Tag Archive | developmental dysplasia of the hip

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.

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

  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].

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

JBJS.IG.17.00187.ig

PAO Results Hold Up over Intermediate Term

Periacetabular Osteotomy for OBuzzThe Bernese periacetabular osteotomy (PAO) has become the procedure of choice for treating symptomatic acetabular dysplasia. But how long-lasting are its benefits? Quite, according to one of the largest intermediate-term follow-up studies on this procedure, authored by Wells et al. in the February 7, 2018 edition of The Journal of Bone & Joint Surgery.

Among 154 hips (average patient age of 26 years) treated with PAO at a single center between 1994 and 2008, the survival rate, with total hip arthroplasty (THA) as the endpoint, was 92% at 15 years postoperatively. When failure was defined as a conversion from PAO to THA or a symptomatic hip, the hip-preservation rate was 79% at a mean follow-up of 10.3 years.

After carefully analyzing the data to identify factors that contributed to failure or success, the authors discovered that:

  • Hips with fair or poor joint congruency before surgery had 9 times the odds of failing when compared with hips that had good or excellent preoperative joint congruency.
  • Hips with a postoperative lateral center-edge angle of >38° had 8 times the odds of failure.
  • Hips that underwent a concurrent head-neck osteochondraplasty at the time of PAO had a 73% decrease in the odds of failing.

These data suggest that preventing excessive femoral head coverage and secondary impingement resulting from surgery improves hip survival. Consequently, Wells et al. reported that their institution, Washington University School of Medicine, “currently assess[es] for secondary impingement intraoperatively following PAO,…and, if it is present, osteochondroplasty of the head-neck junction is performed to relieve potential secondary femoroacetabular impingement.”

The authors also recommend against managing patients with symptomatic acetabular dysplasia with hip arthroscopy because “it fails to address the underlying pathomechanics found in developmental dysplasia of the hip.”

Don’t Delay DDH Treatment to Wait for Ossific Nucleus

Ossific_Nucleus_for_OBuzz.pngThe exact cause of osteonecrosis in the setting of developmental dysplasia of the hip (DDH) is unknown. However, some pediatric orthopaedists are concerned that DDH treatment in the absence of the ossific nucleus of the femoral head increases the risk of subsequent osteonecrosis. That concern has to be weighed against evidence that delayed DDH treatment may lead to more difficult reduction and potentially necessitate additional procedures.

In the May 3, 2017 issue of JBJS, Chen et al. performed a meta-analysis of cohort and case-control studies to clarify this potential “conflict of interests” in DDH treatment. Twenty-one observational studies were included. Of the 969 hips with an ossific nucleus present before reduction, 198 hips (20.4%) had eventual osteonecrosis events; among the 608 hips without an ossific nucleus, 129 (21.2%) had osteonecrosis events. The authors state that this difference “is neither clinically important nor [statistically] significant.”

A sub-analysis determined that the presence of the ossific nucleus was not associated with significantly decreased odds of osteonecrosis even among patients who later developed more severe (grades II to IV) osteonecrosis. Chen et al. also performed a “meta-regression” of studies with short- and long-term follow-ups, finding “no evidence for a protective effect of the ossific nucleus with either short or long-term follow-up.”

Although 11 of the 21 studies in the meta-analysis were deemed high quality and 10 were of moderate quality, the inherent limitations of a meta-analysis derived predominantly from retrospective data prompted the authors to call for “further prospective studies with long-term follow-up and blinded outcome assessors.” Nevertheless, these findings lend additional support to the belief that treatment for DDH should not be delayed based on the absence of the femoral head ossific nucleus.

What’s New in Pediatric Orthopaedics

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 15, 2017 Specialty Update on Pediatric Orthopaedics, selected the five most clinically compelling findings from among the 60 studies summarized in the Specialty Update.

Upper-Extremity Trauma
—A systematic review of eight randomized studies comparing splinting with casting for distal radial buckle fractures confirmed that splinting was superior in function, cost, and convenience, without an increased complication rate.1

Lower-Extremity Trauma
—A review of the treatment of 361 pediatric diaphyseal femoral fractures before and after the 2009 publication of AAOS clinical guidelines for treating such fractures revealed that the guidance had little impact on the treatment algorithm in one pediatric hospital.

Spine
—Bracing remains an integral part of managing adolescent idiopathic scoliosis, but patient compliance with brace wear is variable. A prospective study of 220 patients demonstrated that physician counseling based on compliance-monitoring data from sensors embedded in the brace improved patients’ average daily orthotic use.

Hip
—AAOS-published evidence-based guidelines on the detection and nonoperative management of developmental dysplasia of the hip (DDH) in infants from birth to 6 months of age determined that only two of nine recommendations gleaned from evidence in existing literature could be rated as “moderate” in strength:

  • Universal DDH screening of all newborn infants is not supported.
  • Imaging before 6 months is supported if the infant has one or more of three listed risk factors.

Seven additional recommendations received only “limited” strength of support.

—A study of the utility of inserting an intraoperative intracranial pressure (ICP) monitor during closed reduction and pinning for slipped capital femoral epiphysis (SCFE) found that 6 of 15 unstable hips had no perfusion according to ICP monitoring. However, all 6 hips were subsequently reperfused with percutaneous capsular decompression, and no osteonecrosis developed over the next 2 years.

Reference

  1. Hill CE, Masters JP, Perry DC. A systematic review of alternative splinting versus complete plaster casts for the management of childhood buckle fractures of the wrist. J Pediatr Orthop B. 2016 ;25(2):183–90.

DDH Webinar Tomorrow—CME Available

baby pic for social mediaTreating developmental dysplasia of the hip (DDH) with the Pavlik harness is safe and successful in about 90% of cases. But what about the 10% of patients for whom this treatment is not effective or causes complications The complimentary JBJS webinar on Wednesday, Feb. 24, 2016 at 8:00 PM EST will focus on how orthopaedists can:

  • Identify patient characteristics that help predict Pavlik harness failure
  • Understand the role of ultrasound in managing DDH
  • Recognize and prevent complications from using the harness
  • Successfully treat patients who need a post-Pavlik approach

Following presentations about JBJS-published research by Daniel Sucato, MD; Lucas Murnaghan, MD; and Wudbhav Sankar, MD, DDH expert Scott Mubarak, MD will expand on all three author presentations. The last 15 minutes of the webinar will be devoted to a live Q&A session, during which audience members can ask questions of the authors and commentator. The webinar will be moderated by Paul Sponseller, MD.

CME Credit Available
For those who attend this activity live, The Journal of Bone and Joint Surgery Inc. designates this webinar for a maximum of 1 AMA PRA Category 1 Credits™. The Journal of Bone and Joint Surgery Inc. is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Click here to register.