Pediatric Orthopedic Research

Complications in the Treatment of Femur Fractures in Patients with Pre-Existing Spinal Cord Injury.  Bulletin Hosp Joint Diseases 2019;77(3):211-215.

• Perkins, C., Buck, J.S., Karunakar, M.
• Summary: Surgical treatment of femur fractures in patients with pre-existing spinal cord injury and lower extremity paraplegia is associated with greater complications than non-operative treatment. Treatment of femur fractures in these patients should be with nonoperative techniques.

A Quartet of Elastic Stable Intramedullary Nails for More Challenging Pediatric Femur Fractures. J Pediatr Orthop. 2019 Jan;39(1):e12-e17. doi: 10.1097/BPO.0000000000001273.

• Busch MT1, Perkins CA1, Nickel BT2, Blizzard DJ3, Willimon SC1.
• Summary: The use of four flexible intramedullary nails, as opposed to the traditional two nails, improves the fixation and stability of length-unstable femur fractures which might otherwise require more invasive treatment techniques.

Olecranon fractures in children and adolescents: Outcomes based on fracture fixation. J Child Orthop 2018;12(5):497-501

• Perkins, C.A., Busch, M.T., Christino, M.A., Axelrod, J., Devito, D.P., Fabreags, J.A., Flanagan, J.C., Murphy, J.M., Olszewski, D., Schmitz, M.L., Schrader, T., Willimon, S.C.
• Summary: This study described the outcomes of a common treatment technique for elbow fractures in children and identified a specific population of older children who may benefit from a specific-fixation method.

Reliability of radiographic assessments of adolescent midshaft clavicle fractures by the FACTS multicenter study group. J Orthop Trauma 2017.

• Li, Y., Donohue, K.S., Willimon, S.C., et al.
• Radiographic measurements of clavicle fracture displacement and shortening have good inter- and intra-rater reliability. The cortex-to-corresponding-cortex measurement of shortening is more accurate than end-to-end and should be used in clinical practice.
• Summary: Currently, when a patient breaks her collar bone, there is no standardized way to review imaging studies and calculate displacement. These measurements are important because they guide decision making regarding the need for surgery. Our team collaborated with other centers in the study group to find reliable ways to measure, evaluate and standardize care of clavicle fractures. 

Adolescent clavicle nonunions: Potential risk factors and surgical management. J Shoulder Elbow Surg 2017.

• Pennock, A.T., Willimon, S.C., Busch, M.T., et al.
• Nonunion is a rare outcome in adolescent clavicle fractures. Predictors of nonunion are male patients who have a displaced fracture through a previously fractured clavicle.
• Summary: This study was conducted to better understand the commonality and rarity of nonunions. Our team collaborated with other centers to identify patients whose clavicles did not heal. This occurrence is very low (less than 15 cases). This study showed that nonunions rarely occur. 

Functional outcomes following nonoperative versus operative treatment of clavicle fractures in adolescents. J Child Orthop 2017.

• Herzog, M.M., Busch, M.T., Willimon, S.C., et al. 
• There are no significant differences in function or patient-reported outcomes between patients treated nonoperatively versus operatively for displaced and shortened clavicle fractures.
• Summary: Some clavicle fractures can benefit from surgical repair, while others can be managed successfully without surgery. Our doctors are not just interested in treating the fractures. We want to know that a patient’s functional outcome is better because of the treatment. This study examines patients who had a clavicle fracture that was treated with or without surgery and tests the strength and endurance of their arms.

Intra-articular physeal fractures of the distal femur: A frequently missed diagnosis in adolescent athletes. Orthop J Sports Med 2017.

• Pennock, A.T., Ellis, H.B., Willimon, S.C., et al.
• Intra-articular physeal fractures of the distal femur are commonly missed, and practitioners must have a high index of suspicion for this injury pattern when evaluating skeletally immature athletes with acute knee injuries.
• Summary: A fracture through the growth plate at the end of the femur (thigh bone) is difficult to diagnose and frequently missed in adolescent athletes. It’s important to have a doctor experienced in sports medicine injuries to make sure athletes recognize these injuries and get the treatment they need. This study was performed in order to better understand these fractures and their growth-related complications.

The use of a transolecranon pin in the treatment of pediatric flexion type supracondylar humerus fractures. J Pediatr Orthop. September 2017.

• Green, B.M., Stone, J.A., Fletcher, N.D.
• A transolecranon pin is one technique to obtain provision reduction of flexion-type supracondylar humerus fractures that may otherwise require open reduction.
• Summary: This injury is a relatively rare, hard-to-treat variant of commonly treated injury. Previously, this injury required an open surgery to realign the bones. Open surgery can mean a longer recovery time, more risk for complications and more pain. Our research showed that our new technique helped avoid open surgery in all cases. This was a small study, but showed the minimally invasive technique to be effective and have positive outcomes for patients.

Carpal Injuries in Sport, in Upper Extremity Injuries in Young Athletes, Bauer, Bae (Eds.), Springer, Cham, Switzerland, 2019. Springer 2019.

• Faust, K.C., Peljovich, A.E.
• Summary: This study focuses exclusively on upper extremity injuries in young athletes, including the latest evidence on current diagnostic and treatment strategies.

Outcomes of Operative Treatment of Triangular Fibrocartilage Tears in Pediatric and Adolescent Athletes, J Pediatr Orthop, 38(10): e618-622, 2018

• Fishman, F.G., Barber, J., Lourie, G.M., Peljovich, A.E.
• Summary: Operative treatment of TFCC injuries in adolescent and pediatric athletes after failure of conservative treatment allowed return to sport at the previous level of participation. Concurrent ulnar shortening osteotomy in the setting of ulnar positive variance did not prohibit return to high-level athletic participation.

“Early Predictors of Microsurgical Reconstruction in Brachial Plexus Birth Palsy,” Iowa Orthop J; 39(1): 37-43, 2019

• Shah, A.S., Kalish, L.A., Bae, D.S., Peljovich, A.E., Cornwall, R., Bauer, A.S., Waters, P.M.
• Summary: In patients with brachial plexus birth palsy, early physical examination findings independently predict microsurgical intervention. These factors can be used to provide counseling in early infancy for families regarding injury severity and plan for potential microsurgical intervention.

Recovery of Motor Nerve Injuries Associated With Displaced, Extension-type Pediatric Supracondylar Humerus Fractures. J Pediatr Orthop. 2019 Oct;39(9):e652-e656. doi: 10.1097/BPO.0000000000001056

• Shore, B.J., Gillespie, B.T., Miller, P.E., Bae, D.S., Waters, P.M.
• Summary: Nerve injuries occur in approximately 11% of pediatric extension supracondylar humerus fractures (SCHF), yet there is scarce literature to guide clinicians on management. The primary goal of this study was to report the presentation, treatment and outcome of motor nerve injuries associated with extension SCHF. Our secondary goal was to determine which injury and treatment factors were associated with prolonged motor nerve recovery.

Etiology, Diagnosis, and Treatment of Dynamic Nerve Compression Syndromes of the Elbow Among High-Level Pitchers: A Review of 7 Cases. The Orthopaedic Journal of Sports Medicine.  October, 2018.

• vonBergen, T.N.,  Lourie, G.M.
• Summary: This article describes an injury seen in adolescent and adult pitchers in which nerves about the joint can become compressed with activity resulting in decreased function and performance. Recognition and proper treatment can avoid injury and restore pre-injury performance.

Ulnar Nerve Injury in Pediatric Midshaft Forearm Fractures: A Case Series".  Journal of Orthopedic Trauma.  Volume 32. Number 9. September, 2018.

• Federer, E.F., Murphy, J.M.,  Calandruccio, J.H.,  DeVito, D,P.,  Kozin, S.H.,  Slappey, G.S.,  Lourie, G.M.
• Summary: This article describes the largest series to date of a fracture of the forearm in children that can entrap and injure the ulnar nerve. Early recognition and correct treatment can prevent long term nerve damage.

Outcomes Of Operative Treatment Of Triangular Fibrocartilage Tears In Pediatric And Adolescent Athletes,” Journal of Pediatric Orthopedics, 38(10): e618-622, 2018.

• Fishman F.G., Barbar J, Lourie G.M., Peljovich A.E.
• Summary: Triangular fibrocartilage complex (TFCC) tears are a well known adult wrist injuries, but little has been reported in children. Traditionally associated with distal radius fractures in children, this study reviews the experience in treating these tears in children and adolescents. Nearly all of the tears resulted from injuries sustained during a sport activity, and not from fractures; something previously unreported. Our team reported the findings associated with this injury to raise awareness. Our team also found that eighty percent of patients returned to their previous level of sport within 4.8 months after surgery while nearly all were satisfied with the results of the surgery. When warranted, surgical treatment of TFCC injuries in our young athletes can reliably help them return back to their level of sport.

Hand Injuries in Baseball. (Chapter) Baseball Sports Medicine. (Textbook) Editors Ahmad, and Romeo.

• Metz, J.  Lourie G.M.
• Summary: This chapter focuses on hand injuries particular to baseball in the adolescent and adult.  A thorough description focuses on the pertinent anatomy and treatment of hand injuries common to baseball.

Surgical Treatment of Upper Extremity Contractures in Emery-Dreifuss Muscular Dystrophy,” Journal of Pediatric Orthopedics B, 26(1):32-35, 2017.

• Fishman F.G., Goldstein E.M., Peljovich A.E.
• Summary: Emery-Dreifuss muscular dystrophy is a rare form of muscular dystrophy. Emery-Dreifuss muscular dystrophy is a form of this condition that often leads to impairing elbow contractures. For the first time, this paper reviews the results of muscle lengthening surgery to successfully relieve these contractures in two children with the condition.

"Median Nerve Injury,” in the text book, The Pediatric Upper Extremity

• Peljovich A.E., Fishman F.G.
• Summary: The median nerve is one of the three major nerves of the forearm and hand. It helps control hand movement. This book chapter explores the types of injuries that typically result in median nerve damage as well as treatment options.

Validation of pediatric self-report patient-reported outcomes measurement information system (PROMIS) measures in different stages of Legg-Calve-Perthes Disease

• Matsumoto, H., Hyman, J.E., Shah, H.H., Sankar, W.N., Laine, J.C., Mehlman, C.T., Schrader, T., Kelly, D.M., Rosenfeld, S.B., Janicki, J.A., Thacker, M.M., Trupia, E., Mcguire, M.F., Kim, H.K.W., International Perthes Study Group.
• Summary: Patient reported outcome scores are a useful and validated tool to describe how a patient is functioning during and after their treatment for Legg-Calve-Perthes Disease.

Septic Arthritis of the Hip-Risk Factors Associated With Secondary Surgery. J Am Acad Orthop Surg. 2018 Dec 4. doi: 10.5435/JAAOS-D-18-00058. [Epub ahead of print]

• Murphy R.F., Plumblee L, Barfield W.B., Murphy J.S., Fuerstenau N, Spence D.D., Kelly D.M., Dow M.A., Mooney J.F. 3rd.

Increased Hip Intracapsular Pressure Decreases Perfusion of the Capital Femoral Epiphysis in a Skeletally Immature Porcine Model

• Upasani V.V., Badrinath R, Farnsworth C.L., Jeffords M.E., Hallare J.A., Ahmed S.I., Schrader T.S.
• This study evaluates the relationship between intra-articular hip pressure (IAP) and epiphyseal perfusion pressure (EPP), and its dependency on skeletal maturity to determine if hip pressure has an effect on femoral head avascular necrosis after hip fractures or acute slipped capital femoral epiphysis (SCFE).

• Summary: Posttraumatic femoral head avascular necrosis (AVN) happens when bone tissue begins to die due to lack of blood supply. Hip fractures, dislocations and SCFE have been associated with high rates of AVN. With this study, we found that increased pressure within the hip joint in a young pig with open growth plates led to decreased blood perfusion inside the femoral head. We also found that the decreased perfusion was reversible (in the short term) by decreasing the hip joint pressure. This study is clinically relevant because releasing the pressure of the hip joint (hip capsulotomy) in young patients may help decrease the rate of AVN.

Intraoperative monitoring of epiphyseal perfusion in slipped capital femoral epiphysis. J Bone Joint Surg Am 2016; 98(12):1030-1040.

• Schrader, T.S., Jones, C.R., Kaufman, A.M., et al. 
• Femoral head perfusion in patients with a slipped capital femoral epiphysis (SCFE) can be measured intra-operatively. The presence of femoral head perfusion was predictive of the absence of postoperative osteonecrosis.
• Summary: This novel technique to monitor blood flow to the ball of the hip (femoral head) during surgery for a condition called slipped capital femoral epiphysis (SCFE) was developed by Tim Schrader, MD, Medical Director of Children’s Hip Program. Demonstrating blood flow to the femoral head during surgery was associated with an absence of osteonecrosis after surgery. This study will help improve patient outcomes.

Arthroscopic management of pigmented villonodular synovitis of the hip in children and adolescents. Ortho J Sports Med 2018.

• Willimon, S.C., Schrader, T.S., Perkins, C.A.
• Pigmented villonodular synovitis (PVNS) should be considered in the differential diagnosis of children and adolescents with atypical presentations of hip pain that fail to respond to treatment for rheumatologic or infectious disorders. Arthroscopic synovectomy of the hip following a timely diagnosis of PVNS produces good outcomes. 
• Summary: PVNS is a noncancerous tumor-like condition that affects the joints—most commonly the knee, hip, elbow and shoulder. PVNS is often difficult to diagnose. Our study examined a series of young patients with PVNS of the hip that had not been previously reported. Historically, these surgeries were open procedures. Our sports medicine surgeons perform these arthroscopically, which usually has a shorter recovery time, less pain and fewer complications compared to more traditional approaches.

Radiographic assessment of guided growth: The correlation between screw divergence and change in anatomic alignment. J Pediatr Orthop 2017.

• Sweeney, K.R., Shi, W.J., Gottschalk, M.B., Kappa, J.E., Bruce, R.W. Jr., Fletcher, N.D. 
• In patients treated with guided growth, screw divergence as measured on a knee radiograph as opposed to full-length standing radiographs can be used to reliably determine changes in coronal plane alignment.
• Summary: Typically, screws are used to secure bones in place and harness growth to provide straightening for kids with knocked knees or bow legs if we still expect adequate bone growth. When following a patient’s growth, we typically require full body X-rays, which means exposure to radiation. This study shows that by doing simple calculations, we can eliminate the need for a full body X-ray and just X-ray the knee. This study has helped us reduce our patients’ exposure to radiation.

Test yourself: question: “painless right leg swelling.”  Skeletal Radiol 2019;48(8):1311-1312.

• Shaw, K.A., Murphy, J.S., Marshall, K.W.
• This quiz question was drafted for radiologists in the setting of a neurofibromatosis patient.

Time to return to school following 10 common orthopaedic surgeries among children and adolescents. J Pediatr Orthop 2017.

• Willimon, S.C., Busch, M.T., Herzog, M.M. 
• The average time to return to school following orthopedic surgeries ranges from three days for closed reduction of forearm fractures to 42 days for adolescent idiopathic scoliosis fusion. This information can be used to counsel patients and families regarding postoperative recovery and expectations.
• Summary: Previously, there wasn’t data to guide parents on how much work and school a family could expect to miss after an orthopedic surgery. Doctors would estimate this information based on their past experiences. In this study, the team defined the average number of missed school days for 10 common procedures. This information helps families and caregivers to plan and prepare for surgery and postsurgical recovery.

Use of an accelerated discharge pathway in patients with severe cerebral palsy undergoing posterior spinal fusion for neuromuscular scoliosis. Spine Deform. 2019 Sep;7(5):804-811.

• Bellaire, L..L, Bruce, R.W. Jr., Ward, L.A., Bowman, C.A., Fletcher, N.D.
• This study revealed that implementation ofour post-operative pathway in complex patients with cerebral palsy undergoing posterior spinal fusion led to a shorter length of stay and fewer complications.

Nighttime bracing with the providence thoracolumbosacral orthosis for the treatment of adolescent idiopathic scoliosis: a retrospective consecutive clinical series. Prosthet Orthot Int. 2019 Apr;43(2):158-162.

• Davis, L., Murphy, J.S., Shaw, K.A., Cash, K., Devito, D.P., Schmitz, M.L.
• Identified bracing with the Providence TLSO is best suited for spinal curves less than 35 degrees with an apex at T10 or below in more skeletally mature patients defined as Risser 1 or greater.

Compensatory or pathology? – cervical spine sagittal alignment in adolescent idiopathic scoliosis. J Spine Surg 2019;5(1):174-175.

• Shaw, K.A., Murphy, J.S.
• An invitation to draft a commentary on a published manuscript that analyzed cervical sagittal alignment in children with adolescent idiopathic scoliosis and its effect on their alignment compared to the normal population.

Improving complex pediatric and adult spine care while embracing the value equation. Spine Deform 2019;7(2):228-235.

• Sethi, R.K., Yanamadala, V., Shah, S.A., Fletcher, N.D., Flynn, J., Lafage, V., Schwab, F., Heffernan, M., DeKleuyer, M., Mcleod, L., Leveque, J.C., Vitale, M.
• This was a consensus statement on the way in which standardized processes have improved the delivery of care to pediatric and adult spine patients.

Establishing consensus on the best practice guidelines for use of halo gravity traction for pediatric spinal deformity. J Pediatr Orthop 2019.  Epub ahead of print.

• Roye, B.D., Campbell, M.L., Matsumoto, H., Pahys, J.M., Welborn, M.C., Sawyer, J., Fletcher, N.D., McIntosh, A.L., Stum, P.F., Gomez, J.A., Roye, D.P., Lenke, L.G., Vitale, M.G.; Children’s Spine Study Group.
• This study establishes best practice guidelines for treating patients with halo gravity traction.

Perioperative Complications After Spinal Fusion in Pediatric Patients With Congenital Heart Disease. Spine Deform. 2019 Jan;7(1):158-162. doi: 10.1016/j.jspd.2018.05.002.

• Spitzer A.B., Shaw K.A., Schmitz M., Devito D.P., Murphy J.S.

Predictors of distal adding-on in thoracic major curves with AR lumbar modifiers. Spine 2017.

• Murphy, J.S., Upasani, V.Y., Yaszay, B., et al.
• Skeletally immature patients, those fused short of last substantially touched vertebra (LSTV) and those with relative coronal balance preoperatively are at increased risk of distal adding-on between the initial postoperative visit and two-year follow up.
• Summary: Our orthopedic surgeon, Joshua Murphy, MD, participates in a multicenter collaborative effort with other children’s hospitals to explore the best ways to surgically correct scoliosis and avoid complications. This study aimed to better understand factors that will help doctors design the surgical treatment for patients.

Development of consensus-based best practice guidelines (BPG) for postoperative care following posterior spinal fusion for AIS. Spine 2017.

• Fletcher, N.D., Glotzbecker, M.P., Marks, M.C. The Harms Study Group, Newton PO.
• Nineteen clinical practice guidelines are described for the postoperative management of patients following posterior spinal fusion for adolescent idiopathic scoliosis.
• Summary: We are nationally renowned for our pediatric postoperative spinal fusion pathway. Our team was the first to publish our pathway five years ago. In comparing data across our hospitals, we found a 25 percent decrease in length of stay and no increase in complications due to the implementation of our pathway. Because of the success of the pathway, Nicholas Fletcher, MD, Medical Director of Children’s Spine Quality and Outcomes was asked to lead a team of nationally renowned surgeons to create a best practice guideline for postoperative care following posterior spinal fusion for adolescent idiopathic scoliosis. Most recently, we’ve found that with our pathway sicker kids with more complex conditions also benefited from our guidelines. We saw a 50 percent decrease in complications and a 25 percent shorter length of stay for these patients.

Use of a novel pathway for early discharge was associated with a 48 percent shorter length of stay after posterior spinal fusion following adolescent idiopathic scoliosis. J Pediatr Orthop. March 2017.

• Fletcher, N.D., Andras, L.A., Lazarus, D.E., Owen, R.J., Geddes, B.J., Cao, J., Skaggs, D.L., Oswald, T.S., Bruce, R.W.
• Discharge after posterior spinal fusion for scoliosis may be expedited using a coordinated postoperative pathway without an increase in complications.
• Summary: In order to prove the positive outcomes of Children’s Healthcare of Atlanta’s spinal fusion pathway, we collaborated with Children’s Hospital Los Angeles. When comparing pathways, we found that our patients were released 50 percent sooner with no major difference in complications. As a result, many pediatric hospitals across the country are adopting the spinal fusion pathway created by our team.

Allograft augmentation of hamstring anterior cruciate ligament autografts is associated with increased graft failure in children and adolescents. Am J Sports Med. 2019 Jun;47(7):1576-1582.

• Perkins, C.A., Busch, M.T., Christino, M., Herzog, M.M., Willimon, S.C.
• Hamstring graft sizes in adolescent patients having ACL reconstruction can be variable. If a surgeon obtains a small graft, this study demonstrates that enlarging the graft by folding over the native hamstring tendon has superior results compared to adding allograft tissue to the construct.

Don’t you wish you had fused to the pelvis the first time: a comparison of reoperation rate and correction of pelvic obliquity. Spine 2019;44(8):E465-E469.

• Nielsen, E., Andras, L.M., Bellaire, L.L., Fletcher, N.D., Minkara, A., Vitale, M.G., Troy, M., Glotzbecker, M., Skaggs. D,L.
• This study established that fusion to the pelvis rather than the lower lumbar spine may be preferable in patients undergoing spinal fusion for neuromuscular scoliosis due to the high operating time and blood loss associated with a revision surgery.

Intra-articular physeal fractures of the distal femur: A frequently missed diagnosis in adolescent athletes. Orthop J Sports Med 2017.

• Pennock, A.T., Ellis, H.B., Willimon, S.C., et al.
• Intra-articular physeal fractures of the distal femur are commonly missed, and practitioners must have a high index of suspicion for this injury pattern when evaluating skeletally immature athletes with acute knee injuries.
• Summary: A fracture through the growth plate at the end of the femur (thigh bone) is difficult to diagnose and frequently missed in adolescent athletes. It’s important to have a doctor experienced in sports medicine injuries to make sure athletes recognize these injuries and get the treatment they need. This study was performed in order to better understand these fractures and their growth-related complications.

Transphyseal ACL reconstruction in skeletally immature patients. The Pediatric ACL: Clinical Evaluation and Management Strategies. Springer. 2018.

• Perkins, C.A., Willimon, S.C., Busch, M. 
• ACL reconstruction in skeletally immature patients with a transphyseal technique is appropriate for adolescents with two or fewer years of remaining skeletal growth.
• Summary: This book chapter discusses the strategy and treatment to reconstruct an ACL in children and young teenagers. Sometimes, treating pediatric ACL injuries like you would an adult’s can be risky and dangerous due to remaining skeletal growth. Adolescent patients are also at higher risk for re-injury. Our sports medicine team includes physical therapists, athletic trainers, sports medicine primary care doctors and orthopedic surgeons. Our goal with ACL rehabilitation is to help patients return to activity based on their recovery and function versus a specific timeframe after surgery.  

Pigmented villonodular synovitis of the knee: An underappreciated source of pain in children and adolescents. J Pediatr Orthop 2018;38(8):e482-e485

• Willimon, S.C., Busch, M.T., Perkins, C.A. 
• Summary: Pigminted villonodular synovitis (PVNS) is a noncancerous tumor-like condition that affects the joints—most commonly the knee, hip, elbow and shoulder. PVNS is often difficult to diagnose. This is the largest published series of pediatric patients with PVNS of the knee. Our sports medicine surgeons treat PVNS arthroscopically, which usually has a shorter recovery time, less pain and fewer complications compared to more traditional approaches.

Arthroscopic management of pigmented villonodular synovitis of the hip in children and adolescents. Ortho J Sports Med 2018.

• Willimon, S.C., Schrader, T.S., Perkins, C.A. 
• Pigmented villonodular synovitis (PVNS) should be considered in the differential diagnosis of children and adolescents with atypical presentations of hip pain that fail to respond to treatment for rheumatologic or infectious disorders. Arthroscopic synovectomy of the hip following a timely diagnosis of PVNS produces good outcomes. 
• Summary: PVNS is a noncancerous tumor-like condition that affects the joints—most commonly the knee, hip, elbow and shoulder. PVNS is often difficult to diagnose. Our study examined a series of young patients with PVNS of the hip that had not been previously reported. Historically, these surgeries were open procedures. Our sports medicine surgeons perform these arthroscopically, which usually has a shorter recovery time, less pain and fewer complications compared to more traditional approaches.