From OT Europe

19th EFORT Congress in Barcelona: When should we choose innovative treatments for children?

EFORT

Does the availability of new technologies change the surgeon’s decision-making? Is innovation globally influencing well-established or standard procedures? EFORT has chosen Innovation and New Technologies as the main theme of the 2018 congress, which to some extent will open the debate on how technical progress can, should or will influence medical procedures in the future of orthopaedics and traumatology.

Main theme banner

By focusing on the controversial approaches for treatment of different pediatric deformities and fractures, Prof. Jaroslaw Czubak from the Postgraduate Medical Education Center in Warsaw, Poland, has prepared a symposium program for deep analysis of how innovative treatments influence today’s practice.

Controversies in Pediatric Orthopaedics: Long-term Results vs. Innovative Treatments

Introduction and discussion: Jaroslaw Czubak (Poland)

  • Acute and Chronic Patellar Instability - What Is the Best Surgical Approach? – Manuel Cassiano Neves (Portugal)
  • Lengthening - External Distractors vs. Motorized Intramedullary Nails – Rudolf Ganger (Austria)
  • Traditional vs. Magnetically Growth Modulation Technique in Early Onset Scoliosis - Dror Ovadia (Israel)
  • Treatment of Forearm Fractures (Casting vs. Nailing) - Annelie Martina Weinberg (Austria)

As the surgeon’s decision between a surgical or a conservative approach should always be based on the thorough medical history and physical examination of each individual patient, no matter how advanced the surgical techniques are, the treatment choice remains linked to the diagnosis. To change a well-established procedure, experts need consistent studies with long-term results to prove a new technique leads to a better outcome. Moreover, new technologies are not always at the reach of standard patients as not all hospitals can afford the costs of the materials needed. Probably, over time, if a new technology becomes popular based on its good results (evidence based medicine), the equipment costs will become lower, and treatment will be affordable by a wider population of patients and local governments.

Example of patellar instability

A variety of bony realignment procedures have been proposed to address patellar instability in adults, but remain inapplicable to children and adolescents with open growth plates. Higher incidence of patellar instability has been observed in patients of increasingly younger age, prompting the emergence of procedures designed to respect the soft tissue and improve the ability to address this pathology in the skeletally immature athlete. Recently, several soft-tissue realignment techniques historically used in children (ie, Galeazzi semitendinosus tenodesis), have been associated with the need for repeated surgeries. New approaches should be envisioned, specifically to avoid excessive lateral release of the retinaculum, which can lead to continued lateral instability, medial subluxation or dislocation, persistent anterolateral knee pain or apprehension. Moreover, as recurrent instability of the patella may be one of the most significant disabilities in child and adolescent populations, numerous surgical procedures have been described, leading to a compilation of variable outcomes. This has therefore led to considerable confusion in the literature on how to treat patellofemoral problems in children. For instance, much controversy exists on which procedure is best for a first treatment of ligamentously tight dislocators, regardless of a prior traumatic event.

Limb-length problems: Options to remain or evolve

Distraction osteogenesis has been used for more than 50 years to address limb-length discrepancy and deformity in children. Intramedullary (IM) fixation has been used in conjunction with external fixation to decrease the time of use of the external fixator and prevent deformity and refracture. Recently, a new generation of motorized IM nails has become available to treat limb-length discrepancies and deformities, opening the door to the expectation for supplementary and superior results. These motorized nails provide bone fragment stabilization and lengthening with reliable remote-controlled mechanisms, obviating external fixation use. The procedure allows accurate and well-controlled distraction, reflected in positive clinical results despite the early nature of the data available. As the rate of complications and treatment duration are similar between lengthening over an IM nail and using the classic Ilizarov technique, most of the factors limiting the use of motorized nails are associated with the costs of the equipment. At any rate, motorized nailing systems lead to shorter times of hospitalization and rehabilitation, making this a promising procedure for limb lengthening.

New techniques for early onset scoliosis

Scoliosis treatment in children younger than 5 years of age (early onset scoliosis or EOS) has undergone significant progress in the latest years by the introduction of new growth-sparing techniques. Today, in addition to bracing and fusion or fusionless surgeries, there is a clear distinction between traditional growing rods, which imply repeated surgical lengthening under complete anesthesia, and magnetically controlled growing rods, which allow non-invasive spinal distraction. In addition, the magnetically controlled growth modulation technique unequivocally reduces wound complications, psychological problems and frequent/long hospitalizations in children.

As the management of EOS remains challenging due to the impact of spine growth on lung development, a deeper analysis of these new techniques is clue to assess complications and refine patient selection. Clinical reports with larger cohorts and long-term findings of the magnetically controlled growth modulation technique results should further support the advantages of a less invasive approach and justify the choice of innovation over tradition for correction of spine deformities in the pediatric field.

Forearm fractures: from cast to flexible nailing

Forearm fractures are common traumatic injuries in children. In a pediatric population, forearms bones can be further remodeled by the remaining growth process, allowing a greater fracture displacement to be considered as acceptable in the alignment. IM nailing techniques used for overcoming forearm fractures in children present an advantage of mobility over a conservative treatment using casting alone and a decreased soft-tissue dissection over plating procedures. The patient is indeed allowed immediate active elbow and hand motion. Moreover, as elbow immobilization is not required, there are no concerns about rotational deformity. However, at this time, no randomized trials comparing flexible IM nailing of forearm shaft fractures and cast treatment have been conducted. Recently, a systemic review comparing nailing to cast reported a lower risk of forearm stiffness with nailing (25% stiffness with casting vs. 5% with flexible nailing) but a higher rate of minor complications accompanying the surgical approach (21% vs. 6%). It is important to note that a second operation is needed for nail removal 6 months after the initial procedure. Despite that, nailing appears as an effective strategy for treatment of forearm fractures with acceptable complication rates.

New techniques clearly influence the postoperative handling of patients in the pediatric field in a positive manner: if the hospital stay is shorter, children are able to be back at school earlier and routine activities are established faster. As the pain management has multifactorial background, some new techniques have better long-term results in patients, but others do not. For instance, the lengthening and exchange of the growing rods can also bring some discomfort to the patient. However, in cases where functionality and mobility are equal or superior to traditional surgical approaches, the more innovative treatments, and thus the less invasive ones, should be favored to ease the psychological burden on young children and their parents.

EFORT

Does the availability of new technologies change the surgeon’s decision-making? Is innovation globally influencing well-established or standard procedures? EFORT has chosen Innovation and New Technologies as the main theme of the 2018 congress, which to some extent will open the debate on how technical progress can, should or will influence medical procedures in the future of orthopaedics and traumatology.

Main theme banner

By focusing on the controversial approaches for treatment of different pediatric deformities and fractures, Prof. Jaroslaw Czubak from the Postgraduate Medical Education Center in Warsaw, Poland, has prepared a symposium program for deep analysis of how innovative treatments influence today’s practice.

Controversies in Pediatric Orthopaedics: Long-term Results vs. Innovative Treatments

Introduction and discussion: Jaroslaw Czubak (Poland)

  • Acute and Chronic Patellar Instability - What Is the Best Surgical Approach? – Manuel Cassiano Neves (Portugal)
  • Lengthening - External Distractors vs. Motorized Intramedullary Nails – Rudolf Ganger (Austria)
  • Traditional vs. Magnetically Growth Modulation Technique in Early Onset Scoliosis - Dror Ovadia (Israel)
  • Treatment of Forearm Fractures (Casting vs. Nailing) - Annelie Martina Weinberg (Austria)

As the surgeon’s decision between a surgical or a conservative approach should always be based on the thorough medical history and physical examination of each individual patient, no matter how advanced the surgical techniques are, the treatment choice remains linked to the diagnosis. To change a well-established procedure, experts need consistent studies with long-term results to prove a new technique leads to a better outcome. Moreover, new technologies are not always at the reach of standard patients as not all hospitals can afford the costs of the materials needed. Probably, over time, if a new technology becomes popular based on its good results (evidence based medicine), the equipment costs will become lower, and treatment will be affordable by a wider population of patients and local governments.

Example of patellar instability

A variety of bony realignment procedures have been proposed to address patellar instability in adults, but remain inapplicable to children and adolescents with open growth plates. Higher incidence of patellar instability has been observed in patients of increasingly younger age, prompting the emergence of procedures designed to respect the soft tissue and improve the ability to address this pathology in the skeletally immature athlete. Recently, several soft-tissue realignment techniques historically used in children (ie, Galeazzi semitendinosus tenodesis), have been associated with the need for repeated surgeries. New approaches should be envisioned, specifically to avoid excessive lateral release of the retinaculum, which can lead to continued lateral instability, medial subluxation or dislocation, persistent anterolateral knee pain or apprehension. Moreover, as recurrent instability of the patella may be one of the most significant disabilities in child and adolescent populations, numerous surgical procedures have been described, leading to a compilation of variable outcomes. This has therefore led to considerable confusion in the literature on how to treat patellofemoral problems in children. For instance, much controversy exists on which procedure is best for a first treatment of ligamentously tight dislocators, regardless of a prior traumatic event.

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Limb-length problems: Options to remain or evolve

Distraction osteogenesis has been used for more than 50 years to address limb-length discrepancy and deformity in children. Intramedullary (IM) fixation has been used in conjunction with external fixation to decrease the time of use of the external fixator and prevent deformity and refracture. Recently, a new generation of motorized IM nails has become available to treat limb-length discrepancies and deformities, opening the door to the expectation for supplementary and superior results. These motorized nails provide bone fragment stabilization and lengthening with reliable remote-controlled mechanisms, obviating external fixation use. The procedure allows accurate and well-controlled distraction, reflected in positive clinical results despite the early nature of the data available. As the rate of complications and treatment duration are similar between lengthening over an IM nail and using the classic Ilizarov technique, most of the factors limiting the use of motorized nails are associated with the costs of the equipment. At any rate, motorized nailing systems lead to shorter times of hospitalization and rehabilitation, making this a promising procedure for limb lengthening.

New techniques for early onset scoliosis

Scoliosis treatment in children younger than 5 years of age (early onset scoliosis or EOS) has undergone significant progress in the latest years by the introduction of new growth-sparing techniques. Today, in addition to bracing and fusion or fusionless surgeries, there is a clear distinction between traditional growing rods, which imply repeated surgical lengthening under complete anesthesia, and magnetically controlled growing rods, which allow non-invasive spinal distraction. In addition, the magnetically controlled growth modulation technique unequivocally reduces wound complications, psychological problems and frequent/long hospitalizations in children.

As the management of EOS remains challenging due to the impact of spine growth on lung development, a deeper analysis of these new techniques is clue to assess complications and refine patient selection. Clinical reports with larger cohorts and long-term findings of the magnetically controlled growth modulation technique results should further support the advantages of a less invasive approach and justify the choice of innovation over tradition for correction of spine deformities in the pediatric field.

Forearm fractures: from cast to flexible nailing

Forearm fractures are common traumatic injuries in children. In a pediatric population, forearms bones can be further remodeled by the remaining growth process, allowing a greater fracture displacement to be considered as acceptable in the alignment. IM nailing techniques used for overcoming forearm fractures in children present an advantage of mobility over a conservative treatment using casting alone and a decreased soft-tissue dissection over plating procedures. The patient is indeed allowed immediate active elbow and hand motion. Moreover, as elbow immobilization is not required, there are no concerns about rotational deformity. However, at this time, no randomized trials comparing flexible IM nailing of forearm shaft fractures and cast treatment have been conducted. Recently, a systemic review comparing nailing to cast reported a lower risk of forearm stiffness with nailing (25% stiffness with casting vs. 5% with flexible nailing) but a higher rate of minor complications accompanying the surgical approach (21% vs. 6%). It is important to note that a second operation is needed for nail removal 6 months after the initial procedure. Despite that, nailing appears as an effective strategy for treatment of forearm fractures with acceptable complication rates.

PAGE BREAK

New techniques clearly influence the postoperative handling of patients in the pediatric field in a positive manner: if the hospital stay is shorter, children are able to be back at school earlier and routine activities are established faster. As the pain management has multifactorial background, some new techniques have better long-term results in patients, but others do not. For instance, the lengthening and exchange of the growing rods can also bring some discomfort to the patient. However, in cases where functionality and mobility are equal or superior to traditional surgical approaches, the more innovative treatments, and thus the less invasive ones, should be favored to ease the psychological burden on young children and their parents.