Treating 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.
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
On Monday, Nov. 23, 2015 at 8:00 PM EDT, JBJS will host a one-hour webinar focused on managing pediatric supracondylar humeral fractures.
Because supracondylar humeral fractures present with various degrees of displacement and concomitant injuries may be difficult to assess precisely, there is no single, accepted protocol for managing this condition.This complimentary webinar, moderated by JBJS Deputy Editor for Pediatrics Paul Sponseller, MD, will examine the efficacy of different approaches to supracondylar humeral fractures—and their neurovascular consequences.
Brain Scannell, MD and Christine Ho, MD, will explore pulseless supracondylar humeral fractures by presenting findings from separate but related studies published in JBJS in 2013. In addition, John Flynn, MD, will present findings from his 2014 JBJS study, which investigated isolated anterior interosseous nerve (AIN) injuries accompanying supracondylar humeral fractures.Commentary from pediatric orthopaedist Donald Bae, MD will complement the author presentations, and the webinar will conclude with a live audience Q&A session.
Orthopaedic surgical procedures to correct axial and appendicular skeletal deformities are usually dependent upon fixation devices, either external or internal or both. These devices are often developed through close collaboration with engineers who are generally employed by major manufacturing companies. After the devices successfully clear rigorous bench, in-vitro, and in-vivo testing, the standard initial presentation of clinical results is a case series.
All too often the initial report of results comes from a co-developer of the device, with inherent selection and detection bias that constitute what most readers would consider a conflict of interest. McCarthy and McCullough’s case series on five-year results with Shilla growth guidance in 33 children with early-onset scoliosis in the October 7, 2015 JBJS is an exception to that rule. The authors report every conceivable major and minor adverse event without holding back any negative information. They categorize complications as infection secondary to wound breakdown, spinal alignment issues, and implant issues. The overall complication rate was 73%, a rate that is not surprising given the fact that the device under study is designed to maintain correction of spinal deformity in growing children.
Thankfully, the authors reported no neurologic complications. Also on the positive side, they found that spinal curves averaging 69° preoperatively averaged 38.4° at the most recent follow-up or prior to definitive spinal instrumentation. McCarthy and McCullough also calculated a 73% reduction in the number of surgical procedures among their cohort, relative to what would be necessary to treat the same population with distraction methods every six months.
I applaud the authors for comprehensively reporting the results of correction of spinal deformity in this difficult clinical situation with high accuracy and strict definitions of major and minor events. This is how we will make advances in correcting deformity for skeletally mature and immature patients—with innovation, incremental improvement, and the widespread sharing of adverse events with the orthopaedic community. Armed with the information from this study, we must now see what the number and severity of complications look like when the broader community of orthopaedic surgeons applies these devices.
Marc Swiontkowski, MD
One benefit of our digital age is that it allows virtually real-time “conversations” to be published between authors of orthopaedic studies and their colleagues, without the lag time imposed by print.
Case in point is the engaging back-and-forth between James Sanders, MD (co-author of the April 16, 2014 JBJS study titled “Bracing for Idiopathic Scoliosis: How Many Patients Require Treatment to Prevent One Surgery?”) and Hans-Rudolf Weiss, an orthopaedic surgeon from Germany.
The original study found that bracing for idiopathic adolescent scoliosis substantially decreased the risk of curve progression to a surgical range—but only when patients wore the brace at least 10 hours a day. Among those “highly compliant” patients, the number needed to treat to prevent one surgery was 3. However, only 31% of the 126 subjects in the study were highly compliant. The authors also noted that current bracing indications include many curves that would not have progressed to surgical range even if the patient had not worn a brace.
In an eLetter (click on the “eLetters” tab under the article citation), Dr. Weiss stressed that patient compliance with bracing is largely influenced by the physician, but that half of the members of the Scoliosis Research Society do not believe in bracing. He additionally suggested that the findings pertain to the brace designs used in the study and may not be generalizable to other brace types. Dr. Weiss concluded that “long-term corrections can be achieved when recent bracing standards are applied.”
In a response to Dr. Weiss’s eLetter, Dr. Sanders suggested that the recent publication of the BrAIST study, which provided high-level evidence that bracing can prevent progression to a surgical range, has bolstered the ranks of bracing “believers” among orthopaedists. Despite that, Dr. Sanders points out that even strong physician proponents of bracing are “likely to have patients for whom bracing is unacceptable and their compliance poor.” That fact, he says, “makes it our imperative to develop bracing which is effective while still being both comfortable and psychosocially acceptable to patients.”
The article, “Guiding Femoral Rotational Growth in an Animal Model” by Arami, et al. is an intriguing variation on the common applications of guided growth in pediatric patients. Implants that bridge the physis to inhibit growth in a given anatomic location are widely used to correct angular deformity or leg-length differences in the growing child and to decrease the need for a more invasive corrective osteotomy.
At present, correction of rotational deformity in the pediatric femur or tibia requires a derotational osteotomy and commonly six weeks of casting postoperatively. This study in rabbits demonstrates the ability of implants to alter the rotational profile in the growing femur by bridging the physis in an oblique orientation, rather than in a vertical orientation used for angular deformity correction.
The authors have elegantly demonstrated histologically the swirling or bending appearance of the physeal columns in treated femora, while controls maintained the normal linear columnar appearance of the physis. This interesting and unique animal study lays the foundation for consideration of using oblique placement of physeal-bridging implants to guide rotational growth in skeletally immature patients, without the need for osteotomy.