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
What’s New in Pediatric Orthopaedics 2018
Every 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.
Trauma
—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.
Scoliosis
—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.
Infection
—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.
Hip
—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.
References
- 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].
- 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].
- 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].
- 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 Institute. Closed 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].
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. https://goo.gl/qc7DoY #JBJS #JBJSInfographics
Webinar on March 29 – Spondylolysis in Adolescents: Diagnosis, Treatment, and Outcomes
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.
JBJS 100: Controlling Bone Growth and Revision THA Stats
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:
Control of Bone Growth by Epiphyseal Stapling: A Preliminary Report
W P Blount and G R Clarke: JBJS, 1949 July; 31 (3): 464
This 14-page, amply illustrated article was the oldest paper selected by Kavanagh et al. in their 2013 JBJS bibliometric analysis of the 100 classic papers of pediatric orthopaedics. Blount and Clarke proved definitively that long-bone growth could be arrested by appropriately timed epiphyseal stapling and that growth would resume after staple removal. Their work spared many children with linear or angular leg deformities—often a result of polio—from the risk of more invasive operative methods.
Epidemiology of Revision Total Hip Arthroplasty in the US
K J Bozic, S M Kurtz, E Lau, K Ong, T P Vail, D J Berry: JBJS, 2009 January; 91 (1): 128
Fast forwarding 60 years from the Blount and Clarke study, we arrive at this epidemiological analysis of >51,000 revision hip replacements. The findings from this 2009 Level II prognostic study provided information that has guided THA research, implant design, and clinical decision-making throughout the past decade.
Choosing Wisely Now Addresses Pediatric Orthopaedics
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Matthew R. Schmitz, MD, a member of the JBJS Social Media Advisory Board.
The American Academy of Pediatrics (AAP) Section on Orthopaedics and the Pediatric Orthopaedic Society of North America (POSNA) recently issued a list of tests and treatments that physicians and patients should avoid. The list appears on the Choosing Wisely® website, an initiative of the American Board of Internal Medicine (ABIM) Foundation.
The list highlights 5 commonly encountered pediatric orthopaedic scenarios/conditions that often consume excessive time and resources with little or no clinical value in return. The Evidence Based Committee and Advocacy Committee of POSNA developed the peer-reviewed list and vetted it through both the POSNA Board of Directors and the AAP Executive Committee.
Although geared toward family and primary care physicians, the list contains important take-home points for orthopaedic surgeons who might have pediatric patients walk through their doors. The recommendations include the following:
- Screening ultrasound for developmental hip dysplasia is not needed if the newborn has no risk factors and has a clinically stable hip exam. The substantial rate of false positives with screening ultrasounds likely causes many children to undergo unnecessary treatment.
- Simple in-toeing does not require a radiographic workup or brace or surgical treatment in children younger than 8 years old. Unless there is severe tripping, falling, or marked asymmetry, a watchful waiting approach is best for this condition, which typically resolves with growth.
- Custom orthotics or shoe inserts are not needed for children with asymptomatic or minimally symptomatic flat feet. If the flatfoot is minimally symptomatic and flexible (arch reconstitutes when the child stands on his/her toes), it can be managed with observation or over-the-counter orthotics.
- Advanced imaging such as MRI or CT should not be ordered for most musculoskeletal conditions in children until all appropriate clinical, laboratory, and plain film examinations have been done. Most pediatric conditions can be accurately diagnosed with a good history, physical exam, plain radiographs, and occasional labs. Use advanced imaging only if a specific question arises from the preceding workup. CT scans expose patients to high levels of radiation and should be used judiciously. If MRI is deemed necessary, it is best to have the consulting orthopaedist order the MRI with specific protocols and sequences.
- Buckle fractures do not need follow-up radiographs if pain and tenderness have resolved after immobilization. These common pediatric injuries are inherently stable.
Both POSNA and the AAP should be commended on their evidenced-based and common-sense approach for tackling these common pediatric orthopaedic conditions.
Matthew R. Schmitz, MD is vice chair of the Department of Orthopaedics and chief of Pediatric Orthopaedics and Adolescent Sports Medicine at San Antonio Military Medical Center in Ft. Sam Houston, Texas.
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