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C OPYRIGHT  2017 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED
Specialty Update
What’s New in Pediatric Orthopaedics
Derek M. Kelly, MD, Jennifer M. Weiss, MD, and Jeffrey E. Martus, MD
The past year saw a large number of high-quality studies in the
field of pediatric orthopaedics. Talented researchers and au-
thors 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.
Trauma
Topics of interest in general pediatric orthopaedic trauma in-
clude traumatic pediatric amputations. Borne et al. examined
the National Trauma Data Bank from 2007 to 2011 and iden-
tified 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 complica-
tions. 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 padding 3. After the intervention, the rate de-
creased to 6.6 per 1,000 casts. The use of safety strips is another
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).
J Bone Joint Surg Am. 2017;99:353-9 d http://dx.doi.org/10.2106/JBJS.16.01192
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 in-
corporation of the safety strips, suggesting that the incorpo-
ration of safety strips into casts may decrease the risk of cast
removal injuries. Additional study is planned in a clinical
setting4.
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 com-
pared 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 vali-
dated 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
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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.
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 intramed-
ullary 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 re-
duction 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.
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
W H AT ’ S N E W IN P E D I AT R I C O R T H O PA E D I C S
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-cutting 21.
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 mal-
formations 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 sport 23. 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 compet-
itive 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 counter-
parts, and competitive male athletes carried 4 times the risk
of their counterparts.
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 Inventory 26.
Posterior vertebral column resection (PVCR) is a pow-
erful 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 summa-
tion 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 defor-
mity who had PVCR; 4.0% developed a new neurologic deficit
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postoperatively. A high T-DAR (‡25) or S-DAR (‡15) corre-
lated with a substantially higher risk of intraoperative spinal
cord monitoring events and new neurologic deficits.
Recently, many spinal deformity centers have im-
plemented 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 sat-
isfaction29. 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 con-
trolled 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% re-
duction in the overall number of operative procedures was
estimated.
Hand and Upper Extremity
The Oberg, Manske, and Tonkin (OMT) classification of
congenital hand and upper-extremity anomalies was ap-
proved by the International Federation of Societies for Surgery
of the Hand (IFSSH) in 201433. This classification system
stratifies congenital differences as “malformations,” “defor-
mations,” “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 registry 34. 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 oste-
otomy 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 compli-
cation rate was 12%, but compartment syndrome, dysvascu-
W H AT ’ S N E W IN P E D I AT R I C O R T H O PA E D I C S
larity, 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 intra-
medullary fixation of the ulna36. Major complications were not
noted, but mild angular deformity was present in some
patients.
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 ar-
thritis 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 immu-
noglobulin 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 evalu-
ation 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 mag-
netic resonance imaging (MRI) and noted that 59% had ad-
jacent 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/mL, and absolute neutrophil count of
>8.16 · 103 cells/mL were predictive of an adjacent infection.
Hip
The AAOS published evidence-based guidelines on the detec-
tion and nonoperative management of developmental dyspla-
sia of the hip (DDH) in infants from birth to 6 months of age41.
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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 examina-
tion, repeat screening examination before 6 months of age in
infants with a previously normal screening examination, ob-
servation 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 intra-
operative 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 monitor-
ing. 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 osteone-
crosis. 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 in-
volved gentle closed reduction and the insertion of the ICP
W H AT ’ S N E W IN P E D I AT R I C O R T H O PA E D I C S
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.
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 an-
other 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 extrem-
ities)46. The ability of the procedures to improve femoral an-
teversion 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. In-
ternal 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.
Clubfoot
The predictive value of pre-tenotomy radiographs was evalu-
ated 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 re-
currence; 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
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a mean of 10.8 years. The undercorrection (11 feet) and
overcorrection (17 feet) rates were low, and the mean Inter-
national 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 sublux-
ation, in 82 feet. The Ghanem-Seringe functional score re-
vealed 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 re-
sults, 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.
Evidence-Based Orthopaedics
The editorial staff of The Journal reviewed a large number of
recently published research studies related to the musculo-
skeletal system that received a higher Level of Evidence grade.
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 Dec 2.
[Epub ahead of print].
2. Loftis CM, Sawyer JR, Eubanks JW 3rd, Kelly DM. The impact of child safety
restraint status and age in motor vehicle collisions in predicting type and severity
of bone fractures and traumatic injuries. J Pediatr Orthop. 2016 Jan 11. [Epub ahead
of print].
3. Difazio RL, Harris M, Feldman L, Mahan ST. Reducing the incidence of cast-
related skin complications in children treated with cast immobilization. J Pediatr
Orthop. 2015 Dec 17. [Epub ahead of print].
4. Stork NC, Lenhart RL, Nemeth BA, Noonan KJ, Halanski MA. To cast, to saw, and
not to injure: can safety strips decrease cast saw injuries? Clin Orthop Relat Res.
2016 Jul;474(7):1543-52. Epub 2016 Feb 4.
5. Hill CE, Masters JP, Perry DC. A systematic review of alternative splinting versus
complete plaster casts for the management of childhood buckle fractures of the
wrist. J Pediatr Orthop B. 2016 Mar;25(2):183-90.
6. van der Sluijs JA, Bron JL. Malunion of the distal radius in children: accurate
prediction of the expected remodeling. J Child Orthop. 2016 Jun;10(3):235-40. Epub
2016 May 20.
7. Ryan DD, Lightdale-Miric NR, Joiner ER, Wren TA, Spragg L, Heffernan MJ, Kay
RM, Skaggs DL. Variability of the anterior humeral line in normal pediatric elbows.
J Pediatr Orthop. 2016 Mar;36(2):e14-6.
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 Oct 30. [Epub ahead of print].
9. Lewine E, Kim JM, Miller PE, Waters PM, Mahan ST, Snyder B, Hedequist D, Bae
DS. Closed versus open supracondylar fractures of the humerus in children: a
comparison of clinical and radiographic presentation and results. J Pediatr Orthop.
2016 Apr 20. [Epub ahead of print].
10. Schlitz RS, Schwertz JM, Eberhardt AW, Gilbert SR. Biomechanical analysis of
screws versus K-wires for lateral humeral condyle fractures. J Pediatr Orthop. 2015
Dec;35(8):e93-7.
11. Gilbert SR, MacLennan PA, Schlitz RS, Estes AR. Screw versus pin fixation with
open reduction of pediatric lateral condyle fractures. J Pediatr Orthop B. 2016
Mar;25(2):148-52.
12. Ormsby NM, Walton RD, Robinson S, Brookes-Fazakerly S, Chang FY,
McGonagle L, Wright D. Buried versus unburied Kirschner wires in the management
W H AT ’ S N E W IN P E D I AT R I C O R T H O PA E D I C S
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.
Derek M. Kelly, MD1
Jennifer M. Weiss, MD2
Jeffrey E. Martus, MD3
1Campbell Clinic, Department of Orthopaedic Surgery and Biomechanical
Engineering, University of Tennessee, Memphis, Tennessee
2Divisionof Orthopedic Surgery, Southern California Kaiser Permanente
Medical Group, Los Angeles, California
3Divisionof Pediatric Orthopaedics, Monroe Carell Jr. Children’s Hospital
at Vanderbilt, Nashville, Tennessee
E-mail address for D.M. Kelly: dkelly@campbellclinic.com
of paediatric lateral condyle elbow fractures: a comparative study from a tertiary
centre. J Pediatr Orthop B. 2016 Jan;25(1):69-73.
13. Ersen A, Atalar AC, Birisik F, Saglam Y, Demirhan M. Comparison of simple arm
sling and figure of eight clavicular bandage for midshaft clavicular fractures: a
randomised controlled study. Bone Joint J. 2015 Nov;97-B(11):1562-5.
14. Spence D, DiMauro JP, Miller PE, Glotzbecker MP, Hedequist DJ, Shore BJ.
Osteonecrosis after femoral neck fractures in children and adolescents: analysis
of risk factors. J Pediatr Orthop. 2016 Mar;36(2):111-6.
15. Ju L, Jiang B, Lou Y, Zheng P. Delayed treatment of femoral neck fractures in
58 children: open reduction internal fixation versus closed reduction internal fixation.
J Pediatr Orthop B. 2016 Sep;25(5):459-65.
16. Oetgen ME, Blatz AM, Matthews A. Impact of clinical practice guideline on
the treatment of pediatric femoral fractures in a pediatric hospital. J Bone Joint
Surg Am. 2015 Oct 21;97(20):1641-6.
17. Cage JM, Black SR, Wimberly RL, Cook JB, Gheen WT, Jo C, Riccio AI. Two
techniques for retrograde flexible intramedullary fixation of pediatric femur fractures:
all-lateral entry versus medial and lateral entry point. J Pediatr Orthop. 2015 Oct 21.
[Epub ahead of print].
18. Edmonds EW, Fornari ED, Dashe J, Roocroft JH, King MM, Pennock AT.
Results of displaced pediatric tibial spine fractures: a comparison between
open, arthroscopic, and closed management. J Pediatr Orthop. 2015
Oct-Nov;35(7):651-6.
19. Bell DR, Post EG, Trigsted SM, Hetzel S, McGuine TA, Brooks MA. Prevalence of
sport specialization in high school athletics: a 1-year observational study. Am J
Sports Med. 2016 Jun;44(6):1469-74. Epub 2016 Feb 26.
20. Soomro N, Sanders R, Hackett D, Hubka T, Ebrahimi S, Freeston J, Cobley S.
The efficacy of injury prevention programs in adolescent team sports: a meta-
analysis. Am J Sports Med. 2016 Sep;44(9):2415-24. Epub 2015 Dec 16.
21. Zebis MK, Andersen LL, Brandt M, Myklebust G, Bencke J, Lauridsen HB,
Bandholm T, Thorborg K, Hölmich P, Aagaard P. Effects of evidence-based prevention
training on neuromuscular and biomechanical risk factors for ACL injury in
adolescent female athletes: a randomised controlled trial. Br J Sports Med. 2016
May;50(9):552-7. Epub 2015 Sep 23.
22. Collins MJ, Arns TA, Leroux T, Black A, Mascarenhas R, Bach BR Jr, Forsythe B.
Growth abnormalities following anterior cruciate ligament reconstruction in the
skeletally immature patient: a systematic review. Arthroscopy. 2016 Aug;32
(8):1714-23. Epub 2016 May 7.
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23. Gornitzky AL, Lott A, Yellin JL, Fabricant PD, Lawrence JT, Ganley TJ. Sport-
specific yearly risk and incidence of anterior cruciate ligament tears in high school
athletes: a systematic review and meta-analysis. Am J Sports Med. 2016 Oct;44
(10):2716-23. Epub 2015 Dec 11.
24. Johnsen MB, Guddal MH, Småstuen MC, Moksnes H, Engebretsen L, Storheim
K, Zwart JA. Sport participation and the risk of anterior cruciate ligament
reconstruction in adolescents: a population-based prospective cohort study (the
Young-HUNT study). Am J Sports Med. 2016 Apr 27. [Epub ahead of print].
25. Karol LA, Virostek D, Felton K, Wheeler L. Effect of compliance counseling on
brace use and success in patients with adolescent idiopathic scoliosis. J Bone Joint
Surg Am. 2016 Jan 6;98(1):9-14.
26. Schwieger T, Campo S, Weinstein SL, Dolan LA, Ashida S, Steuber KR. Body
image and quality-of-life in untreated versus brace-treated females with adolescent
idiopathic scoliosis. Spine (Phila Pa 1976). 2016 Feb;41(4):311-9.
27. Wang XB, Lenke LG, Thuet E, Blanke K, Koester LA, Roth M. Deformity angular
ratio describes the severity of spinal deformity and predicts the risk of neurologic
deficit in posterior vertebral column resection surgery. Spine (Phila Pa 1976). 2016
Sep 15;41(18):1447-55.
28. Muhly WT, Sankar WN, Ryan K, Norton A, Maxwell LG, DiMaggio T, Farrell S,
Hughes R, Gornitzky A, Keren R, McCloskey JJ, Flynn JM. Rapid recovery pathway
after spinal fusion for idiopathic scoliosis. Pediatrics. 2016 Apr;137(4):
e20151568. Epub 2016 Mar 23.
29. Rao RR, Hayes M, Lewis C, Hensinger RN, Farley FA, Li Y, Caird MS. Mapping the
road to recovery: shorter stays and satisfied patients in posterior spinal fusion.
J Pediatr Orthop. 2016 May 2. [Epub ahead of print].
30. Sanders A, Andras L, Sousa T, Kissinger C, Cucchiaro G, Skaggs DL.
Accelerated discharge protocol for posterior spinal fusion (PSF) patients with
adolescent idiopathic scoliosis (AIS) decreases hospital post-operative charges 22.
Spine (Phila Pa 1976). 2016 Apr 26. [Epub ahead of print].
31. Choi E, Yazsay B, Mundis G, Hosseini P, Pawelek J, Alanay A, Berk H, Cheung K,
Demirkiran G, Ferguson J, Greggi T, Helenius I, La Rosa G, Senkoylu A, Akbarnia BA.
Implant complications after magnetically controlled growing rods for early onset
scoliosis: a multicenter retrospective review. J Pediatr Orthop. 2016 Jun 18. [Epub
ahead of print].
32. McCarthy RE, McCullough FL. Shilla growth guidance for early-onset scoliosis:
results after a minimum of five years of follow-up. J Bone Joint Surg Am. 2015 Oct
7;97(19):1578-84.
33. IFSSH Scientific Committee on Congenital Conditions. Ezaki M, chair. Classifi-
cation of congenital hand and upper limb anomalies. Feb 2014. http://www.ifssh.
info/Congenital_Conditions2014.pdf. Accessed 2016 Oct 26.
34. Bae DS, Canizares MF, Miller PE, Roberts S, Vuillermin C, Wall LB, Waters PM,
Goldfarb CA. Intraobserver and interobserver reliability of the Oberg-Manske-Tonkin
(OMT) classification: establishing a registry on congenital upper limb differences.
J Pediatr Orthop. 2016 Feb 2. [Epub ahead of print].
35. Simcock X, Shah AS, Waters PM, Bae DS. Safety and efficacy of derotational
osteotomy for congenital radioulnar synostosis. J Pediatr Orthop. 2015 Dec;35
(8):838-43.
36. Hwang JH, Kim HW, Lee DH, Chung JH, Park H. One-stage rotational osteotomy
for congenital radioulnar synostosis. J Hand Surg Eur Vol. 2015 Oct;40(8):855-61.
Epub 2015 Mar 31.
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
W H AT ’ S N E W IN P E D I AT R I C O R T H O PA E D I C S
37. Baldwin KD, Brusalis CM, Nduaguba AM, Sankar WN. Predictive factors for
differentiating between septic arthritis and Lyme disease of the knee in children.
J Bone Joint Surg Am. 2016 May 4;98(9):721-8.
38. Carter K, Doern C, Jo CH, Copley LA. The clinical usefulness of polymerase chain
reaction as a supplemental diagnostic tool in the evaluation and the treatment of
children with septic arthritis. J Pediatr Orthop. 2016 Mar;36(2):167-72.
39. Telleria JJ, Cotter RA, Bompadre V, Steinman SE. Laboratory predictors for
risk of revision surgery in pediatric septic arthritis. J Child Orthop. 2016 Jun;10
(3):247-54. Epub 2016 May 12.
40. Rosenfeld S, Bernstein DT, Daram S, Dawson J, Zhang W. Predicting the
presence of adjacent infections in septic arthritis in children. J Pediatr Orthop. 2016
Jan;36(1):70-4.
41. Mulpuri K, Song KM, Gross RH, Tebor GB, Otsuka NY, Lubicky JP, Szalay EA,
Harcke HT, Zehr B, Spooner A, Campos-Outcalt D, Henningsen C, Jevsevar DS,
Goldberg M, Brox WT, Shea K, Bozic KJ, Shaffer W, Cummins D, Murray JN,
Mohiuddin M, Shores P, Woznica A, Martinez Y, Sevarino K. The American Academy
of Orthopaedic Surgeons evidence-based guideline on detection and nonoperative
management of pediatric developmental dysplasia of the hip in infants up to six
months of age. J Bone Joint Surg Am. 2015 Oct 21;97(20):1717-8.
42. Sucato DJ, De La Rocha A, Lau K, Ramo BA. Overhead Bryant’s traction does
not improve the success of closed reduction or limit AVN in developmental dysplasia
of the hip. J Pediatr Orthop. 2016 Apr 1. [Epub ahead of print].
43. Jackson JB 3rd, Frick SL, Brighton BK, Broadwell SR, Wang EA, Casey VF.
Restoration of blood flow to the proximal femoral epiphysis in unstable slipped
capital femoral epiphysis by modified Dunn procedure: a preliminary angiographic
and intracranial pressure monitoring study. J Pediatr Orthop. 2016 May 12. [Epub
ahead of print].
44. Schrader T, Jones CR, Kaufman AM, Herzog MM. Intraoperative monitoring of
epiphyseal perfusion in slipped capital femoral epiphysis. J Bone Joint Surg Am.
2016 Jun 15;98(12):1030-40.
45. Shore BJ, Zurakowski D, Dufreny C, Powell D, Matheney TH, Snyder BD.
Proximal femoral varus derotation osteotomy in children with cerebral palsy: the
effect of age, gross motor function classification system level, and surgeon volume
on surgical success. J Bone Joint Surg Am. 2015 Dec 16;97(24):2024-31.
46. Saglam Y, Ekin Akalan N, Temelli Y, Kuchimov S. Femoral derotation osteotomy
with multi-level soft tissue procedures in children with cerebral palsy: does it improve
gait quality? J Child Orthop. 2016 Feb;10(1):41-8. Epub 2015 Nov 23.
47. Wong C, Pedersen SA, Kristensen BB, Gosvig K, Sonne-Holm S. The effect of
botulinum toxin A injections in the spine muscles for cerebral palsy scoliosis,
examined in a prospective, randomized triple-blinded study. Spine (Phila Pa 1976).
2015 Dec;40(23):E1205-11.
48. O’Halloran CP, Halanski MA, Nemeth BA, Zimmermann CC, Noonan KJ. Can
radiographs predict outcome in patients with idiopathic clubfeet treated with the
Ponseti method? J Pediatr Orthop. 2015 Oct-Nov;35(7):734-8.
49. Bocahut N, Simon AL, Mazda K, Ilharreborde B, Souchet P. Medial to posterior
release procedure after failure of functional treatment in clubfoot: a prospective
study. J Child Orthop. 2016 Apr;10(2):109-17. Epub 2016 Mar 31.
50. Alkar F, Louahem D, Bonnet F, Patte K, Delpont M, Cottalorda J. Long-term
results after extensive soft tissue release in very severe congenital clubfeet.
J Pediatr Orthop. 2015 Dec 2. [Epub ahead of print].
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 ad-
junct 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
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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, expe-
rienced 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 con-
secutive 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 non-
operatively 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.
W H AT ’ S N E W IN P E D I AT R I C O R T H O PA E D I C S
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 ec-
centric 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 lido-
caine 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 in-
formed 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 ad-
olescents 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 un-
dergoing 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 hemo-
globin 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.