345 C OPYRIGHT Ó 2014
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T HE J OURNAL
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AND J OINT
S URGERY, I NCORPORATED
Specialty Update
What’s New in Pediatric Orthopaedics Nirav K. Pandya, MD, Norman Y. Otsuka, MSc, MD, FRCSC, and James O. Sanders, MD
Spine There are wide variations with regard to the treatment of spinal deformity across the United States, with few studies identifying the best practices. A 2013 study on the use of bone morphogenetic protein (BMP), which is currently not approved by the U.S. Food and Drug Administration for use in children, found a 3.4-fold increase in its use from 2003 to 2009 in pediatric spinal fusions, with geographic variation in usage rates1. The use of BMP was more common in children who had private rather than state-funded insurance coverage, and in private hospitals as compared with teaching hospitals. BMP was more likely to be used in older adolescents and in the treatment of patients with congenital scoliosis, thoracolumbar fractures, or spondylolisthesis as opposed to patients with adolescent idiopathic scoliosis. The safety of BMP has not been studied in adolescents, and there is concern about cancer risk with BMP use. There are also variations with regard to the care of children following spinal surgery. Shan et al. retrospectively studied patients with adolescent idiopathic scoliosis who were admitted to the pediatric intensive care unit (PICU) following surgery as compared with those who were admitted to the general hospital floor2. Patients admitted to the general hospital floor had 16% lower overall costs, fewer blood draws, less medication usage, and an earlier discharge than did the patients who were admitted to the PICU. As a caveat, the investigators noted that their study was performed at a high-volume academic tertiary-care pediatric hospital where the floor nurses were very experienced in treating patients who had adolescent idiopathic scoliosis, and thus the generalizability of the study may be limited. Pedicle screw fixation has become a mainstay of surgical correction of scoliosis in North America, and articles continue to compare the results of screw fixation to hybrid (hook and/or Specialty Update has been developed in collaboration with the Board of Specialty Societies (BOS) of the American Academy of Orthopaedic Surgeons.
wire fixation) constructs. Hwang et al. investigated loss of correction in patients who had surgery to correct adolescent idiopathic scoliosis and were followed postoperatively for at least two years3. Loss of correction was defined radiographically as an increase of ‡10° in the coronal Cobb angle of an instrumented curve or clinically as an increase of >5° in the inclinometer reading. They identified both larger curve magnitude and the use of hybrid instrumentation as risk factors for loss of correction. The mean loss of correction in the patients who received pedicle screws was 10.43° as compared with 12.50° in the patients who received hybrid instrumentation. The clinical significance of this difference is uncertain. Postoperative spinal infection is a major ongoing concern. A retrospective study evaluated risk factors for infection following spinal deformity surgery in children4. The rate of infection was 1.2% in patients who had idiopathic scoliosis, 13.1% in patients who had neuromuscular scoliosis, 10.3% in patients who underwent growing rod revision, and 13.7% for patients in whom pelvic instrumentation was used. Multivariate regression identified the strongest predictors of infection as being non-idiopathic scoliosis (adjusted odds ratio, 2.01; 95% confidence interval, 1.03 to 3.91) and instrumentation to the pelvis (adjusted odds ratio, 3.05; 95% confidence interval, 1.83 to 5.09). Furthermore, in an effort to develop best-practice methods of preventing infection following spinal deformity surgery in high-risk patients, Vitale et al., using a Delphi process and nominal group technique, developed a consensus-based guideline5. The attractiveness of the technique is that it allows for the rapid development of clinical improvement initiatives when the studies needed to validate the individual components are of varying quality and/or of limited number. Finally, the optimum evaluation pathways for pediatric back pain have not been established. Specific concerns in children include radiation exposure, the need for sedation in younger children receiving magnetic resonance imaging
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
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What’s New in Pediatric Orthopaedics (MRI), and the ethics of quality randomized controlled trials in children. A recent review of the records of 2846 children with back pain pointed to the increased radiation dose associated with lumbar computed tomography scans and nuclear medicine scans in children that may occur during work-up6. Most children had resolution of their symptoms without the need for advanced imaging. Deformity Sabharwal et al. compared skeletal maturity between patients with Blount disease and their peers who did not have Blount disease and found advanced skeletal maturity in patients with Blount disease (bone age was advanced twenty-six months in patients with early-onset Blount disease and ten months in patients with late-onset Blount disease)7. Because skeletal maturity affects the strategy for surgical realignment or even its likelihood of success, the authors recommended performing an evaluation of skeletal maturity as part of the surgical decisionmaking process. Implant removal in pediatric orthopaedics is controversial, particularly around the hip where concerns remain in regard to interference with adult hip surgical procedures. In a case-matched series of total hip arthroplasty patients with and without retained pediatric implants, Woodcock et al. found that patients with retained implants had more complications, a longer length of hospital stay, and an increased need for allograft8. The results of that study suggest that pediatric orthopaedists should consider removing implants that have been placed in children. Foot and Ankle Randomized controlled studies in the field of pediatric orthopaedics remain rare. The use of botulinum toxin remains an exception, likely because of the minimally invasive nature of the injections and parents’ willingness to participate. In a recent Level-I study performed in patients with idiopathic toewalking, Engstr¨om et al. compared the results of cast treatment with the results of injection of botulinum toxin A followed by cast treatment9. The authors found no difference in the results between the two groups, thus demonstrating the limited efficacy of injections before casting in this subgroup. The Ponseti method for clubfoot has become a worldwide treatment. Methods have been developed for extending the treatment to developing regions, which often have few surgical resources. The first 5000 feet treated as part of a Ponseti program in Bangladesh were recently reported10. Each site was required to keep details regarding clubfoot severity, procedures, results, and complications. Only 12% of patients were lost to follow-up at two years, and 13% of the clubfeet were noted to be atypical. The majority of patients (76%) underwent heel cord tenotomy. The records noted a complication rate of 2%. The project highlights how a relatively straightforward public health model can markedly improve care for orthopaedic disorders in underserved nations.
A rival of the Ponseti method is the ‘‘French’’ method, which relies on frequent manipulation, splinting, and selective surgery. Rampal et al. reported on their treatment results with this method at an average of 14.7 years of follow-up; their patients had 98% good or very good results with use of a composite scoring system11. Hsu et al. reported on the longterm follow-up of patients with clubfoot resistant to casting who were treated with extensive soft-tissue release and manual derotation of the talus with a Kirschner wire12. At an average of twenty-one years after surgery, 27% of patients had required some form of additional surgery. In patients with unilateral clubfoot, the affected foot had decreased range of motion, foot length, and calf circumference as compared with the contralateral foot. Yet, quality of life scores did not decline over time, particularly in patients who did not require additional surgery. Sports Medial epicondylar fractures continue to be an area of controversy, particularly with regard to optimal treatment. Lawrence et al. retrospectively examined the outcomes after operative or nonoperative management of medial epicondylar fractures in twenty adolescent athletes13. Regardless of the type of treatment used, all fractures healed with an osseous union and all patients returned to a high level of sports activity. Further analysis of the results suggests that nonoperative management can be successful in the treatment of patients who have sustained low-energy injuries with minimal fracture displacement and without associated elbow laxity, whereas operative management can be successful in the treatment of patients with higher-energy trauma with appreciable fracture displacement and elbow instability. Medial patellofemoral ligament reconstruction for patellar instability has shown early success in restoring the primary restraint to lateral translation of the patella. Limited long-term data are available regarding complications in patients who are less than twenty-one years of age. Parikh et al. retrospectively reported a 16.2% complication rate after medial patellofemoral ligament reconstruction in 179 patients less than three years postoperatively14. Of these complications, nearly half were considered preventable because they were secondary to technical errors, particularly improper tunnel placement in the femur and patella. The results of this study provide factors that must be considered when performing medial patellofemoral ligament reconstruction to improve outcomes. Anterior cruciate ligament (ACL) injuries in skeletally immature patients continue to be a ‘‘hot’’ topic in the lay press15,16. The increase in ACL reconstruction in skeletally immature patients has resulted from the premise that postponement of ACL reconstruction can lead to a higher rate of meniscal and articular cartilage injury. Moksnes et al. prospectively examined the prevalence and incidence of new meniscus and cartilage injuries in skeletally immature patients with ACL injuries that were treated nonoperatively17. The authors examined MRI at the time of injury and at two
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What’s New in Pediatric Orthopaedics subsequent times, with one to two years between studies. The overall incidence of new injuries from the time of the initial MRI until follow-up (mean time and standard deviation, 3.8 ± 1.4 years after injury) was 19.5% for meniscal injury and 7.1% for articular cartilage injuries. Delayed reconstruction may be associated with a lower rate of meniscal and/or chondral damage than was previously thought. Kumar et al. examined the results of transphyseal ACL reconstruction in thirty-two consecutive patients (mean age, 11.25 years) who were less than fourteen years of age and at Tanner stage 1 or 2, or less than twelve years of age and at Tanner stage 318. At a mean of 72.3 months after surgery, there was only one rerupture, one mild valgus deformity with no functional disturbance, and no limb-length discrepancies, suggesting that transphyseal reconstruction even in skeletally immature patients can be performed safely with good-toexcellent outcomes. Trauma Supracondylar humeral fractures have been examined in several studies over the past several years, but few investigators have looked at postoperative pain management. Georgopoulos et al. examined the efficacy of intra-articular injections of 0.25% bupivacaine or 0.20% ropivacaine after fracture fixation19. Requirements for morphine and/or fentanyl were significantly (p = 0.004) lower in the bupivacaine group (10%) than in the ropivacaine (36%) and control (44%) groups. Total opioid consumption was also significantly lower in the first seventy-two hours postoperatively in the bupivacaine group than it was in the control group. Intra-articular administration of bupivacaine can be a potential consideration in postoperative pain control in patients with these injuries, although additional studies are necessary to assess the impact on the postoperative neurological examination and chondral toxicity. In contrast to studies examining operative intervention of supracondylar humeral fractures, Moraleda et al. examined the long-term (mean, 6.6 ± 2.8 years) outcomes of forty-six Gartland type-II supracondylar humeral fractures that were treated nonoperatively 20. The authors reported that functional results were excellent. The treatment of problematic pediatric femoral fractures poses a challenge. Li et al. examined the use of titanium elastic nails compared with plate fixation in subtrochanteric femoral fractures21. In this multicenter retrospective study of fifty-four children, the overall complication rate was significantly higher (48%) in the titanium elastic nail group than it was in the plating group (14%). The most common complications in the titanium elastic nail group were fracture malalignment, limblength inequality, and pain associated with a prominent implant. For the treatment of problematic subtrochanteric femoral fractures, surgeons may consider the use of plating instead of titanium elastic nails. Heyworth et al. reported distal femoral valgus deformity after plate fixation of distal femoral shaft fractures22. In eighty-
five patients who underwent plate fixation of a diaphyseal femoral fracture, the authors noted the development of a distal femoral valgus deformity in ten patients. The risk factors for distal femoral valgus deformity included a plate-to-physis distance of ‡20 mm, a distal fracture, and a distal bend in the plate (although this was not an independent factor). The results of this study suggest that when plating is used for these injuries, care should be taken to monitor these patients for the development of deformity, and utilize appropriate techniques when inserting the plate. Infection Choe et al., in an effort to provide a more accurate diagnosis of septic arthritis and to guide antibiotic treatment, combined basic and clinical science by examining the utilization of realtime polymerase chain reaction (PCR) assays for the diagnosis of septic arthritis in children23. The sensitivity of PCR (0.79) for diagnosis of infection and bacterial differentiation was higher than that of microbiologic cultures (0.47) although the specificity (1.00) was the same. The results of this study suggest that not only can a more successful diagnosis of infection be obtained with use of PCR but also differentiation of bacterial type can lead to earlier, targeted antibiotic treatment. Liberman et al. examined the value of ultrasound-guided hip aspiration in the emergency room in suspected pediatric transient synovitis24. In their study, patients with transient synovitis of the hip were treated with bed rest and nonsteroidal anti-inflammatory drugs alone (group 1) or with the addition of hip aspiration (group 2). The authors found that, twentyfour hours after admission, patients in whom aspiration had been performed had significantly less limping (10% versus 92%), refusal to bear weight (1% versus 14%), and hip joint pain (6% versus 81%). The results of this study suggest that hip aspiration of intra-articular fluid may be diagnostic and therapeutic in patients with transient synovitis. Basic Science Cappello et al. examined the effect of ketorolac on fracturehealing in a juvenile rat model25. Tibial shaft fractures in fortyfive juvenile rats were surgically induced and then stabilized. The rats were randomized into treatment with ketorolac or saline solution postoperatively and were then killed at seven, fourteen, or twenty-one days after fracture. Regardless of treatment with ketorolac or saline solution, the strength and stiffness of the tibiae increased from day seven to day twentyone and the quality of the fracture callus was similar in both groups at each time point. The results of this immature animal study suggest that anti-inflammatory drugs such as ketorolac can be utilized for pain relief without adverse effects on pediatric fracture-healing. Lyon et al. examined the role of extracorporeal shock wave therapy (ESWT) in the healing of osteochondral lesions of the rabbit knee26. ESWT has been shown to enhance healing in long-bone nonunions, although its utility in enhancing the
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What’s New in Pediatric Orthopaedics healing of osteochondral lesions is unknown. Utilizing twenty skeletally immature rabbits with osteochondral lesions, the authors found that there was more mature bone formation, healing, and cartilage density histologically after ESWT. In addition, increased osseous density was seen on radiographs. Non-weight-bearing has been postulated as a treatment for Legg-Calve´ -Perthes disease but remains controversial due to a lack of scientific data. Using an animal model, Kim et al. examined the effects of osteochondral lesions on the immature femoral head following ischemic osteonecrosis27. Sixteen piglets with induced femoral head ischemia were randomized to non-weight-bearing on the ischemic limb (via amputation) or weight-bearing. The authors found that localized non-weightbearing after ischemic femoral head osteonecrosis decreased deformity, increased revascularization, and increased the amount of resorption of the infarcted epiphysis. Neuromuscular Dreher et al. examined the long-term results (mean follow-up, nine years) of distal rectus femoris transfer accomplished during multilevel surgery in fifty-three ambulatory patients who had spastic diplegic cerebral palsy and stiff-knee gait28. The results demonstrated that, in patients with decreased peak knee flexion in the swing phase, rectus femoris transfer can provide long-lasting improvements in gait, although prophylactic transfer may not be appropriate. In patients with stiff-knee gait, Scully et al. compared the outcomes achieved with distal rectus femoris transfer to one of three sites: medial to the semitendinosus, medial to the sartorious, or lateral to the iliotibial band29. Significant improvements in knee arc of motion, timing of peak knee flexion in the swing phase, and knee extension at initial contact were seen in all three transfer groups, with no significant differences among groups. According to the results of this study, the location of the transfer site can be based on surgeon preference and concomitant procedures. Rethlefsen et al. examined the role of revision hamstring lengthening in patients with crouch gait30. Thirty-nine patients were retrospectively reviewed who underwent hamstring lengthening (single versus repeat). Seventy-one percent of patients in the single lengthening group had improvements in stance-phase knee extension as compared with 28% in the repeat lengthening group, suggesting that alternative treatments should be considered instead of repeat hamstring lengthening in patients with crouch gait. With regard to equinus treatment, Firth et al. retrospectively examined the role of conservative surgery (distal gastrocnemius recession or differential gastrocnemius-soleus complex lengthening) in preventing overcorrection (calcaneal deformity and crouch gait) or recurrence in the context of single-event multilevel surgery in patients with spastic diplegia31. The authors found that the majority of children had the equinus deformity corrected with conservative surgery, with a low rate of overcorrection (2.5%). Even though there was a high rate of recurrent equinus (35%), only 12.5% of patients
required revision surgery. At the time of midterm follow-up (seven years), the results of this study showed that, when combined with multimodal treatment (i.e., bracing and physical therapy), a more conservative approach that preserves lower leg strength can be successful in the treatment of equinus. Pediatric Hip Slipped Capital Femoral Epiphysis Sankar et al. performed a multicenter retrospective review of the modified Dunn procedure for unstable slipped capital femoral epiphysis32. Twenty-seven patients who together had a mean follow-up of 22.3 months were included in the study. The authors found that the procedure was capable of restoring proximal femoral anatomy with a mean postoperative slip angle of 6°, yet 26.0% of patients developed osteonecrosis at a mean of 21.4 weeks after surgery (range, ten to thirty-nine weeks). Although restoration of proximal femoral anatomy can be performed via the modified Dunn procedure, the surgeon and family should be prepared for the possibility of osteonecrosis, whether due to surgical technique or the injury itself. Nasreddine et al. examined risk factors for a subsequent contralateral slipped capital femoral epiphysis in 173 patients with slipped capital femoral epiphysis33. Postoperative obesity and acute chronicity were associated with the development of a subsequent slipped capital femoral epiphysis, whereas sex, age, slip stability, and slip angle were not. Patients who reduced their body mass index to below the ninety-fifth percentile postoperatively had a decreased risk of developing a contralateral slipped capital femoral epiphysis (odds ratio, 0.16). The benefits of weight loss must be discussed with the patient postoperatively. In a separate study, Sankar et al. found that prophylactic pinning to prevent a subsequent slipped capital femoral epiphysis is not an entirely benign procedure. In a review of prophylactic fixation, those authors reported a 2% rate of osteonecrosis, a 2% rate of peri-implant femoral fracture, and a 3% rate of symptomatic implant in the unaffected, surgically treated hip34. Developmental Dysplasia of the Hip Palocaren et al. examined the efficacy of the Pavlik harness in treating patients with bilateral or unilateral hip dislocations35. The authors found no difference in the rate of failure between unilateral (54.5%) and bilateral dislocations (57%). This illustrates a high rate of failure of Pavlik treatment in general with dislocated hips, but no difference in treatment success between the two groups studied. Wang et al. compared the outcomes of surgical treatment of unilateral and bilateral developmental dysplasia of the hip in children of walking age who were followed for a minimum of five years after open reduction and pelvic osteotomy with or without femoral osteotomy36. The authors found that the clinical outcome after open reduction for bilateral developmental dysplasia of the hip was significantly worse (46%
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What’s New in Pediatric Orthopaedics satisfactory in the bilateral group versus 71% satisfactory in the unilateral group), largely due to asymmetry with regard to the outcomes of the hips. The occurrence of osteonecrosis was greater in patients with bilateral hip involvement, older patient age, and higher T¨onnis grade. This study demonstrates that early intervention should be undertaken to prevent the need for surgical intervention at walking age. Legg-Calve´-Perthes Disease Maranho et al. examined the prevalence of acetabular labral and cartilage abnormalities in patients with healed Legg-Calve´ Perthes disease37. In a subgroup of fifty-four patients who underwent noncontrast MRI (at an average of eight years after disease onset), 75% of the hips had labral abnormalities and 47% had cartilage abnormalities. An alpha angle of ‡55° and coxa brevis were significantly associated with both labral and cartilage abnormalities, whereas isolated labral pathology was seen with coxa magna and a high greater trochanter. The results of this study demonstrate the need for long-term counseling of patients with regard to intra-articular pathology after healing of Legg-Calve´ -Perthes disease, particularly in patients who have elevated alpha angles. Park et al. examined the factors for predicting residual shortening (limb-length discrepancy) at skeletal maturity in patients with Legg-Calve´ -Perthes disease38. The authors examined three factors: (1) the extent of femoral head involvement, (2) varus osteotomy treatment, and (3) patient demographics. The mean limb-length discrepancy at maturity was 19 mm (range, 10 to 38 mm) and was associated with the extent of femoral head deformity. Lateral pillar B/C or C
classification was the strongest predictor of limb-length discrepancy, whereas varus osteotomy, age at diagnosis, and sex were not predictors. This study is pertinent to considering the need for intervention for limb-length discrepancy when patients are skeletally immature. NOTE: The authors express their thanks for the support of the Publications Committee of the Pediatric Orthopaedic Society of North America.
Nirav K. Pandya, MD Department of Orthopedic Surgery, Children’s Hospital of Oakland and Research Center/ University of California, San Francisco, 747 52nd Street, Oakland, CA 94609. E-mail address: [email protected]
Norman Y. Otsuka, MSc, MD, FRCSC Center for Children, NYU Langone Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10003
James O. Sanders, MD Department of Orthopaedics, University of Rochester, 601 Elmwood Avenue, Rochester, NY 14642
References 1. Jain A, Kebaish KM, Sponseller PD. Factors associated with use of bone morphogenetic protein during pediatric spinal fusion surgery: an analysis of 4817 patients. J Bone Joint Surg Am. 2013 Jul 17;95(14):1265-70. 2. Shan LQ, Skaggs DL, Lee C, Kissinger C, Myung KS. Intensive care unit versus hospital floor: a comparative study of postoperative management of patients with adolescent idiopathic scoliosis. J Bone Joint Surg Am. 2013 Apr 3;95(7):e40. 3. Hwang SW, Samdani AF, Stanton P, Marks MC, Bastrom T, Newton PO, Betz RR, Cahill PJ. Impact of pedicle screw fixation on loss of deformity correction in patients with adolescent idiopathic scoliosis. J Pediatr Orthop. 2013 Jun;33(4):377-82. 4. Mackenzie WG, Matsumoto H, Williams BA, Corona J, Lee C, Cody SR, Covington L, Saiman L, Flynn JM, Skaggs DL, Roye DP Jr, Vitale MG. Surgical site infection following spinal instrumentation for scoliosis: a multicenter analysis of rates, risk factors, and pathogens. J Bone Joint Surg Am. 2013 May 1;95(9):800-6, S1-2. 5. Vitale MG, Riedel MD, Glotzbecker MP, Matsumoto H, Roye DP, Akbarnia BA, Anderson RC, Brockmeyer DL, Emans JB, Erickson M, Flynn JM, Lenke LG, Lewis SJ, Luhmann SJ, McLeod LM, Newton PO, Nyquist AC, Richards BS 3rd, Shah SA, Skaggs DL, Smith JT, Sponseller PD, Sucato DJ, Zeller RD, Saiman L. Building consensus: development of a Best Practice Guideline (BPG) for surgical site infection (SSI) prevention in high-risk pediatric spine surgery. J Pediatr Orthop. 2013 JulAug;33(5):471-8. 6. Miller R, Beck NA, Sampson NR, Zhu X, Flynn JM, Drummond D. Imaging modalities for low back pain in children: a review of spondylolysis and undiagnosed mechanical back pain. J Pediatr Orthop. 2013 Apr-May;33(3):282-8. 7. Sabharwal S, Sakamoto SM, Zhao C. Advanced bone age in children with Blount disease: a case-control study. J Pediatr Orthop. 2013 Jul-Aug;33(5):551-7. 8. Woodcock J, Larson AN, Mabry TM, Stans AA. Do retained pediatric implants impact later total hip arthroplasty? J Pediatr Orthop. 2013 Apr-May;33(3): 339-44.
˚ 9. Engstr¨om P, Bartonek A, Tedroff K, Orefelt C, Haglund-Akerlind Y, GutierrezFarewik EM. Botulinum toxin A does not improve the results of cast treatment for idiopathic toe-walking: a randomized controlled trial. J Bone Joint Surg Am. 2013 Mar 6;95(5):400-7. 10. Ford-Powell VA, Barker S, Khan MS, Evans AM, Deitz FR. The Bangladesh clubfoot project: the first 5000 feet. J Pediatr Orthop. 2013 Jun;33(4): e40-4. 11. Rampal V, Chamond C, Barthes X, Glorion C, Seringe R, Wicart P. Long-term results of treatment of congenital idiopathic clubfoot in 187 feet: outcome of the functional ‘‘French’’ method, if necessary completed by soft-tissue release. J Pediatr Orthop. 2013 Jan;33(1):48-54. 12. Hsu LP, Dias LS, Swaroop VT. Long-term retrospective study of patients with idiopathic clubfoot treated with posterior medial-lateral release. J Bone Joint Surg Am. 2013 Mar 6;95(5):e27. 13. Lawrence JT, Patel NM, Macknin J, Flynn JM, Cameron D, Wolfgruber HC, Ganley TJ. Return to competitive sports after medial epicondyle fractures in adolescent athletes: results of operative and nonoperative treatment. Am J Sports Med. 2013 May;41(5):1152-7. Epub 2013 Mar 18. 14. Parikh SN, Nathan ST, Wall EJ, Eismann EA. Complications of medial patellofemoral ligament reconstruction in young patients. Am J Sports Med. 2013 May;41(5):1030-8. Epub 2013 Mar 28. 15. Reynolds G. What to Do If Your Child Tears an ACL. The New York Times. 2013 Sep 4. http://well.blogs.nytimes.com/2013/09/04/what-to-do-if-your-child-tearsan-a-c-l/. Accessed 2013 Dec 3. 16. Reynolds G. Why A.C.L. Injuries Sideline So Many Athletes. The New York Times. 2013 Aug 28. http://well.blogs.nytimes.com/2013/08/28/why-a-c-l-injuriessideline-so-many-athletes/. Accessed 2013 Dec 3. 17. Moksnes H, Engebretsen L, Risberg MA. Prevalence and incidence of new meniscus and cartilage injuries after a nonoperative treatment algorithm for ACL
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What’s New in Pediatric Orthopaedics tears in skeletally immature children: a prospective MRI study. Am J Sports Med. 2013 Aug;41(8):1771-9. Epub 2013 Jun 14. 18. Kumar S, Ahearne D, Hunt DM. Transphyseal anterior cruciate ligament reconstruction in the skeletally immature: follow-up to a minimum of sixteen years of age. J Bone Joint Surg Am. 2013 Jan 2;95(1):e1. 19. Georgopoulos G, Carry P, Pan Z, Chang F, Heare T, Rhodes J, Hotchkiss M, Miller NH, Erickson M. The efficacy of intra-articular injections for pain control following the closed reduction and percutaneous pinning of pediatric supracondylar humeral fractures: a randomized controlled trial. J Bone Joint Surg Am. 2012 Sep 19;94(18):1633-42. 20. Moraleda L, Valencia M, Barco R, Gonz´alez-Moran G. Natural history of unreduced Gartland type-II supracondylar fractures of the humerus in children: a two to thirteen-year follow-up study. J Bone Joint Surg Am. 2013 Jan 2;95(1):28-34. 21. Li Y, Heyworth BE, Glotzbecker M, Seeley M, Suppan CA, Gagnier J, VanderHave KL, Caird MS, Farley FA, Hedequist D. Comparison of titanium elastic nail and plate fixation of pediatric subtrochanteric femur fractures. J Pediatr Orthop. 2013 AprMay;33(3):232-8. 22. Heyworth BE, Hedequist DJ, Nasreddine AY, Stamoulis C, Hresko MT, Yen YM. Distal femoral valgus deformity following plate fixation of pediatric femoral shaft fractures. J Bone Joint Surg Am. 2013 Mar 20;95(6):526-33. 23. Choe H, Inaba Y, Kobayashi N, Aoki C, Machida J, Nakamura N, Okuzumi S, Saito T. Use of real-time polymerase chain reaction for the diagnosis of infection and differentiation between gram-positive and gram-negative septic arthritis in children. J Pediatr Orthop. 2013 Apr-May;33(3):e28-33. 24. Liberman B, Herman A, Schindler A, Sherr-Lurie N, Ganel A, Givon U. The value of hip aspiration in pediatric transient synovitis. J Pediatr Orthop. 2013 Mar;33(2):124-7. 25. Cappello T, Nuelle JA, Katsantonis N, Nauer RK, Lauing KL, Jagodzinski JE, Callaci JJ. Ketorolac administration does not delay early fracture healing in a juvenile rat model: a pilot study. J Pediatr Orthop. 2013 Jun;33(4):415-21. 26. Lyon R, Liu XC, Kubin M, Schwab J. Does extracorporeal shock wave therapy enhance healing of osteochondritis dissecans of the rabbit knee?: a pilot study. Clin Orthop Relat Res. 2013 Apr;471(4):1159-65. 27. Kim HK, Aruwajoye O, Stetler J, Stall A. Effects of non-weight-bearing on the immature femoral head following ischemic osteonecrosis: an experimental investigation in immature pigs. J Bone Joint Surg Am. 2012 Dec 19;94(24):2228-37.
28. Dreher T, Wolf SI, Maier M, Hagmann S, Vegvari D, Gantz S, Heitzmann D, Wenz W, Braatz F. Long-term results after distal rectus femoris transfer as a part of multilevel surgery for the correction of stiff-knee gait in spastic diplegic cerebral palsy. J Bone Joint Surg Am. 2012 Oct 3;94(19):e142. 29. Scully WF, McMulkin ML, Baird GO, Gordon AB, Tompkins BJ, Caskey PM. Outcomes of rectus femoris transfers in children with cerebral palsy: effect of transfer site. J Pediatr Orthop. 2013 Apr-May;33(3):303-8. 30. Rethlefsen SA, Yasmeh S, Wren TA, Kay RM. Repeat hamstring lengthening for crouch gait in children with cerebral palsy. J Pediatr Orthop. 2013 Jul-Aug;33(5):501-4. 31. Firth GB, Passmore E, Sangeux M, Thomason P, Rodda J, Donath S, Selber P, Graham HK. Multilevel surgery for equinus gait in children with spastic diplegic cerebral palsy: medium-term follow-up with gait analysis. J Bone Joint Surg Am. 2013 May 15;95(10):931-8. 32. Sankar WN, Vanderhave KL, Matheney T, Herrera-Soto JA, Karlen JW. The modified Dunn procedure for unstable slipped capital femoral epiphysis: a multicenter perspective. J Bone Joint Surg Am. 2013 Apr 3;95(7):585-91. 33. Nasreddine AY, Heyworth BE, Zurakowski D, Kocher MS. A reduction in body mass index lowers risk for bilateral slipped capital femoral epiphysis. Clin Orthop Relat Res. 2013 Jul;471(7):2137-44. 34. Sankar WN, Novais EN, Lee C, Al-Omari AA, Choi PD, Shore BJ. What are the risks of prophylactic pinning to prevent contralateral slipped capital femoral epiphysis? Clin Orthop Relat Res. 2013 Jul;471(7):2118-23. 35. Palocaren T, Rogers K, Haumont T, Grissom L, Thacker MM. High failure rate of the Pavlik harness in dislocated hips: is it bilaterality? J Pediatr Orthop. 2013 JulAug;33(5):530-5. 36. Wang TM, Wu KW, Shih SF, Huang SC, Kuo KN. Outcomes of open reduction for developmental dysplasia of the hip: does bilateral dysplasia have a poorer outcome? J Bone Joint Surg Am. 2013 Jun 19;95(12):1081-6. 37. Maranho DA, Nogueira-Barbosa MH, Zamarioli A, Volpon JB. MRI abnormalities of the acetabular labrum and articular cartilage are common in healed Legg-Calv´ePerthes disease with residual deformities of the hip. J Bone Joint Surg Am. 2013 Feb 6;95(3):256-65. 38. Park KW, Jang KS, Song HR. Can residual leg shortening be predicted in patients with Legg-Calv´e-Perthes’ disease? Clin Orthop Relat Res. 2013 Aug;471(8):2570-7. Epub 2013 Apr 25.
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Specialty Update
What’s New in Pediatric Orthopaedics Nirav K. Pandya, MD, Norman Y. Otsuka, MSc, MD, FRCSC, and James O. Sanders, MD
Spine There are wide variations with regard to the treatment of spinal deformity across the United States, with few studies identifying the best practices. A 2013 study on the use of bone morphogenetic protein (BMP), which is currently not approved by the U.S. Food and Drug Administration for use in children, found a 3.4-fold increase in its use from 2003 to 2009 in pediatric spinal fusions, with geographic variation in usage rates1. The use of BMP was more common in children who had private rather than state-funded insurance coverage, and in private hospitals as compared with teaching hospitals. BMP was more likely to be used in older adolescents and in the treatment of patients with congenital scoliosis, thoracolumbar fractures, or spondylolisthesis as opposed to patients with adolescent idiopathic scoliosis. The safety of BMP has not been studied in adolescents, and there is concern about cancer risk with BMP use. There are also variations with regard to the care of children following spinal surgery. Shan et al. retrospectively studied patients with adolescent idiopathic scoliosis who were admitted to the pediatric intensive care unit (PICU) following surgery as compared with those who were admitted to the general hospital floor2. Patients admitted to the general hospital floor had 16% lower overall costs, fewer blood draws, less medication usage, and an earlier discharge than did the patients who were admitted to the PICU. As a caveat, the investigators noted that their study was performed at a high-volume academic tertiary-care pediatric hospital where the floor nurses were very experienced in treating patients who had adolescent idiopathic scoliosis, and thus the generalizability of the study may be limited. Pedicle screw fixation has become a mainstay of surgical correction of scoliosis in North America, and articles continue to compare the results of screw fixation to hybrid (hook and/or Specialty Update has been developed in collaboration with the Board of Specialty Societies (BOS) of the American Academy of Orthopaedic Surgeons.
wire fixation) constructs. Hwang et al. investigated loss of correction in patients who had surgery to correct adolescent idiopathic scoliosis and were followed postoperatively for at least two years3. Loss of correction was defined radiographically as an increase of ‡10° in the coronal Cobb angle of an instrumented curve or clinically as an increase of >5° in the inclinometer reading. They identified both larger curve magnitude and the use of hybrid instrumentation as risk factors for loss of correction. The mean loss of correction in the patients who received pedicle screws was 10.43° as compared with 12.50° in the patients who received hybrid instrumentation. The clinical significance of this difference is uncertain. Postoperative spinal infection is a major ongoing concern. A retrospective study evaluated risk factors for infection following spinal deformity surgery in children4. The rate of infection was 1.2% in patients who had idiopathic scoliosis, 13.1% in patients who had neuromuscular scoliosis, 10.3% in patients who underwent growing rod revision, and 13.7% for patients in whom pelvic instrumentation was used. Multivariate regression identified the strongest predictors of infection as being non-idiopathic scoliosis (adjusted odds ratio, 2.01; 95% confidence interval, 1.03 to 3.91) and instrumentation to the pelvis (adjusted odds ratio, 3.05; 95% confidence interval, 1.83 to 5.09). Furthermore, in an effort to develop best-practice methods of preventing infection following spinal deformity surgery in high-risk patients, Vitale et al., using a Delphi process and nominal group technique, developed a consensus-based guideline5. The attractiveness of the technique is that it allows for the rapid development of clinical improvement initiatives when the studies needed to validate the individual components are of varying quality and/or of limited number. Finally, the optimum evaluation pathways for pediatric back pain have not been established. Specific concerns in children include radiation exposure, the need for sedation in younger children receiving magnetic resonance imaging
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
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What’s New in Pediatric Orthopaedics (MRI), and the ethics of quality randomized controlled trials in children. A recent review of the records of 2846 children with back pain pointed to the increased radiation dose associated with lumbar computed tomography scans and nuclear medicine scans in children that may occur during work-up6. Most children had resolution of their symptoms without the need for advanced imaging. Deformity Sabharwal et al. compared skeletal maturity between patients with Blount disease and their peers who did not have Blount disease and found advanced skeletal maturity in patients with Blount disease (bone age was advanced twenty-six months in patients with early-onset Blount disease and ten months in patients with late-onset Blount disease)7. Because skeletal maturity affects the strategy for surgical realignment or even its likelihood of success, the authors recommended performing an evaluation of skeletal maturity as part of the surgical decisionmaking process. Implant removal in pediatric orthopaedics is controversial, particularly around the hip where concerns remain in regard to interference with adult hip surgical procedures. In a case-matched series of total hip arthroplasty patients with and without retained pediatric implants, Woodcock et al. found that patients with retained implants had more complications, a longer length of hospital stay, and an increased need for allograft8. The results of that study suggest that pediatric orthopaedists should consider removing implants that have been placed in children. Foot and Ankle Randomized controlled studies in the field of pediatric orthopaedics remain rare. The use of botulinum toxin remains an exception, likely because of the minimally invasive nature of the injections and parents’ willingness to participate. In a recent Level-I study performed in patients with idiopathic toewalking, Engstr¨om et al. compared the results of cast treatment with the results of injection of botulinum toxin A followed by cast treatment9. The authors found no difference in the results between the two groups, thus demonstrating the limited efficacy of injections before casting in this subgroup. The Ponseti method for clubfoot has become a worldwide treatment. Methods have been developed for extending the treatment to developing regions, which often have few surgical resources. The first 5000 feet treated as part of a Ponseti program in Bangladesh were recently reported10. Each site was required to keep details regarding clubfoot severity, procedures, results, and complications. Only 12% of patients were lost to follow-up at two years, and 13% of the clubfeet were noted to be atypical. The majority of patients (76%) underwent heel cord tenotomy. The records noted a complication rate of 2%. The project highlights how a relatively straightforward public health model can markedly improve care for orthopaedic disorders in underserved nations.
A rival of the Ponseti method is the ‘‘French’’ method, which relies on frequent manipulation, splinting, and selective surgery. Rampal et al. reported on their treatment results with this method at an average of 14.7 years of follow-up; their patients had 98% good or very good results with use of a composite scoring system11. Hsu et al. reported on the longterm follow-up of patients with clubfoot resistant to casting who were treated with extensive soft-tissue release and manual derotation of the talus with a Kirschner wire12. At an average of twenty-one years after surgery, 27% of patients had required some form of additional surgery. In patients with unilateral clubfoot, the affected foot had decreased range of motion, foot length, and calf circumference as compared with the contralateral foot. Yet, quality of life scores did not decline over time, particularly in patients who did not require additional surgery. Sports Medial epicondylar fractures continue to be an area of controversy, particularly with regard to optimal treatment. Lawrence et al. retrospectively examined the outcomes after operative or nonoperative management of medial epicondylar fractures in twenty adolescent athletes13. Regardless of the type of treatment used, all fractures healed with an osseous union and all patients returned to a high level of sports activity. Further analysis of the results suggests that nonoperative management can be successful in the treatment of patients who have sustained low-energy injuries with minimal fracture displacement and without associated elbow laxity, whereas operative management can be successful in the treatment of patients with higher-energy trauma with appreciable fracture displacement and elbow instability. Medial patellofemoral ligament reconstruction for patellar instability has shown early success in restoring the primary restraint to lateral translation of the patella. Limited long-term data are available regarding complications in patients who are less than twenty-one years of age. Parikh et al. retrospectively reported a 16.2% complication rate after medial patellofemoral ligament reconstruction in 179 patients less than three years postoperatively14. Of these complications, nearly half were considered preventable because they were secondary to technical errors, particularly improper tunnel placement in the femur and patella. The results of this study provide factors that must be considered when performing medial patellofemoral ligament reconstruction to improve outcomes. Anterior cruciate ligament (ACL) injuries in skeletally immature patients continue to be a ‘‘hot’’ topic in the lay press15,16. The increase in ACL reconstruction in skeletally immature patients has resulted from the premise that postponement of ACL reconstruction can lead to a higher rate of meniscal and articular cartilage injury. Moksnes et al. prospectively examined the prevalence and incidence of new meniscus and cartilage injuries in skeletally immature patients with ACL injuries that were treated nonoperatively17. The authors examined MRI at the time of injury and at two
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What’s New in Pediatric Orthopaedics subsequent times, with one to two years between studies. The overall incidence of new injuries from the time of the initial MRI until follow-up (mean time and standard deviation, 3.8 ± 1.4 years after injury) was 19.5% for meniscal injury and 7.1% for articular cartilage injuries. Delayed reconstruction may be associated with a lower rate of meniscal and/or chondral damage than was previously thought. Kumar et al. examined the results of transphyseal ACL reconstruction in thirty-two consecutive patients (mean age, 11.25 years) who were less than fourteen years of age and at Tanner stage 1 or 2, or less than twelve years of age and at Tanner stage 318. At a mean of 72.3 months after surgery, there was only one rerupture, one mild valgus deformity with no functional disturbance, and no limb-length discrepancies, suggesting that transphyseal reconstruction even in skeletally immature patients can be performed safely with good-toexcellent outcomes. Trauma Supracondylar humeral fractures have been examined in several studies over the past several years, but few investigators have looked at postoperative pain management. Georgopoulos et al. examined the efficacy of intra-articular injections of 0.25% bupivacaine or 0.20% ropivacaine after fracture fixation19. Requirements for morphine and/or fentanyl were significantly (p = 0.004) lower in the bupivacaine group (10%) than in the ropivacaine (36%) and control (44%) groups. Total opioid consumption was also significantly lower in the first seventy-two hours postoperatively in the bupivacaine group than it was in the control group. Intra-articular administration of bupivacaine can be a potential consideration in postoperative pain control in patients with these injuries, although additional studies are necessary to assess the impact on the postoperative neurological examination and chondral toxicity. In contrast to studies examining operative intervention of supracondylar humeral fractures, Moraleda et al. examined the long-term (mean, 6.6 ± 2.8 years) outcomes of forty-six Gartland type-II supracondylar humeral fractures that were treated nonoperatively 20. The authors reported that functional results were excellent. The treatment of problematic pediatric femoral fractures poses a challenge. Li et al. examined the use of titanium elastic nails compared with plate fixation in subtrochanteric femoral fractures21. In this multicenter retrospective study of fifty-four children, the overall complication rate was significantly higher (48%) in the titanium elastic nail group than it was in the plating group (14%). The most common complications in the titanium elastic nail group were fracture malalignment, limblength inequality, and pain associated with a prominent implant. For the treatment of problematic subtrochanteric femoral fractures, surgeons may consider the use of plating instead of titanium elastic nails. Heyworth et al. reported distal femoral valgus deformity after plate fixation of distal femoral shaft fractures22. In eighty-
five patients who underwent plate fixation of a diaphyseal femoral fracture, the authors noted the development of a distal femoral valgus deformity in ten patients. The risk factors for distal femoral valgus deformity included a plate-to-physis distance of ‡20 mm, a distal fracture, and a distal bend in the plate (although this was not an independent factor). The results of this study suggest that when plating is used for these injuries, care should be taken to monitor these patients for the development of deformity, and utilize appropriate techniques when inserting the plate. Infection Choe et al., in an effort to provide a more accurate diagnosis of septic arthritis and to guide antibiotic treatment, combined basic and clinical science by examining the utilization of realtime polymerase chain reaction (PCR) assays for the diagnosis of septic arthritis in children23. The sensitivity of PCR (0.79) for diagnosis of infection and bacterial differentiation was higher than that of microbiologic cultures (0.47) although the specificity (1.00) was the same. The results of this study suggest that not only can a more successful diagnosis of infection be obtained with use of PCR but also differentiation of bacterial type can lead to earlier, targeted antibiotic treatment. Liberman et al. examined the value of ultrasound-guided hip aspiration in the emergency room in suspected pediatric transient synovitis24. In their study, patients with transient synovitis of the hip were treated with bed rest and nonsteroidal anti-inflammatory drugs alone (group 1) or with the addition of hip aspiration (group 2). The authors found that, twentyfour hours after admission, patients in whom aspiration had been performed had significantly less limping (10% versus 92%), refusal to bear weight (1% versus 14%), and hip joint pain (6% versus 81%). The results of this study suggest that hip aspiration of intra-articular fluid may be diagnostic and therapeutic in patients with transient synovitis. Basic Science Cappello et al. examined the effect of ketorolac on fracturehealing in a juvenile rat model25. Tibial shaft fractures in fortyfive juvenile rats were surgically induced and then stabilized. The rats were randomized into treatment with ketorolac or saline solution postoperatively and were then killed at seven, fourteen, or twenty-one days after fracture. Regardless of treatment with ketorolac or saline solution, the strength and stiffness of the tibiae increased from day seven to day twentyone and the quality of the fracture callus was similar in both groups at each time point. The results of this immature animal study suggest that anti-inflammatory drugs such as ketorolac can be utilized for pain relief without adverse effects on pediatric fracture-healing. Lyon et al. examined the role of extracorporeal shock wave therapy (ESWT) in the healing of osteochondral lesions of the rabbit knee26. ESWT has been shown to enhance healing in long-bone nonunions, although its utility in enhancing the
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What’s New in Pediatric Orthopaedics healing of osteochondral lesions is unknown. Utilizing twenty skeletally immature rabbits with osteochondral lesions, the authors found that there was more mature bone formation, healing, and cartilage density histologically after ESWT. In addition, increased osseous density was seen on radiographs. Non-weight-bearing has been postulated as a treatment for Legg-Calve´ -Perthes disease but remains controversial due to a lack of scientific data. Using an animal model, Kim et al. examined the effects of osteochondral lesions on the immature femoral head following ischemic osteonecrosis27. Sixteen piglets with induced femoral head ischemia were randomized to non-weight-bearing on the ischemic limb (via amputation) or weight-bearing. The authors found that localized non-weightbearing after ischemic femoral head osteonecrosis decreased deformity, increased revascularization, and increased the amount of resorption of the infarcted epiphysis. Neuromuscular Dreher et al. examined the long-term results (mean follow-up, nine years) of distal rectus femoris transfer accomplished during multilevel surgery in fifty-three ambulatory patients who had spastic diplegic cerebral palsy and stiff-knee gait28. The results demonstrated that, in patients with decreased peak knee flexion in the swing phase, rectus femoris transfer can provide long-lasting improvements in gait, although prophylactic transfer may not be appropriate. In patients with stiff-knee gait, Scully et al. compared the outcomes achieved with distal rectus femoris transfer to one of three sites: medial to the semitendinosus, medial to the sartorious, or lateral to the iliotibial band29. Significant improvements in knee arc of motion, timing of peak knee flexion in the swing phase, and knee extension at initial contact were seen in all three transfer groups, with no significant differences among groups. According to the results of this study, the location of the transfer site can be based on surgeon preference and concomitant procedures. Rethlefsen et al. examined the role of revision hamstring lengthening in patients with crouch gait30. Thirty-nine patients were retrospectively reviewed who underwent hamstring lengthening (single versus repeat). Seventy-one percent of patients in the single lengthening group had improvements in stance-phase knee extension as compared with 28% in the repeat lengthening group, suggesting that alternative treatments should be considered instead of repeat hamstring lengthening in patients with crouch gait. With regard to equinus treatment, Firth et al. retrospectively examined the role of conservative surgery (distal gastrocnemius recession or differential gastrocnemius-soleus complex lengthening) in preventing overcorrection (calcaneal deformity and crouch gait) or recurrence in the context of single-event multilevel surgery in patients with spastic diplegia31. The authors found that the majority of children had the equinus deformity corrected with conservative surgery, with a low rate of overcorrection (2.5%). Even though there was a high rate of recurrent equinus (35%), only 12.5% of patients
required revision surgery. At the time of midterm follow-up (seven years), the results of this study showed that, when combined with multimodal treatment (i.e., bracing and physical therapy), a more conservative approach that preserves lower leg strength can be successful in the treatment of equinus. Pediatric Hip Slipped Capital Femoral Epiphysis Sankar et al. performed a multicenter retrospective review of the modified Dunn procedure for unstable slipped capital femoral epiphysis32. Twenty-seven patients who together had a mean follow-up of 22.3 months were included in the study. The authors found that the procedure was capable of restoring proximal femoral anatomy with a mean postoperative slip angle of 6°, yet 26.0% of patients developed osteonecrosis at a mean of 21.4 weeks after surgery (range, ten to thirty-nine weeks). Although restoration of proximal femoral anatomy can be performed via the modified Dunn procedure, the surgeon and family should be prepared for the possibility of osteonecrosis, whether due to surgical technique or the injury itself. Nasreddine et al. examined risk factors for a subsequent contralateral slipped capital femoral epiphysis in 173 patients with slipped capital femoral epiphysis33. Postoperative obesity and acute chronicity were associated with the development of a subsequent slipped capital femoral epiphysis, whereas sex, age, slip stability, and slip angle were not. Patients who reduced their body mass index to below the ninety-fifth percentile postoperatively had a decreased risk of developing a contralateral slipped capital femoral epiphysis (odds ratio, 0.16). The benefits of weight loss must be discussed with the patient postoperatively. In a separate study, Sankar et al. found that prophylactic pinning to prevent a subsequent slipped capital femoral epiphysis is not an entirely benign procedure. In a review of prophylactic fixation, those authors reported a 2% rate of osteonecrosis, a 2% rate of peri-implant femoral fracture, and a 3% rate of symptomatic implant in the unaffected, surgically treated hip34. Developmental Dysplasia of the Hip Palocaren et al. examined the efficacy of the Pavlik harness in treating patients with bilateral or unilateral hip dislocations35. The authors found no difference in the rate of failure between unilateral (54.5%) and bilateral dislocations (57%). This illustrates a high rate of failure of Pavlik treatment in general with dislocated hips, but no difference in treatment success between the two groups studied. Wang et al. compared the outcomes of surgical treatment of unilateral and bilateral developmental dysplasia of the hip in children of walking age who were followed for a minimum of five years after open reduction and pelvic osteotomy with or without femoral osteotomy36. The authors found that the clinical outcome after open reduction for bilateral developmental dysplasia of the hip was significantly worse (46%
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What’s New in Pediatric Orthopaedics satisfactory in the bilateral group versus 71% satisfactory in the unilateral group), largely due to asymmetry with regard to the outcomes of the hips. The occurrence of osteonecrosis was greater in patients with bilateral hip involvement, older patient age, and higher T¨onnis grade. This study demonstrates that early intervention should be undertaken to prevent the need for surgical intervention at walking age. Legg-Calve´-Perthes Disease Maranho et al. examined the prevalence of acetabular labral and cartilage abnormalities in patients with healed Legg-Calve´ Perthes disease37. In a subgroup of fifty-four patients who underwent noncontrast MRI (at an average of eight years after disease onset), 75% of the hips had labral abnormalities and 47% had cartilage abnormalities. An alpha angle of ‡55° and coxa brevis were significantly associated with both labral and cartilage abnormalities, whereas isolated labral pathology was seen with coxa magna and a high greater trochanter. The results of this study demonstrate the need for long-term counseling of patients with regard to intra-articular pathology after healing of Legg-Calve´ -Perthes disease, particularly in patients who have elevated alpha angles. Park et al. examined the factors for predicting residual shortening (limb-length discrepancy) at skeletal maturity in patients with Legg-Calve´ -Perthes disease38. The authors examined three factors: (1) the extent of femoral head involvement, (2) varus osteotomy treatment, and (3) patient demographics. The mean limb-length discrepancy at maturity was 19 mm (range, 10 to 38 mm) and was associated with the extent of femoral head deformity. Lateral pillar B/C or C
classification was the strongest predictor of limb-length discrepancy, whereas varus osteotomy, age at diagnosis, and sex were not predictors. This study is pertinent to considering the need for intervention for limb-length discrepancy when patients are skeletally immature. NOTE: The authors express their thanks for the support of the Publications Committee of the Pediatric Orthopaedic Society of North America.
Nirav K. Pandya, MD Department of Orthopedic Surgery, Children’s Hospital of Oakland and Research Center/ University of California, San Francisco, 747 52nd Street, Oakland, CA 94609. E-mail address: [email protected]
Norman Y. Otsuka, MSc, MD, FRCSC Center for Children, NYU Langone Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10003
James O. Sanders, MD Department of Orthopaedics, University of Rochester, 601 Elmwood Avenue, Rochester, NY 14642
References 1. Jain A, Kebaish KM, Sponseller PD. Factors associated with use of bone morphogenetic protein during pediatric spinal fusion surgery: an analysis of 4817 patients. J Bone Joint Surg Am. 2013 Jul 17;95(14):1265-70. 2. Shan LQ, Skaggs DL, Lee C, Kissinger C, Myung KS. Intensive care unit versus hospital floor: a comparative study of postoperative management of patients with adolescent idiopathic scoliosis. J Bone Joint Surg Am. 2013 Apr 3;95(7):e40. 3. Hwang SW, Samdani AF, Stanton P, Marks MC, Bastrom T, Newton PO, Betz RR, Cahill PJ. Impact of pedicle screw fixation on loss of deformity correction in patients with adolescent idiopathic scoliosis. J Pediatr Orthop. 2013 Jun;33(4):377-82. 4. Mackenzie WG, Matsumoto H, Williams BA, Corona J, Lee C, Cody SR, Covington L, Saiman L, Flynn JM, Skaggs DL, Roye DP Jr, Vitale MG. Surgical site infection following spinal instrumentation for scoliosis: a multicenter analysis of rates, risk factors, and pathogens. J Bone Joint Surg Am. 2013 May 1;95(9):800-6, S1-2. 5. Vitale MG, Riedel MD, Glotzbecker MP, Matsumoto H, Roye DP, Akbarnia BA, Anderson RC, Brockmeyer DL, Emans JB, Erickson M, Flynn JM, Lenke LG, Lewis SJ, Luhmann SJ, McLeod LM, Newton PO, Nyquist AC, Richards BS 3rd, Shah SA, Skaggs DL, Smith JT, Sponseller PD, Sucato DJ, Zeller RD, Saiman L. Building consensus: development of a Best Practice Guideline (BPG) for surgical site infection (SSI) prevention in high-risk pediatric spine surgery. J Pediatr Orthop. 2013 JulAug;33(5):471-8. 6. Miller R, Beck NA, Sampson NR, Zhu X, Flynn JM, Drummond D. Imaging modalities for low back pain in children: a review of spondylolysis and undiagnosed mechanical back pain. J Pediatr Orthop. 2013 Apr-May;33(3):282-8. 7. Sabharwal S, Sakamoto SM, Zhao C. Advanced bone age in children with Blount disease: a case-control study. J Pediatr Orthop. 2013 Jul-Aug;33(5):551-7. 8. Woodcock J, Larson AN, Mabry TM, Stans AA. Do retained pediatric implants impact later total hip arthroplasty? J Pediatr Orthop. 2013 Apr-May;33(3): 339-44.
˚ 9. Engstr¨om P, Bartonek A, Tedroff K, Orefelt C, Haglund-Akerlind Y, GutierrezFarewik EM. Botulinum toxin A does not improve the results of cast treatment for idiopathic toe-walking: a randomized controlled trial. J Bone Joint Surg Am. 2013 Mar 6;95(5):400-7. 10. Ford-Powell VA, Barker S, Khan MS, Evans AM, Deitz FR. The Bangladesh clubfoot project: the first 5000 feet. J Pediatr Orthop. 2013 Jun;33(4): e40-4. 11. Rampal V, Chamond C, Barthes X, Glorion C, Seringe R, Wicart P. Long-term results of treatment of congenital idiopathic clubfoot in 187 feet: outcome of the functional ‘‘French’’ method, if necessary completed by soft-tissue release. J Pediatr Orthop. 2013 Jan;33(1):48-54. 12. Hsu LP, Dias LS, Swaroop VT. Long-term retrospective study of patients with idiopathic clubfoot treated with posterior medial-lateral release. J Bone Joint Surg Am. 2013 Mar 6;95(5):e27. 13. Lawrence JT, Patel NM, Macknin J, Flynn JM, Cameron D, Wolfgruber HC, Ganley TJ. Return to competitive sports after medial epicondyle fractures in adolescent athletes: results of operative and nonoperative treatment. Am J Sports Med. 2013 May;41(5):1152-7. Epub 2013 Mar 18. 14. Parikh SN, Nathan ST, Wall EJ, Eismann EA. Complications of medial patellofemoral ligament reconstruction in young patients. Am J Sports Med. 2013 May;41(5):1030-8. Epub 2013 Mar 28. 15. Reynolds G. What to Do If Your Child Tears an ACL. The New York Times. 2013 Sep 4. http://well.blogs.nytimes.com/2013/09/04/what-to-do-if-your-child-tearsan-a-c-l/. Accessed 2013 Dec 3. 16. Reynolds G. Why A.C.L. Injuries Sideline So Many Athletes. The New York Times. 2013 Aug 28. http://well.blogs.nytimes.com/2013/08/28/why-a-c-l-injuriessideline-so-many-athletes/. Accessed 2013 Dec 3. 17. Moksnes H, Engebretsen L, Risberg MA. Prevalence and incidence of new meniscus and cartilage injuries after a nonoperative treatment algorithm for ACL
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What’s New in Pediatric Orthopaedics tears in skeletally immature children: a prospective MRI study. Am J Sports Med. 2013 Aug;41(8):1771-9. Epub 2013 Jun 14. 18. Kumar S, Ahearne D, Hunt DM. Transphyseal anterior cruciate ligament reconstruction in the skeletally immature: follow-up to a minimum of sixteen years of age. J Bone Joint Surg Am. 2013 Jan 2;95(1):e1. 19. Georgopoulos G, Carry P, Pan Z, Chang F, Heare T, Rhodes J, Hotchkiss M, Miller NH, Erickson M. The efficacy of intra-articular injections for pain control following the closed reduction and percutaneous pinning of pediatric supracondylar humeral fractures: a randomized controlled trial. J Bone Joint Surg Am. 2012 Sep 19;94(18):1633-42. 20. Moraleda L, Valencia M, Barco R, Gonz´alez-Moran G. Natural history of unreduced Gartland type-II supracondylar fractures of the humerus in children: a two to thirteen-year follow-up study. J Bone Joint Surg Am. 2013 Jan 2;95(1):28-34. 21. Li Y, Heyworth BE, Glotzbecker M, Seeley M, Suppan CA, Gagnier J, VanderHave KL, Caird MS, Farley FA, Hedequist D. Comparison of titanium elastic nail and plate fixation of pediatric subtrochanteric femur fractures. J Pediatr Orthop. 2013 AprMay;33(3):232-8. 22. Heyworth BE, Hedequist DJ, Nasreddine AY, Stamoulis C, Hresko MT, Yen YM. Distal femoral valgus deformity following plate fixation of pediatric femoral shaft fractures. J Bone Joint Surg Am. 2013 Mar 20;95(6):526-33. 23. Choe H, Inaba Y, Kobayashi N, Aoki C, Machida J, Nakamura N, Okuzumi S, Saito T. Use of real-time polymerase chain reaction for the diagnosis of infection and differentiation between gram-positive and gram-negative septic arthritis in children. J Pediatr Orthop. 2013 Apr-May;33(3):e28-33. 24. Liberman B, Herman A, Schindler A, Sherr-Lurie N, Ganel A, Givon U. The value of hip aspiration in pediatric transient synovitis. J Pediatr Orthop. 2013 Mar;33(2):124-7. 25. Cappello T, Nuelle JA, Katsantonis N, Nauer RK, Lauing KL, Jagodzinski JE, Callaci JJ. Ketorolac administration does not delay early fracture healing in a juvenile rat model: a pilot study. J Pediatr Orthop. 2013 Jun;33(4):415-21. 26. Lyon R, Liu XC, Kubin M, Schwab J. Does extracorporeal shock wave therapy enhance healing of osteochondritis dissecans of the rabbit knee?: a pilot study. Clin Orthop Relat Res. 2013 Apr;471(4):1159-65. 27. Kim HK, Aruwajoye O, Stetler J, Stall A. Effects of non-weight-bearing on the immature femoral head following ischemic osteonecrosis: an experimental investigation in immature pigs. J Bone Joint Surg Am. 2012 Dec 19;94(24):2228-37.
28. Dreher T, Wolf SI, Maier M, Hagmann S, Vegvari D, Gantz S, Heitzmann D, Wenz W, Braatz F. Long-term results after distal rectus femoris transfer as a part of multilevel surgery for the correction of stiff-knee gait in spastic diplegic cerebral palsy. J Bone Joint Surg Am. 2012 Oct 3;94(19):e142. 29. Scully WF, McMulkin ML, Baird GO, Gordon AB, Tompkins BJ, Caskey PM. Outcomes of rectus femoris transfers in children with cerebral palsy: effect of transfer site. J Pediatr Orthop. 2013 Apr-May;33(3):303-8. 30. Rethlefsen SA, Yasmeh S, Wren TA, Kay RM. Repeat hamstring lengthening for crouch gait in children with cerebral palsy. J Pediatr Orthop. 2013 Jul-Aug;33(5):501-4. 31. Firth GB, Passmore E, Sangeux M, Thomason P, Rodda J, Donath S, Selber P, Graham HK. Multilevel surgery for equinus gait in children with spastic diplegic cerebral palsy: medium-term follow-up with gait analysis. J Bone Joint Surg Am. 2013 May 15;95(10):931-8. 32. Sankar WN, Vanderhave KL, Matheney T, Herrera-Soto JA, Karlen JW. The modified Dunn procedure for unstable slipped capital femoral epiphysis: a multicenter perspective. J Bone Joint Surg Am. 2013 Apr 3;95(7):585-91. 33. Nasreddine AY, Heyworth BE, Zurakowski D, Kocher MS. A reduction in body mass index lowers risk for bilateral slipped capital femoral epiphysis. Clin Orthop Relat Res. 2013 Jul;471(7):2137-44. 34. Sankar WN, Novais EN, Lee C, Al-Omari AA, Choi PD, Shore BJ. What are the risks of prophylactic pinning to prevent contralateral slipped capital femoral epiphysis? Clin Orthop Relat Res. 2013 Jul;471(7):2118-23. 35. Palocaren T, Rogers K, Haumont T, Grissom L, Thacker MM. High failure rate of the Pavlik harness in dislocated hips: is it bilaterality? J Pediatr Orthop. 2013 JulAug;33(5):530-5. 36. Wang TM, Wu KW, Shih SF, Huang SC, Kuo KN. Outcomes of open reduction for developmental dysplasia of the hip: does bilateral dysplasia have a poorer outcome? J Bone Joint Surg Am. 2013 Jun 19;95(12):1081-6. 37. Maranho DA, Nogueira-Barbosa MH, Zamarioli A, Volpon JB. MRI abnormalities of the acetabular labrum and articular cartilage are common in healed Legg-Calv´ePerthes disease with residual deformities of the hip. J Bone Joint Surg Am. 2013 Feb 6;95(3):256-65. 38. Park KW, Jang KS, Song HR. Can residual leg shortening be predicted in patients with Legg-Calv´e-Perthes’ disease? Clin Orthop Relat Res. 2013 Aug;471(8):2570-7. Epub 2013 Apr 25.
