Award-winning clinical research presented during the 2015 annual meeting of the Pediatric Orthopaedic Society of North America (POSNA) covered a variety of orthopaedic conditions and overlapped specialties such as spine, trauma, and hip.
Top clinical paper
The top clinical paper was “Treatment of Congenital Vertical Talus: Comparison of Minimally Invasive vs. Traditional Surgical Technique with Minimum 5-Year Follow-Up” by Matthew B. Dobbs, MD, of the Washington University School of Medicine, St. Louis. He reported on a series of 28 consecutive vertical talus patients (44 feet), retrospectively reviewed at a median of 7.1 years (range: 5 to 11.3 years) after initial correction was achieved using a minimally invasive treatment approach (Dobbs method) that relies primarily on serial cast correction.
The less invasive Dobbs technique resulted in a greater average arc of motion, superior pain scores, and greater correction of the anteroposterior talar axis-first metatarsal base angle compared to extensive soft-tissue release surgery. However, the report also called for longer term studies to ensure that results are maintained through adulthood.
Four spine studies were among the clinical award papers. A team at Children’s Hospital Colorado found that compliance with a “bundle” of antibiotic recommendation decreases infection rate in pediatric spine surgery. The following three criteria were part of the antibiotic treatment bundle:
- appropriate intravenous (IV) antibiotics completely administered within 1 hour prior to incision
- IV antibiotics appropriately administered intraoperatively, based on blood loss and surgical time
- IV antibiotics discontinued within 24 hours postoperatively
This retrospective cohort study of 660 consecutive patients found an overall compliance rate of 82.3 percent. The overall infection rate was significantly higher in the noncompliant group (7.7 percent) compared to the compliant group (3.5 percent, P = 0.04).
Research conducted at the Phoenix Children’s Hospital focused on minimizing complications in scoliosis surgery in children with cerebral palsy (CP). This prospective, matched cohort analysis investigated the impact of having two attending surgeons, rather than a single surgeon assisted by a resident, physician assistant, or registered nurse first assistant. The use of a second attending surgeon resulted in a lower surgical time, less blood loss, a lower complication rate, and a reduced length of stay for patients with CP who underwent posterior spinal fusion.
Two other papers also examined treatment of scoliosis patients. A retrospective review conducted at Montefiore Medical Center (Bronx, N.Y.) documented evidence of pulmonary hypertension (pulm HT) in patients with adolescent idiopathic scoliosis (AIS), the severity of which directly correlated with the size of the curve. They also found that corrective surgery for AIS reverses pulm HT, avoiding potentially fatal compromise.
A study on the effect of compliance monitoring on brace use and success in patients with AIS, conducted at Texas Scottish Rite Hospital (Dallas), found that AIS patients who received compliance feedback and counseling wore their orthoses an average of 3 hours per day more than those who did not receive such counseling. Patients who wore their braces more hours per day experienced less curve progression, reducing the need for surgery.
Trauma in kids
Noting the recent increase in the surgical treatment of pediatric fractures, a team at Children’s Medical Center (Dallas) compared the results of spica casting and intramedullary nailing (IMN) of femur fractures in a group of 278 preschool age children (ages 4 to 5 years). They found similar clinical and radiographic outcomes with either immediate treatment method, but children treated with IMN (109 patients) required longer periods of follow-up and had a “dramatically” higher rate of repeat procedures due to elective implant removal than those treated with spica casting (169 patients). The team called for prospective studies examining cost effectiveness as well as patient- and family-centered outcomes.
Cast application and removal, however, are often performed by providers with variable experience and training. Citing statistics that cast saw burns occur in about 1 in 50 casts, a team at Boston Children’s Hospital sought to develop, validate, and implement a simulation trainer and curriculum to improve safety during cast removal. Using a distal radius fracture model, they measured temperatures generated using “good” and “poor” techniques. They found a 32.2°C temperature decrease when proper cast saw technique was used compared to “poor” technique; technique improved with years of experience.
A cohort study on the outcomes of selective ultrasound screening for developmental dysplasia of the hip (DDH) conducted by researchers in the United Kingdom found that, “despite advances in screening for DDH over the last 40 years, there has been no change in either the incidence of late diagnosis DDH, or rates of surgery for DDH in our region.” According to the researchers, selective ultrasound screening appears to be no better than clinical screening alone in identifying DDH.
Another study from the Texas Scottish Rite Hospital examined femoral head revascularization in patients with Legg-Calvé-Perthes disease, using serial perfusion MRI. They found a general pattern of revascularization starting from the periphery of the posterior, lateral, and medial aspects of the epiphysis and converging toward the anterocentral region of the epiphysis, but also noted a wide range among patients in the rate of revascularization. Surgically treated patients appeared to have a higher rate of revascularization.
Finally, a study from the Hospital for Special Surgery examined the long-term clinical outcomes of arthroscopic partial meniscectomy for the treatment of discoid lateral meniscus in children. The authors noted that although several studies have found good-to-excellent short-term outcomes, their long-term study (average follow-up of nearly 14 years) suggests that clinical outcome scores decline over time, with an increased rate of knee pain, mechanical symptoms, and functional limitations.
Mary Ann Porucznik is managing editor, AAOS Now. She can be reached at email@example.com
CLINICAL AWARD PAPERS
- Treatment of Congenital Vertical Talus: Comparison of Minimally Invasive vs. Traditional Surgical Technique with Minimum Five-Year Follow-Up (page 199)
- The Outcomes of Selective Ultrasound Screening for Developmental Dysplasia of the Hip are No Better Than Clinical Screening Alone: A Cohort Study Using A 40-Year Old Historic Control Group (page 200)
- Intramedullary Nailing of Femur Fractures in Preschool Age Children Does Not Improve Radiographic Outcomes vs. Immediate Spica Casting but Does Increase Intervention (page 201)
- Antibiotic Compliance Decreases Infection Rate in Pediatric Spine Surgery: A Retrospective Cohort Study (page 202)
- Minimizing Complications in Scoliosis Surgery in Children with Cerebral Palsy (page 203)
- Training Away Pediatric Cast Saw Burns via Simulation: A Novel Simulation Trainer and Curriculum (page 205)
- Long-Term Clinical Follow-Up of Arthroscopic Treatment of Discoid Lateral Meniscus in Children (page 207)
- Adolescent Idiopathic Scoliosis Patients Are at Increased Risk for Pulmonary Hypertension Which Reverses After Scoliosis Surgery (page 208)
- The Effect of Compliance Monitoring on Brace Use and Success in Patients with AIS: A Final Report (page 209)
- Assessment of Femoral Head Revascularization in Legg-Calvé-Perthes Disease (LCPD) Using Serial Perfusion MRI (page 210)