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Orthopaedic Surgeons Must Educate Communities About Youth Sports Injuries

girl basketball player2OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Carl Nunziato, MD and Anthony Johnson, MD in response to a TV news segment on WLWT in Cincinnati.

While viewing the WLWT segment on youth sports injury, we were encouraged that the reporter sought out a local orthopedic surgeon to comment on the risks associated with single-sport specialization. As orthopaedic surgeons, our opinions are a trusted voice in our communities, and we need to educate athletes, coaches, and parents alike of the dangers of such specialization. We commend Dr. Timothy Kremchek for his involvement in his local community and have felt the frustration he expressed regarding the rising sport-injury rates among adolescents.

However, we caution providers against characterizing single-sport specialization as “child abuse,” as Dr. Kremchek did in this segment. This extreme language, even if used to emphasize the potentially serious nature of some sport injuries, is counterproductive. Instead, we encourage all musculoskeletal clinicians to focus on educating the public on how to reduce risk in adolescent athletes, rather than shaming or blaming.

We’ve helped many patients—both minors and adults—as they struggled to rehab from injuries, only to realize that returning to the same level of competition may not be possible. In such cases, many patients and/or their parents ask the same guilt-ridden questions as the mother of the young basketball player in the news segment: “Did I make a mistake? Did I push too hard?”

It is true that youthful participation in a single sport year-round has been shown to result in increased injury rates, burnout, and possibly even limitations in peak performance in the chosen sport due to delayed development of other muscle groups and fine motor skills. We also cannot deny the risks and costs associated with the increase in operations on young athletes. It’s key to remember, however, the principal concept of patient autonomy. As the young patient in the story reminds us, these kids often truly love their sport – and many would choose to continue participating even if they knew the risk and seriousness of eventual injury.

Instead of using sensational phrases like “child abuse,” which may frighten  families or stir up feelings of guilt, we should provide resources for coaches, parents, physicians, and athletes aimed at encouraging healthy participation and minimization of one-sport injuries. One example is the AAOS/AOSSM OneSport initiative. Educating patients and their families requires significant time and effort on the part of the orthopaedic surgeon, but it is likely to result in a more positive interaction with the patient and parents. And these interactions may help emphasize the long-term lifestyle behaviors that we are hoping to cultivate among these vulnerable populations.

Carl A. Nunziato, MD is a resident in orthopaedic surgery at Dell Medical School in Austin, Texas. Anthony Johnson, MD is the orthopaedic surgery residency program director in the Department of Surgery and Perioperative Care at Dell Medical School.

Young Kids and Lawn Mowers Don’t Mix

Amputation for OBuzzUntil I completed my pediatric orthopaedics rotation as a resident, I never thought much about pediatric lawn-mower injuries. I don’t recall how many such accidents we cared for during that time period, but I clearly remember one. It was grotesque and life-changing for the child–and definitely avoidable. That recollection was reinforced while I read the epidemiological study by Fletcher et al. in the October 17, 2018 edition of The Journal.

The authors analyzed 20 years of data from their institution in an effort to better understand these horrific injuries. They found two main demographic populations among the 157 patients who sustained mower-related injuries, which were lower-extremity injuries in 84% of all the patients. Those in the younger at-risk population (mean age of 4 years) were frequently injured by (or were passengers on) a riding lawn mower, usually operated by an older family member. This younger cohort had higher injury severity scores and higher amputation rates than the older pediatric population of mower-injured patients (mean age of 15 years). Most of those older patients were hurt while operating the lawn mower themselves.  Not surprisingly, the authors found that these patients, whatever their age, underwent an average of almost three operations and spent close to a week in the hospital.

While there are a lot of important epidemiological data points in this article, the most important take-home message is the role that education must play in the prevention of these injuries.  As the author state:

Education for the younger population should target the operators (parents, grandparents, older siblings) and emphasize the importance of keeping children out of the yard while lawn mowers are in use. Under no circumstance should a child of any age be the passenger on a lawn mower.

Despite ample literature on lawn-mower injuries, their incidence among pediatric patients has remained largely unchanged. I’m hopeful that this study will prompt more widespread implementation of patient education in this area. The American Academy of Orthopaedic Surgeons has information regarding lawn mower safety, and the Pediatric Orthopaedic Society of North America and the American Academy of Pediatrics are partnering on lawn-mower injury prevention. Accidents cannot be eradicated completely,  but the more we avail ourselves of resources such as these—and  share them with patients of all ages—the greater the likelihood of preventing these potentially devastating injuries.

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

JBJS 100: Epiphyseal Plate Injuries, Spinal Osteomyelitis

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 full-text 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:

Injuries Involving the Epiphyseal Plate
RB Salter, WR Harris: JBJS, 1963 April; 45 (3): 587
In addition to presenting the fracture classification, the authors laid the groundwork with basic principles of mechanical failure and vascularity of the physis. The authors then explain how physeal damage may arise from misalignment, crushing, or vascular interruption. This enduring orthopaedic schema lives on because of its clarity of presentation and its implications for treatment.

Pyogenic Osteomyelitis of the Spine
J Kulowski: JBJS, 1936 April; 18 (2): 343
In this 22-page analysis and discussion of 102 cases, the author notes that pyogenic osteomyelitis of the spine can affect any part of the vertebral system. In 1936—8 years after the discovery of penicillin—Kulowski said, “It may be axiomatically stated that operative intervention is imperative, as soon as the diagnosis is made with a reasonable degree of accuracy, when suppuration is present…,” adding that “the primary spinal focus requires the first attention of the surgeon.”

Properly Selected Patients with Cerebral Palsy Benefit from Upper-Extremity Surgery

CP Image for OBuzzThe 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

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:

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.

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JBJS 100: Juvenile Rheumatoid Arthritis, Tibial Fracture Healing

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:

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

Scoliosis for OBuzzHealth-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