Top Studies of 2020
The clinician-researchers of the Pediatric Orthopaedic Service maintained a productive program of research in 2020. The department’s collaborative research model involves every member of the faculty, along with an engaged research staff, to advance pediatric surgeries to be as safe and effective as possible. The studies below were selected by Roger F. Widmann, MD, Chief of the Pediatric Orthopaedic Service at HSS, and Emily R. Dodwell, MD, MPH, Director of Pediatric Orthopaedic Research at HSS.
Although tranexamic acid (TXA) has been shown to reduce blood loss in adult spine and arthroplasty settings, it had not been tested widely in pediatrics. A randomized clinical trial published by Ernest Sink, MD, Chief of the Adult Hip Preservation Service; Dr. Dodwell; Alexander S. McLawhorn, MD; and colleagues in the August issue of the Bone & Joint Journal shows that TXA is safe and effective in children and teenagers undergoing periacetabular osteotomy. Intravenous use of TXA reduced postoperative calculated blood loss by 293 ml and the frequency of allogeneic transfusions by 73 percent.
In this double-blind, placebo-controlled randomized trial published by David M. Scher, MD, Dr. Dodwell and colleagues in the July issue of the Journal of Pediatric Orthopaedics, ε-aminocaproic acid (EACA) was found to have no effect on blood loss compared to placebo in patients with cerebral palsy undergoing bilateral varus rotational femoral osteotomies.
Dr. Scher and Dr. Sink’s studies on blood loss have changed our practice. Need for TXA is now part of our surgical time out.
Prior studies of EACA had shown that its use could potentially decrease blood loss and transfusion requirements in several pediatric surgical populations. “Dr. Scher and Dr. Sink’s studies on blood loss have changed our practice,” says Dr. Dodwell. “Need for TXA is now part of our surgical time out. It is the preferred medical prophylactic treatment when there’s a risk of significant blood loss.”
A new study published by Peter D. Fabricant, MD, MPH, and colleagues demonstrated the cost effectiveness of an enhanced rehabilitation program in youth athletes after ACL reconstruction. The work, which appeared in the April issue of the American Journal of Sports Medicine, looked at a return-to-play strategy that incorporates additional neuromuscular retraining and physician follow-up as well as advanced testing goals. The data suggests these additions are more cost-effective than rehabilitation alone. “Even though there is a modest increased upfront cost to insurers for these additional therapy visits and neuromuscular screening and training programs, this cost is offset by the decreased risk of graft tear and subsequent need for revision surgery,” says Dr. Fabricant. “We hope this study highlights the importance of insurers covering these services for their patients, as they both improve clinical outcomes and decrease the cost of care overall.”
In this longitudinal study of New York State’s surgically treated infant hip dislocations, the authors, Drs. Dodwell, Widmann, Sink and Scher, reported on the incidence and outcomes of open and closed hip reductions. Among the 897 patients identified, 637 underwent closed reduction and 260 underwent an open procedure.
Around 30-40 percent went on to require additional hip surgeries in childhood. “Both closed and open reductions had a relatively high rate of subsequent surgery,” observes Dr. Dodwell. “This is important information to share when counseling families when surgically treating a dislocated hip, as the journey to treating hip dysplasia can be a long one.”
This is important information to share when counseling families…as the journey to treating hip dysplasia can be a long one.
Around one-third of American children and adolescents ages 10 to 18 years old reported experiencing back pain within the last year, according to an epidemiologic cross-sectional survey published by Dr. Widmann; Dr. Fabricant; Daniel W. Green, MD, MS; Shevaun M. Doyle, MD; and colleagues in the February issue of Spine. Nearly 9 percent reported severe pain. Prevalence increased with age and was more common in female patients. “There is more back pain than we might have expected,” says Dr. Widmann. “It highlights the need for more education about back pain and ways to avoid it.” The study also found that despite the prevalence of the condition, the vast majority of young patients do not undergo treatments such as surgery or injections.
This retrospective chart review, published in the Bone & Joint Journal in February, was the first to compare sublaminar bands and pedicle screws in the correction of thoracic adolescent idiopathic scoliosis (AIS). Dr. Widmann; John Blanco, MD; Matthew E. Cunningham, MD, PhD; Han Jo Kim, MD, and colleagues found that pedicle screws provide a good coronal correction that is maintained at two-year follow-up. However, pedicle screws were associated with a flattening of the thoracic spine, whereas sublaminar bands with associated ligamentum flavum release were associated with improved sagittal correction in patients with significant hypokyphosis. “Surgeons may consider this approach in appropriate patients," says Dr. Blanco.