JBJS Essential Surgical Techniques (EST) is pleased to congratulate the winners of its two Editor’s Choice Awards for 2017:
The award for best surgical-technique article went to Morteza Kalhor, MD; Diego Collado, MD; Michael Leunig, MD; Paulo Rego, MD; and Reinhold Ganz, MD for Recommendations to Reduce Risk of Nerve Injury During Bernese Periacetabular Osteotomy (PAO).
The recipients of the best Key Procedures video award were Jorge Chahla, MD; Gilbert Moatshe, MD; Lars Engebretsen, MD, PhD; and Robert F. LaPrade, MD, PhD for Anatomic Double-Bundle Posterior Cruciate Ligament Reconstruction.
Periacetabular Osteotomy Yields Good Midterm Outcomes for Patients with Down Syndrome and Hip Dysplasia
The treatment of hip dysplasia in patients with Down syndrome is challenging. Until the March 7, 2018 issue of JBJS, only short-term results from periacetabular osteotomies (PAOs) for treating hip dysplasia in this population had been reported. Now, Maranho et al. review the outcomes among 19 patients (26 hips) who underwent PAOs at Boston Children’s Hospital over 20 years, with an average follow up of 13.1 years.
Defining a “failed PAO” as a postoperative Harris Hip Score (HHS) <60 or a recommendation for a total hip arthroplasty or arthrodesis, the authors demonstrated the following key findings:
- There were significant improvements in all radiographic parameters after the PAOs were performed.
- More than 60% of the patients at their last follow up retained a good or excellent outcome from the procedure (HHS >80).
- The authors found a 36% increase in the odds of failure for every one-year increase in patient age at the time of the PAO and a 17-fold increase in the odds of failure when a patient had Tonnis grade-2 arthritis at the time of PAO, compared to patients with Tonnis grades 0 or 1.
These findings seem to indicate that younger, less arthritic patients with Down syndrome can expect to have reliable outcomes following a PAO. This is encouraging, as it may help those patients maintain independent living by decreasing their arthritis progression and increasing the stability of their hips. Even though the factors most associated with PAO failure are beyond the surgeon’s control, this data should facilitate focused discussions among surgeons, patients, and their parents or guardians about expected outcomes in these situations.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
The 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.”
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.