Whats New in Pediatric Orthopaedics

Kelly, Derek M. MD; Weiss, Jennifer M. MD; Martus, Jeffrey E. MD

Journal of Bone & Joint Surgery - American Volume:
doi: 10.2106/JBJS.16.01192
Specialty Update
Disclosures
Author Information

1Campbell Clinic, Department of Orthopaedic Surgery and Biomechanical Engineering, University of Tennessee, Memphis, Tennessee

2Division of Orthopedic Surgery, Southern California Kaiser Permanente Medical Group, Los Angeles, California

3Division of Pediatric Orthopaedics, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee

E-mail address for D.M. Kelly: dkelly@campbellclinic.com

Article Outline

The past year saw a large number of high-quality studies in the field of pediatric orthopaedics. Talented researchers and authors continue to investigate and report on all subspecialty areas of pediatric orthopaedics. The studies summarized in this article, and the myriad of others for which we did not have space, are sure to have an important impact on the lives and health of children with musculoskeletal conditions.

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Trauma

Topics of interest in general pediatric orthopaedic trauma include traumatic pediatric amputations. Borne et al. examined the National Trauma Data Bank from 2007 to 2011 and identified 2,238 patients who had undergone amputations. Male patients were represented 3 times more often than female patients. Fingers (54%) and toes (20%) were the most common locations of amputation. Despite increased public awareness, lawnmower injuries continue to commonly occur among children ≤5 years of age1.

Loftis et al. reported on orthopaedic trauma related to motor vehicle accidents. They reviewed the records of 967 patients ≤12 years of age who sustained injuries in motor vehicle accidents and found that unrestrained passengers (most commonly older children) were more likely to sustain internal thoracic injuries, open head wounds, and open upper-extremity wounds2.

Although the application of a cast is the most frequent method of treatment of fractures in children, it is not always benign; cast removal often is associated with skin complications. Provider education and the use of additional padding during the application of a cast have been shown to reduce rates of cast removal complications. A retrospective review found that cast-related skin events were identified at a rate of 13.6 per 1,000 casts before an intervention of provider education and the use of extra padding3. After the intervention, the rate decreased to 6.6 per 1,000 casts. The use of safety strips is another strategy to decrease cast removal complications. Stork et al. compared cast removal in pediatric models with and without safety strips (those commonly used in waterproof casting). Both experienced and nonexperienced health-care providers demonstrated fewer simulated cast saw injuries with the incorporation of the safety strips, suggesting that the incorporation of safety strips into casts may decrease the risk of cast removal injuries. Additional study is planned in a clinical setting4.

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Upper-Extremity Trauma

The use of splinting as a safe and preferred alternative to casting in the treatment of distal radial buckle fractures continues to be supported by recent literature. A systematic review of 8 randomized prospective studies in which splinting was compared with casting in the treatment of such fractures confirmed that splinting was superior in terms of function, cost, and convenience, without an increased rate of complications5.

Refracture was linked to residual angulation of >15° in a retrospective review of 2,590 forearm fractures, suggesting that longer immobilization might benefit fractures with greater angulation6.

The diagnosis and management of pediatric elbow fractures received substantial attention over the past year. Ryan et al. confirmed that the anterior humeral line bisects the capitellum on a lateral radiograph of the elbow in children ≥5 years of age; however, in one-third of younger children, the anterior humeral line is in the anterior third of the capitellum7. The Appropriate Use Criteria (AUC) developed by the American Academy of Orthopaedic Surgeons (AAOS) for the treatment of supracondylar humeral fractures were validated in a retrospective study to determine the appropriateness of treatment8. Of 94 cases, 84 were deemed “appropriate,” 9 were “maybe appropriate,” and 1 was “rarely appropriate.” Surprisingly, open supracondylar humeral fractures were shown to have clinical and radiographic results similar to those of closed fractures9.

Screw fixation was found in 2 studies to be superior to Kirschner-wire fixation in the treatment of lateral condylar fractures. In a biomechanical study, Schlitz et al. found that screw fixation provided superior stability compared with the use of Kirschner wires10. In a retrospective review, Gilbert et al. found that 3 of 43 patients treated with the use of Kirschner wires had delayed union, while the 41 patients treated with screw fixation had no delayed union, less time in a cast, and better range of motion11. When Kirschner-wire fixation is used, Ormsby et al. recommended leaving the wires unburied; of 60 buried wires, there was a 40% rate of subsequent infection12.

Ersen et al. conducted a prospective randomized study comparing the use of arm slings to figure-of-8 bandages in the treatment of clavicular fractures in 60 patients ranging in age from 15 to 75 years13. Figure-of-8 bandages were more difficult to apply, and pain was greater in the group with this method of immobilization.

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Lower-Extremity Trauma

Femoral neck fractures were revisited in 2016 with respect to risk factors for osteonecrosis and other complications. Spence et al. retrospectively reviewed the cases of 70 patients treated for femoral neck fractures and found a 29% rate of osteonecrosis14. Risk factors were fracture displacement and location. Among 58 patients with femoral neck fractures, Ju et al. found that patients treated >24 hours after injury had a better outcome after anatomical reduction and internal fixation than did those who had closed reduction and screw fixation with “acceptable” alignment, suggesting that reduction and exposing the fracture site might be more important than the timing of surgery15.

A pediatric femoral fracture update examined the impact of the 2009 AAOS clinical practice guideline on the treatment of pediatric diaphyseal femoral fractures16. A review of the treatment of 361 pediatric femoral fractures from 2007 to 2012 revealed that the guideline did not have much impact on the treatment algorithm in a pediatric hospital. In a study comparing the all-lateral (AL) entry technique with the medial-lateral (ML) entry technique for retrograde flexible intramedullary nailing of femoral fractures, no significant differences were found in shortening, healing, or the need for implant removal17. Malunions were more common with the ML technique, while healing in >10° of valgus was more common with use of the AL entry technique. The surgical time was 30 minutes less with use of the AL technique.

Tibial spine fractures were studied retrospectively by Edmonds et al., who noted that advanced imaging such as computed tomography (CT) may not be necessary to delineate displacement in such fractures18. Arthroscopic and open reduction resulted in a lower risk of future surgery compared with reduction and cast application, although arthrofibrosis was more common among the patients treated with surgery.

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Sports

Overuse injuries in children and adolescents continue to command attention. Bell et al. found that high-school athletes who specialized early reported more overuse injuries19. Athletes in a large school were more likely to specialize, train in a single sport >8 months per year, and report more knee injuries and overuse injuries. Injury prevention, with regard to both sports injury and overuse, continues to be recommended. A meta-analysis of injury-prevention programs found that injury rates were reduced when such programs were implemented and that these reductions were significant compared with the injury rate of control groups without injury-prevention programs20. In a prospective randomized study of 15 and 16-year-old female football (soccer) and handball players, Zebis et al. found that a 12-week injury-prevention program altered the pattern of agonist-antagonist muscle preactivity during the maneuver of side-cutting21.

In a systematic review of studies reporting on anterior cruciate ligament (ACL) reconstruction in patients with open physes, Collins et al. identified 16 cases of angular malformations and 29 cases of limb-length discrepancies22. Genu valgum was the most common deformity (13 patients, 81%). Physeal-sparing techniques were used in 25% of the patients with angular malformations and in 47% of the patients with limb-length discrepancy. Gornitzky et al. conducted a meta-analysis to determine the incidence and yearly risk of ACL tears in high-school athletes by sex and by sport23. Girls were 1.6 times more likely to sustain an ACL tear than were boys, and the highest risk sports were soccer, football, basketball, and lacrosse. A population-based cohort of adolescents was studied by Johnsen et al., who reported that participation in competitive sports significantly increased the risk of an ACL tear24. Competitive female athletes carried 5 times the risk of tearing an ACL compared with their noncompetitive female counterparts, and competitive male athletes carried 4 times the risk of their counterparts.

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Spine

Brace wear remains an integral part of the management of adolescent idiopathic scoliosis. Karol et al. demonstrated that physician counseling based on compliance monitoring data improved patients’ average daily orthotic use25. Schwieger et al. analyzed data from the Bracing in Adolescent Idiopathic Scoliosis Trial and found that, in comparison with results for patients who were observed only, brace treatment did not negatively impact body image or quality of life as measured by the Spinal Appearance Questionnaire and the Pediatric Quality of Life Inventory26.

Posterior vertebral column resection (PVCR) is a powerful but high-risk procedure for severe spinal deformity. In an effort to quantify the higher risk associated with sharp, angulated deformities, Wang et al. described the total deformity angular ratio (T-DAR), which is calculated from the summation of the maximum Cobb measurement divided by the number of vertebrae involved in both the coronal (C-DAR) and sagittal (S-DAR) planes27. These ratios were evaluated in a series of 202 adult and pediatric patients with spinal deformity who had PVCR; 4.0% developed a new neurologic deficit postoperatively. A high T-DAR (≥25) or S-DAR (≥15) correlated with a substantially higher risk of intraoperative spinal cord monitoring events and new neurologic deficits.

Recently, many spinal deformity centers have implemented rapid recovery pathways for the surgical treatment of idiopathic scoliosis in an effort to minimize the length of stay. Muhly et al. reported that a standardized pathway with multimodal pain management and early mobilization reduced the length of stay without an increase in pain scores or readmission rates28. Rao et al. described preoperative plan-of-care education combined with a refined postoperative care protocol that was associated with reductions in the time to sitting and the time to discharge while increasing patient satisfaction29. Sanders et al. noted that an accelerated discharge protocol led to a reduction in the average length of stay from 5.0 to 3.7 days, with a 22% decrease in postoperative hospital charges30.

Management of early onset scoliosis (EOS) remains challenging. Choi et al. performed a multicenter retrospective review of patients with EOS treated with magnetically controlled growing rods and noted a lower infection rate compared with that for traditional growing rods; however, the rates of implant-related complications were similar31. McCarthy and McCullough described the results of EOS treatment with the Shilla growth-guidance technique at a minimum 5-year follow-up and found favorable curve correction, spinal growth, and sagittal alignment despite a high complication rate32. When compared with a traditional growing-rod strategy, a 73% reduction in the overall number of operative procedures was estimated.

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Hand and Upper Extremity

The Oberg, Manske, and Tonkin (OMT) classification of congenital hand and upper-extremity anomalies was approved by the International Federation of Societies for Surgery of the Hand (IFSSH) in 201433. This classification system stratifies congenital differences as “malformations,” “deformations,” “dysplasias,” and “syndromes.” Bae et al. studied the reliability of the OMT classification among a randomly selected cohort from the prospective, multicenter Congenital Upper Limb Differences registry34. Substantial agreement was shown with respect to the interobserver reliability, and almost perfect agreement among 4 pediatric hand surgeons from different institutions was demonstrated for the intraobserver reliability.

Most children with congenital radioulnar synostosis have minimal functional impairment and do not require surgical intervention; however, those with bilateral involvement or hyperpronation (>60°) may benefit from a derotational osteotomy of the forearm. Simcock et al. described the results of 31 forearm derotational osteotomies performed at the level of the synostosis35. The surgical technique was standardized and included prophylactic forearm fasciotomies. The complication rate was 12%, but compartment syndrome, dysvascularity, nonunion, and loss of fixation did not occur. Hwang et al. described an alternative osteotomy technique (involving the proximal third of the ulna and the distal third of the radius) for congenital radioulnar synostosis, with or without intramedullary fixation of the ulna36. Major complications were not noted, but mild angular deformity was present in some patients.

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Musculoskeletal Infection

Failure to properly diagnose and treat septic arthritis is a potential source of severe morbidity in children. In regions endemic to Lyme disease, differentiating between septic arthritis and Lyme disease is challenging because of overlapping clinical and radiographic features. Baldwin et al. reviewed the records of 189 patients who presented with a knee effusion and were ultimately diagnosed with either septic arthritis (positive culture or synovial white blood-cell count of >60,000 cells/mm3) or Lyme disease (positive Lyme immunoglobulin G on Western blot analysis)37. Independent predictive factors for septic arthritis were an age of <2 years, a history of fever, C-reactive protein (CRP) of >4 mg/L, and knee pain with a short arc of motion.

One problem in the management of presumed pediatric musculoskeletal infections is the difficulty in identifying the causative organism. Carter et al. prospectively studied the use of polymerase chain reaction (PCR) to supplement the evaluation of children with septic arthritis and found that PCR identified bacterial presence in 20.6% of culture-negative cases38. However, the prolonged time from aspiration to PCR results (mean, 14.6 days) currently limits the usefulness of this test.

While most children with septic arthritis respond to a single operative drainage, some require multiple procedures. In a review of the medical records of 105 children treated operatively for septic arthritis, Telleria et al. identified risk factors for revision surgery, which included delayed diagnosis, bacteremia at presentation, and marked CRP elevation at presentation or over the first 4 postoperative days39. These findings suggest that patients who may have failure of a single debridement can be identified and treated more aggressively. Adjacent infections may be one of the reasons for failure of an initial operative drainage. Rosenfeld et al. reviewed 87 patients with septic arthritis who were evaluated with the use of magnetic resonance imaging (MRI) and noted that 59% had adjacent foci of infection (osteomyelitis, subperiosteal abscess, or intramuscular abscess)40. An age of >3.6 years, CRP of >13.8 mg/L, symptom duration of >3 days, platelet count of <314 × 103 cells/μL, and absolute neutrophil count of >8.16 × 103 cells/μL were predictive of an adjacent infection.

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Hip

The 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 age41. The guideline was endorsed by the American Academy of Pediatrics (AAP), the Pediatric Orthopaedic Society of North America (POSNA), the Society for Pediatric Radiology (SPR), and the Society of Diagnostic Medical Sonography (SDMS). The strength of 2 recommendations was rated as “moderate” on the basis of evidence in the existing literature; universal ultrasound screening of all newborn infants is not supported, but imaging before the age of 6 months is supported if the infant has 1 of the following risk factors: breech presentation, family history, or history of clinical instability. Additional recommendations received only “limited” strength of support: the use of an anteroposterior radiograph instead of ultrasound after 4 months of age, use of ultrasound to guide the decision to treat an infant with a positive instability examination, repeat screening examination before 6 months of age in infants with a previously normal screening examination, observation without the use of a brace for infants with a normal examination but ultrasonographic abnormalities, immediate or delayed brace treatment for hips with positive instability examinations, use of the von Rosen splint over Pavlik, Craig, or Frejka splints for the initial treatment of an unstable hip, and periodic physical and ultrasonographic examinations during the management of unstable hips.

Overhead Bryant traction was studied to determine if open reduction rates and osteonecrosis rates could be lowered if traction was used preoperatively for children with DDH42. The retrospective investigation included 342 hips in children <3 years of age who were treated for DDH during a study period of nearly 30 years. Fixed dislocations and Ortolani-positive hips were both studied. Traction was used for 276 hips. Overhead Bryant traction offered no benefit for achieving successful closed reduction or lowering the osteonecrosis rate in the treatment of both types of dislocations.

Two studies related to slipped capital femoral epiphysis (SCFE) evaluated the use of intraoperative intracranial pressure (ICP) monitoring for unstable SCFE. Jackson et al. performed preoperative and postoperative superselective angiography of the medial femoral circumflex artery in a series of 9 patients with unstable SCFE undergoing open reduction through a modified Dunn approach43. The patients also had intraoperative ICP monitoring. Six of the patients had no arterial flow to the femoral head on a preoperative angiogram; 4 of those had restoration of flow on a postoperative angiogram. Five of the patients had intraoperative return of blood flow as assessed with ICP monitoring; however, 2 of the patients subsequently developed osteonecrosis, including 1 who had intraoperative evidence of blood flow based on ICP monitoring. The authors concluded that, while the presence of flow by ICP monitoring does not guarantee that osteonecrosis will not develop, the absence of flow was predictive of osteonecrosis. Schrader et al. studied the utility of intraoperative ICP monitoring in 23 patients (29 hips) treated with pinning for SCFE44. Fifteen of the hips were unstable. Their technique involved gentle closed reduction and the insertion of the ICP monitor through the canal of a 7.0-mm cannulated screw used to stabilize the hip. Six unstable hips had no perfusion by ICP monitoring, but blood flow was restored in all 6 with percutaneous capsular decompression. No osteonecrosis developed over the 2-year follow-up period.

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Neuromuscular Conditions

Two studies evaluated proximal femoral osteotomy for the treatment of children with cerebral palsy and hip deformity. Shore et al. looked at mid-term results (mean follow-up, 8.3 years) of 320 children (567 hips) treated with varus derotation osteotomy (VDRO). They found that older age, lower Gross Motor Functional Classification System (GMFCS) level, and increased surgeon surgical volume were predictors of improved surgical success, with survivorship defined by the need for a subsequent surgical procedure or a hip migration percentage of >50%45. Furthermore, they found that soft-tissue release at the time of VDRO was protective against revision surgery. In another study, femoral derotational osteotomy combined with multilevel soft-tissue procedures was performed in 93 patients with cerebral palsy (mean age, 6.2 years; 175 affected extremities)46. The ability of the procedures to improve femoral anteversion and maintain correction and gait improvement over time was evaluated by comparing preoperative findings and those of the last follow-up (average, 6.3 years) as assessed on clinical examination and through an analysis of gait. Internal and external hip ranges of motion were significantly improved, and gait analysis demonstrated the greatest gains in transverse plane hip rotation and foot progression angle.

The effect of botulinum toxin A (BTX) injections into the spinal muscles of patients with cerebral palsy and associated neuromuscular scoliosis was evaluated in a study conducted with a prospective, randomized, triple-blinded, cross-over design47. The BTX injections were compared with saline solution (NaCl), and were given at 6-month intervals under ultrasonographic guidance. Outcomes included radiographic parameters, quality-of-life outcome score, and results of a parental interview regarding the child’s well-being. Sixteen patients were included, but the study was terminated early when 1 patient developed pneumonia resulting in death. Underpowered data analysis demonstrated no radiographic or clinical benefits of BTX over NaCl.

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Clubfoot

The predictive value of pre-tenotomy radiographs was evaluated for a series of patients treated with the Ponseti method for clubfoot deformity48. Of all of the radiographic parameters studies, only limited dorsiflexion on a forced-dorsiflexion lateral radiograph was associated with an increased risk of recurrence; a cutoff of >15° past neutral was predictive of Ponseti success. Bocahut et al. reported their experience with clubfeet resistant to the physiotherapy method of treatment49. Over a 14-year period (1995 to 2009), they performed medial-to-posterior releases on 137 patients and followed the patients for a mean of 10.8 years. The undercorrection (11 feet) and overcorrection (17 feet) rates were low, and the mean International Clubfoot Study Group outcome score was good. The authors concluded that extensive soft-tissue release is a valuable option with stable results for those feet that do not respond to the physiotherapy method. In contrast, Alkar et al. found less favorable results with extensive soft-tissue release in patients with severe clubfoot50. They reviewed the records of 66 patients (105 feet) at an average follow-up of 22 years. Navicular necrosis was seen in 28 feet and subluxation, in 82 feet. The Ghanem-Seringe functional score revealed no excellent results, 19 good results, 16 fair results, and 70 poor results. Moderate osteoarthritis was seen in 32 feet. Despite these rather dismal functional and radiographic results, 92% of the patients were satisfied. Women were much less satisfied than men, and satisfaction seemed to be related to perceptions regarding gait, while dissatisfaction was related to calf atrophy.

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Evidence-Based Orthopaedics

The editorial staff of The Journal reviewed a large number of recently published research studies related to the musculoskeletal system that received a higher Level of Evidence grade. In addition to articles cited already in the Update, 10 other articles with a higher Level of Evidence grade were identified that were relevant to pediatric orthopaedics. A list of those titles is appended to this review after the standard bibliography. We have provided a brief commentary about each of the articles to help guide your further reading, in an evidence-based fashion, in this subspecialty area.

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Evidence-Based Articles Related to Pediatric Orthopaedics

Williams MA, Heine PJ, Williamson EM, Toye F, Dritsaki M, Petrou S, Crossman R, Lall R, Barker KL, Fairbank J, Harding I, Gardner A, Slowther AM, Coulson N, Lamb SE. Active Treatment for Idiopathic Adolescent Scoliosis (ACTIvATeS): a feasibility study. Health Technol Assess. 2015 Jul;19(55):1-242.

A group of U.K. researchers conducted a small study to determine the feasibility of a large-scale, multicenter study assessing the utility of scoliosis-specific exercises for the treatment of adolescent idiopathic scoliosis (AIS). They recruited 58 subjects, aged 10 to 16 years, with AIS curve magnitudes of <50°. The researchers determined that physician and patient participation was good, recruitment was more robust than anticipated (1.4 subjects/center/month), and the follow-up rate was acceptable (73%); however, adherence to the treatment protocols was variable (56%). They concluded that a definitive, randomized controlled trial evaluating the efficacy and cost-effectiveness of scoliosis-specific exercises for AIS was warranted and feasible.

Mills PB, Finlayson H, Sudol M, O’Connor R. Systematic review of adjunct therapies to improve outcomes following botulinum toxin injection for treatment of limb spasticity. Clin Rehabil. 2016 Jun;30(6):537-48. Epub 2015 Jul 21.

A systematic review of 17 randomized controlled trials evaluated adjunct therapies after botulinum toxin injection for the treatment of spasticity. The use of electrical stimulation, modified constraint-induced movement therapy, physiotherapy, casting, and splinting all showed benefit; the use of taping, segmental muscle vibration, cyclic functional electrical stimulation, and a motorized arm ergometer showed no improvement over toxin alone. None of these findings have been replicated in follow-up studies, and all interventions would benefit from further investigation of high-quality research design.

Sitoula P, Verma K, Holmes L Jr, Gabos PG, Sanders JO, Yorgova P, Neiss G, Rogers K, Shah SA. Prediction of curve progression in idiopathic scoliosis: validation of the Sanders Skeletal Maturity Staging System. Spine (Phila Pa 1976). 2015 Jul 1;40(13):1006-13.

This study sought to validate the use of the Sanders Skeletal Maturity Staging System as it pertains to AIS curve progression. The Sanders system is divided into 7 groups (Sanders stage [SS] 1 to 7) and is determined from hand radiographs obtained at the time of scoliosis imaging. One hundred and sixty-one patients with AIS were followed from diagnosis to skeletal maturity (fully capped Risser stage 4 or Risser stage 5) or spinal fusion. No curve progression was found in patients in group SS5, SS6, or SS7 with curves measuring <30°. All patients with curves of >40°, with the exception of those in group SS7, experienced progression. The researchers concluded that SS, combined with initial Cobb angle, has a strong predictive value for AIS curve progression.

Yeung DE, Jia X, Miller CA, Barker SL. Interventions for treating ankle fractures in children. Cochrane Database Syst Rev. 2016 Apr 01;4:CD010836.

This systematic review of the literature found only 3 studies that met the authors’ inclusion criteria. All 3 studies evaluated immobilization options for children with predominantly nondisplaced Salter-Harris type-I distal fibular fractures. Two of the studies compared the AirCast Air-Stirrup ankle brace and a rigid splint or cast, and the other study compared the Tubigrip bandage and a plaster cast. Functional outcome and return to play were slightly better with bracing, but the quality of evidence was poor. All 3 trials had a high risk of bias related to the inability to blind the clinicians or participants. Furthermore, a recent study involving MRI assessment of low-energy pediatric ankle fractures determined that these injuries are more often soft-tissue trauma (sprains) than actual fractures.

Abdel Karim M, Hosny A, Nasef Abdelatif NM, Hegazy MM, Awadallah WR, Khaled SA, Azab MA, A ElNahal W, Mohammady H. Crossed wires versus 2 lateral wires in management of supracondylar fracture of the humerus in children in the hands of junior trainees. J Orthop Trauma. 2016 Apr;30(4):e123-8.

In this randomized controlled trial, the researchers evaluated 60 consecutive patients (mean age of 5.1 years) with displaced supracondylar humeral fractures. All 60 patients were treated surgically by junior-level trainees (first 3 years of training) and were randomized to undergo either crossed Kirschner-wire fixation or lateral-only Kirschner-wire fixation. The lateral-wire-only group had a significantly higher rate of loss of reduction (20%) than did the crossed-wire group (0%) (p = 0.031). Furthermore, the only ulnar neurapraxia in the study occurred in the lateral-wire-only group. The authors concluded that crossed-wire fixation was more stable than lateral-wire-only fixation when performed by junior-level orthopaedic trainees.

Wiig O, Huhnstock S, Terjesen T, Pripp AH, Svenningsen S. The outcome and prognostic factors in children with bilateral Perthes’ disease: a prospective study of 40 children with follow-up over five years. Bone Joint J. 2016 Apr;98-B(4):569-75.

This study looked at a subset of patients from the Norwegian database for Legg-Calvé-Perthes disease. Forty children (mean age, 5.9 years) treated nonoperatively for bilateral Legg-Calvé-Perthes disease were followed for 5 years. Twenty-three had concurrent disease, while 17 developed sequential disease of the contralateral hip (mean delay, 1.9 years). Outcome was based primarily on the modified Stulberg classification (spherical head, good; oval head, fair; and flattened head, poor). The strongest predictors of a poor outcome were >50% necrosis, an age of >6 years at diagnosis, and sequential, rather than concurrent, disease. From the larger database, the authors concluded that Legg-Calvé-Perthes disease carries a 5% risk of contralateral disease. Furthermore, they concluded that sequential-onset Legg-Calvé-Perthes disease carries a worse prognosis than concurrent bilateral disease or unilateral disease.

Wiegerinck JI, Zwiers R, Sierevelt IN, van Weert HC, van Dijk CN, Struijs PA. Treatment of calcaneal apophysitis: wait and see versus orthotic device versus physical therapy: a pragmatic therapeutic randomized clinical trial. J Pediatr Orthop. 2016 Mar;36(2):152-7.

A prospective, single-blinded therapeutic trial involving 101 children with a diagnosis of calcaneal apophysitis (Sever disease) compared 3 treatment methods: “wait and see,” heel-raise inlay, and physiotherapy-supervised eccentric exercise regimen. Outcome measures included the Faces scale, the Oxford Ankle Foot Questionnaire (OAFQ), and patient satisfaction. Subjects were evaluated at 6 weeks and 3 months. The heel-insert group had higher OAFQ scores among the children at 6 weeks than did the wait-and-see group, while the physiotherapy group did better according to the OAFQ parents’ version than did the wait-and-see group. All treatment modalities, including wait and see, demonstrated improvement over baseline at the time of final follow-up, but no significant difference was identified among the three methods.

Dulai SK, Firth K, Al-Mansoori K, Cave D, Kemp KA, Silveira A, Saraswat MK, Beaupre LA. Does topical anesthetic reduce pain during intraosseous pin removal in children? A randomized controlled trial. J Pediatr Orthop. 2016 Mar;36(2):126-31.

Pin removal is a common but not entirely benign procedure in pediatric orthopaedic clinics. In the hope of identifying a method to decrease pain, a triple-blinded, randomized study examined the use of topical liposomal lidocaine in the removal of intraosseous pins in 281 subjects. The use of topical analgesia showed no benefit in pain reduction. The removal of pins was confirmed to be a painful procedure for children.

Theologis AA, Anaya A, Sabatini C, Sucato DJ, Parent S, Erickson M, Diab M. Surgical consent of children and guardians for the treatment of adolescent idiopathic scoliosis is incompletely informed. Spine (Phila Pa 1976). 2016 Jan;41(1):53-61.

Informed consent is critical so that patients and caregivers have a thorough understanding of risks, benefits, and expected outcomes of spinal deformity correction. In a prospective multicenter study, the authors evaluated the comprehension of patients with AIS and their guardians following informed consent and found that only approximately 60% of the surgical consent information was understood. The authors noted that comprehension may be improved by preoperative multimodal teaching techniques and “peer-support groups.”

Helenius I, Keskinen H, Syvänen J, Lukkarinen H, Mattila M, Välipakka J, Pajulo O. Gelatine matrix with human thrombin decreases blood loss in adolescents undergoing posterior spinal fusion for idiopathic scoliosis. Bone Joint J. 2016 Feb 26;98-B(3):395-401.

This prospective randomized trial evaluated gelatin matrix with human thrombin in addition to conventional methods of hemostasis for patients undergoing posterior spinal fusion for AIS. In comparison with conventional methods alone, the use of gelatin matrix with human thrombin significantly reduced intraoperative blood loss, drain output, and the magnitude of hemoglobin concentration change from preoperative to the second postoperative day. Additionally, it was noted that for each pedicle instrumented, the postoperative hemoglobin level was decreased by 0.26 g/dL.

Specialty Update has been developed in collaboration with the Board of Specialty Societies (BOS) of the American Academy of Orthopaedic Surgeons.

Disclosure: The authors received a stipend for this work from JBJS; the authors donated this stipend to the Pediatric Orthopaedic Society of North America (POSNA). The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/A16).

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References

1. Borne A, Porter A, Recicar J, Maxson T, Montgomery C. Pediatric traumatic amputations in the United States: a 5-year review. J Pediatr Orthop. 2015 . [Epub ahead of print].
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8. Ibrahim T, Hegazy A, Abulhail SI, Ghomrawi HM. Utility of the AAOS Appropriate Use Criteria (AUC) for pediatric supracondylar humerus fractures in clinical practice. J Pediatr Orthop. 2015 . [Epub ahead of print].
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