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W3116011569 abstract "This pediatric orthopaedic update represents a review of key articles predominantly from July 2019 to September 2020. Trauma In a study evaluating the reliability of smartphone-based instant messaging for decision-making, 5 pediatric orthopaedic surgeons reviewed 73 cases via radiographs on an iPhone 6 (Apple) and then compared them with their evaluation 4 weeks later on a computer picture archiving and communication system (PACS). They found near-perfect agreement with regard to diagnosis (κ of 0.84), classification (κ of 0.82), and treatment (κ of 0.89)1. Supracondylar Humeral Fractures A prior recommendation that pulseless supracondylar humeral fractures with associated median or anterior interosseous nerve injuries require open operative treatment was called into question in a series from 4 pediatric trauma centers. Of the 71 pulseless supracondylar humeral fractures with nerve injuries (40 median nerve and 31 anterior interosseous nerve), Harris et al. found that 70% (50 of 71) had been successfully treated with closed reduction2. In light of concerns about opioid use and misuse, Nelson et al. reported that postoperative pain in 81 patients with supracondylar humeral fractures had decreased to a clinically unimportant level by postoperative day 3. Patients used <25% of prescribed opioid medication, with a mean of 4.8 doses used postoperatively. The authors recommended that a prescription for 7 opioid doses following discharge should be adequate in the majority of patients with a supracondylar humeral fracture3. Femoral Fractures Adherence to the American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines for pediatric femoral fractures (published in 2009) was investigated by 2 studies. In a review of 2,646 fractures from 4 institutions before and after the publication of the guidelines, Roaten et al. found a significant increase in locked intramedullary nails in patients <11 years of age and an increase in surgical management in patients <5 years of age; the authors concluded that there is a potential need to update the guidelines4. Blatz et al. evaluated compliance with the clinical practice guideline of performing a nonaccidental trauma workup for patients <36 months of age with a femoral fracture and found that only 41% of 281 patients received a nonaccidental trauma workup, despite the guideline. Given the grave consequence of missing nonaccidental trauma, the authors stressed the importance of more rigorous adherence to the guidelines5. Tibial Fractures Yang et al. investigated the prevalence of the Cozen phenomenon in proximal tibial fractures. In their study of 181 fractures, the prevalence of valgus deformity was low, with only 14.3% of patients with <4° of initial valgus angulation developing ≥4° of valgus angulation during follow-up and none of these patients with minimal initial angulation undergoing surgical correction for valgus deformity. The authors concluded that only patients with initial valgus deformity of >4°, an ipsilateral fibular fracture, or a metaphyseal medial gap should be followed for a Cozen phenomenon, to decrease unnecessary cost and radiation exposure6. Lurie et al. evaluated 57 distal tibial fractures (34 treated operatively and 23 treated nonoperatively) with a 2 to 5-mm intra-articular gap. At the mean 4.5-year follow-up, the authors found that an increased articular gap was a negative predictor of the functional outcome score and surgical treatment showed the greatest functional benefit when the articular gap was >2.5 mm7. Spine Adolescent Idiopathic Scoliosis Efforts continue to optimize the prediction of peak height velocity in patients with scoliosis. Minkara et al. reviewed the radiographs of 165 patients with adolescent idiopathic scoliosis for mismatches between Risser staging and Sanders classification. The authors defined mismatch as patients with Risser stage 2 to 5 (limited growth remaining) corresponding to Sanders stage 3 to 5 (considerable growth potential), or, conversely, Risser stage 0 to 1 (considerable growth potential) corresponding to Sanders 6 to 7 (limited growth potential). Minkara et al. found that mismatch occurred in 1 in 4 patients and the majority of these would be undertreated if Risser staging alone was utilized8. Alternatively, Li et al. reported on a classification based on ossification of the proximal part of the humerus. In a review of >400 radiographs, the authors found that the accuracy of predicting peak height velocity was improved compared with Risser staging with the humeral-head ossification system. This has the added benefit that there is no increase in radiation, time, or cost as the humeral head is visible on most standard spinal radiographs9. In another interesting study on this topic, Grothaus et al. focused specifically on patients with a Sanders stage 7 classification with a curve magnitude <50°. The authors found that, at the 2-year follow-up after reaching Sanders stage 7, there was progression of ≥5° in 51% of patients and of ≥10° in 19% of patients. This study highlighted that continued monitoring beyond skeletal maturity is warranted in patients with adolescent idiopathic scoliosis with curves of >40°10. Helenius et al. performed a double-blinded, placebo-controlled, randomized trial of perioperative pregabalin use in 63 patients with adolescent idiopathic scoliosis. Unlike in prior literature, the authors did not see any decrease in pain scores (p = 0.196) or opioid consumption (p = 0.752) following posterior spinal fusion with pregabalin11. In a series of 113 patients, Fletcher et al. found a 40% decrease in opioid use in the group that received corticosteroids. Patients in the corticosteroid group received 3 doses of dexamethasone (median, 8.0 mg/dose). The patients who received corticosteroids were also more likely to walk at their initial physical therapy evaluation (60.4%) compared with those who did not (35.4%) (p = 0.013). There was no increase in wound issues or other complications with corticosteroids12. The pursuit of motion-sparing alternatives to fusion has led to enthusiasm for vertebral body tethering. Newton et al. compared 23 patients with adolescent idiopathic scoliosis treated with vertebral body tethering and 26 patients treated with posterior spinal fusion at a follow-up of 2 to 5 years. Their results showed that curve correction was better maintained in the posterior spinal fusion group; the mean curve magnitude was 33° for the vertebral body tethering group compared with 16° for the posterior spinal fusion group (p < 0.001) and the rate of revision surgical procedures was 39% (9 of 23) for vertebral body tethering and 0% for posterior spinal fusion. Twelve patients (52%) had evidence of tether breakage13. Roye et al. surveyed 42 surgeons to establish consensus-based recommendations for halo traction. They recommended using at least 6 to 8 pins, under 4 to 8 pounds (1.8 to 3.6 kg) of torque and starting with a small weight advanced to a maximum of 50% total body weight14. Early-Onset Scoliosis Klyce et al. noted a marked increase in the use of magnetically controlled growing rods for early-onset scoliosis, demonstrated objectively in a series by examining growing instrumentation trends from 2007 to 2017. The authors showed that magnetically controlled growing rods went from <5% of the growing spine implants in 2007 to 83% in 201715. A large series of 170 patients with early-onset scoliosis and a 5-year follow-up after “graduation” from growing spine surgery showed that 21% had at least 1 reoperation, highlighting that “final” fusion is frequently not the final procedure for these patients16. Talmage et al. found that 6% of 81 patients with early-onset scoliosis had hip dysplasia that was not diagnosed in a timely manner despite radiographic evidence, reminding us that children with early-onset scoliosis frequently have other orthopaedic conditions17. Infection Shin et al. reported on 40 patients with osteomyelitis and/or septic arthritis. Blood culture bottles detected growth of organisms in 68%, compared with 45% with swab cultures and 38% with tissue cultures. Additional advantages of using the blood culture bottles were that they permitted a smaller-volume specimen and reduced time for microbial identification18. Ojeaga et al. reported on an interdisciplinary quality improvement program with the hospitalists, radiologists, and orthopaedic surgeon working concomitantly to determine not only whether magnetic resonance imaging (MRI) was needed but also if contrast or particular sequences were indicated in the evaluation of suspected musculoskeletal infection. In the final 6-month period, the mean scan duration had been decreased to 24.4 minutes from 73.6 minutes, anesthesia duration was down to 40.9 minutes from 94.1 minutes, and the rate of contrast agent administration was only 8.5%19. A 4 to 6-week course of intravenous antibiotics has historically been used for the treatment of osteomyelitis, despite a paucity of evidence for this approach. Islam et al. reported on their results in 74 patients before and after initiating an early transition to oral antibiotics for the treatment of osteoarticular infections. In their early transition group, the median duration of intravenous antibiotics was 7 days and there were no return emergency department visits or readmissions. Interestingly, this also avoided complications related to the peripherally inserted central catheters, which caused 16% of patients in the group receiving the longer course of intravenous antibiotics to return to the emergency department20. Venous thromboembolism in children with musculoskeletal infection has been increasingly recognized. Amaro et al. examined C-reactive protein (CRP) as being predictive of a venous thromboembolism risk and found that a threshold of 20 mg/dL conferred a 29% increased risk of venous thromboembolism compared with patients with a normal CRP21. Upper Extremity Kallini et al. investigated 28 patients with intra-articular distal radial fractures (Salter-Harris Types III and IV) and found a rate of growth disturbance of 43%. All patients who sustained an intra-articular fracture at ≤10 years of age underwent additional procedures to address the resultant wrist deformity caused by growth disturbance. The authors stressed the importance of long-term follow-up in these patients given the high rate of physeal disturbance, particularly for those in the younger age group22. For patients with radial longitudinal deficiency, the advantages of radialization compared with centralization are frequently debated. Mittal et al. performed a prospective randomized controlled trial of 14 patients with 17 limbs that were assigned to either radialization or centralization. At the 24-month follow-up, the results of radialization were superior with regard to maintaining deformity correction and forearm length23. In a study on the management of trigger thumbs in the pediatric population, the results of 193 thumbs in 149 patients treated over a 5-year period found that resolution occurred in 53% of thumbs with conservative management. Stage-IV thumbs (in which the thumb cannot be passively extended) were 4.6 times more likely than Stage-II thumbs (trigger occurs with active extension) or Stage-III thumbs (cannot be actively extended and trigger occurs with passive extension) to have failure of conservative management. The authors recommended surgical management for Stage-IV thumbs in older children without an observation period, whereas Stage-II and III thumbs may be safely observed for at least 1 year prior to the consideration of a surgical procedure24. Wall et al. investigated the use of synthetic dermal substitute for syndactyly repair to avoid skin grafting. Of 21 webs, normal vascularity was present in 20 webs, pigmentation was normal in 17 webs, and scar height was not elevated in 15 webs. There were no postoperative complications, and this appears to provide a satisfactory alternative to avoid the donor-site morbidity of skin grafting. Of note, the cost of a small sheet of synthetic dermal substitute is approximately $35025. Zinger et al. contacted 90 patients with wrist ganglia (50 nonoperatively treated and 40 operatively treated) at a mean follow-up of 4.6 years. In the nonoperatively treated group, if a ganglion resolved, it did so within 18 months in 94% of patients. Dorsal ganglia persisted more often (63%) than volar ganglia (33%), and older children had a higher rate of persistence (58%) than did younger children (31%). In the operatively treated group, the recurrence rate was 15%26. Hip Developmental Dysplasia of the Hip Developmental dysplasia of the hip continues to be an attractive topic in pediatric orthopaedic research, with a recent Level-I multinational study showing that around 14% of dislocated hips were missed by expert clinicians during examination, but were confirmed later on ultrasound27. This study questioned the screening systems that are based only on clinical examination and encouraged further research to find optimal screening methods. Asymmetry of the thigh and groin skin creases was discussed again and was found to be associated with acetabular dysplasia even without a dislocation28. Subluxation of the hip was defined as femoral head coverage of between 34% and 50%29. With regard to the management of developmental dysplasia of the hip, it was suggested that a less-strict protocol for Pavlik harness treatment (23 hours) has the same benefit as continuous wearing of the harness (24 hours) for reducible dislocated hips30. In addition, a late start of the Pavlik harness treatment, after the first 30 days of age, did not negatively affect the outcomes as long as swaddling was avoided31. The predictors for the need of an open hip reduction were defined as high dislocations (grade IV according to the International Hip Dysplasia Institute classification), an irreducible hip on examination (negative Ortolani sign), and a Graf-IV classification on the initial ultrasound32. Both closed and open reduction showed a substantial benefit relative to the natural history of developmental dysplasia of the hip in terms of hip survival33. However, total hip arthroplasty remains the expected outcome in middle adulthood as shown over 45 years of follow-up, especially for bilateral hips managed with closed reduction after the age of 18 months33. When femoral shortening is needed, the use of femoral diaphyseal autograft in the pelvic osteotomy site showed less graft collapse and loss of position when compared with iliac autograft34. Slipped Capital Femoral Epiphysis The risk of contralateral slipped capital femoral epiphysis has been studied further in an attempt to identify patients who benefit from prophylactic fixation and to avoid late sequelae. A posterior slip angle of 12° to 14.5° was shown by multiple authors to be a risk factor35-37. Younger age was also confirmed as a risk factor37,38. Moreover, abnormally elevated levels of insulin were associated with slipped capital femoral epiphysis39. A history of pelvic radiation and chemotherapy was found for some children who presented with a valgus slip, suggesting that a slipped capital femoral epiphysis diagnosis needs to be ruled out for childhood cancer survivors who have hip pain40. Epiphyseal cupping around the metaphysis was associated with higher epiphyseal stability and less risk of slipped capital femoral epiphysis41. Although in situ fixation with a threaded screw remains the main method of prophylactic fixation, iatrogenic proximal femoral deformity was shown to be a risk in those cases, especially for patients with a low Modified Oxford Score for skeletal maturity, suggesting a role for the use of growth-friendly implants42. The negative effect of elevated intracapsular pressure on epiphyseal perfusion was further confirmed using an immature porcine model, emphasizing the importance of hip capsulotomy and decompression in young patients with intra-articular hip fractures43. Although the modified Dunn procedure continues to be considered useful for unstable hips, caution has been recommended when it is used for stable slipped capital femoral epiphysis because of a higher rate of osteonecrosis44,45. Legg-Calvé-Perthes Disease The validity of the Patient-Reported Outcomes Measurement Information System (PROMIS) was studied in a multicenter study, which showed that the PROMIS has construct validity in measuring health-related quality of life for patients with Legg-Calvé-Perthes disease46. The benefit of early proximal femoral varus osteotomy on shortening the fragmentation phase was further shown in a prospective multicenter study47. In addition, predictable radiographic healing and clinical improvement were reported after surgical reduction and fixation of symptomatic osteochondritis dissecans lesions seen as sequelae to Legg-Calvé-Perthes disease48. Other Related Topics Radiographic measurements of acetabular morphology showed similar intrarater and interrater reliability when EOS imaging was used compared with conventional radiographs49. More centers are obtaining EOS imaging as it provides an opportunity for less radiation and possible inclusion of other measurements that EOS imaging could provide, such as rotational measurements and version of the acetabulum and femoral neck. Another study on immature pig hips showed greater bone stimulation after multiple epiphyseal drilling compared with transphyseal neck-head tunneling50. Neither method affected physeal growth50. A new modification of the triple innominate osteotomy was proposed using a single incision51. This less-invasive modification was effective in obtaining improved acetabular coverage and hip stability51. Neuromuscular Disorders Hip Displacement New studies continue to focus on hip displacement in cerebral palsy. Medical comorbidities, such as gastrointestinal or respiratory impairment, seizures, and communication impairment, have again been found to be a predictor for postoperative complications after hip reconstruction, and, in turn, result in a longer length of stay52. The safety of a single-event bilateral hip reconstruction was reassessed and was found to be greater, with less major complications, than for a staged surgical procedure53. Less blood loss and need for transfusion were seen with the intraoperative administration of tranexamic acid54. However, the intraoperative use of ε-aminocaproic acid did not show a difference when compared with placebo55. A low risk of venous thromboembolism was found after an orthopaedic surgical procedure, supporting that no prophylaxis is needed56. With regard to proximal femoral implant removal, a reactive approach, rather than prophylactic, was supported, with the removal of implants if needed57. In this study, 80% of patients who were managed with the reactive approach did not require implant removal, and only 4.7% of patients who had this approach needed removal due to fracture or deep infection57. Knee Alignment and Gait Crouch gait and associated deformity were studied further. Growth modulation at the anterior aspect of the distal femoral physis was supported as an effective treatment of knee flexion contracture58. Hamstring lengthening combined with stretching casts was also shown to improve crouch gait58,59. Although patella alta was associated with knee pain60, the relationship between patella alta and gait dysfunction remained unclear, and the presence of radiographic patella alta by itself does not justify surgical correction61. The effect of ankle alignment on knee hyperextension in stance was further confirmed62; however, performing surgical correction of the ankle in these cases only to correct the knee hyperextension remains a question for future research because children with diplegic cerebral palsy show a tendency toward greater knee flexion with age62. Clubfoot Numerous studies have been conducted to assess the outcomes of clubfoot treatment. The Ponseti method continues to show efficacy even in complex and rigid clubfoot deformity, such as the deformity associated with arthrogryposis63,64. Deformity scores, followed during casting, emphasized that equinus is the most resistant deformity, and several deformity components did not correct to zero in older children65. The duration of casting was shown to be a significant predictor of recurrence, and compliance with bracing, as reported by caregivers, was not66. Plantar pressure studies showed greater deviations after posteromedial release compared with posterior release and nonoperative treatments67. Long-term follow-up showed that foot morphology, which also showed greater deviations after a comprehensive surgical procedure, was correlated with pain68. For recurrent clubfoot, repeated Ponseti casting was also shown to be an effective treatment69. Moreover, Ponseti casting for recurrent clubfoot could minimize the surgical procedures needed for residual deformity70. Distal tibial anterior hemiepiphysiodesis showed promising results as a safe treatment for recurrent rigid equinus deformity71. As previously reported, further gait data emphasized that tibialis anterior tendon transfer is effective in correcting the dynamic components of recurrent clubfoot deformity72,73. Lower-Extremity Deformity and Malalignment For patients with fibular hemimelia, recent studies showed that growth around the knee may be unpredictable, which could affect the results and expectations of growth modulation surgical procedures73. In addition, tibial osteotomy at a young age, concomitantly with foot ablation, was recommended to lead to comfort in a prosthesis74. The efficacy of tension-band plating in the correction of a Blount deformity was reassessed75. The use of titanium constructs and metaphyseal cannulated screws has been associated with mechanical failures75. Despite a 41% failure rate, growth modulation with tension-band plating remains a recommended procedure for a Blount deformity because of its minimally invasive nature75. Epiphysiodesis of the proximal part of the fibula did not prevent fibular overgrowth when performed concomitantly with proximal tibial epiphysiodesis76. It was not considered necessary if the patients had ≤2 years of remaining growth76. Moreover, a new technique expanded the use of these nails to include lengthening in younger children. An extramedullary or submuscular placement of the nail over the femur was described and showed promising outcomes77. Sports Injuries The outcomes of anterior cruciate ligament (ACL) reconstruction continue to be the focus of multiple studies. Although all-epiphyseal reconstruction showed excellent results when using pediatric-specific patient-reported functional outcome scores78, inferior results were reported compared with other extraphyseal techniques79,80. Revision ACL reconstruction was associated with higher complication rates81. Graft reinjury was seen in 20% of cases. Only 69% of patients returned to sports, with 55.2% of them being able to return to their same level of play81. The patellofemoral anatomic relationship has also been studied further. New MRI with 3-dimensional reconstruction of the distal part of the femur showed a decrease in the trochlear depth and volume in patients with patellar instability82. This relationship was also shown when concurrent changes in the patella and femoral trochlea were seen in a cadaveric study83. Early reconstruction of the extensor mechanism with a 4-in-1 technique showed promising results with low dislocation rates84. Osteochondritis dissecans remains a challenging pathology. Subtotal meniscectomy of the discoid meniscus in young patients was also presented as a risk factor for lateral condyle osteochondritis dissecans85. Single-plug and matrix-assisted autologous transplantation surgery were reported as safe and effective treatment options for unstable osteochondritis dissecans86,87. Evidence-Based Orthopaedics The editorial staff of JBJS reviewed a large number of recently published studies related to the musculoskeletal system that received a higher Level of Evidence grade. In addition to articles cited already in this update, 5 other articles relevant to pediatric orthopaedic surgery are appended to this review after the standard bibliography, with a brief commentary about each article to help guide your further reading, in an evidence-based fashion, in this subspecialty area. Evidence-Based Orthopaedics Bina S, Pacey V, Barnes EH, Burns J, Gray K. Interventions for congenital talipes equinovarus (clubfoot). Cochrane Database Syst Rev. 2020 May 15;5:CD008602. This report reviewed 21 trials that included 905 participants. The review showed that there was a lack of evidence for the addition of botulinum toxin A during the Ponseti technique. Adverse events following serial casting included cast slippage, pressure sores, and skin irritation, and adverse events following the surgical procedure included infection and the need for skin grafting. Relapse following the Kite technique most often required a major surgical procedure compared with relapse following the Ponseti technique. Overall, the available evidence showed that the Ponseti technique may produce better short-term foot alignment compared with the Kite technique. Chen SL, Maldonado DR, Go CC, Kyin C, Lall AC, Domb BG. Outcomes of hip arthroscopic surgery in adolescents with a subanalysis on return to sport: a systematic review. Am J Sports Med. 2020 May;48(6):1526-34. Epub 2019 Sep 20. This study was a systematic review of 10 studies that included 618 adolescent hips. The mean follow-up was 34.5 months. At the latest follow-up, all adolescents showed significant improvement on a visual analog scale (VAS) of pain, the Non-Arthritic Hip Score (NAHS), the Hip Outcome Score-Sports Specific Subscale (HOS-SSS), the Hip Outcome Score-Activities of Daily Living (HOS-ADL), the physical component of the 12-item Short Form Health Survey (SF-12P), and both versions of the International Hip Outcome Tool (iHOT-12 and iHOT-33). The collective return-to-sport rate was 84.9%. The authors concluded that hip arthroscopy can be safely performed in adolescents to address labral tears and femoroacetabular impingement, with significant functional improvement and a high level of returning to sport. Gao B, Dwivedi S, Patel S, Nwizu C, Cruz AI Jr. Operative vs. non-operative management of displaced midshaft clavicle fractures in pediatric and adolescent patients: a systematic review and meta-analysis. J Orthop Trauma. 2019 Nov;33(11):e439-e446. In this systematic review and meta-analysis, the authors reviewed the results of both operatively and nonoperatively treated midshaft clavicle fractures in the pediatric and adolescent populations. There were 12 articles that met the inclusion criteria, with a total of 497 patients. Both operatively and nonoperatively treated patients had excellent rates of union and patient-reported outcome measures. Operatively treated patients returned to activity approximately 6 to 7 weeks more quickly than patients treated nonoperatively. Twenty-one percent (37) of the 173 operatively treated patients underwent an additional surgical procedure, most commonly for implant prominence, although 8 patients (4.6%) had refractures. This study demonstrates that the operative group experienced an earlier return to activity at the expense of a high rate of reoperation. Tsou PY, Ma YK, Wang YH, Gillon JT, Rafael J, Deanehan JK. Diagnostic accuracy of ultrasound for upper extremity fractures in children: a systematic review and meta-analysis. Am J Emerg Med. 2020 Apr 27. [Epub ahead of print]. The authors reviewed 32 studies, which encompassed a total of 2,994 patients, and concluded that this evidence suggested that ultrasound has excellent diagnostic accuracy for non-elbow, upper-extremity, pediatric fractures and can serve as an alternative diagnostic modality to radiographs. They also noted that the fracture sites affected the diagnostic accuracy of ultrasound (elbow compared with non-elbow, p < 0.01). Although the overall sensitivity with ultrasound was 0.95, this was as low as 0.80 in some series. There are several concerns with the generalizability of these results, including that ultrasound is a very operator-dependent technique and that intraosseous pathology (such as tumors) may go undetected if ultrasound is used to substitute for radiographs. Xavier VB, Avanzi O, de Carvalho BDMC, Alves VLDS. Combined aerobic and resistance training improves respiratory and exercise outcomes more than aerobic training in adolescents with idiopathic scoliosis: a randomised trial. J Physiother. 2020 Jan;66(1):33-8. Epub 2019 Dec 16. In this randomized controlled trial with concealed allocation, 40 patients with adolescent idiopathic scoliosis and major curve angles of ≥45° were assigned 1 of 2 training regimens. Both groups were instructed to do three 60-minute training sessions per week for 12 weeks. The experimental group performed combined aerobic and resistance training, and the control group performed only aerobic training. The group that performed combined aerobic and resistance training had greater improvement in forced expiratory volume in 1 second (FEV1), maximal inspiratory pressure, peak expiratory flow, and the 6-minute walk test and lower perceived exertion at the end of the 12 weeks. As has been shown in many other populations, this study demonstrated the benefit of a combined training regimen for patients with scoliosis with regard to lung function." @default.
W3116011569 created "2021-01-05" @default.
W3116011569 creator A5058748383 @default.
W3116011569 creator A5068741966 @default.
W3116011569 date "2020-12-24" @default.
W3116011569 modified "2023-10-18" @default.
W3116011569 title "What’s New in Pediatric Orthopaedics" @default.
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W3116011569 doi "https://doi.org/10.2106/jbjs.20.01953" @default.
W3116011569 hasPubMedId "https://pubmed.ncbi.nlm.nih.gov/33369978" @default.
W3116011569 hasPublicationYear "2020" @default.
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