It is well accepted that kids with Legg-Calve-Perthes (LCP) disease do best when their condition is diagnosed and managed before 6 years of age. Surgical treatment is often recommended for children 6 years and older who have more severe femoral-head involvement, and orthopaedists perform combined pelvic and femoral varus osteotomies on some of those children.
In the February 1, 2107 edition of The Journal, Mosow et al. compare 10-year outcomes in 52 LCP patients who underwent combined osteotomies (mean age at surgery of 7.9 years) with results reported in the literature for single pelvic or femoral osteotomies. Although the postoperative radiographic and functional results after combined osteotomy were good, they were overall no better than those reported in the literature for either osteotomy alone.
The authors admit that in the absence of a randomized study design, these findings should be interpreted with caution, but they conclude that “it is not recommended that combined osteotomies for this age group routinely be used.”
In the November 16, 2016 edition of The Journal of Bone & Joint Surgery, Kim et al. improve our understanding of how blood flow is restored to the necrotic femoral head in Legg-Calve-Perthes disease. Using a series of perfusion MRI scans, the authors evaluated 30 hips with Stage-1 or -2 disease; 15 of the hips were treated conservatively, and 15 underwent one of three operative interventions.
Revascularization rates varied widely (averaging 4.9% ± 2.3% per month), but the revascularization pattern was similar, converging in a horseshoe-shaped pattern toward the anterocentral region of the femoral epiphysis from the posterior, lateral, and medial aspects of the epiphysis. The MRIs yielded no evidence of regression or fluctuation of perfusion of femoral heads, which casts some doubt on the proposed repeated-infarction theory of pathogenesis for this disease.
In a related commentary, Pablo Castaneda emphasizes that the study was not designed to evaluate the effects of different treatments, but he says knowing about an MRI pattern that is predictive of final outcomes in Legg-Calve-Perthes disease “has potential for improving our prognostic abilities.” Still, neither the commentator nor the authors suggest routinely obtaining serial MRIs in this patient population.
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.