cultures were positive. As all patients with true-positive cultures had a history of penetrating injury, immunocompromise, or failure of primary treatment, the authors recommended not routinely obtaining specimens for these cultures unless one of these risk factors is present. During the treatment of acute hematogenous osteomyelitis, some children fail to respond to treatment and ultimately require multiple operative debridements with a prolonged length of stay. Tuason et al. performed a retrospective comparative study to identify factors associated with multiple
interventions among fifty-seven children treated for acute hematogenous osteomyelitis in 200948. Repeated surgical intervention was associated with four or more febrile days despite antibiotics and with C-reactive protein (CRP) of >19.8 mg/dL at admission, >21.5 mg/dL at forty-eight hours after the initial operation, and >15.3 mg/dL at ninety-six hours after the initial operation. The authors concluded that patients with acute hematogenous osteomyelitis should be carefully assessed for additional operative intervention if there is persistent fever and CRP is elevated at ninety-six hours postoperatively. Weeks of post-discharge antibiotic therapy are required following inpatient treatment of acute hematogenous osteomyelitis in children. Keren et al. performed a retrospective cohort study of 2060 patients with pediatric osteomyelitis utilizing the Pediatric Health Information System from 2009 to 201249. Post-discharge oral antibiotics were compared with intravenous antibiotics administered with a peripherally inserted central catheter. The primary outcome was treatment failure and was similar between groups (5% oral and 6% peripherally inserted central catheter). Adverse drug reactions were
