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.
—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
—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.
—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.
—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.
- 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.
In the March 1, 2017 edition of The Journal, Eliezer et al. report on their experience managing femoral fractures in a major treatment center in Dar es Salaam, Tanzania, one of many low-resource locations around the world.
The authors tracked one-year outcomes for 331 femoral fractures in 329 patients. The vast majority of those fractures were treated with intramedullary nails, with open reduction and without intraoperative imaging. The actual reoperation rate for nails was 3.4%, with infection being the most common reason for reoperation.
Eliezer et al. also found that the factors most strongly associated with reoperation were proximal fractures with varus coronal alignment, small nail diameter (8 mm vs larger diameters), and a Winquist type-3 fracture pattern (comminution that included 50% to 75% of the femoral shaft).
Road-traffic accidents are the major cause of disability and loss of work productivity in the developing world among the young, economically productive segments of society. Through the support of organizations like SIGN Fracture Care International, local surgeons in low-resource countries have been able to treat patients who’ve sustained diaphyseal long bone fractures safely and with good functional outcomes. Carefully conducted follow-up studies such as this one give data-driven reassurance to everyone who supports these efforts that surgery can be safely conducted with good patient outcomes.
Performing intramedullary fixation allows early weight bearing and joint motion to limit muscle atrophy and joint stiffness. As long as we can be assured that these procedures have acceptably low rates of reoperation and patient morbidity, we can more confidently encourage the expansion of these programs in the developing world. Organizations like SIGN deserve our support in this regard.
Marc Swiontkowski, MD
The study by Ramo et al. in the February 17, 2016 JBJS examines the evolution toward more aggressive operative treatment of children with isolated femoral fractures. This movement started 30 years ago, initially with the notion that adolescents should be treated as adults, with preferential intramedullary (IM) nail fixation. Concerns regarding damage to the femoral-head arterial supply led to the development of nails that could be started at the trochanteric region.
In the five- to twelve-year-old group, the options that have been documented as safe and effective include flexible nailing, plating, and external fixation, each with its own set of advantages and downsides. Fractures in kids ages four and five have generally been treated by spica cast management. However, parental concerns over cast care, more frequent radiographs, and the negative impact on family life have influenced many centers to move toward IM fixation even in this “preschool” age group.
The Ramo et al. study has all the limitations of a retrospective study, but it strongly suggests that in four- and five-year-olds, the radiographic outcomes of nailing and casting are equivalent after a mean follow-up of 32 weeks. These findings will provide some information for a shared decision-making discussion with parents, but as with many topics in pediatric fracture management, the clinical questions raised by this study beg for a prospective, controlled, multicenter trial. I agree with commentator Merv Letts, who points out that the Ramo et al. study raises important and complex clinical and family-environment issues that we need to grapple with as an orthopaedic community, but that more definitive answers will come only with prospective research and longer follow-up periods.
Marc Swiontkowski, MD
Over the last 10 years, the AAOS has invested a great deal of effort and resources into developing Clinical Practice Guidelines (CPGs) and Appropriate Use Criteria. One rationale for these efforts was to follow the lead of our cardiovascular brethren, who have disseminated the highest level of evidence available to their community to help ensure that clinical decision making, in collaboration with the patient and family, is supported by the most solid science.
The paper published in the October 21, 2015 edition of JBJS by Oetgen et al. provides us with an evaluation of the impact of CPGs in managing femoral shaft fractures in children. The authors performed detailed chart reviews on 361 patients treated for a pediatric diaphyseal femoral fracture between 2007 and 2012. They analyzed each patient record to determine whether age-specific CPGs—which were published for this condition in 2009—were followed.
The results are somewhat discouraging. Oetgen et al. identified little if any impact of the CPG on clinical practice. Is that because surgeons are unaware of these tools? Or do they feel they know better than the literature synthesis at their disposal? Without more research, we will not know the answer to that question, but I suspect that recognition of the utility of CPGs will take a decade at least. I have the impression that younger surgeons are more accepting of the concepts of meta-analysis and levels of evidence as they influence clinical decision making—and as they were utilized to develop CPGs. Waiting longer to make judgments about the impact of CPGs seems appropriate.
There is another factor also. These documents are guidelines, not restrictive formulas. Oetgen et al. emphasize that point in their introduction. Physicians everywhere wish to retain the privilege of making the best educated decision for each patient and family; this fact is partly responsible for the pushback that AAOS leadership received when starting down the CPG path. Additionally, during decision making for children with femoral shaft fractures, parental preferences will play a very strong role, regardless of the guidelines. This reality may ultimately limit efforts to accurately measure the clinical impact of CPGs by analyzing administrative databases.
So let’s give these guidelines a little more time to mature, and let’s give our orthopaedic community more time to become familiar with the utility of these documents. And, above all, let’s not turn guidelines into “cookbook” patterns of clinical decision making. Inputs from the treating physician, patient, and family should always be preeminent.
Marc Swiontkowski, MD
Each month during the coming year, OrthoBuzz will bring you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators will highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation about these classics by clicking on the “Leave a Comment” button in the box to the left.
The classic 1984 JBJS review of 520 cases of intramedullary (IM) nailing by Winquist, Hansen, and Clawson changed everything for patients with fractures of the femoral shaft.
In North America during the 1960s and 70s, the debate was all about details of traction management for femoral-shaft fractures: Balanced skeletal traction versus Perkins traction, where to place the traction pin, how many weeks until the spica cast and what type of spica cast, and whether a fracture brace was a viable option. At the same time in Europe, the Swiss orthopaedic community, which was the focal point for the AO, was advocating plate fixation to avoid “fracture disease,” pneumonia, and pulmonary emboli by mobilizing patients.
Meanwhile, Kay Clawson had traveled extensively in Europe and became aware of the outstanding results being achieved with closed, reamed, femoral nailing, as published (originally in German) by Gerhard Kuntscher. Dr. Clawson ordered the equipment—including the reamers, intramedullary nails, and fracture table—and had them shipped to the University of Washington in Seattle.
There they sat on a pallet for more than a year until Dr. Clawson sent Bob Smith, one of the chief residents, to Europe to work with Kuntscher directly. Dr. Smith brought back the knowledge to do reamed IM nailing of the femur, and as experience increased, a Spokane farm boy turned orthopaedic resident named Ted Hansen became especially skilled at the procedure. When Dr. Hansen became an attending, he taught the procedure to another highly skilled resident, Bob Winquist.
Experience grew to the point where they were able to publish this classic manuscript with all its tips, tricks, and outcomes, including which fracture patterns could be treated without keeping patients in traction for weeks to maintain length, and which fractures required open cerclage to create length stability. During this time, there were no commercially available interlocking nails, so we developed ways to drill holes through Kuntscher rods and inserted cortical screws through them with free-hand technique. We also began retrograde nailing these fractures by increasing the bend of the rods to allow them to be inserted off the articular surface in the medial condyle.
This paper, which also carefully explains how procedures were refined as the authors’ experience grew from 1968 to 1979, ushered in the standard of care that exists today and spelled the end of traction treatment and plate fixation. It remains one of the most-cited articles in the history of musculoskeletal trauma literature.
Marc Swiontkowski, MD