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What’s New in Pediatric Orthopaedics

2024; Wolters Kluwer; Linguagem: Inglês

10.2106/jbjs.24.01272

1535-1386

Christina K. Hardesty, Jochen P. Son-Hing, Allison Gilmore, Katharine Hollnagel,

Shoulder and Clavicle Injuries

This Guest Editorial presents a collection of noteworthy studies published recently, in general and subspecialty journals, mostly between October 2023 and September 2024. Preference was given to studies with a higher Level of Evidence. Trauma Shoulder and Elbow Fractures Two studies showed equivalent outcomes in comminuted clavicular fractures as well as displaced proximal humeral fractures treated nonoperatively1,2. Another study showed similar outcomes in adolescents 10 to 16 years of age with displaced proximal humeral fractures treated in situ compared with closed reduction3. One study showed that patients with nonemergency supracondylar humeral fractures who were transferred between facilities by privately owned vehicles and those who were transferred by ground ambulance had similar complication rates4. A systematic review with 1,446 patients showed that patients who underwent nonoperative treatment of type-II supracondylar humeral fractures had higher rates of residual sagittal deformity and need for a subsequent surgical procedure, although there were similar functional outcomes and patient satisfaction5. Two studies emphasized the difficulty in analyzing pediatric elbow radiographs because of anatomic variability and patient positioning, with 1 study recommending using the humeral shaft rather than the distal humerus to gauge the anterior humeral line6,7. In another study, Miller et al. recommended using the modified Jakob classification for lateral condyle humeral fractures, touting excellent interrater reliability; arthrography changed the treatment plan in only 8% of cases8. In another study on lateral condyle humeral fractures, Tippabhatla et al. identified increased age, concomitant elbow dislocation, and treatment with open reduction as risk factors for postoperative stiffness9. In a study on medial epicondyle humeral fractures, screws >4.0 mm in diameter and the use of a washer were associated with higher rates of symptoms prompting implant removal10. Forearm Fractures One investigation demonstrated an 88.7% success rate and no infections with closed reduction for type-I open both-bone forearm fractures; there are increased odds of failure for every standard deviation (0.7) increase in the cast index and post-reduction radial translation of 25% on the anteroposterior radiograph11. Another study examining refractures following operative treatment of 402 both-bone forearm fractures showed a 5.5% rate, with higher rates in patients ≤10 years of age, in single-bone fixation with an intramedullary device, and when the radius was treated nonoperatively12. Lower-Extremity Injuries Fractures and dislocations around the hip continue to be challenging. At a minimum follow-up of 6 years, in a study of Delbet II and III femoral neck fractures, Haider et al. did not find any significant difference between proximal femoral locking plates and cannulated screws with regard to union rates, osteonecrosis, or secondary surgery, although the articulotrochanteric distance was decreased in the cannulated screw group13. A systematic review with 575 patients showed that dislocations were most commonly posterior and most commonly treated with closed reduction; osteonecrosis was the most common long-term adverse event, and the most common associated injuries were labral and capsular injuries (14.0%) and acetabular fractures (9.4%)14. A randomized controlled trial of femoral fractures in children between 2 and 6 years of age showed single-limb and one-and-a-half hip spica cast treatment groups to have comparable functional and radiographic outcomes, with higher parental satisfaction and lower skin pressure ulcer rates in the single-limb hip spica cast group15. Several studies have expanded our knowledge of tibial tubercle fractures. Milner et al. found that there was a significantly higher incidence of these fractures in patients with Osgood-Schlatter disease compared with a control group at all time points, particularly at 1 month following the diagnosis16. Patients with these fractures also had 15 times greater odds of having been receiving recombinant human growth hormone therapy at the time of the injury, compared with a matched control group with midshaft tibial fractures17. Two other studies showed that the rates of acute compartment syndrome in these fractures were much lower than previously reported, suggesting that prophylactic fasciotomy and admission for monitoring may not be warranted18,19. Sheth et al. identified 3 common distal tibial physeal fracture patterns, suggesting an ability to optimize the screw trajectory in the axial plane with intraoperative fluoroscopy20. Onay et al. found that closed reduction and percutaneous fixation of distal tibial physeal fractures, compared with anatomic reduction and open techniques, could provide satisfactory intermediate-term to long-term functional outcomes without increasing complications21. Zimmerman et al. examined the practice of removing epiphyseal screws, due to potentially increased contact forces on the tibiotalar joint, and found that, at a minimum 2-year postoperative follow-up, patients with retained epiphyseal implants had similar functional outcomes to patients who had the implants removed22. Infection Magnetic resonance imaging (MRI) is the gold standard for the diagnosis of acute pediatric musculoskeletal infections, which may be easier with rapid MRI protocols without contrast and anesthesia. A study implementing such a protocol in 18-month-old to 18-year-old patients undergoing workup for acute pediatric musculoskeletal infections showed improved time to imaging, duration of imaging, and interpretation time with an approximately 10% rescan rate. These patients had a shorter hospital stay and decreased charges for their visit23. Although the Kocher-Caird criteria have been widely used to diagnose septic arthritis in children, Valisena et al. concluded that they may not be fully adequate in the current clinical environment with the increasing prevalence of Kingella kingae24. Because patients with Kingella septic arthritis often present with milder symptoms and lower inflammatory marker laboratory values, children infected with K. kingae may not meet all of the Kocher-Caird criteria, which may lead to an underdiagnosis or misdiagnosis. Furthermore, Kingella cultures are better diagnosed with nucleic acid amplification assays. In a retrospective review of 135 children with septic arthritis, Moore-Lotridge et al. looked at the preoperative to postoperative change in C-reactive protein (CRP) at postoperative day 2 as an indicator of next steps in care25. There was a 22% increased risk of escalated care for each 10-unit increase in preoperative or postoperative CRP. Patients with a preoperative CRP of >90 mg/L and a postoperative day 2 elevation had markedly greater length of hospital stay and adverse outcomes. Lower Extremity Clubfoot How do patients with idiopathic clubfoot treated with Ponseti casting compare with their peers with regard to gross motor skills at 3 years of age? Rice et al. found that approximately 50% of their patients scored below the 25th percentile, with approximately one-quarter of patients scoring below the 10th percentile26. Factors associated with low gross motor scores were the need for repeat percutaneous heel cord tenotomy and poor compliance with bracing; bracing compliance reduced the odds of being below the 25th percentile by 80%. Limb Deformity and Reconstruction When comparing Kirschner wire with plate fixation for calcaneal lengthening osteotomies in flexible flatfoot, Tippabhatla et al. found that both methods were equivalent in terms of correction achieved, duration of casting, time to healing, and clinical outcome scores at the final follow-up, but the plate group experienced higher rates of complications and of reoperation due to pain caused by implants27. A study of distraction osteogenesis in a goat model found that reverse dynamization, using modular struts during the distraction phase followed by rigid fixation during the consolidation phase, resulted in earlier formation of regenerate bone compared with static fixation and demonstrated a more mature regenerate28. Two studies of the sleeper plate technique identified continued concerns. A retrospective study compared 25 patients treated with a sleeper plate with 47 patients treated with complete removal and found that 48.5% of patients in the sleeper group maintained the correction compared with 72.2% of patients in the removal group, and 17.3% of the patients with sleeper plates experienced tethering29. Another retrospective study evaluated the sleeper plate technique in 13 patients (19 knees) with multiple hereditary exostosis who underwent tibial or femoral hemiepiphysiodesis30. All patients with tibial sleeper plates developed osseous ingrowth into the empty screw hole leading to tethering and overcorrection, indicating that sleeper plates should not be used in multiple hereditary exostosis. Neuromuscular Disorders A long-term follow-up study investigating hip displacement in children with cerebral palsy following selective dorsal rhizotomy found that the rate of displacement, when evaluated by the Gross Motor Function Classification System (GMFCS), was consistent with that reported in published population studies31. Selective dorsal rhizotomy did not positively or negatively affect hip displacement when reviewed 5 years after the procedure, and the GMFCS level was still the most predictive factor of hip pathology. Kiapekos et al. had a 5-year follow-up study of children who underwent either a proximal femoral osteotomy alone or proximal femoral osteotomy combined with a pelvic osteotomy32. Despite having a higher preoperative migration percentage, the combined procedure group had a lower rate of failure (migration percentage of >50%). For hips that have already dislocated, the McHale procedure has been described for salvage. In a study of 65 hips (52 patients), a significant reduction in pain was noted along with improvements in personal hygiene and quality of life33. Despite a complication rate of 33.9%, >80% of caregivers would choose this procedure again or recommend the procedure to others. In a randomized study comparing functional electrical stimulation with traditional ankle-foot orthosis use, over one-half of the patients with hemiplegic cerebral palsy (13 of 25) chose to continue with functional electrical stimulation treatment, despite no significant improvement in ankle dorsiflexion or the participation domain of the Cerebral Palsy Quality of Life Questionnaire34. The authors emphasized the opportunity for a functional electrical stimulation trial when considering treatment strategies for patients with foot drop. Upper-extremity function in children with cerebral palsy was studied in a longitudinal fashion from the patient age of 18 months to 18 years to identify how hand function changes over time. Children had significant development at an early age, mainly before 2 years and 6 months of age, in the group classified as Manual Ability Classification System (MACS) level I35. The period of rapid development was somewhat longer for children in MACS level II (during the preschool period), and until the age of 7 years in MACS level III. The amount of hand function persisted until the age of 18 years, indicating the need for intensive motor training during the early preschool period. The landscape of treatment for children with spinal muscular atrophy has become a moving target since the introduction of disease-modifying agents, leaving us with gaps in the knowledge with regard to the new natural history of hips and spines. When nusinersen was administered in later childhood after the onset of symptoms, Kuong et al. found that 95% of hips subluxated or dislocated within 3 years36. Moreover, the Reimer migration index continued to deteriorate for most hips over time, indicating that muscle imbalance with weaker hip abductors persists despite some improvement in muscle power with nusinersen treatment. Hip Developmental Dysplasia of the Hip (DDH) Residual acetabular dysplasia (RAD) after treatment for DDH continues to be an important topic. Bavan et al. evaluated 305 patients treated with a Pavlik harness and found that 27% of hips had RAD at 2 years and 19% of hips had RAD at 4 years. Patients with RAD were in the harness longer and had a lower alpha angle at the conclusion of treatment37. For a minimum 4-year follow-up, Paranjape et al. examined 41 patients (46 hips) with a dislocated hip treated with a Pavlik harness38. At the final follow-up, 30% of hips had RAD. Of the hips with RAD, 93% had normal morphology at the conclusion of treatment. No differences were detected between groups with regard to age at presentation or time in the harness. Two retrospective studies evaluated the role of abduction bracing and the development of RAD after closed and open reduction39,40. In both studies, abduction bracing was not associated with decreased rates of RAD at 2 years and 4 years following reduction, but was associated with a lower rate of early secondary surgery. Legg-Calvé-Perthes Disease The treatment of residual deformity in Legg-Calvé-Perthes disease is challenging, with little known about intermediate and long-term outcomes. Of 51 patients who underwent surgical hip dislocation with relative femoral neck lengthening and femoral head-neck osteochondroplasty (minimum follow-up of 4 years), survival was 80% at 5 years and 66% at 10 years41. Factors associated with failure were preoperative pain and severity of the proximal deformity. Slipped Capital Femoral Epiphysis (SCFE) The timely diagnosis of SCFE, which helps to minimize the risk of associated complications, can be affected by socioeconomic determinants of health. In a retrospective study, Smith et al. evaluated 351 patients who underwent surgical treatment for SCFE42. In their cohort, 37% of patients had a delay in diagnosis of ≥12 weeks, with increased risk for patients with public insurance and those from single-family households. Although there are known risk factors for the development of SCFE, some of these associations are being revisited. A retrospective study of 65 patients with SCFE found that 32% had abnormal thyroid-stimulating hormone values at presentation, a rate much higher than previously reported43. Another study used a multi-institutional database to analyze risk factors for SCFE44. The incidence of SCFE in patients undergoing human growth hormone treatment was high and increased in a dose-dependent manner. Sports In a prospective study to assess for growth disturbance, Bolzinger et al. followed patients with a mean age of 13.2 years (range, 9 to 16 years) at the time of primary anterior cruciate ligament (ACL) reconstruction using semitendinosus autograft for 2 years45. Transphyseal fixation yielded a high rate of growth disturbances (leg-length discrepancy and axial deviation), although none was clinically relevant. The incidence of ACL injuries continues to rise in the adolescent population. In a study of patients ≤18 years of age (mean age, 16.1 ± 1.3 years [range, 13 to 18 years], regardless of the sport played) who underwent a primary ACL reconstruction between 2015 and 2020, Maheshwer et al.46 found that high school freshmen and seniors had an increased risk of ACL retear and that football (31.8%) and soccer (27.3%) were the most common sports played by patients with an ipsilateral retear. Patients who underwent hamstring autograft reconstruction had a higher incidence of retear compared with other graft types. Although allografts used for ACL reconstruction historically have demonstrated higher failure rates, 1 group showed that its use in patients who do not participate in competitive pivoting sports may bring the failure rate down to an acceptable level47. In a study of patients with bilateral patellar instability, Parikh and Rajdev evaluated the presence of and side-to-side differences in risk factors between knees48. Thirty-two patients with a mean age of 14.6 ± 2.3 years were included. The most common risk factors were trochlear dysplasia (92.1%) and patella alta (79.7%). The authors also noted that there was symmetry between paired knees for each anatomical risk factor, with no significant differences. Upper Extremity Children with neonatal brachial plexus palsy experience deficits but often have the potential for good outcomes, even with conservative management. In a cohort of 429 children, patients who received a referral to a multidisciplinary brachial plexus clinic within 30 days of birth had better overall recovery of active range of motion for shoulder abduction, forward flexion, external rotation, and forearm supination, with a reduced loss of active elbow extension range of motion49. Upper-extremity motion in children with brachial plexus palsy can now be assessed using a real-time 3-dimensional motion capture system50. As participants reach for targets, multiple aspects of their range of motion are measured simultaneously and can be compared with the opposite limb or compared with previous examinations in the same child. Children with hemiplegic cerebral palsy were also found to benefit from early intervention using the Hand-Arm Bimanual Intensive Therapy Including Lower Extremities (HABIT-ILE)51. In a randomized controlled trial of 50 children, significant improvements in bimanual motor function were found for the cohort who underwent HABIT-ILE, with even greater improvements seen in children who were 12 months at the initial evaluation. Spine Adolescent Idiopathic Scoliosis Research continues on techniques to obviate or decrease progression to a surgical procedure. Two studies on nighttime braces showed a high rate of brace adherence (98% at 3 months and 84% at discharge) and similar rates of surgical procedures to the Boston orthosis in the Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST)54,55. However, another study showed that 34% of patients had curves that continued to progress after brace cessation or weaning, and found limited information on risk factors, aside from larger curves, to predict progression56. A randomized, double-blinded, controlled trial of the ultrasound-guided bilateral and bilevel erector spinae plane block revealed lower Numerical Rating Scale scores for pain at all times after the surgical procedure, with lower intraoperative remifentanil and propofol, total opioid consumption, and incidence of nausea and/or vomiting, and without interference with neuromonitoring57. Another study examining intraoperative computed tomography-based navigation attempted to quantify iatrogenic cancer risk and advocated for radiation budgeting protocols and the development of lower-radiation technologies58. In terms of the preservation of motion segments, a study with mean follow-up of 6.7 ± 0.8 years suggested that selective thoracic fusion of Lenke 1C curves had an acceptable risk of adverse radiographic outcomes59. Another study cautioned that selective thoracic fusion in patients with double or triple major curves demonstrated only spontaneous coronal correction of the lumbar curve, without significant improvement in the sagittal and axial planes60. Early-Onset Scoliosis There are numerous difficulties when guiding patients to their presumptive definitive procedure. A Kaplan-Meier analysis showing a declining trend in complication rates with increasing age at the index surgical procedure led to a recommendation to delay growing rod treatment until >71 months of age61. With respect to proximal foundation failure in magnetically controlled growing rods (MCGR), upper instrumented vertebrae at T2 and T3 (compared with T4) and the use of all screws or screw-and-hook combinations (compared with all hooks) were associated with lower rates of an unplanned return to the operating room62. For Shilla-type systems, proximal junctional kyphosis was identified in 43% of patients postoperatively, and changes in sagittal balance, in either direction, were the strongest predictors for its development postoperatively63. In another study, McIntosh et al. found the rate of an unplanned return to the operating room after MCGR to be 38% after a mean of 2 years after implantation, and only 39% of the patients in the study had not had an unplanned return to the operating room at 5 years after the implantation64. When comparing the final 24-item Early Onset Scoliosis Questionnaire (EOSQ-24; a parent proxy questionnaire that assesses the health-related quality of life) with the Early Onset Scoliosis Self-Report Questionnaire (EOSQ-SELF; a novel, self-reported questionnaire that assesses health-related quality of life in older children and adolescents), the EOSQ-SELF group had significantly less favorable scores in the pain and discomfort, pulmonary function, and fatigue and energy-level domains, suggesting a disconnect between caregivers and patients65. In 834 patients with a minimum 2-year follow-up after graduation from growth-friendly surgery, the overall risk of revision was 13%, with 66% of those patients (71 of 108) having acute revisions (0 to 2 years from graduation), most commonly for infection (26 [37%] of 71)66. In a concerning finding, patients treated with titanium alloy growth-friendly implants (traditional growing rod, MCGR, and vertical expandable prosthetic titanium rib) had elevated serum titanium levels that persisted over time, with no evidence of renal excretion67. A retrospective database review of 2,355 patients with congenital early-onset scoliosis from the Pediatric Spine Study Group (PSSG) showed 107 patients who reported a symptom of back pain, with only 42 of those patients being evaluated with an MRI scan; underlying pathology was found on MRI in 21 (50%) of those 42 patients68. Motion-Sparing Surgery A Kaplan-Meier analysis of 208 patients from 10 centers who underwent thoracic anterior vertebral body tethering revealed a tether breakage incidence of 50% by 36 months postoperatively; such patients later required conversion to posterior spinal fusion significantly more often and had larger mean major coronal Cobb angles at the final follow-up, compared with those without identified tether breakage69. A study on 29 patients with a posterior dynamic distraction device showed measurable spinal motion over the construct in both the coronal and sagittal planes, without evidence of autofusion, at a mean of 1.9 years postoperatively; however, 11 patients (38%) had undergone reoperation, most commonly due to implant breakage (4 [14% of all 29 patients])70. Evaluating Skeletal Age and Maturity Assessing skeletal maturity continues to be a topic generating much research as we develop more procedures for which success is affected by a patient's stage of growth. Two studies described the modified Fels knee skeletal maturity system and the abbreviated Fels knee skeletal maturity system71,72. The first study established that the modified Fels system and the abbreviated Fels system appear to provide reliable, accurate, and rapid estimations of skeletal maturity, and the second study established high interrater reliability for use of the modified Fels system with a very short learning curve (7 cases). Another study sought to establish a bone age atlas that could be utilized with radiographs of the ankle, tibia, fibula, or hindfoot73. The distal tibial and fibular ossification centers provided the best age assessment for early childhood, and the calcaneal apophysis provided the best age assessment in the preadolescent stage. The closure of the distal tibial and fibular physes provided the most insight into skeletal maturity in adolescents. Evidence-Based Orthopaedics The editorial staff of JBJS reviewed a large number of recently published studies related to the musculoskeletal system that received a higher Level of Evidence grade. In addition to articles cited already in this update, 4 other articles relevant to pediatric orthopaedics are appended to this review after the standard bibliography, with a brief commentary about each article to help guide your further reading, in an evidence-based fashion, in this subspecialty area. Evidence-Based Orthopaedics Birch JG, Makarov MR, Jo CH. Ipsilateral healthy-segment response to leg length discrepancy. J Pediatr Orthop. 2024 Jan 1;44(1):e57-60. The fate of the ipsilateral healthy lower limb is unknown when children undergo treatment for a leg-length discrepancy. Of 209 patients who had unilateral shortening, the diagnoses included osteonecrosis, Legg-Calvé-Perthes disease, posteromedial bowing, distal femoral physeal injury, or tibial physeal injury. With rare exceptions, the ipsilateral healthy segment did not grow more than the contralateral segment for all diagnoses except for posteromedial bowing. This knowledge allows surgeons to plan interventions for both limbs as well as counsel patients and parents on expectations for limb development before and after surgery. Hsu CM, Sheu H, Lee WC, Kao HK, Yang WE, Chang CH. Soft tissue releases with simultaneous guided growth decrease risk of spastic hip displacement recurrence. J Pediatr Orthop. 2023 Oct 1;43(9):e707-12. In this study, children classified as GMFCS II to V and who had a migration percentage of >45% were treated with soft-tissue release with or without proximal femoral guided growth. The authors found that a postoperative change in the migration percentage of >5% in the second postoperative year correlated with a recurrence on displacement, defined as a migration percentage of ≥40%. Recurrence of hip displacement occurred in 44% of the 66 patients, and the use of guided growth decreased the risk of recurrence. Although this study did not have a natural history cohort for comparison, it contributes to a growing body of evidence that proximal femoral guided growth may be an effective way to help to prevent hip dislocation in some children with cerebral palsy. Lackey JT, Seiler PL, Lee BR, Sinclair MK. Clinically significant treatment delay in pediatric scaphoid fractures. J Hand Surg Am. 2024 Feb;49(2):108-13. What is the clinically important treatment delay that could predict casting failure in pediatric patients with a scaphoid fracture? This study found that children presenting ≥21 days after the injury had a 25% failure rate with casting alone compared with 3.6% for those who presented before 21 days. Although 75% of adolescents with delayed presentation healed with casting alone, this study allows orthopaedic surgeons to better counsel families on the risks of nonunion in scaphoid fractures. Trobisch PD, Kim HJ, Da Paz S, Chang DG. The efficacy of anterior vertebral body tethering in Lenke type 6 curves for adolescent idiopathic scoliosis. Eur Spine J. 2024 Jul;33(7):2696-703. As the indications and appropriate curves for tethering are explored, a group of European surgeons reported on the outcomes of tethering Lenke 6 curves. Thoracic and thoracolumbar or lumbar curves were tethered in 25 children and were followed for >2 years. The mean correction was 48.9% for the thoracic and thoracolumbar or lumbar curves at the 24-month follow-up, and was 48.3% for the thoracic curves. Tether breakage was noted in 22 patients and 3 of these required another vertebral body tethering, but the authors chose not to perform any posterior spinal fusion. Although still controversial, successful treatment of carefully chosen Lenke 6 curves was demonstrated by this group of authors. We can continue to explore the optimal use of tethers in light of the potential complications.