Archive | March 2018

Periacetabular Osteotomy Yields Good Midterm Outcomes for Patients with Down Syndrome and Hip Dysplasia

PAO for OBuzz The treatment of hip dysplasia in patients with Down syndrome is challenging. Until the March 7, 2018 issue of JBJS, only short-term results from periacetabular osteotomies (PAOs) for treating hip dysplasia in this population had been reported.  Now, Maranho et al. review the outcomes among 19 patients (26 hips) who underwent PAOs at Boston Children’s Hospital over 20 years, with an average follow up of 13.1 years.

Defining a “failed PAO” as a postoperative Harris Hip Score (HHS) <60 or a recommendation for a total hip arthroplasty or arthrodesis, the authors demonstrated the following key findings:

  • There were significant improvements in all radiographic parameters after the PAOs were performed.
  • More than 60% of the patients at their last follow up retained a good or excellent outcome from the procedure (HHS >80).
  • The authors found a 36% increase in the odds of failure for every one-year increase in patient age at the time of the PAO and a 17-fold increase in the odds of failure when a patient had Tonnis grade-2 arthritis at the time of PAO, compared to patients with Tonnis grades 0 or 1.

These findings seem to indicate that younger, less arthritic patients with Down syndrome can expect to have reliable outcomes following a PAO. This is encouraging, as it may help those patients maintain independent living by decreasing their arthritis progression and increasing the stability of their hips.  Even though the factors most associated with PAO failure are beyond the surgeon’s control, this data should  facilitate focused discussions among surgeons, patients, and their parents or guardians about expected outcomes in these situations.

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

What’s New in Pediatric Orthopaedics 2018

Pediatrics Image from HUBEvery month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.

This month, Derek Kelly, MD, co-author of the February 21, 2018 Specialty Update on Pediatric Orthopaedics, selected the most clinically compelling findings from among the more than 50 studies summarized in the Specialty Update.


—An analysis of pediatric femoral shaft fractures before and after the publication of clinical practice guidelines1 revealed a significant increase in the use of interlocked intramedullary nails in patients younger than 11 years of age, and an increase in surgical management for patients younger than 5 years of age. Considerable variability among level-I pediatric trauma centers highlights the need for further outcome studies to facilitate updating of existing guidelines.


—A prospective cohort study of pain and opioid use among patients following posterior spinal fusion for adolescent idiopathic scoliosis found that increased age, male sex, greater BMI, and preoperative pain levels were associated with increased opioid use. Findings like these may help guide clinicians in opioid dispensing practices that minimize the problem of leftover medication.


—Two stratification/scoring systems may aid in the early prediction of musculoskeletal infection severity and promote efficient allocation of hospital resources. A 3-tiered stratification system described by Mignemi et al.2 correlated with markers of inflammatory  response and hospital outcomes. Athey et al.3 validated a severity-of-illness score and then modified it for patients with acute hematogenous osteomyelitis.


—A study of closed reduction for developmental dysplasia of the hip4 revealed that 91% of 87 hips achieved stable closed reduction. Of those, 91% remained stable at the 1-year follow-up. Osteonecrosis occurred in 25% of cases, but it was not associated with the presence of an ossific nucleus, a history of femoral-head reducibility, or age at closed reduction.

—Regardless of obesity status, serum leptin levels increase the odds of slipped capital femoral epiphysis (SCFE), according to a recent study. Researchers reached that conclusion after comparing serum leptin levels in 40 patients with SCFE with levels in 30 BMI-matched controls.


  1. Roaten JD, Kelly DM, Yellin JL, Flynn JM, Cyr M, Garg S, Broom A, Andras LM,Sawyer JR. Pediatric femoral shaft fractures: a multicenter review of the AAOS clinical practice guidelines before and after 2009. J Pediatr Orthop.2017 Apr 10. [Epub ahead of print].
  2. Mignemi ME, Benvenuti MA, An TJ, Martus JE, Mencio GA, Lovejoy SA, Copley LA, Williams DJ, Thomsen IP, Schoenecker JG. A novel classification system based on dissemination of musculoskeletal infection is predictive of hospital outcomes. J Pediatr Orthop.2016 Jun 13. [Epub ahead of print].
  3. Athey AG, Mignemi ME, Gheen WT, Lindsay EA, Jo CH, Copley LA. Validation and modification of a severity of illness score for children with acute hematogenous osteomyelitis. J Pediatr Orthop.2016 Oct 12. [Epub ahead of print].
  4. Sankar WN, Gornitzky AL, Clarke NM, Herrera-Soto JA, Kelley SP, Matheney T, Mulpuri K, Schaeffer EK, Upasani VV, Williams N, Price CT; International Hip Dysplasia InstituteClosed reduction for developmental dysplasia of the hip: early-term results from a prospective, multicenter cohort. J Pediatr Orthop.2016 Nov 11. [Epub ahead of print].

Aspirin Noninferior to Rivaroxaban for Anticoagulation after Joint Replacement

Aspirin for OBuzzOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Amir Khoshbin, MD in response to a recent randomized trial in the New England Journal of Medicine.

The ideal anticoagulation protocol for patients who have received a total knee or hip replacement remains controversial. Results from the recently published “Extended Venous Thromboembolism Prophylaxis Comparing Rivaroxaban to Aspirin Following Total Hip and Knee Arthroplasty (EPCAT) II” trial add some clarity to this topic.

This large double-blind, randomized noninferiority trial compared two outpatient anticoagulation regimens after elective unilateral primary or revision hip or knee arthroplasty. Almost 3,500 patients were enrolled, and they all received 10 mg of rivaroxaban daily until postoperative day five. After that, 1,707 patients were randomized to receive 81 mg of aspirin daily, while the remaining 1,717 patients received 10 mg of rivaroxaban daily. Per previous recommendations, total knee arthroplasty patients received anticoagulation for a total of 14 days, and total hip arthroplasty patients continued anticoagulation for 30 days.

Twelve patients in the rivaroxaban group (0.7%) had a venous thromboembolism event in the 90-day postsurgical period, versus 11 patients (0.64%) in the aspirin group (p >0.05). In terms of complications from anticoagulation treatment, 5 patients (0.29%) in the rivaroxaban group and 8 patients in the aspirin group (0.47%) had a major bleeding event (p >0.05).  It is worth noting that there were multiple different implants, approaches, and perioperative protocols followed in the study. Also, very few patients with a history of venous thromboembolism (81 patients, 2.4%), cancer (80 patients, 2.3%) or smoking (319 patients, 9.3%) were included in the study. These patients would be considered at higher risk for venous thromboembolism after joint replacement.

These limitations notwithstanding, the results from prophylaxis with aspirin after an initial five days of rivaroxaban were not significantly different from results with continued rivaroxaban. Institutional prices vary, but in this time of bundled care, the financial implications of studies like this one could be great. Anecdotally, in our institution the price of rivaroxaban is 140 times that of aspirin.

This is not the first study whose findings support the use of aspirin for venous thromboembolism prophylaxis, but it is one of the largest. It appears that such findings are starting to change the practice of some orthopaedic surgeons. We expect that additional large studies will provide further insight into this question.

Amir Khoshbin, MD is an assistant professor of orthopaedics at the University of Toronto and a member of the JBJS Social Media Advisory Board. He can be reached at

Teaching Patients How to Reduce a Shoulder Dislocation

BHM self-administered technique can be used as a first-line technique in the emergency department for reducing shoulder dislocation. #JBJS


Video Summary: Teaching Patients How to Reduce a Shoulder Dislocation

BHM self-administered technique can be used as a first-line technique in the emergency department for reducing shoulder dislocations. #JBJSVideoSummaries #JBJS

Unexpected Long Lower Limb in Patients with Unilateral Hip Dislocation

Full-length standing AP radiographs best for predicting lower-limb-length discrepancy (LLD) in DDH patients. #JBJS #JBJSInfographics


Webinar on March 29 – Spondylolysis in Adolescents: Diagnosis, Treatment, and Outcomes

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Low back pain is not typically thought to be a pediatric issue; however, this condition occurs in 33% of adolescents each year—a rate similar to that seen in adults. The most common identifiable cause of low back pain in the adolescent is spondylolysis, a defect in the pars interarticularis. How is this condition best diagnosed and treated? Do oblique radiographs help diagnose spondylolysis in adolescents? What kind of short- and long-term clinical outcomes can adolescents—and especially adolescent athletes—diagnosed with acute spondylolysis expect to have? What factors might predict long-term outcomes?

These important and clinically applicable questions will be addressed during a complimentary LIVE webinar, hosted jointly by the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) and The Journal of Bone & Joint Surgery (JBJS).

JBJS presenter, Peter Passias, MD, will discuss findings from a retrospective study of adolescents with and without L5 spondylolysis to address whether oblique radiographic views add value in the diagnosis of this cause of low back pain. This paper specifically addresses whether the diagnostic benefit of four-view studies outweighs the additional cost and radiation exposure, especially for young people.

JOSPT co-author Mitchell Selhorst, DPT, OCS, will share the results of a retrospective review of acute spondylolytic injuries in young athletes. This study reports long-term clinical outcomes for these patients and identifies significant predictors of these outcomes.

Moderated by JBJS Deputy Editor Andrew J. Schoenfeld, MD, who specializes in spondylolisthesis, spinal stenosis, and spinal surgery, the webinar will include additional insights from expert commentators, Chris Bono, MD,from Brigham and Women’s Hospital in Boston, and Michael Allen, PT, from Cincinnati Children’s Hospital Medical Center. The last 15 minutes will be devoted to a live Q&A session between the audience and panelists.

Space is limited, so Register Now.

Some Flags for Low Back Pain Screening Should be Yellow, Not Red

Low-Back-Pain for OBuzzAn estimated 85% of all adults will experience low back pain at some point in their lives. So-called “red flag” questions were developed to help primary care providers determine whether a patient’s back pain warranted an escalation of care, either through advanced imaging or referral to a spine specialist. However, in the March 7, 2018 issue of JBJS, Premkumar et al. found that, despite the widespread use of red flag questions, it appears that they have limited clinical usefulness when applied in isolation in a referral spine practice setting.

The authors analyzed the responses to commonly asked red flag questions from more than 9,000 patients presenting to a spine center with low back pain. They found that >90% of the patients had a positive response to at least one of the questions, but only 8% actually had a red flag diagnosis. Furthermore, the authors found that a negative response to one or two of the questions did not preclude a red flag diagnosis. No single red flag question had a sensitivity >75% or a clinically useful negative likelihood ratio—a measure of a screening tool’s ability to rule out a diagnosis.

Importantly, however, certain combinations of positive answers were predictive of specific disease processes. For example, a history of trauma in patients over the age of 50 years was predictive for a diagnosis of spinal compression fracture, and back pain in a patient with a history of a primary oncologic diagnosis should alert physicians to the possibility of metastatic disease. Conversely, the authors say that low back pain that awakens a patient from sleep was not found to be a useful parameter for making any diagnosis.

This is the first large-scale study to evaluate the clinical utility of these questions in the setting of low back pain, and the authors question their usefulness as screening tools. While the concept behind red flag questions remains valid, the rigid application of such questions in decision making regarding advanced imaging or additional testing is not appropriate. The utility of red flag screening questions for low back pain needs additional testing, especially in the primary care setting.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

JBJS 100: Shoulder Replacement and Odontoid Process Fractures

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

Recent Experience in Total Shoulder Replacement
C S Neer, K C Watson, F J Stanton: JBJS, 1982 March; 64 (3): 319
“Recent” in this context refers to more than 30 years ago, but many aspects of this meticulous review of nearly 200 total shoulder replacements, followed for 24 to 99 months, remain instructive. To get a sense of the explosion in research on this topic, compare the 18 references accompanying this study, most citing work by Neer himself, to the 70 references in a 2015 JBJS Reviews article focused on one detail (glenoid bone deficiency) of shoulder replacement.

Fractures of the Odontoid Process of the Axis
L D Anderson and R T D’Alonzo: JBJS, 1974 December; 56 (8): 1663
The basic fracture classification posited in this article has stood the test of time. Since the 1980s, however, surgeons have developed treatments for type-II odontoid fractures that provide direct fixation without the need for fusion and subsequent loss of rotatory motion.

March 2018 Article Exchange with JOSPT

JOSPT_Article_Exchange_LogoIn 2015, JBJS launched an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.

During the month of March 2018, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Pragmatically Applied Cervical and Thoracic Nonthrust Manipulation versus Thrust Manipulation for Patients with Mechanical Neck Pain: A Multicenter Randomized Clinical Trial.”

To thrust or not to thrust–that was the question investigated among 103 patients with mechanical neck pain in this randomized trial. Thrust and nonthrust manipulation produced equivalent outcomes.