What’s New in Pediatric Orthopaedics 2019

Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in one of 13 subspecialties. Click here for a collection of all OrthoBuzz subspecialty summaries.

This month, Kelly L. VanderHave, MD, co-author of the February 20, 2019 “What’s New in Pediatric Orthopaedics,” selected the five most compelling findings from among the more than 50 noteworthy studies summarized in the article.

Pediatric Trauma
—A before-and-after comparison found that, after implementation of a dedicated, weekday operating room reserved for pediatric trauma, length of stay for 5 common pediatric orthopaedic fractures was reduced by >5 hours. In addition, cost was reduced by about $1,200 per patient; complication rates improved slightly; frequency of after-hours surgery decreased by 48%; and wait times for surgery were significantly reduced.

—Forty-two patients with a distal radial buckle fracture received a removable wrist brace during an initial clinic visit, along with instructions to wear it for 3 to 4 weeks. No follow-up was scheduled, but the family was contacted at 1 week and at 5 to 10 months following treatment. No complications or refractures occurred; 100% of respondents said they would select the same treatment.1

Pediatric Sports Medicine
—Among a continuous cohort of 85 patients (mean age 13.9 years) who underwent primary ACL reconstruction (77% with open physes at time of surgery) and who were followed for a  minimum of 2 years, overall prevalence of a second ACL surgery was 32%, including 16 ACL graft ruptures and 11 contralateral ACL tears. A slower return to sport was found to be protective against a second ACL injury.

Infection and Scoliosis Surgery
—A preliminary study of 36 pediatric patients who underwent a total of 191 procedures for early-onset scoliosis found that the use of vancomycin powder during closure significantly decreased the rate of surgical site infection (13.8% per procedure in the control group versus 4.8% per procedure in the vancomycin group).

Clubfoot
—A retrospective review of >1,100 clubfeet that were presumed to be idiopathic upon presentation found that the condition in 112 feet (8.9%) was later determined to be associated with neurological, syndromic, chromosomal, or spinal abnormalities—and therefore nonidiopathic.2 The nonidiopathic group was less likely to have a good result at the 2- and 5-year follow-up, and more likely to require surgery. The authors conclude, however, that surgery is avoidable for most patients with nonidiopathic clubfoot.

References

  1. Kuba MHM, Izuka BH. One brace: one visit: treatment of pediatric distal radius fractures with a removable wrist brace and no follow-up visit. J Pediatr Orthop.2018 Jul;38(6):e338-42.
  2. Richards BS, Faulks S. Clubfoot infants initially thought to be idiopathic, but later found not to be. How do they do with nonoperative treatment?J Pediatr Orthop. 2017 Apr 10. [Epub ahead of print].

Benchmark Data on Aseptic Revision after Knee Replacement

The main advantage of joint registries is their large number of recorded procedures, ideally with very few patient “types” not represented in the database. This is the case with the Australian Orthopaedic Association National Joint Replacement Registry, which includes data on almost 100% of all joint replacements performed in Australia since 2002. In the February 20, 2019 issue of The Journal, Jorgenson et al. analyze almost 6,000 major aseptic total knee arthroplasty (TKA) revisions from a cohort of 478,000 primary TKAs registered between 1999 and 2015. This analysis provides robust benchmark data for patients and surgeons, although it comes too late for the 3% of patients who required such a revision surgery within the 15-year study period.

The authors found that fixed bearings were revised for aseptic reasons at a significantly lower rate than mobile bearings (2.7% vs 4.1%, respectively) and that patients <55 years old had an almost 8-fold higher revision rate compared to patients ≥75 years old ( 7.8% versus 1.0%, respectively). The study also found lower aseptic revision rates with minimally stabilized total knee prostheses compared to posterior-stabilized prostheses, and higher aseptic revision rates with completely cementless fixation relative to either hybrid or fully cemented fixation. These are valuable data for arthroplasty surgeons in terms of selecting implants and surgical techniques and for preoperative counseling of patients—especially younger ones. While many of these findings have been previously reported, these registry-based results add significant strength to published data.

Ideally, data such as these would be controlled for confounding variables such as surgeon experience and additional patient-specific variables such as activity demands and medical comorbidities. Still, these data provide useful prosthesis-specific factors for shared decision making with patients. We look forward to more helpful information from this and other national joint registries and encourage the continued growth of similar registries in other subspecialties.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Arthroscopy Beats PT for FAI at 8 Months

OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent BMJ studythe following commentary comes from Matthew R. Schmitz, MD, FAOA.

Femoroacetabular impingement (FAI) syndrome continues to be a hot topic in the orthopaedic community. The first two decades of this century have seen huge increases in the number of hip arthroscopies performed in the US and UK,1,2 most of those to treat FAI.  In the February 7, 2019 issue of BMJ, Palmer et al., reporting on behalf of the Femoroacetabular Impingement Trial (FAIT), published preliminary findings from a multicenter randomized controlled trial comparing arthroscopic hip surgery to activity modification and physiotherapy for symptomatic FAI.3

The trial randomized 222 patients with a clinical diagnosis of FAI into each cohort (110 in the physiotherapy group and 112 in the arthroscopy group). Follow-up assessments were performed by clinicians blinded to the treatment arm, and attempts were made to standardize both interventions. The participants will eventually be followed for 3 years, but this early report evaluated outcomes 8 months after randomization, with follow-up data available for  >80% of patients in both groups.

Baseline characteristics with regard to demographics, radiographic findings, and clinical measurements were similar between the two groups. After adjusting for multiple potential confounders, the authors found that the mean Hip Outcomes Score Activities of Daily Living (HOS ADL) was 10 points higher in the arthroscopy group than in the physiotherapy group, exceeding the prespecified minimum clinically important difference (MCID) of 9 points. The MCID was reached in 51% of surgical patients compared to 32% in the therapy cohort. In addition, the patient acceptable symptomatic state (PASS)—defined as a HOS ADL ≥87 points—was achieved in 48% of surgical patients and only 19% of therapy patients. Relative to the physiotherapy group, the arthroscopic group also had better hip flexion and superior results in a variety of commonly used hip patient-reported outcomes scores.

The 8-month data from this study show that there is a real improvement in patient function and reported outcomes from arthroscopic management for FAI. It will be important, however, to follow these patients for the entire 3 years of the FAIT study to show whether these improvements persist. It should also be emphasized that only half of the patients treated with surgical management achieved MCID at the 8-month point. That finding supports what I tell patients in my young-adult hip-preservation clinics, which seems relevant as baseball season starts: There are rarely any home runs in arthroscopic hip surgery. There are mainly singles and doubles that we hope to stretch into doubles and triples. Still, it appears that even those base hits with arthroscopic surgery are better than the physiotherapy alternative—at least in the early innings of the game.

Matthew R. Schmitz, MD, FAOA is an orthopaedic surgeon specializing in adolescent sports and young adult hip preservation at the San Antonio Military Medical Center in San Antonio, TX. He is also a member of the JBJS Social Media Advisory Board.

References

  1. Maradit Kremers H, Schilz SR, Van Houten HK et al. Trends in Utilization and Outcomes of Hip Arthrocopy in the United States Between 2005 and 2013. J Arthroplasty 2017; 32:750-5.
  2. Palmer AJ, Malak TT, Broomfield J, et al. Past and projected temporal trends in arthroscopic hip surgery in England between 2002 and 2018. BMJ Open Sport Exerc Med 2016;2:e000082
  3. Palmer AJ, Gupta VA, Fernquest S, et al. Arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of symptomatic femoroacetabular impingement: multicenter randomized controlled trial. BMJ 2019; 364:l185

Letting Go of the Script

OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent New England Journal of Medicine Perspectivethe following commentary comes from Adam Bitterman, DO.

The physician-patient relationship is highly regarded and has withstood the test of time. Unfortunately, today it appears to be under significant stress. While it is still possible to maintain a meaningful and professional doctor-patient connection, the balance between arriving at a correct diagnosis, moving down your patient list, and truly caring for each individual patient is difficult to find. The advent of electronic medical records (and their attendant task lists and button clicking) and satisfaction scores have not made maintaining meaningful patient relationships any easier.

In her February 7, 2019 Perspective piece for The New England Journal of Medicine, cardiologist Dr. Lisa Rosenbaum describes her encounters with the medical system as a patient after sustaining a Jones fracture. As she highlights her experience from the initial presentation in the emergency department to the follow-up examination with an orthopedic surgeon, she describes the repeated sensation of being a diagnosis treated by an algorithm rather than an individual with an ailment receiving care.

She also highlights an anecdote about another patient’s family pleading with a staff physician to “get off your script” and focus on treating the unique patient. Invoking the legacy of Sir Robert Jones, the orthopaedist after whom the foot fracture is named, Dr. Rosenbaum observes that “medicine teeters atop an edifice of workarounds,” as physicians try to play by the rules while taking good care of patients.

Standardization and treatment protocols have a useful role in many instances, but we physicians must remember that behind every complaint is a patient, an individual with personal connections to friends and family. It is easy to get caught up in the standardized protocols that reside within electronic medical records, but it takes only a moment to disconnect yourself from the screen and keyboard and provide the creative connection that patients desire. (A study in the upcoming February 20, 2019 JBJS addresses this topic.)

Although you may be encountering your seventh patient of the day with a Jones fracture, for each of those people, their foot is all that matters. It is our job—a decidedly difficult one—to provide the unique and sometimes creative treatment plan to all our patients, while somehow maintaining a top-tier standard of care that is reproducible for all.

Adam Bitterman, DO is a fellowship-trained foot and ankle surgeon practicing at Northwell Health in Huntington, NY. He is also a member of the JBJS Social Media Advisory Board.

PE Prevention—There’s an App for That

OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Matthew Herring, MD in response to a recent study in the Journal of Orthopaedic Trauma.

Pulmonary embolism (PE) is a potentially life-threatening complication among many orthopaedic trauma patients. PE can be a silent killer, with only about 30% of fatal PEs being detected before death. Chemical prophylaxis with “blood thinners” such as injectable enoxaparin is effective in mitigating the risk of PE, but in the poly-traumatized patient, its application is often contraindicated. In an effort to develop a more effective approach to PE prevention in the trauma population, Starr et al. built a tool to estimate the risk of PE early and effectively, and then developed a multidisciplinary protocol for deep vein thrombosis (DVT) prophylaxis. They present their preliminary experience with the risk-assessment tool and the new protocol in the February 2019 issue of the Journal of Orthopaedic Trauma.

The smart-phone app (ParkLandOrtho) to risk-stratify trauma patients in the ED is based on 7 easily captured variables that the authors’ prior work identified as statistically significant predictors for developing a PE. Patients who are identified as “high risk” are aggressively started on enoxaparin, with the first dose ideally given prior to ED discharge. If contraindications for chemical prophylaxis are present, enoxaparin is withheld for up to 24 hours after admission. After 24 hours, if the patient is still unable to receive enoxaparin, a removable inferior vena cava (IVC) filter is placed.

The authors performed a retrospective review of PE incidence among 368 consecutive orthopaedic trauma patients admitted to their hospital after this new protocol was implemented and compared it to PE incidence among a historic cohort of 420 similar consecutive patients admitted during the year prior to the protocol. The two groups were similar in age and injury severity. In the control group, 51 patients were retrospectively classified as high risk, and 9 patients (2.1%) developed symptomatic PEs, one of which was fatal. In the group managed under the new protocol, 40 patients were identified as high risk, and only 1 patient (0.27%) developed a nonfatal PE. The difference in incidence of PE between the two groups was statistically significant (P = 0.02).

This paper highlights two significant achievements in my opinion. First, I was excited to see the success of a smart-phone app to facilitate rapid risk assessment. This was a significant key to the success of the multidisciplinary PE protocol, which depends on buy-in and compliance. Second, this thoughtful, decisive, and team-based protocol for DVT/PE prophylaxis in an orthopaedic trauma setting seems to be making a meaningful impact on patient outcomes.

The authors report that they are currently designing a multicenter trial to prospectively validate their protocol. I eagerly await this and hope that their next step includes a ParklandOrtho app release for Android devices, as it is only available now for iPhone and Samsung users.

Matthew Herring, MD is a fellow in orthopaedic trauma at the University of California, San Francisco and a member of the JBJS Social Media Advisory Board.

More Help Predicting Risk of Second SCFE

Up to 40% of kids who experience a slipped capital femoral epiphysis (SCFE) in one hip develop a slip in the contralateral hip. Recent research in pediatric orthopaedics has attempted to identify risk factors for a second SCFE in patients who have had a first. A retrospective study by Maranho et al. in the February 6, 2019 issue of JBJS provides additional evidence about one particular risk factor.

The authors radiographically measured the epiphyseal tilt, epiphyseal extension ratio, alpha angle, and epiphyseal angle of the uninvolved, contralateral hip among 318 patients (mean age of 12.4 years) who presented for treatment of a unilateral SCFE between 2000 and 2017. After adjusting for triradiate cartilage status, Maranho et al. found that, over a minimum follow-up of 18 months:

  • Increased posterior epiphyseal tilt was associated with an increased risk of contralateral SCFE, which corroborates recent findings. Specifically, an epiphyseal tilt of >10° corresponded to a 54% predicted probability of a contralateral slip in patients with open triradiate cartilage.
  • Increased epiphyseal extension around the metaphysis in the superior plane had a protective effect against a contralateral SCFE. For each 0.01 increase in superior epiphyseal extension ratio, the odds of a contralateral slip decreased by 6%.
  • The alpha angle and epiphyseal angle were not independently associated with a contralateral slip.

Clinically, the authors suggest that the tilt findings may be more useful than the extension-ratio findings, especially when it comes to the difficult decision around whether to perform prophylactic percutaneous pinning of the contralateral hip. They write that “prophylactic fixation may be discussed with the families of patients presenting with unilateral SCFE who have a tilt angle of >10°,” noting that this threshold “would result in a low proportion of patients undergoing unnecessary prophylactic pinning.” Maranho et al. are quick to add that even contralateral hips with epiphyseal tilt angles <10° are at risk of SCFE and should be closely monitored.

Read the JBJS Clinical Summary on SCFE.

Musculoskeletal Infections: Oral Antibiotics Not Inferior to IV

OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent New England Journal of Medicine studythe following commentary comes from Daniel Leas, MD and Joseph R. Hsu, MD.

Deep infections continue to be one of the most resource-intensive problems that orthopaedic surgeons face. Long-standing dogma has favored 6 or more weeks of intravenous (IV) antibiotics, resulting in increased healthcare costs during both the inpatient and outpatient treatment periods.

To explore the possibility of utilizing targeted oral antibiotics as an alternative, effective treatment for musculoskeletal infections, the OVIVA (Oral versus Intravenous Antibiotics) multicenter research collaboration conducted a prospective, randomized controlled trial. A total of 1,054 patients with deep musculoskeletal infections were randomized to oral or IV arms for 6 weeks of antibiotic treatment and followed for 1 year to determine treatment efficacy. The primary end point was treatment failure within 1 year, defined as the presence of predefined clinical symptoms of deep infection, microbiologic evidence of continued infection, or histologic presence of microorganisms or inflammatory tissue. Secondary outcomes included catheter-associated complications, discontinuation of therapy, and Clostridium difficile diarrhea.

Of the 1,054 patients enrolled, 909 patients were included in the final analysis. Treatment failure occurred in 14.6% of patients treated with IV antibiotics and 13.2% of patients in the oral-therapy group. This -1.4% difference indicated noninferiority based on the predetermined 7.5% noninferiority margin. Secondary outcomes between the groups differed only in catheter-related complications being more common in the IV group (9.4% vs 1.0% in the oral group).

These findings and conclusions should challenge us to re-evaluate the basis for extended IV antibiotics to treat complex musculoskeletal infections, and to consider a greater role for oral antibiotics for such infections. Further study of this question focused on patients with retained hardware is warranted.

Daniel P. Leas, MD is a PGY-5 orthopaedic resident at Carolinas Medical Center.

Joseph R. Hsu, MD is a Professor of Orthopaedic Trauma and Vice Chair of Quality at the Atrium Health Musculoskeletal Institute.

Persistent Pain after TKA: Can it Be Trained Away?

The anticipation of postoperative pain associated with a large operation such as a total knee arthroplasty (TKA) scares many patients. Some worry to the point of “catastrophizing” pain prior to surgery. As orthopaedic surgeons, we try to assuage our patients’ fears through preoperative education and multimodal pain-management modalities after surgery, but there are still some patients in whom the fear of pain—and the pain itself that inevitably accompanies arthroplasty— negatively affect their outcome. Preparing such patients for surgery and helping them recover afterward despite this high anxiety are big challenges for the orthopaedic care team. Some data suggest that cognitive behavioral therapy (CBT) might help.

However, a multisite randomized trial by Riddle et al. published in the February 6, 2019 issue of JBJS did not find any differences in pain or function among patients with moderate to high preoperative pain catastrophizing scores who underwent a form of CBT focused on pain coping skills, when their outcomes were compared to those of similar patients in “usual care” or “arthritis education” arms of the study. Each group had similar WOMAC pain scores and pain catastrophizing scores to start, and all patients were found to have significant but very similar decreases in their pain scores at 2, 6, and 12 months postoperatively. Independent assessors determined that the quality of the intervention in the coping-skills and arthritis-education arms was high, suggesting that it was not poor-quality interventions that accounted for the consistent similarities among the 3 groups.

While there are many physiological and psychological factors contributing to an individual’s experience of pain, the results of this study ran surprisingly counter to prior evidence. The authors speculate that differences between the 3 groups may have been masked by the fact that all patients had such a large decrease in pain after the TKA. While that would appear to be  good news, we know that there is a stubbornly large subset of patients (cited in this article as 20%) who undergo a technically and radiographically ”successful” knee arthroplasty only to have continued pain without an obvious cause. (See related OrthoBuzz Editor’s Choice post.)

These findings lead me to believe a statement that probably cannot be proven: there are some patients who will experience function-limiting pain no matter what surgery is performed, no matter which drugs are administered, and no matter what rehabilitative therapy is provided. Learning how to identify those patients and clearly communicating expectations to them pre- and postoperatively might help improve their satisfaction with their procedure.

Chad A. Krueger, MD
JBJS Deputy Editor for Social Media

Smoking, Depression Adversely Affect Outcomes after TAA

After some relatively poor results in the 1980s, there was a “reboot” with total ankle arthroplasty (TAA) in the late 1990s to improve outcomes so that TAA would provide a reliable treatment for patients with end-stage ankle arthritis. Advances in the understanding of the biomechanical requirements for ankle prostheses and which patients might benefit from them the most—plus the realization  that TAA is a technically demanding surgical procedure that requires advanced education—have vastly improved the outcomes of these procedures. In fact, TAA has become reliable enough that we can now begin to tease out the patient variables that seem to affect outcomes.

In the February 6, 2019 issue of The Journal, Cunningham et al. use an extensive clinical TAA registry to identify patient characteristics that impact TAA outcomes. The good news is that, 30-plus years after the inauspicious outcomes of first-generation TAA, overall pain and function significantly improved among the patients in this study. However, current smoking was associated with poorer patient outcomes at the 5-year follow-up, as it seems to be with the vast majority of orthopaedic procedures. Also, at a mean 1- to 2-year follow-up,  a previous surgical procedure on the ankle was associated with significantly smaller improvements in at least 1 patient-reported outcome. This makes sense because prior surgery leads to scarring and its attendant risk of infection and increased difficulty with exposure and the ideal placement of TAA components. Cunningham et al. also identified depression as being associated with worse TAA outcomes at all follow-up points, adding to our already ample body of evidence that patient psychological factors play a major role in orthopaedic surgical results.

Interestingly, these authors found that patients undergoing staged bilateral ankle arthroplasty did not do as well as those undergoing simultaneous bilateral TAAs. And somewhat surprisingly, the authors found obesity to be associated with better outcomes at the 5-year follow-up. This may be related to increased bone density and greater soft-tissue coverage, but this finding is still seemingly counterintuitive based on everything else we know about the negative associations between obesity and outcomes of other joint replacements.

As more surgeons and orthopaedic centers make use of TAA, it will be important for us to follow the lead of the total knee and total hip communities in providing large datasets to further clarify which factors—patient-related and surgical—lead to the best and worst patient outcomes. This study by Cunningham et al. provides a starting point upon which other research will hopefully build.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

In Chronic Sciatica, Gabapentin Quells Nerve Pain Better than Pregabalin

This post comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson. 

Orthopaedic surgeons may not be at the forefront of dealing with nonoperative nerve pain, but many of our patients who are not candidates for surgery suffer from spine-related nerve pain in their limbs, such as sciatica. Both gabapentin (GBP, Neurontin) and pregabalin (PGB, Lyrica) are used to treat chronic sciatica (CS).

Gamma-aminobutyric acid (GABA) is an important pain-related neurotransmitter, although neither GBP nor PGB affect the GABA receptor. Instead, both drugs associate with the ligand of the auxiliary α2δ-1 and α2δ-2 subunits of certain voltage-dependent calcium channels in nerves. Among other uses, Neurontin is prescribed to treat diabetic peripheral neuropathy, and Lyrica is commonly used to treat fibromyalgia.

Investigators reporting in JAMA Neurology sought to help guide practitioners in the initial choice of drug. Eighteen patients with MRIs corroborating single-sided nerve-root sciatic pain of at least 3 months duration were evaluated in an interim analysis as part of a randomized, double-blind, double-dummy crossover trial of PGB vs GBP (8 weeks of exposure to each drug with a 1-week washout in between). The primary outcome was pain intensity measured with a 10-point visual analog scale (VAS) at baseline and 8 weeks. Secondary outcomes included disability as measured with the Oswestry Disability Index and the severity and frequency of adverse events.

Relative to baseline, both drugs showed significant VAS pain reductions and disability-score improvements, However, head-to-head, GBP showed superior VAS pain reduction (mean [SD], GBP: 1.72 [1.17] vs PGB: 0.94 [1.09]; P = 0.035), regardless of the order in which it was given. There were no between-drug differences in disability scores, but adverse events for PGB were more frequent (PGB, 31 [81%] vs GBP, 7 [19%]; P = 0.002), especially when PGB was taken first.

The authors conclude that GBP was superior with fewer and less severe adverse events, and they suggest that gabapentin should be commenced before PGB to permit optimal crossover of medicines.

Reference
Robertson K, Marshman LAG, Plummer D, Downs E. Effect of Gabapentin vs Pregabalin on Pain Intensity in Adults WIth Chronic Sciatica: A Randomized Clinical Trial. JAMA Neurol. 2018 Oct 15. doi: 10.1001/jamaneurol.2018.3077. [Epub ahead of print] PMID: 30326006