Orthopedic Research

Flexible intramedullary nailing of pediatric femoral fractures. JBJS Essential Surgical Techniques. March 2021.

• Murphy, J.S., Koehler, K., Johnson, M., Hosseinzadeh, P.
• Summary: Flexible intramedullary nail and stainless steel is a great choice for treating of pediatric patients ages 5 to 13 years old with closed femoral shaft fractures. This technique can provide a rapid recovery, as well as short rehabilitation and immobilization with few complications and a very high union rate.  

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. January 2019;39(1):e12-e17. doi: 10.1097/BPO.0000000000001273.

• Busch M.T., Perkins C.A., Nickel, B.T., Blizzard, D.J., Willimon, S.C.
• 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., Fabregas, 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.

Descriptive epidemiology of adolescent clavicle fractures: results from the FACTS prospective multicenter cohort study. Orthop J Sports Med 2020;8(5).

• Ellis, H.B., Li, Y., Bae, D.S., Willimon, S.C., Heyworth, B.E., et al.
• Summary: Adolescent clavicle fractures occur most commonly in male athletes as a result of a direct blow to the shoulder. In this multicenter study of 545 teenage patients, approximately 50% of these fractures were completely displaced and the majority of these fractures were successfully managed without surgery.

 

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

• 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.

Early predictors of microsurgical reconstruction in brachial plexus birth palsy. Iowa Orthop J. 2019;39(1):37-43

• 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. October 2019;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 seven 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. September 2018;32(9).

• 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: TFCC tears are a well-known adult wrist injury, but little has been reported in children. Though these injuries are 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 sports 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 80% 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.

Slipped Capital Femoral Epiphysis Associated with Endocrinopathy: A Narrative Review.

• Shaw, K.A., Shiver, A.L., Oakes, T., Fletcher, N.D., et al. 
• Summary: Recombinant growth hormone therapy has also been identified as a risk factor for the development of SCFE.Patients with unilateral slipped capital femoral epiphysis presentations with an underlying endocrinopathy are at a heightened risk for contralateral slip development and should be treated with prophylactic fixation.

Reliability and Validity of Visual Estimation of Femoral Head Hypoperfusion on Perfusion MRI in Legg-Calve-Perthes Disease. October 2021.

Hip Morphology in Early-stage LCPD: Is There an Argument for Anatomic-specific Containment? July 2021. 

Tractionless hip arthroscopy for septic arthritis in children. Feb. 19, 2021. 

• Ellis, H., Copley, L., Pennock, A.T., Nepple, J.J., Willimon, S.C., Mayer, S., Yen, Y. 
• Summary: The purpose of this study is to describe a safe technique to perform hip arthroscopy without traction in the pediatric hip and to report short-term results of a case series. Pediatric hip arthroscopy can be safely performed without traction on a radiolucent table, and allows joint irrigation and debridement, including drain placement through the use of one or two portals. Hip arthroscopy is a safe, valuable, minimally invasive technique in the treatment of children with septic arthritis of the hip.

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. Dec. 4, 2018; 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. J Pediatr Orthop. 2020 Apr;40(4):176-182. doi: 10.1097/BPO.0000000000001284. PMID: 32132447.

• 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: Post-traumatic 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 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 SCFE was developed by Dr. Schrader, Medical Director of the 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.

Increased hip intracapsular pressure decreases perfusion of the capital femoral epiphysis in a skeletally immature porcine model. J Pediatr Orthop 2020;40(4):176-182.

• Upasani, V.V., Badrinath, R., Farnsworth, C.L., Jeffords, M.E., Hallare, J.A., Ahmed, S.I., Schrader, T.
• Summary: Increased pressure around the hip, caused by bleeding from a fracture or slipped capital femoral epiphysis can result in avascular necrosis (loss of blood flow to a portion of the femur). In this animal study, the increase in pressure was successfully treated with decompression and opening of the hip capsule. This evidence supports opening the capsule and decompressing the increased pressure in the joint when treating children with certain hip fractures.
  

Continued increase in cost of care despite decrease in stay after posterior spinal fusion for adolescent idiopathic scoliosis. March 2022.

• Shaw, K.A., Ange, B., George, V., Murphy, J.S., Fletcher, N.D.
• Summary: Previous studies have demonstrated decreased hospital length of stay (LOS) for children undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Findings from this study indicate there continues to be a significant decrease in LOS for PSF hospitalization events for AIS; however, total treatment charges continue to rise. Future research should investigate potential factors influencing total treatment charges after PSF for AIS.

Absent baseline intraoperative neuromonitoring signals part I: Adolescent idiopathic scoliosis. January 2022.

• Spitzer, A., Patel, R., Hasan, S., Blas, D., Floccari, L., Glotzbecker, M., Murphy, J.S., Fletcher, N.D., Gomez, J. 
• Summary: This publication provides guidelines in the event the surgical team needs to troubleshoot reduced or absent neuromonitoring signals together at any point during posterior spinal fusion for the adolescent idiopathic scoliosis patient.

Absent baseline intraoperative neuromonitoring signals part 2: Neuromuscular scoliosis. January 2022.

• Spitzer, A., Patel, R., Hasan, S., Blas, D., Floccari, L., Glotzbecker, M., Murphy, J.S., Fletcher, N.D., Gomez, J. 
• Summary: Intraoperative neurologic monitoring (IONM) for neuromuscular scoliosis (NMS) is recommended to decrease risk of neurologic deficit. This study asserts the use of IONM is recommended during spinal fusion for neuromuscular patients, including severely affected Gross Motor Function Classification System IV and V spastic quadriplegic cerebral palsy patients with epilepsy. Weight-bearing ability, baseline motor function, supratentorial brain lesions, and antiepileptics are associated with ability to achieve baseline signals.

Blood loss estimation during posterior spinal fusion for adolescent idiopathic scoliosis. November 2021.

• Fletcher, N.D., Gilbertson, L.E., Bruce, R.W. Jr., Lewis, M., Lam, H., Austin, T.M.
• Summary: The purpose of this study was to investigate common methods for BL estimation. Results indicate published formulaic approaches do not approximate true blood loss. Multiplying the cell saver volume by 3 or using the cell salvage-based estimator had the highest correlation coefficient and intraclass correlation coefficient.

Risk factors for the development of DJK in AIS patients undergoing posterior spinal instrumentation and fusion. September 2021. 

• Harms Study Group, including, Fletcher, N.D.
• Summary: Typically, selection of lowest instrumented vertebra in adolescent idiopathic scoliosis is based on the coronal radiograph; however, increasing evidence suggests that fusions proximal to the stable sagittal vertebrae on the lateral radiograph can result in distal junctional kyphosis. The purpose of this study is to compare rates of distal junctional kyphosis in patients with adolescent idiopathic scoliosis that have a discordance between the lowest touched vertebra and the stable sagittal vertebrae and to identify risk factors for developing distal junctional kyphosis.

Power pedicle tract preparation and screw placement: A multicenter study of early adopters. September 2021.

• Skaggs, D.L., Compton, E., Andras, L., Illingworth, K., Vitale, M.G., Stone, J., Fletcher, N.D., Keil, L., Garg, S., Martinez, R., Kim, E., Harris, H.
• Summary: This retrospective review compared patients who underwent posterior spinal fusion by seven pediatric spine surgeons at six institutions over 11 years to determine the safety of power-assisted pedicle tract preparation by early adopters of this technology. This is the first multi-center study examining power pedicle preparation. Overall, 99.9% of pedicle screws placed with power pedicle preparation did not have complications or revision.

Surgical outcomes of obese patients with adolescent idiopathic scoliosis from endemic areas of obesity in the United States. August 31, 2021.

• McDonald, T.C., Heffernan, M.J., Ramo, B., Haber, L., Sheffer, B., Murphy, J.S., Murphy, R., Fletcher, N.D., Coyne, K., Lubicky, J., Bumpass, D.B., Crawford, C. 3rd, Carreon, L., Toner, S., Stafford, W.H., Poppino, K., Adams, T., Song, B.M., Gidwani, S., Taillac, H., Cornaghie, M., Sukkarieh, H., Wright, P.B., Conklin, M., Gilbert, S., Thimothee, J., Bhanat, E., Brooks, J.T.
• Summary: A multicenter research consortium was formed to evaluate the effect of obesity on pediatric musculoskeletal disorders. Results of this study indicate obese and overweight adolescent idiopathic scoliosis patients have significantly greater superficial surgical site infection rates than normal weight patients, even after controlling for socioeconomic status.  

Modified Clavien-Dindo-Sink classification system for adolescent idiopathic scoliosis. August 5, 2021.

• Guisse, N.F., Stone, J.D., Keil, L.G., Bastrom, T.P., Erickson, M.A., Yaszay, B., Cahill, P.J., Parent, S., Gabos, P.G., Newton, P.O., Glotzbecker, M.P., Kelly, M.P., Pahys, J.M., Fletcher, N.D.
• Summary: This study aimed to modify the Clavien-Dindo-Sink classification system for application in patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion to assess its inter- and intra-rater reliability for describing complications faced by this population.

Current concept review: Gastrostomy tubes in children with non-ambulatory cerebral palsy and neuromuscular scoliosis: An enemy or an ally? July 26, 2021.

• Shiver, A.L., Shaw, K.A., Murphy, J.S., Fletcher, N.D.
• Summary: This current concept review evaluates postoperative complications of gastrostomy tubes or equivalent invasive nutritional support devices for maintaining apppropriate nutrition for children with cerebral palsy who have oromotor dysfunction. 

Indications for lumbar fusion in the skeletally mature athlete: How to address oblique takeoff and leg length discrepancy. July 14, 2021.

• Li, Y., Fletcher, N.D.
• Summary: The purpose of this review is to discuss the potential advantages and disadvantages of posterior spinal fusion with segmental spinal instrumentation in a hypothetical skeletally mature adolescent with a 45-degree lumbar curve, pelvic obliquity, and limb length discrepancy. Although the clinical and radiographic outcomes of posterior spinal fusion with segmental spinal instrumentation are excellent, patients should be counseled about the impact of fusing the lumbar spine on back pain, decreased spinal mobility and potential inability to return to athletics at the same level.

Shoulder balance in patients with Lenke type 1 and 2 idiopathic scoliosis appears satisfactory at 2 years following anterior vertebral body tethering of the spine. June 16, 2021.

• Miyanji, F., Fields, M.W., Murphy, J.S., Matsumoto, H., Fano, A.N., Roye, B.D., Skaggs, D., El-Hawary, R., Vitale, M.G., Parent, S.; Pediatric Spine Study Group (PSSG) 
• Summary: Shoulder balance is an important factor for patient satisfaction following surgery for idiopathic scoliosis. In this study, postoperative shoulder imbalance in patients with idiopathic scoliosis undergoing anterior vertebral body tethering was seen in 16% of patients, a reduction from 30% preoperatively.     

Comparative cost-utility analysis of postoperative discharge pathways following posterior spinal fusion for scoliosis in non-ambulatory cerebral palsy patients. Spine Deformity Journal. May 18, 2021. 

• Shaw, K.A., Heboyan, V., Fletcher, N.D., Murphy, J.S.
• Summary: Accelerated postoperative discharge (AD) pathways have demonstrated numerous benefits for patients with adolescent idiopathic scoliosis (AIS) after undergoing a posterior spinal fusion (PSF). Although early evidence supports the application of AD pathways over more traditional discharge (TD) approaches for patients with neuromuscular scoliosis, the economic impact of these pathways has not been investigated. This cost-utility analysis demonstrated that the implementation of an AD pathway following PSF for non-ambulatory CP scoliosis is economically more effective. The cost-effectiveness of the AD was maintained despite implant cost variations.  

Does body mass index affect outcomes after vertebral body tethering surgery? Canadian Undergraduate Conference on Healthcare Journal, 2(1). April 28, 2021. 

• Mishreky, A., Parent, S., Miyojni, F., Murphy, J.S., El Hawary, R.
• Summary: The outcomes of adolescent idiopathic scoliosis patients treated with vertebral body tethering (VBT) were compared between underweight, normal weight and overweight patients. All groups had similar scoliosis correction on first erect S-rays and similar risk of complication at the two-year post-operative appointment. However, overweight patients had a risk ratio of 4.7 for progression of scoliosis from first post-operative erect to two-year post-operative, as compared to underweight and normal weight patients. 

Risk of early complication following anterior vertebral body tethering for idiopathic scoliosis. Spine Deformity Journal. April 9, 2021. 

• Abdullah, A., Parent, S., Miyanji, F., Smit, K., Murphy, J.S., Skaggs, D., Gupta, P., Vitale, M., et al. 
• Summary: The purpose of this study was to determine peri-operative morbidity associated with anterior vertebral body tethering (aVBT) for idiopathic scoliosis. This large, multicenter series of aVBT procedures  demonstrated a 15.8% complication rate and 6.7% UPROR rate at two-year post-operatively.

In-hospital opioid usage following posterior spinal fusion for adolescent idiopathic scoliosis: Does methadone offer an advantage when used with an ERAS pathway? Spine Deformity Journal. March 18, 2021.   

• Shaw, K.A., Fletcher, N.D., Devito, D.P., Schmitz, M.L., Fabregas, J.A., Gidwani, S., Chhatbar, P., Murphy, J.S.
• Summary: Intraoperative methadone has been shown to decrease opioid medication required after a posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). No study to date has investigated the effect of methadone on opioid medication requirement when used in conjunction with an enhanced recovery after surgery (ERAS) protocol following PSF. The study concluded that there was no decrease of in-hospital opioid usage when methadone was used with an ERAS protocol. Total opioid usage is correlated with hospital length of stay following the surgery.

Risk factors for gastrointestinal complications after spinal fusion in children with cerebral palsy. Spine Deformity Journal. March 9, 2021. 

• Verhofste, B.P., Berry, J.G., Miller, P.E., Crofton, C.N., Garrity, B.M., Fletcher, N.D., Marks, M.C., Shah, S.A., Newton, P.O., Samdani, A.F., Abel, M.F., Sponseller, P.D., Harms Study Group, Glotzbecker, M.P.
• Summary: Gastrointestinal (GI) complications like pancreatitis and ileus are not uncommon after a spinal fusion in children with cerebral palsy. This is the first study to investigate the validity of the modified Clavien-Dindo-Sink classification in GI complications after a spinal fusion. Results suggest a correlation between complication severity grade and hospital length of stay. The complexity of perioperative enteral nutritional supplementation requires prospective studies dedicated to enteral feeding protocols.

Application of a halo fixator for the treatment of pediatric spinal deformity. JBJS Essential Surgical Techniques. March 2021.

• Shaw, K.A., Griffith, M., Schmitz, M.L., Brahma, B., Fletcher, N.D., Murphy, J.S.
• Summary: For spinal deformities, the halo fixator can be expected to lengthen the spine and increase deformity flexibility before definitive surgical treatment in the spine or growth-friendly spinal instrumentation. 

Short-term outcomes of an enhanced recovery after surgery (ERAS) pathway versus a traditional discharge pathway after posterior spinal fusion for adolescent idiopathic scoliosis. Spine Deformity Journal. Jan. 18, 2021.  

• Fletcher, N.D., Murphy, J.S., Austin, T.M., Bruce, R.W., Harris, H., Bush, P., Yu, A., Kusumoto, H., Schmitz, M.L., Devito, D.P., Fabregas, J.A., Miyanji, F.
• Summary: Enhanced recovery after surgery (ERAS) pathways have been shown to decrease length of stay after a posterior spinal fusion (PSF) for patients with adolescent idiopathic scoliosis (AIS). The aim of this study was to compare immediate post-operative outcomes following an ERAS pathway with a traditional pathway for AIS. Patients managed with an ERAS pathway had similar pain scores at discharge than those managed with a traditional discharge (TD) pathway. Both groups showed evidence of rapid return to normalcy by the first follow-up visit.

The reliability of the AOSpine thoracolumbar classification system in children: Results of a multicenter study. J Pediatr Orthop. February 2020. doi: 10.1097.

• Mo, A.Z., Miller, P.E., Glotzbecker, M.P., Li Y., Fletcher, N.D., Upasani V.V., Riccio, A.I., Hresko, M.T., Krengel, W.F., Spence, D., Garg S., Hedequist, D.J.
• Summary: This study aimed to determine whether the new AOSpine thoracolumbar spine injury classification system is reliable and reproducible when applied to the pediatric population.

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

• Bellaire, L.L, Bruce, R.W. Jr., Ward, L.A., Bowman, C.A., Fletcher, N.D.
• Summary: 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.
• Summary: 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.
• Summary: 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.
• Summary: 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.
• Summary: 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. January 2019;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: Dr. Murphy 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% 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% decrease in complications and a 25% 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.

Fusions ending above the sagittal stable vertebrae in adolescent idiopathic scoliosis: does it matter? Spine Deform 2020.

• Segal, D.N., Orland, K.J., Yoon, E., Bastrom, T., Fletcher, N.D., Harms Study Group.
• Summary: Posterior spinal fusion is a treatment for teenage patients with scoliosis. This study evaluates the ideal spinal levels for fusion to preserve spinal motion, while preventing the later development of additional deformity.
  

Traumatic hip dislocations in the pediatric patient: Injury patterns, need for axial imaging, outcomes, and selective hip arthroscopy. April 2022.

• Willimon, S.C., Egger, A.C., Perkins, C.A.
• Summary: Traumatic hip dislocations are uncommon injuries in the pediatric population.  Injury recognition and prompt closed reduction is standard of care. Results of this study indicate selective hip arthroscopy after traumatic hip dislocations may be a viable less invasive method for treatment of incarcerated fragments and labral injury.

Descriptive epidemiology from the Research in Osteochondritis Dissecans of the Knee (ROCK) Prospective Cohort. January 2022.

• ROCK Group, including, Perkins, C.A., Willimon, S.C., Busch, M.T., et al.
• Summary: The aim of this study was to provide a baseline report of the ROCK multicenter prospective cohort and present a descriptive analysis of baseline data for patient characteristics, lesion characteristics, and clinical findings of the first 1,000 cases enrolled into the prospective cohort. The multicenter ROCK group has been able to enroll the largest knee OCD cohort to date.

Assessment of skeletal maturity and post-operative growth disturbance after anterior cruciate ligament reconstruction in skeletally immature patients: A systematic review. American Journal of Sports Medicine. May 2021. 

• PLUTO Study Group, including, Perkins, C.A., Willimon, S.C., Busch, M.T., et al.
• Summary: Growth disturbance is an uncommon but potentially serious complication after anterior cruciate ligament (ACL) reconstruction in skeletally immature patients. The purpose of this study was to describe how pediatric ACL literature has assessed preoperative skeletal maturity and the amount of growth remaining, and to comprehensively review the incidence, reporting and monitoring of post-operative growth disturbance.

Rates of concomitant meniscal tears in pediatric patients with anterior cruciate ligament injuries increase with age and body mass index. Orthopaedic Journal of Sports Medicine. March 2021. 

• Perkins, C.A., Christino, M.A., Busch, M.T., Murata, A., Egger, A.C., Kelleman, M., Willimon, S.C.
• Summary: Anterior cruciate ligament (ACL) tears are frequently associated with meniscal injury. Risk factors for concomitant meniscal injuries have been studied in the adult population but less so in pediatric patients. Pediatric patients undergoing ACL reconstruction had a 58% incidence of concomitant meniscal pathology. Increasing age and body mass index (BMI) were independent risk factors for these injuries, while no association was found between time to surgery and meniscal pathology.

Early operative versus delayed operative versus nonoperative treatment of pediatric and adolescent anterior cruciate ligament injuries. American Journal of Sports Medicine. December 2021. 

• PLUTO Study Group, including, Perkins, C.A., Willimon, S.C., Busch, M.T., et al.
• Summary: Early and delayed operative treatment achieved satisfactory knee stability. However, delaying anterior cruciate ligament (ACL) reconstruction in pediatric patients younger than 12 weeks old significantly increased the risk of meniscal injuries and irreparable meniscal tears.  Nonoperative management resulted in high rates of residual knee instability, increased risk of meniscal tears and comparatively low rates of return to sports.

Transosseous repair of patellar sleeve fractures: A case series and surgical technique guide. Journal of Knee Surgery. February 2021. 

• Perkins, C.A., Egger, A.C., Willimon, S.C.
• Summary: The purpose of this study is to describe the surgical technique and outcomes of transosseous repair of patellar sleeve fractures in a pediatric cohort. A retrospective review was performed on patients younger than 16 years old who underwent transosseous repair of distal patellar sleeve fractures. Primary outcomes included intact extensor mechanism function and range of motion (ROM) at final follow-up. All patients who began knee ROM  physical therapy within 21 days of surgery obtained full knee ROM. No patients experienced construct failure or extensor lag. Operative management of displaced patellar sleeve fractures with anatomic transosseous suture repair of the sleeve fracture, brief immobilization no more than 21 days, and initiation range of early ROM results in excellent outcomes.

Saucerization and repair of discoid lateral menisci with peripheral rim instability: intermediate term outcomes in children and adolescents.  J Pediatr Orthop 2021;14(1):23-27.

• Perkins, C.A., Busch, M.T., Christino, M., Willimon, S.C.
• Summary: A single-institution retrospective review was performed of consecutive patients less than 18 years of age treated with saucerization and repair for a meniscocapsular tear of a discoid lateral meniscus from 2013 to 2017. Saucerization of discoid lateral menisci with repair of meniscocapsular tears is associated with low rates of revision surgery and good intermediate-term outcomes. 

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.
• Summary: 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.
• Summary: 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: 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. 
• 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. 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.

Key presenters at 2022 PRiSM Annual Meeting

Our sports medicine physicians were proud to host the following sessions and presentations at the 2022 Pediatric Research in Sports Medicine Society Annual Meeting. 

Thursday, January 27

• Cliff Willimon, MD and Crystal Perkins, MD: Hot off the Press- Top 5 in 60

Saturday, January 29

• Crystal Perkins, MD: Poster: Does Shortening Change in the First 2 Weeks Following Completely Displaced Adolescent Clavicle Fractures?

Key presenters at 2021 Scoliosis Research Society (SRS) Annual Meeting

Dr. Fletcher presented his research and represented our Spine Program at the 2021 SRS Annual Meeting. 

Wednesday, September 22

• Nicholas Fletcher, MD: 10-Year Follow Up of Lenke V Curves in Patients with Adolescent Idiopathic Scoliosis

Saturday, September 25

• Nicholas Fletcher, MD: Lowest Instrumented Vertebral Discordance in Adolescent Idiopathic Scoliosis: When Coronal and Sagittal Parameters Conflict

 

Key presenters at 2021 Pediatric Orthopaedic Society of North American (POSNA) Annual Meeting

Children’s Healthcare of Atlanta was honored to have many orthopaedic surgeons among the presenters and speakers for POSNA 2021.

Wednesday, May 12

• Nicholas Fletcher, MD: Saving Yourself and Others From Bad Meetings

Friday, May 14

• Nicholas Fletcher, MD: 10-Year Follow Up of Lenke V Curves in Patients with Adolescent Idiopathic Scoliosis

Saturday, May 15

• S. Clifton Willimon, MD: Opiod Use in Children and Adolescents Following Common Orthopaedic Surgeries

• Robert Bruce, MD: Perioperative Steroid Use in Patients Undergoing Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

• Nicholas Fletcher, MD: Establishing a Gold Standard for Estimation of Blood Loss During Spine Surgery

e-Poster

• Crystal Perkins, MD: Osteochondral Lesions of the Talus: Factors Predictive of Cartilage Integrity

• Nicholas Fletcher, MD: Evaluation of the AOSpine Injury Classification in the Pediatric Population: Results of a Multi-Center POSNA Grant

Key presenters at 2020 PRiSM

A number of our pediatric orthopedic surgeons—Drs. Busch, Willimon and Perkins—are key members of Pediatric Research in Sports Medicine (PRiSM) and recently presented on several topics at the 2020 annual meeting in Glendale, Ariz. Dr. Willimon was also elected Chair of the PRiSM Research Committee, which oversees 13 different research interests.

Presentations by our pediatric orthopedic experts for the 2020 annual meeting included:

Rehabilitation Pearls for Multi-Ligament Knee Injuries

• Dr. Perkins shared updates on the Multi-Ligament Knee Injury Research Group in which she is the leader for 2020 and Dr. Willimon is a member.

Multi-Ligament Knee Injury: Anatomy and Diagnosis

• Dr. Willimon

Autologous Chondrocyte Implantation To Manage Unsalvageable Osteochondritis Dissecans

• Dr. Willimon

Osteochondral Lesions of the Talus: Factors Predictive of Cartilage Integrity

• Drs. Busch, Perkins and Willimon, in addition to John Erickson, DO, and Kiery Braithwaite, MD

Podium presentation: Research on the Children’s cartilage imaging in the ankle

• Asahi Murata, MPH

Information in presentations was current at the time of the conference in January 2020.

2019 PRiSM

Our team was excited to share our current research in sports medicine with leaders from across the country at the 2019 PRiSM annual meeting, including:

Post-Operative Wound Care in Sports Medicine

• Dr. Erickson

Graft Choice For Adolescent Athletes Returning to High-Risk Sports: A Matched Cohort Analysis of Patellar Tendon and Hamstring Autografts

• Dr. Perkins

Surgical Technique: Quadriceps Tendon ACL Reconstruction

• Drs. Busch, Perkins and Willimon

Outcomes of Discoid Meniscus Repairs in Children and Adolescents

• Dr. Willimon

Meniscus Root Tears in Children and Adolescents

• Dr. Willimon

Avulsions of the Distal Femur and Proximal Tibia: Rare Ligamentous Injuries in Children and Adolescents

• Dr. Perkins

Multi-Ligament Knee Injury Research Interest Group—Research Update and Literature Review

• Dr. Willimon

Knotless Labral Repair in the Young Contact Athlete

• Dr. Busch

Opioid Use in Adolescents Following Hip and Knee Arthroscopy

• Dr. Willimon

The Rate of Meniscus Tears in Association with Anterior Cruciate Ligament Injuries Increases with Age

• Drs. Busch, Perkins and Willimon

American Osteopathic Academy of Orthopedics (AOAO), October 2018

• Dr. Busch presented on Clavicle Fractures in Children and Adolescents at this recent conference.

QSVI Value Webinar (from POSNA), June 2018

• Dr. Nicholas Fletcher, MD, Medical Director Spine Quality and Outcome presented on Improving value of scoliosis care: Real life lessons from the field

Pigmented Villonodular Synovitis: Arthroscopic Management of an Underappreciated Cause of Joint Pain in Children and Adolescents, May 2018

This presentation won best POSNA E-Poster. View the presentation slides

• Presented by Drs. Willimon, Busch, Schrader and Perkins

The Association of Children's Prosthetic-Orthotic Clinics (ACPOC) Annual Meeting, April 2018

Is Inclinometer Reading in Scoliosis Screening Reliable for Guiding Referral Decisions: A Retrospective Analysis

• Presented by Dr. Schmitz, Mary Lou Oliver, RN, BSN, MSPH, and Janet R. Lombardo, CPO, LPO, MBA, Prosthetist Orthotist

The Use of Immediate Postoperative Prostheses (IPOPS) Following Transfemoral Amputations in Adolescents

• Presented by: Richard Welling Jr., MSPO, CPO, CSCS, Prosthetic Orthotist; Rebecca Hernandez, CPO, Prosthetist; Brian Giavedoni, MBA, CP, LP, Prosthetist; Colleen P. Coulter-O’Berry,PT, DPT, PhD, PCS, Team Leader of the Limb Deficiency Program; Jill Cannoy, DPT; and Jorge A. Fabregas, MD, Orthopedic Surgeon