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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].

Bundled Payments: Patient-Specific Care Calls for Patient-Specific Reimbursements

Hip Fracture for OBuzzThe bundled-payment model has found some early success within the field of orthopaedic surgery, most notably in joint replacement (see related OrthoBuzz post), However, more robust risk-adjustment methods are needed, especially in terms of patient factors. That is the message delivered by Cairns et al. in their retrospective analysis of Medicare data from 2008 to 2012 published in the February 21, 2018 edition of JBJS. The authors make a compelling case for improved risk stratification of hip- and femur-fracture patients to ensure that all patient populations have and retain access to appropriate care.

The authors analyzed reimbursements for the surgical hospitalization and 90 days of post-discharge care among nearly 28,000 patients who met inclusion criteria for the Surgical Hip and Femur Fracture Treatment (SHFFT) model proposed by the Centers for Medicare and Medicaid Services (CMS). Their findings highlighted various inconsistencies that could have unintended consequences if not accounted for in the bundled-payment model. For example, reimbursements were $1000 to $2000 lower for patients in their 80s, who tend to have more comorbidities that require more care, than for younger patients.  CMS proposed using Diagnosis Related Groups (DRGs) and geographic location to adjust for risk in its SHFFT bundled-payment model, but Cairns et al. identify several other factors (such as patient age and gender, ASA and Charlson Comorbidity Index scores, and procedure type) that could provide a more realistic stratification of risk.

The article clearly articulates how risk adjustments that don’t include more specific patient factors could lead to a multitude of unintended consequences for patients, providers, and the entire healthcare system. These findings could remain relevant now that CMS has announced an “advanced” voluntary bundled-payment model after the Trump administration cancelled SHFFT in late 2017.

Whatever bundled-payment model takes hold, the totality of the orthopaedic literature strongly suggests that the best outcomes are derived from making specific treatment plans for each patient based on the individual characteristics of his or her case. It seems reasonable that the best bundled-payment plans would do the same.

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

Cord Compression Reflects Neurological Outcomes after Thoracolumbar Injuries

cord compression for OBuzzThe association between spinal cord compression and functional deficits following cervical spine trauma has been well studied using both CT and MRI. However, until now, there was little data evaluating whether that same association is true for thoracic spine injuries. In the February 21, 2018 edition of The Journal, Skeers et al. identified the same correlations between canal compromise, cord compression, and functional outcome in the T1 to L1 region.

Using retrospective data, the authors showed that the severity of neurologic deficits was associated with the amount of maximal cord compression, as measured with advanced imaging. More specifically, their univariate analysis showed that cord compression >40% was associated with a tenfold greater likelihood of complete spinal cord injury compared to cord compression <40%. This study also found that MRI measures osseous canal compromise more accurately than CT, probably because it more clearly visualizes soft tissue changes related to the posterior longitudinal ligament, ligamentum flavum, and facet capsule.

A major issue with this study (and with almost all studies that evaluate spine trauma) is that these advanced imaging techniques are temporally static; even when they’re obtained relatively soon after injury, they cannot capture the position of vertebral body fragments and posterior structure deformities that existed upon impact. This shortcoming is probably more relevant for younger patients, who are more likely to experience higher-velocity trauma.

The population in the Skeers et al. study is skewed a bit toward older patients (mean age 34.8) with relatively severe spinal injuries (mean TLICS of 7.8 and mean cord compression of 40%). These factors may highlight the roles that lower bone density and decreased soft tissue elasticity play in the setting of high-energy spine trauma.

Although the data reflect some variability, this study should help spine surgeons counsel patients and their families following these tragic injuries. The more severe the initial cord compression in the thoracic spine, the more likely there is to be severe neurologic injury without improvement.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Fragility Fracture Risk Prediction: Beyond BMD

BMD for OBuzzThis basic science tip 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.

Bone mineral density (BMD)—a measure of both cortical and trabecular bone—has been widely used as an index of bone fragility. The femoral neck and lumbar vertebrae are the areas most commonly measured with BMD, but hip osteoarthritis and lumbar spondylosis can mask systemic osteoporosis. In addition, the most common fragility fractures occur at the distal radius.

Investigators conducted a prospective study using high-resolution peripheral quantitative computed tomography (HR-pQCT) of the distal radius and tibia to determine whether baseline skeletal parameters could predict fragility fractures in women. A second goal was to establish whether women who have fragility fractures experience bone loss at a faster rate than those who do not have fractures.

Among 149 women older than 60 years who had baseline and 5-year follow-up HR-pQCT, 22 had a fragility fracture during the study period and 127 did not. HR-pQCT is able to record total bone mineral density (Tt.BMD), trabecular bone mineral density (Tb.BMD), trabecular number (Tb.N), and trabecular separation (Tb.Sp).

The analysis showed that women with fragility fractures had lower baseline Tt.BMD (19%), Tb.BMD (25%), and Tb.N (14%), along with higher Tb.Sp (19%) than women who did not experience a fracture. Analysis of the tibia measures yielded similar results, showing that women with incident fracture had lower Tt.BMD (15%), Tb.BMD (12%), cortical thickness (14%), and cortical area (12%). Also, women with fractures had lower failure load (10%) with higher total area and trabecular area than women without fractures.

For each standard deviation decrease of a measure at the distal radius, the odds ratio for fragility fracture was 2.1 for Tt.BMD. 2.0 for Tb.BMD, and 1.7 for Tb.N. ORs for those measures at the tibia were similar.

In contrast to these findings, the annualized percent rate of bone loss was not different between groups with and without fractures. These results suggest that future fragility-fracture risk prediction should rely at least as much on bone architecture and strength as on simple BMD measurements.

Burt LA, Manske SL, Hanley DA, Boyd SK. Lower Bone Density, Impaired Microarchitecture, and Strength Predict Future Fragility Fracture in Postmenopausal Women: 5-Year Follow-up of the Calgary CaMos Cohort. J Bone Miner Res. 2018 Jan 24. doi: 10.1002/jbmr.3347 PMID: 29363165

No Harm When Residents Are Involved in Hip-Fracture Surgery

Intertrochanteric FX for OBuzzWhile patients are sometimes concerned that resident involvement in their surgical case might lead to untoward outcomes, the article by Neuwirth et al. in the January 17, 2018 edition of JBJS provides data to alleviate some of those fears. The authors used the NSQIP database to evaluate whether resident involvement with the surgical treatment of intertrochanteric hip fractures resulted in increased 30-day mortality or morbidity, compared to similar cases in which a resident did not participate. The study found no differences in either 30-day mortality or severe morbidity between cases that involved a resident and those that did not.  However, cases involving residents did have significantly longer operative times, lengths of hospital stay, and times from operation to discharge.

These findings, which are similar to those of studies performed in other orthopaedic subspecialties, provide both relief and unease. Surgical education is built on apprenticeship and increasing autonomy throughout residency, so it is comforting that cases of this fracture type involving residents do not increase patient risks of mortality or severe morbidity. The findings suggest that residents are being appropriately supervised and given responsibilities that are commensurate with their level of training.

However, this study also shows that there is a price to be paid for resident education. Any “extra” time that a patient spends in the operating room or the hospital has associated costs to the health care system. Neuwirth et al. show that cases involving residents had a five times greater incidence of lasting more than 90 minutes and an average operative time that was more than 20 minutes longer, compared to cases not involving residents. If one were to extrapolate those added time-related costs across all intertrochanteric fracture surgeries performed in the US each year, the total added annual costs could be astronomical.

My concern is that as we move further toward value-based care, justifying these resident-training costs will become more challenging. Should resident involvement in a case be stopped after a certain amount of operative time? How close should a resident’s surgical time be to that of an attending surgeon’s by the time of graduation? What is the actual cost of resident training per surgical case? This study prompts these and similar difficult questions.

Education, like most investments, requires both time and money in order to pay dividends. While everyone can agree that it is important to train our future surgeons appropriately, there will likely be increasing pressure to do so in the most cost-efficient manner possible.

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

Nov. 15 Webinar—Treating Clavicle Fractures

Capture_Clavicle FX for OBuzzOn November 15, 2017 at 7 PM EDTJBJS will join with JSES (Journal of Shoulder and Elbow Surgery) to present a webinar looking at the current paradigm for treating  clavicle fractures. Co-moderated by Drs. William Mallon, editor-in-chief of JSES, and Andrew Green, deputy editor of JBJS, the webinar will focus on two recent clavicle-fracture papers:

  • Dr. Philip Ahrens will discuss his recent JBJS paper, “The Clavicle Trial: A Multicenter Randomized Controlled Trial Comparing Operative with Nonoperative Treatment of Displaced Midshaft Clavicle Fractures.”
  • Dr. Brian Feeley will discuss his 2016 JSES paper, “Plate Fixation of Midshaft Clavicular Fractures: Patient-Reported Outcomes and Hardware-Related Complications.”

After each author presentation, expert commentary will be provided. Discussing Dr. Ahrens’ paper will be Dr. Michael McKee, recently named chairman of orthopaedics at the University of Arizona. Dr. Gus Mazzocca, chairman of orthopaedics at the University of Connecticut, will comment on Dr. Feeley’s paper. The webinar will then be open to addressing viewer-submitted questions for the authors and the commentators.

Seats are limited, so register now!

Pulsatile Lavage Harms Muscle in Rat Model of Blast Injury

Rat Limb for OBuzzBasic science investigations into clinically relevant orthopaedic conditions are very common—and often very fruitful. What’s not very common is seeing results from large, multicenter randomized trials published in the same time frame as high-quality in vivo basic-science research on the same clinical topic.

But the uncommon has occurred. In the November 1, 2017 issue of The Journal, Chiaramonti et al. present research on the effects of 20-psi pulsatile lavage versus 1-psi bulb-syringe irrigation on soft tissue in a rat model of blast injuries. With support from the US Department of Defense, Chiaramonti et al. developed an elegant animal study that found radiological and histological evidence that lavage under pressure—previously thought to be critical to removing contamination in high-energy open fractures—results in muscle necrosis and wound complications.

Although none of the rats developed heterotopic ossification during the 6-month study period, the authors plausibly suggest that the muscle injury and dystrophic calcification they revealed “may potentiate the formation of heterotopic ossification by creating a favorable local environment.” Heterotopic ossification is an unfortunately common sequela in patients who suffer blast-related limb amputations.

The aforementioned rare alignment between basic-research findings and clinical findings in people relates to a large multicenter randomized clinical trial recently published in The New England Journal of Medicine. That study found that one-year reoperation rates among nearly 2,500 patients treated surgically for open-fracture wounds were similar whether high, low, or very low irrigation pressures were used. This is a case where the clinical advice from basic-study authors Chiaramonti et al. to keep “delivery device irrigation pressure below the 15 to 20-psi range” when managing open fractures is based on very solid ground.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

TEA Proves Durable in Elderly Patients with Distal Humeral Fractures

TEA for OBuzzSeveral studies have demonstrated good short- and intermediate-term outcomes with total elbow arthroplasty (TEA) to treat acute distal humeral fractures. Now, in the September 20, 2017 issue of The Journal of Bone & Joint Surgery, Barco et al. provide data confirming that TEA provides durable pain relief and motion improvements over a minimum of 10 years, albeit with a number of major complications.

Among 44 TEAs performed in elderly patients with and without inflammatory arthritis whom the authors followed for ≥10 years, the mean Mayo Elbow Performance Score was 90.5 points. Five elbows (11%) developed deep infection that required surgical treatment. The revision-free survival rates for elbows with rheumatoid arthritis were 85% at 5 years and 76% at 10 years, while survival rates for elbows without rheumatoid arthritis were 92% at both time points. That difference was not statistically significant, although men in the study were much more likely to experience a revision than women. Twenty-five of the 44 patients died during the long-term follow-up, but the majority of those had their implant in place.

While reporting on these promising long-term revision-free survival rates, Barco et al. emphasize that complications were “frequent and diverse in nature…and have required a reoperation, including implant revision, in 12 of 44 patients.” So, while the good news is that a majority of patients in this situation will die with a useful joint and sound implant, the authors conclude that “surgeons treating this kind of injury should follow their patients over time and should be prepared to manage a wide array of complications using complex techniques.”

More Clinical Data on the “Clavicle Question”

clavicle_fracture_for_obuzzThe last time OrthoBuzz reported on a JBJS randomized trial looking at treatment of midshaft clavicle fractures, the authors concluded that “neither treatment option [nonoperative or surgical] is clearly superior for all patients” and that “the clavicular fracture is preeminently suitable for shared treatment decision-making.”

Now, a multicenter randomized trial by Ahrens et al. published in the August 16, 2017 JBJS adds more data for that shared decision-making discussion. In this trial, 300 patients with a displaced midshaft clavicle fracture were randomized to receive either open reduction and internal fixation (ORIF) with a plate or nonoperative management. Patients were recruited from a range of UK hospitals, and a single implant and standardized technique were used in the operative group. The rehabilitation protocol was the same for both groups.

The union rate in both groups at 3 months was low, approximately 70%. But at 9 months after the injury, the nonunion rate was <1% in the surgically treated patients, compared to 11% in the nonsurgically treated patients. The patient-reported scores (DASH and Constant-Murley) were significantly better in the operative group at 6 weeks and 3 months, but were equivalent to those in the nonoperative group at 9 months.

“Overall,” the authors conclude, “we think that surgical treatment for a displaced midshaft clavicle fracture should be offered to patients, and [these findings] can provide clear, robust data to help patients make their choices.”

What’s New in Musculoskeletal Infection

PPI Image for O'BuzzEvery 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, Arvind Nana, MD, co-author of the July 19, 2017 Specialty Update on musculoskeletal infection, selected the five most compelling findings from among the more than 120 studies cited in the Specialty Update.

Periprosthetic Joint Infection

–Much of the discussion around treating periprosthetic joint infections (PJIs) centers around comparing one-stage versus two-stage exchange arthroplasty. Two-stage exchange arthroplasty requires the use of a temporary cement spacer, and one study1 found that debris from articulating spacers may induce CD3, CD20, CD11(c), and IL-17 changes, raising the possibility of associated immune modulation.

–When performing debridement to treat a PJI, instead of an irrigation solution containing antibiotics, a 20-minute antiseptic soak with 0.19% vol/vol acetic acid reduced the risk of reinfection.2


–Four studies helped bolster evidence that surgical-site infections are the leading cause of reoperations after spine surgery, both early (within 30 days)3, 4 and late (after 2 years).5, 6


–A 100-patient prospective cohort study found that posttraumatic osteomyelitis treated with a 1-stage protocol and host optimization in Type B hosts resulted in 96% infection-free outcomes.7


–As in lower-extremity procedures, the risk of infection after shoulder arthroplasty and arthroscopy is higher when the surgeries are performed less than 3 months after a corticosteroid injection. This finding suggests elective shoulder procedures should be delayed for at least 90 days after such injections.8


  1. Singh G, Deutloff N, Maertens N, Meyer H, Awiszus F, Feuerstein B, Roessner A, Lohmann CH. Articulating polymethylmethacrylate (PMMA) spacers may have an immunomodulating effect on synovial tissue. Bone Joint J. 2016 ;98-B(8):1062–8.
  2. Williams RL, Ayre WN, Khan WS, Mehta A, Morgan-Jones R. Acetic acid as part of a debridement protocol during revision total knee arthroplasty. J Arthroplasty. 2017 ;32(3):953–7. Epub 2016 Sep 28.
  3. Medvedev G, Wang C, Cyriac M, Amdur R, O’Brien J. Complications, readmissions, and reoperations in posterior cervical fusion. Spine (Phila Pa 1976). 2016 ;41(19):1477–83.
  4. Hijas-Gómez AI, Egea-Gámez RM, Martínez-Martín J, González-Díaz RC, Losada-Viñas JI, Rodríguez-Caravaca G. Surgical wound infection rates and risk factors in spinal fusion in a university teaching hospital in Madrid, Spain. Spine. November 2016.
  5. Ohya J, Chikuda H, Takeshi O, Kato S, Matsui H, Horiguchi H, Tanaka S, Yasunaga H. Seasonal variations in the risk of reoperation for surgical site infection following elective spinal fusion surgery: a retrospective study using the Japanese diagnosis procedure combination database. Spine (Phila Pa 1976). 2016 . Epub 2016 Nov 22.
  6. Ahmed SI, Bastrom TP, Yaszay B, Newton PO; Harms Study Group. 5-year reoperation risk and causes for revision after idiopathic scoliosis surgery. Spine (Phila Pa 1976). 2016 . Epub 2016 Nov 9.
  7. McNally MA, Ferguson JY, Lau ACK, Diefenbeck M, Scarborough M, Ramsden AJ, Atkins BL. Single-stage treatment of chronic osteomyelitis with a new absorbable, gentamicin-loaded, calcium sulphate/hydroxyapatite biocomposite: a prospective series of 100 cases. Bone Joint J. 2016 ;98-B(9):1289–96.
  8. Werner BC, Cancienne JM, Burrus MT, Griffin JW, Gwathmey FW, Brockmeier SF. The timing of elective shoulder surgery after shoulder injection affects postoperative infection risk in Medicare patients. J Shoulder Elbow Surg. 2016 ;25(3):390–7. Epub 2015 Nov 30.