Properly Selected Patients with Cerebral Palsy Benefit from Upper-Extremity Surgery
The orthopaedic community has been abuzz lately with conversations about the value of interdisciplinary teamwork among clinicians and shared decision-making between patients and clinicians. The positive results of both those approaches, implemented with children and adolescents who have cerebral palsy (CP), are revealed in a clinical cohort study by Louwers et al. in the August 15, 2018 JBJS.
The authors engaged 66 patients with CP in a comprehensive, multidisciplinary screening process and shared decision-making to determine each patient’s suitability for upper-extremity surgery. Forty-four patients were deemed eligible for surgery and 39 (mean age of 15 years) underwent surgery. Seven types of surgery were performed, depending on each patient’s predetermined goals, values, and preferences. Seventy-seven percent of patients had surgery that consisted of flexor carpi ulnaris tendon release or transfer and adductor pollicis muscle slide plus extensor pollicis longus rerouting.
The authors itemize the preoperative and postoperative assessment tools used in the study and describe them as “suitable for selecting patients for upper-extremity surgery and for evaluating the effect of that surgery.”
The bottom line: All outcomes improved significantly after patient-specific upper-extremity surgery in those deemed suitable for it and who opted for surgery after the shared decision-making process. Most of the patients experienced clinically relevant improvement in their functional and cosmetic goals and in manual performance 9 months after their operation.
The two patients who chose nonsurgical treatment after going through the assessment and shared decision-making process did so due to a lack of motivation for the intensive postoperative rehabilitation, which began with upper-limb immobilization for 5 to 6 weeks, followed by a program customized for each patient by his or her rehabilitation physician and occupational therapist.
JBJS 100: SCFE Outcomes, Scoliosis Treatment
Under 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:
Long-term Follow-up of Slipped Capital Femoral Epiphysis
B T Carney, S L Weinstein, J Noble: JBJS, 1991 January; 73 (5): 667
In this retrospective study of 155 hips with SCFE followed for a mean of 41 years after onset of symptoms, Carney et al. found that pinning in situ provided the best long-term function and delay of degenerative arthritis—and that realignment techniques were associated with a risk of substantial complications.
Treatment of Scoliosis: Correction and Internal Fixation by Spine Instrumentation
P R Harrington: JBJS, 1962 June; 44 (4): 591
The need for this at-the-time revolutionary instrumented approach was the polio epidemic, which left Dr. Harrington caring for many patients with severe, collapsing curves that threatened their health. Just as current hip arthroplasty techniques represent incremental improvements to the contribution of Charnley, current techniques in scoliosis surgery are stepwise improvements to Harrington’s work.
Casting Is Effective for Recurrence Following Ponseti Treatment of Clubfoot
Up to 40% of patients with idiopathic clubfoot who are treated with the Ponseti method experience recurrence of deformity. https://bit.ly/2IuVOm1
Related video from JBJS Essential Surgical Techniques.
JBJS 100: Juvenile Rheumatoid Arthritis, Tibial Fracture Healing
Under 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:
Changes in the Cervical Spine in Juvenile Rheumatoid Arthritis
R N Hensinger, P D DeVito, C G Ragsdale: JBJS, 1986 January; 68 (2): 189
This study of 121 patients with juvenile rheumatoid arthritis (RA) found that severe neck pain was not common, although neck stiffness and radiographic changes were commonly seen in the subset of patients with polyarticular-onset disease. The authors concluded that patients with juvenile RA who present with evidence of disease in the cervical spine should be examined carefully for involvement of multiple joints.
A Functional Below-the-Knee Cast for Tibial Fractures
A Sarmiento: JBJS, 1967 July; 49 (5): 855
In this report of 100 consecutive tibial shaft fractures, Gus Sarmiento encouraged early weight bearing in a skin-tight plaster cast that was molded proximally to contain the muscles of the leg. All 100 fractures healed, and healing occurred with minimal deformity or shortening. While most tibial shaft fractures are now treated with intramedullary nails, the principles developed by Dr. Sarmiento still apply, as the nail acts much like the fracture brace to maintain alignment during the weight-bearing healing process.
Scoliosis Management Shows Success Long-Term
Health-related quality of life (HRQOL) in adulthood is an important outcome measure for patients diagnosed with juvenile or adolescent idiopathic scoliosis. In the May 16, 2018 issue of The Journal of Bone & Joint Surgery, a cross-sectional study of 1,187 Swedish patients with scoliosis by Diarbakerli et al. reveals patient-reported HRQOL outcomes at an average follow-up of approximately 18 years. Using the Scoliosis Research Society-22r (SRS-22r) and the EuroQol 5-Dimensions (EQ-5D) instruments, the authors analyzed outcomes among those who had been untreated (n = 347), brace-treated (n = 459), or surgically treated (n = 381) in accordance with standards at the time of diagnosis.
The surgically treated group had significantly lower scores in the SRS-22r domains of function and self-image, compared with the scores in those domains among the other two groups. According to Daniel J. Sucato, MD, who commented on the study, those findings “most likely reflect the various effects of the surgical procedure, including the stiffness imparted by the arthrodesis of the spine,… stiffness of the soft tissues, and the presence and awareness of implants and a surgical incision.” Diarbakerli et al. also found that untreated patients did not report a decrease in HRQOL with age.
Interestingly, patients treated surgically had higher SRS-22r satisfaction-domain scores than brace-treated patients, even though overall SRS-22r and EQ-5D scores were lower among surgically treated patients than brace-treated patients. For spine surgeons, one key finding was that “a more caudal extent of fusion may be one of the most important characteristics that negatively affects quality of life” in patients undergoing scoliosis surgery.
With its large number of patients and long-term, patient-focused outcomes, this study generally corroborates findings from previous, smaller studies. But, as Dr. Sucato points out in his commentary, “the brace and surgical groups had treatments that were current at the time but not relevant today, especially as they involved the use of first-generation techniques and instrumentation.”
Innovation + Persistence: A Crucial Combination
In the 1970s and 80s, the debate regarding management of clubfoot deformity centered around the location of incisions and how aggressive to be with open releases of hindfoot joints. At that time, Prof. Ignacio Ponseti had been working on his conservative method of clubfoot correction for decades, but his technique was relegated to the sidelines and dismissed as being out of the main stream. Yet he persisted in carefully documenting his results, quietly perfecting his methods, and disseminating his technique by teaching other practitioners. Ever so slowly, the pediatric orthopaedic community migrated in his direction as the complications of the other aggressive surgical procedures, including stiff and painful feet, became apparent.
In the May 2, 2018 edition of The Journal, Zionts et al. report medium-term results from their center with Ponseti’s method. This is a very important study because most of the previously published data regarding mid- to long-term outcomes had come from Dr. Ponseti’s medical center.
The authors found that all 101 patients in the study treated with the Ponseti method had fair to good outcomes at a mean follow-up of 6.8 years. Nevertheless, >60% of the parents reported noncompliance with the bracing recommendations; almost 70% of patients had at least one relapse; and 38% of all patients eventually required an anterior tibial tendon transfer. Increased severity of the initial deformity, occurrence of a relapse, and a shorter duration of brace use were all associated with worse outcomes.
Taken as a whole, the results of this study are comparable to those presented by Ponseti and others from his institution. Even though the Zionts et al. investigation was also a single-center study, the findings are important considering the widespread use of his technique and limited “external” data confirming the validity of this method.
Dr. Ponseti created and refined a highly impactful technique that yields good outcomes in patients with a difficult problem. Although it took decades for his methods to be widely accepted, the lesson here is that what wins the day are careful documentation, thoughtful attention to how best to teach a method, and persistence in the face of skepticism.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Childhood Toe-Walking: Usually a Transient Condition
Parenting is a lot like medicine. Parents seek to “fix” their children, and physicians seek to “fix” their patients. However, sometimes the best “fix” is to observe closely, do nothing, and let nature take its course. That’s the main conclusion of the study by Engstrom et al. in the April 18, 2018 edition of JBJS. The authors set out to document the natural history of idiopathic toe-walking to determine how often the condition resolves without intervention.
After analyzing a cohort of more than 1,400 children, the authors found that 63 (5%) had been toe-walkers at some point as a toddler—but that almost 80% of those children spontaneously ceased being toe-walkers by the time they were 10 years of age. However, the authors found that children with ankle contractures before age 5 were unlikely to spontaneously cease toe-walking and would benefit from early surgical intervention. This study also demonstrated a correlation between neurodevelopmental comorbidities and toe-walking. Although 4 of the 8 children who still toe-walked at 10 years of age had received a neurodevelopmental diagnosis between the ages of 5.5 and 10 years, the authors state that “even in this subgroup of children, the idiopathic toe-walking seems, for the majority of children, to be a transient condition.”
Taken as a whole, this Level-I prognostic study provides relatively clear treatment pathways for clinicians and parents to follow when a child presents with toe-walking. The findings can be used to help calm the fears of parents regarding their child’s development while also giving surgeons the confidence to treat the majority of these children with observation unless there is a contracture of the calf musculature.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
Topical Vancomycin in Spine Surgery: Pediatric Patients Benefit Too
When >10% of patients undergoing procedures to correct a spinal deformity develop one or more surgical-site infections, investigations into how to mitigate such infections seem warranted. This is especially true when a single such infection can cost nearly $1 million to treat—not to mention the physical and psychological burdens.
In the March 21, 2018 edition of JBJS, Thompson et al. report important findings from a retrospective study that sought to evaluate the efficacy of adding topical vancomycin powder to the wounds of patients undergoing growing-spine surgeries to address early-onset scoliosis. The mean patient age at the beginning of the study was 7.1 years.
Cases in which topical vancomycin powder was placed into the wounds at the time of fascial closure (n = 104 cases) had a significantly lower surgical-site infection rate (4.8%), compared with the rate in the 87 cases in which no vancomycin was used (13.8%). Furthermore, the “number needed to treat” found in this study was 11, meaning that for every 11 cases in which vancomycin powder was used, a surgical-site infection was prevented. The authors found no complications related to the use of topical vancomycin and note that their study provides the first evidence supporting the efficacy of vancomycin powder in pediatric spine patients.
Because this study was retrospective and based out of one center, further multicenter, prospective studies are needed to verify these results and to address open questions such as appropriate vancomycin dosages. Still, considering the extremely high costs (economic, physical, social, and psychological) associated with surgical-site infections in these complex patients, it appears that a vial of vancomycin powder costing between $10 and $40 may deliver outstanding value in these scenarios.
Chad A. Krueger, MD
JBJS Deputy editor for Social Media
Periacetabular Osteotomy Yields Good Midterm Outcomes for Patients with Down Syndrome and Hip Dysplasia
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
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