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.
Orthopaedic surgery is generally a discipline where functional restoration and pain relief take precedence over esthetics. However, all practicing surgeons know that how incisions appear is important to many patients and their families. This is especially true in pediatric orthopaedics, where parents feel a responsibility to limit any adverse experiences their child may have.
In the August 17, 2016 edition of The Journal, Davids et al. provide our community with an important contribution regarding some basic principles of scar management in children—in this case, kids with cerebral palsy who had a second surgery to remove an implant. The take-home message is that scars that are acceptably thin with minimal discoloration are safe to treat and do well cosmetically with a repeat incision through the original scar. Scars that are broad and/or discolored basically end up with the same appearance when the implant is removed through excision (a second incision about the margins of the first incision) and layer closure.
This field is ripe for further investigation, and careful attention to methodology will be very important. Interventions that deserve additional study include topical and intralesional treatments for healing incisions, the impact of immobilization on the quality of scars below the knee, and the effects on scars of limited weight bearing, to name a few. Similar investigations in select groups of adults with scars about the shoulder, knee, and ankle will also be welcome additions to this objective evaluation of surgical-incision outcomes by Davids et al.
Marc Swiontkowski, MD
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. Here is a summary of selected findings cited in the February 17, 2016 Specialty Update on pediatric orthopaedics:
Guidelines and AUCs
–The AAOS updated its clinical practice guidelines on the treatment of pediatric diaphyseal femoral fractures1 and adopted appropriate use criteria (AUC) for pediatric supracondylar humeral fractures with vascular injury.2
–A matched case control study of surgical spinal procedures found that neuromuscular scoliosis, weight for age ≥95th percentile, ASA score of ≥3, and prolonged operative time were associated with a higher risk of surgical site infection.3
–Several groups, including the Scoliosis Research Society and POSNA, endorsed the definition of early-onset scoliosis as “scoliosis with onset less than the age of ten years, regardless of etiology.”4, 5
–A prospective randomized study found that preoperative education and orientation for scoliosis surgery paradoxically increased immediate postoperative anxiety among patients and caregivers, relative to controls who received standard perioperative information.6
–A randomized trial investigating perioperative blood loss and transfusion rates in patients undergoing posterior spinal arthrodesis for adolescent idiopathic scoliosis found that tranexamic acid and epsilon-aminocaproic acid reduced operative blood loss but not transfusion rates when compared with placebo.
–A study of 30 patients with severe stable slipped capital femoral epiphysis found that good or excellent results were achieved over 2.5 years in a higher proportion of those receiving a modified Dunn realignment compared with those treated with in situ fixation. The reoperation rate was greater in the in situ fixation cohort.7
–A prospective study analyzing complications after periacetabular osteotomy for acetabular dysplasia using the modified Clavien-Dindo grading scheme found grade III or IV complications in 5.9% of 205 patients, with a nonsignificant trend associating complications with male sex and obesity.
–A registry-based study found that, compared with matched controls, patients with Legg-Calve-Perthes disease had an elevated hazard ratio of 1.5 for ADHD, 1.3 for depression, and 1.2 for mortality. It remains unclear whether patients with Legg-Calve-Perthes disease would benefit from routine psychiatric screening.8
–A case control study of 822 injured athletes and 368 uninjured athletes found that overuse injuries represented 67.4% of all injuries. The risk of serious overuse injury was two times greater if the weekly hours of sports participation were greater than the athlete’s age in years.9
–A meta-analysis of initial nonoperative treatment compared with operative treatment of ACL tears in children and adolescents noted instability and pathologic laxity in 75% of patients with nonoperative treatment compared with 14% of patients following reconstruction.10
–A review of more than 4,400 supracondylar humeral fractures with isolated anterior interossesous nerve palsies but without sensory nerve injury or dysvasculartity found that postponing treatment for up to 24 hours did not delay neurologic recovery.
–A randomized controlled trial investigating the effectiveness of analgesics during intraossesous pin removal found that acetaminophen and ibuprofen were clinically equivalent to placebo in terms of pain reduction and heart rate.
Foot and Ankle
–A study exploring risk factors for failure of allograft bone after calcaneal lengthening osteotomy found a lower risk of failure with tricortical iliac crest allograft relative to patellar allograft. The risk of radiographic graft failure increased with patient age.11
–A prospective nonrandomized study of symptomatic planovalgus feet comparing subtalar arthroereisis with lateral column lengthening found similar postoperative improvements and complication rates in both groups after one year.12
Musculoskeletal Infection & Neuromuscular Conditions
–A cohort study of 869 children with osteomyelitis, septic arthritis, pyomyositis, or abscess concluded that routinely culturing for anaerobic, fungal, and acid-fast bacterial organisms is not recommended except in patients with a history of penetrating injury, immunocompromise, or failure of primary treatment.
–A prospective study comparing tendon transfers, botulinum toxin injections, and ongoing therapy in children with upper-extremity cerebral palsy found that tendon transfer demonstrated greater improvements than the alternatives in joint positioning during functional tasks and grip and pinch strength.
- American Academy of Orthopaedic Surgeons.Guideline on the treatment of pediatric diaphyseal femur fractures. 2015.http://www.aaos.org/Research/guidelines/PDFFguideline.asp.
- American Academy of Orthopaedic Surgeons.Appropriate use criteria: pediatric supracondylar humerus fractures with vascular injury. 2015.http://www.aaos.org/research/Appropriate_Use/pshfaucvascular.asp.
- Croft LD, Pottinger JM, Chiang HY, Ziebold CS, Weinstein SL, Herwaldt LA. Risk factors for surgical site infections after pediatric spine operations. Spine (Phila Pa 1976). 2015 Jan 15;40(2):E112-9
- El-Hawary R, Akbarnia BA. Early onset scoliosis – time for consensus. Spine Deformity. 2015 Mar;3(2):105-6
- Skaggs DL, Guillaume T, El-Hawary R, Emans J, Mendelow M, Smith J. Early onset scoliosis consensus statement, SRS Growing Spine Committee, 2015. Spine Deformity. 2015;3(2):107.
- Rhodes L, Nash C, Moisan A, Scott DC, Barkoh K, Warner WC Jr, Sawyer JR, Kelly DM.Does preoperative orientation and education alleviate anxiety in posterior spinal fusion patients? A prospective, randomized study. J Pediatr Orthop. 2015 Apr-May;35(3):276-9.
- Novais EN, Hill MK, Carry PM, Heare TC, Sink EL. Modified Dunn procedure is superior to in situ pinning for short-term clinical and radiographic improvement in severe stable SCFE. Clin Orthop Relat Res. 2015 Jun;473(6):2108-17. Epub 2014 Dec 12
- Hailer YD, Nilsson O. Legg-Calvé-Perthes disease and the risk of ADHD, depression, and mortality. Acta Orthop. 2014 Sep;85(5):501-5. Epub 2014 Jul 18.
- Jayanthi NA, LaBella CR, Fischer D, Pasulka J, Dugas L. Sports-specialized intensive training and the risk of injury in young athletes: a clinical case-control study. Am J Sports Med. 2015 Apr;43(4):794-801. Epub 2015 Feb 2.
- Ramski DE, Kanj WW, Franklin CC, Baldwin KD, Ganley TJ. Anterior cruciate ligament tears in children and adolescents: a meta-analysis of nonoperative versus operative treatment. Am J Sports Med. 2014 Nov;42(11):2769-76. Epub 2013 Dec 4.
- Lee IH, Chung CY, Lee KM, Kwon SS, Moon SY, Jung KJ, Chung MK, Park MS. Incidence and risk factors of allograft bone failure after calcaneal lengthening. Clin Orthop Relat Res. 2015 May;473(5):1765-74. Epub 2014 Nov 14.
- Chong DY, Macwilliams BA, Hennessey TA, Teske N, Stevens PM. Prospective comparison of subtalar arthroereisis with lateral column lengthening for painful flatfeet. J Pediatr Orthop B. 2015 Jul;24(4):345-53.
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. Here is a summary of key findings from Level I and II studies cited in the November 18, 2015 Specialty Update on orthopaedic rehabilitation:
- A prospective comparison of patients who received either skilled physical therapy (PT) or a standardized home exercise program after total knee arthroplasty (TKA) found that range of motion and functional outcome were similar in the two groups after two years, but the home program was nearly half the cost of PT.1
- A randomized trial of 198 patients who underwent TKA compared telerehabilitation with face-to-face rehab. After two months, WOMAC and KOOS scores and functional and range-of-motion tests were all noninferior for telerehabilitation.
- A randomized trial of community-dwelling elderly patients who had undergone hip fracture surgery found that an individualized home-based rehab program produced superior functional outcomes, balance, and mobility recovery when compared with a standard, non-structured home exercise program.2
- A claims-data study of 4733 people who underwent hip or knee replacement found a 29% decrease in postoperative acute service utilization among those who had preoperative PT.
- A randomized trial comparing active transcutaneous nerve stimulation (TENS), placebo TENS, and standard care during rehab for TKA found that adding either active or placebo TENS to standard care significantly reduced movement pain in the immediate postoperative period.3
- A randomized study found that in-hospital sling-based range-of-motion therapy had a clinically beneficial effect up to three months after TKA surgery in terms of passive knee flexion range of motion, compared with an in-hospital continuous passive motion protocol.4
- A randomized trial comparing weight-bearing and non-weight-bearing for nonoperative treatment of Achilles tendon ruptures found no significant between-group differences in the Total Rupture Score or heel-rise strength.
- A systematic review and meta-analysis comprising 402 patients who had undergone surgical Achilles tendon repair found that postoperative early weight-bearing and early ankle motion exercises were associated with a lower minor complication rate and greater functional recovery when compared with conventional immobilization.5
- A randomized trial comparing 12 weeks of individualized resistance training to physiotherapy without resistance training in adolescents and young adults with bilateral spastic cerebral palsy found that neither group demonstrated improvements in performance of daily physical activity.6
- A randomized trial of three methods of weight-bearing training (verbal instruction, bathroom scale training, and haptic biofeedback) found that haptic feedback was superior to the other methods at helping patients maintain weight-bearing status.7
Amputation and Prosthetics
- A systematic review of studies comparing rigid versus soft dressings after amputation determined that rigid dressings resulted in significantly shorter time from amputation to fitting of a prosthesis.8
- A randomized trial of phantom pain found that a protocol of progressive muscle relaxation, mental imagery, and phantom exercises yielded more significant reductions in the rate and intensity of phantom pain than a program of standard physical therapy.9
Low Back Pain
- Among patients with low back pain, a three-way randomized trial (standard care, standard care + extensible lumbosacral orthoses, and standard care + inextensible lumbosacral orthoses) found that inextensible lumbar orthoses led to a greater improvement in Oswestry Disability Index scores than the other two approaches.10
- Büker N,,Akkaya S, Akkaya N, Gökalp O, Kavlak E, Ok N, Kıter AE, Kitiş A.Comparison of effects of supervised physiotherapy and a standardized home program on functional status in patients with total knee arthroplasty: a prospective study. J Phys Ther Sci. 2014 Oct;26(10):1531-6. Epub 2014 Oct 28.
- Salpakoski A, Törmäkangas T, Edgren J, Kallinen M, Sihvonen SE, Pesola M,Vanhatalo J, Arkela M, Rantanen T, Sipilä S. Effects of a multicomponent home-based physical rehabilitation program on mobility recovery after hip fracture: a randomized controlled trial. J Am Med Dir Assoc. 2014 May;15(5):361-8. Epub 2014 Feb 20.
- Rakel BA, Zimmerman MB, Geasland K, Embree J, Clark CR, Noiseux NO,Callaghan JJ, Herr K, Walsh D, Sluka KA. Transcutaneous electrical nerve stimulation for the control of pain during rehabilitation after total knee arthroplasty: A randomized, blinded, placebo-controlled trial. Pain. 2014 Dec;155(12):2599-611.Epub 2014 Sep 28.
- Mau-Moeller A, Behrens M, Finze S, Bruhn S, Bader R, Mittelmeier W. The effect of continuous passive motion and sling exercise training on clinical and functional outcomes following total knee arthroplasty: a randomized active-controlled clinical study. Health Qual Life Outcomes. 2014 May 9;12:68.
- Huang J, Wang C, Ma X, Wang X, Zhang C, Chen L. Rehabilitation regimen after surgical treatment of acute Achilles tendon ruptures: a systematic review with meta-analysis. Am J Sports Med. 2015 Apr;43(4):1008-16. Epub 2014 May 2.
- Bania TA, Dodd KJ, Baker RJ, Graham HK, Taylor NF. The effects of progressive resistance training on daily physical activity in young people with cerebral palsy: a randomised controlled trial. Disabil Rehabil. 2015 Jun 9:1-7. [Epub ahead of print].
- Fu MC, DeLuke L, Buerba RA, Fan RE, Zheng YJ, Leslie MP, Baumgaertner MR, Grauer JN. Haptic biofeedback for improving compliance with lower-extremity partial weight bearing. Orthopedics. 2014 Nov;37(11):e993-8.
- Churilov I, Churilov L, Murphy D. Do rigid dressings reduce the time from amputation to prosthetic fitting? A systematic review and meta-analysis. Ann Vasc Surg. 2014 Oct;28(7):1801-8. Epub 2014 Jun 6.
- Brunelli S, Morone G, Iosa M, Ciotti C, De Giorgi R, Foti C, Traballesi M. Efficacy of progressive muscle relaxation, mental imagery, and phantom exercise training on phantom limb: a randomized controlled trial. Arch Phys Med Rehabil. 2015Feb;96(2):181-7. Epub 2014 Oct 23.
- Morrisette DC, Cholewicki J, Logan S, Seif G, McGowan S. A randomized clinical trial comparing extensible and inextensible lumbosacral orthoses and standard care alone in the management of lower back pain. Spine (Phila Pa 1976). 2014 Oct 1;39(21):1733-42.
The goals of orthopaedic surgery for children with cerebral palsy (CP) include pain and spasticity reduction and improvements in hygiene and functional mobility. A multicenter study by Mulcahey et al. in the September 16, 2015 JBJS found that when assessing changes in lower-extremity mobility derived from orthopaedic surgery among 255 CP patients, computerized adaptive testing (CAT) was more sensitive than other commonly used instruments. Specifically, improvements in function detected by the CAT at 12 and 24 months following surgery were greater than the changes detected by the relevant domains of the oft-administered Pediatric Outcomes Data Collection Instrument (PODCI).
Interestingly, neither of those two instruments, nor the timed “up & go” test, performed well with patients at level II of the Gross Motor Function Classification System. Furthermore, the authors note that CAT results are based on parent reports and therefore provide perceived outcomes rather than direct measures. Nevertheless, this study yields sound evidence that the benefits of orthopaedic surgery in people with CP heretofore measured with less sensitive instruments are in fact substantial.
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. Here is a summary of key findings from studies cited in the November 19, 2014 Specialty Update on orthopaedic rehabilitation:
- Among geriatric hip fracture patients, those who received comprehensive postsurgical care (including a multidisciplinary assessment of health, function, and social situation) had significantly more upright time and better Short Physical Performance Battery scores than counterparts who received hospital physiotherapy and conventional care.
- Seventy-two percent of 51 orthopaedic inpatients exceeded their target goal for prescribed partial weight bearing after being trained. The inability to comply with the training was not associated with poorer outcomes at three months, suggesting clinical support for less-restrictive weight-bearing protocols.
- A prospective study of 38 unilateral TKA patients revealed that results from squatting exercises more accurately predicted overall functional difficulties than did results from standing with increased weight.
- A prospective randomized trial among 36 patients who underwent primary ACL reconstruction with semitendinosus-gracilis autograft found no difference in knee laxity, peak isometric force, or subjective IKDC scores between those who had aggressive early rehabilitation versus those undergoing a nonaggressive protocol.
Pediatric Rehabilitation (focused on cerebral palsy patients)
- Among 100 young children with cerebral palsy, the development of mobility and self-care was faster in children with less severe levels as assessed with the Gross Motor Function Classification System (GMFCS). A separate assessment study supported the validity of the Patient Reported Outcomes Measurement Information System (PROMIS) Mobility Short Form.
- Results from two gait-analysis studies suggested that using gait analysis in planning interventions for children with cerebral palsy can lead to beneficial alterations in gait.
Amputation and Prosthetics
- A study comparing functional outcomes after two types of unilateral transtibial amputation (modified Ertl and modified Burgess procedures) found no significant between-group differences.
Spinal Cord Injury
- A study to assess the safety and efficacy of ReWalk (a lower-limb powered exoskeleton) among 12 patients with motor-complete thoracic spinal cord injury found that all subjects were able to walk independently and continuously for at least 50 to 100 meters. No falls were reported, but a few adverse events related to pressure and irritation occurred.
Vernon Tolo, MD, JBJS Editor-in-Chief Emeritus, provided outstanding editorial stewardship for The Journal during the last four years. In this interview, he explains what the experience has meant to him.
JBJS: As you transition out of the role of Editor-in-Chief at JBJS, what will you miss the most?
Dr. Tolo: There are a few things I will miss. One is the opportunity to work with a great group of Deputy Editors, whose work is essential and so important to the Editor. I will miss the JBJS staff, who are all talented professionals and who provided great support to me during my time as Editor. And I will miss seeing the latest in research reports, often months before publication occurs. The time I spent as Editor were some of the most exciting and rewarding years of my orthopaedic career… a true privilege to be able to carry forward the tradition of JBJS. Nonetheless, I will not miss the relentless assignment of manuscripts which required nightly connection to my computer….but I still had a great time.
JBJS: When you first joined JBJS, what surprised you the most about The Journal or about journal publishing in general?
Dr. Tolo: I had known primarily about the editorial side of journal publishing from my years being a JBJS Deputy Editor. What surprised me the most when I became Editor was how little I knew about trends in medical publishing and the challenges facing journals such as JBJS in today’s publishing world. Being involved in meeting these challenges has stimulated me to think about problems and challenges that I otherwise would not have considered.
JBJS: As JBJS celebrates its 125th anniversary this year, how would you describe the impact of The Journal on orthopaedics?
Dr. Tolo: The Journal has had a tremendous impact on orthopaedics. For the first 100 years, JBJS was the primary written source of orthopaedic education for all orthopaedic surgeons in North America. Articles published in JBJS were the source of a large percentage of questions in the Board examinations for years. Even after the explosion of educational sources in the past 25 years, The Journal still holds a pre-eminent position for quality, trusted research reports that affect day-to-day patient care.
JBJS: How do you think JBJS can best support orthopaedics going forward?
Dr. Tolo: We need to continue to be the trusted source for new orthopaedic knowledge that improves patient care. The multiple journals that the JBJS family has developed over the past few years have really broadened the choices available to orthopaedists, as has the option for webinars throughout the year.
JBJS: What trends in orthopaedics are you most intrigued by?
Dr. Tolo: I am not sure “intrigued” is the right word, but I am concerned about the ongoing tendency for super-specialization within our profession. Despite having exposure to and training for the treatment of a wide variety of orthopaedic conditions during residency, orthopaedists are increasingly claiming they are inadequately trained to treat a wide variety of orthopaedic conditions, particularly once they have completed a fellowship in a subspecialty. For example, pediatric orthopaedists may feel uncomfortable treating hand or pelvic fractures. Sports medicine orthopaedists will often not get involved with treatments outside their fellowship training. And it goes on with many other examples. This situation only seems to be increasing. The ongoing challenge is how to adjust training programs to allow for appropriate broad-based training opportunities and still allow residents to focus on the subspecialty in which they will eventually practice.
The trend over the past several years of orthopaedics being a specialty selected by more medical students than there are residency openings will likely continue. We are still the most underrepresented surgical specialty for women in training programs and on faculties. While some progress has been made in this area, we need to increase the number of women in orthopaedics.
JBJS: Looking ahead to the next 20 years or so, what do you think might be three significant advances or changes in orthopaedics?
Dr. Tolo: The changes in orthopaedics have been so dramatic in the past 20 years that it is a challenge for me to predict how our profession will look in 2034. I think medical schools will finally include education in musculoskeletal disorders commensurate with the percentage of patients with these conditions who are seen by primary care physicians. Robotic surgery, currently so common in surgical specialties that deal with soft tissue disorders, may soon be ready for orthopaedic use, but that will be a decade or more from now. Biologics will be used more often, particularly in settings to decrease the onset of articular cartilage damage after ACL injury or intraarticular fractures, and this would be a major advance. It may be that a “bone glue” may supplant casts as a fracture treatment. Whatever advances occur, JBJS is where they should be published.
JBJS: What is your favorite thing about your profession?
Dr. Tolo: No question….it is helping patients get better. I am fortunate to have worked in pediatric orthopaedics my entire career. All children want to get better, and the ability to play a part in helping advance the health of children has been extremely rewarding for me. I still love going to work every day, and the grateful feedback that I receive almost daily from families is incredible. There are few other professions or vocations that provide this benefit.
JBJS: What are you looking forward to most as you make this transition?
Dr. Tolo: Once I have dealt with my withdrawal symptoms from my time at JBJS, I will increase my clinical outpatient and operative activity at the Children’s Hospital Los Angeles, mainly in spinal deformity, skeletal dysplasia, and cerebral palsy, though probably a bit less than 100% full time. I look forward to spending quality time with my wife Charlene, who has put up with a sometimes crazy schedule for 49 years of marriage, and to getting my golf handicap down to the low teens. It will be difficult for me to break away completely from orthopaedics, which has provided me with an incredibly satisfying career and multiple opportunities to contribute to our profession globally, through a number of societies/associations–and through JBJS.