2023 Publication Highlights from the Division of Orthopaedics

The Division of Othopaedics is one of the largest and most established pediatric programs in the world. A core part of our mission is to improve children's lives through research. Here are some of our recent highlights of publications from 2023.

Tong, Y., Udupa, J.K., McDonough, J.M., Wu, C., Sun, C., Xie, L., Lott, C., Clark, A., Mayer, O.H., Anari, J.B. and Torigian, D.A., Cahill, P.J. 2023. Assessment of Regional Functional Effects of Surgical Treatment in Thoracic Insufficiency Syndrome via Dynamic Magnetic Resonance Imaging. JBJS, 105(1), pp.53-62.

Led by teams of Dr. Cahill and Dr. Udupa, this study is an amalgamation of long-standing collaboration between the two groups. The investigative team focused on thoracic insufficiency syndrome (TIS) patients undergoing vertical expandable prosthetic titanium rib (VEPTR) surgery. The team have pioneered a new 4D imaging technique, Quantitative dynamic magnetic resonance imaging emerges for assessing pulmonary function. Now patented, this imaging technique offers a non-invasive, radiation-free, and effort-independent alternative to spirometry while providing detailed information on regional respiratory function, demonstrating improvements in lung volumes and thoracic dynamics postoperatively. The study highlights the potential of dynamic MRI in assessing deviations from normal thoracic function, guiding surgical interventions, and serving as a benchmark for various conditions affecting respiratory health. Read the publication. 

Belardo, Z.E., Talwar, D., Blumberg, T.J., Nelson, S.E., Upasani, V.V., Sankar, W.N. and Shah, A.S., 2023. Opioid Analgesia Compared with Non-Opioid Analgesia After Operative Treatment for Pediatric Supracondylar Humeral Fractures: Results from a Prospective Multicenter Trial. JBJS, pp.10-2106.

Funded by POSNA, in a project led by Dr. Shah along with Dr. Sankar, our team collaborated with Dr. Upasani at Rady’s Children Hospital, Dr. Blumberg at Seattle Children’s Hospital and Dr. Nelson at University of Rochester. The study investigated the efficacy of opioid versus non-opioid analgesia in pediatric patients undergoing closed reduction and percutaneous pinning (CRPP) for supracondylar humerus fractures. Results indicated no significant difference in postoperative pain between the Non-Opioid Cohort (ibuprofen and acetaminophen) and Opioid Cohort (oxycodone, acetaminophen, and ibuprofen) from postoperative day 1 to 21. Opioid prescriptions, when given, were underutilized, suggesting potential for opioid stewardship. This study provides support for recommending acetaminophen and ibuprofen to patients after elbow fracture surgery, which will improve opioid stewardship for this common surgery and potentially for others like it. Reviewing the important implications of the study, a commentary was written on it in JBJS where Dr. Dale Blasier described the study as “remarkable for its simplicity and sensibility.” Read the publication.

Masquijo, J.J., Ortiz, M.S., Ponzone, A., Korosec, L.F. and Arkader, A., 2023. Management of Lateral Condyle Humeral Fracture Associated with Elbow Dislocation in Children. A Retrospective International Multicenter Cohort Study. Journal of Pediatric Orthopaedics, pp.10-1097.

In these international multicenter collaboration, Dr. Arkader partnered with Dr. Masquijo to investigate the surgical treatment outcomes of lateral condyle humerus fractures combined with elbow dislocation in pediatric patients. The authors found that 35% of the patients experienced poor clinical outcomes with complications like persistent elbow stiffness, avascular necrosis (AVN), and chronic instability. Elbow stiffness was the most common complication, emphasizing the importance of early mobilization. The study proposes that internal fixation with screws and a shorter postoperative immobilization period may lead to improved outcomes. Read the publication.

Kiani, S.N., Gornitzky, A.L., Matheney, T.H., Schaeffer, E.K., Mulpuri, K., Shah, H.H., Yihua, G., Upasani, V., Aroojis, A., Krishnamoorthy, V. and Sankar, W.N., 2023. A Prospective, Multicenter Study of Developmental Dysplasia of the Hip: What Can Patients Expect After Open Reduction? Journal of Pediatric Orthopaedics, 43(5), pp.279-285.

Dr. Sankar partnered with Global Hip Dysplasia Registry, a prospectively collected international multicenter database, on a study focusing on the early outcomes of open reduction for developmental dysplasia of the hip (DDH) in infants. The primary goals were to report overall results with specific attention to re-dislocation, avascular necrosis (PFGD), and residual acetabular dysplasia (RAD). The study reveals a 7.0% rate of re-dislocation, with the majority occurring within the first year after surgery. PFGD is identified in 43.9% of cases, higher than some previous studies, and RAD is influenced by factors like older age and absence of pelvic osteotomy. The study emphasizes the need for shared decision-making and consideration of pelvic osteotomies to improve outcomes. Read the publication.

Jia, L., King, J.D., Goubeaux, C., Belardo, Z.E., Little, K.J., Samora, J.B., Marks, J. and Shah, A.S., 2023. Presentation and Management of the Pediatric Trigger Finger: A Multicenter Retrospective Cohort Study. The Journal of Hand Surgery.

In a multicenter collaboration across three sites led by Dr. Apurva Shah, the study investigates Pediatric Trigger Finger (PTF), an acquired condition in children, distinguishing it from pediatric trigger thumb. PTF is less common than pediatric trigger thumb and has variable etiologies, making its natural history poorly understood. The study, conducted across three children's hospitals, includes 321 patients with 449 PTFs, revealing a mean age of onset at 5.4 years. Nonoperative management was initially pursued in 80.1% of cases, with a 30% rate of complete resolution. Operative management, including A1 pulley release, resulted in a significantly higher resolution rate of 97.1%. Patients with multidigit involvement, higher Quinnell grade, and palpable nodules were more likely to progress to surgery. The study provides insights into PTF presentation, management, and outcomes in a large multicenter cohort. Read the publication.

Tibial Spine Research Interest Group, Orellana, K.J., Houlihan, N.V., Carter, M.V., Baghdadi, S., Baldwin, K., Stevens, A.C., Cruz Jr, A.I., Ellis Jr, H.B., Green, D.W. Kushare, I., Ganley, T.G. Tibial Spine Fractures in the Child and Adolescent Athlete: A Systematic Review and Meta-analysis. The American Journal of Sports Medicine, p.3635465231175674.

In a systematic review led by Dr. Ganley along with Tibial Spine Research Interest Group, the team evaluated current trends in treatment approaches, outcomes, and complications. With an incidence of 3 per 100,000, TSFs can lead to time away from sports and unwanted consequences. Overall, good outcomes were observed, but controversies exist around fixation methods, surgical timing, and imaging modalities. The study emphasizes the importance of early mobilization after treatment to avoid complications such as ROM loss and arthrofibrosis. Despite the variety of treatment methods, good outcomes are expected, with a focus on diagnosing and treating concomitant injuries, obtaining stable fixation, and early rehabilitation. The study acknowledges limitations in the evidence level and calls for larger comparative studies for a better understanding of long-term effects on patients. Read the publication.

Corwin, D.J., Mandel, F., McDonald, C.C., Mohammed, F.N., Margulies, S., Barnett, I., Arbogast, K.B. and Master, C.L., 2023. Maximizing accuracy of adolescent concussion diagnosis using individual elements of common standardized clinical assessment tools. Journal of athletic training. 58(11/12):962–973. doi: 10.4085/1062-6050-0020.22

In a study led by Dr. Master from Mind Matters Concussion program, the team evaluated concussion assessments in adolescents, researchers to identify a streamlined combination of subcomponents from four commonly used clinical assessments. The top concussion batteries contributing to accurate concussion diagnosis included visio-vestibular examination (VVE), Sport Concussion Assessment Tool, fifth edition (SCAT5; including the modified Balance Error Scoring System), King-Devick test (K-D), and Post-concussion Symptom Inventory (PCSI). The findings suggest a potential reduction in the number of elements needed for diagnosis, emphasizing the importance of clinical testing beyond symptom evaluation. The study proposes a diagnostic test focused on the top four factors (i.e., symptoms, attention, balance, and the visio-vestibular system), is critical, which performed as well as complete batteries, potentially reducing time and cost for clinicians. As next steps, the authors emphasize the need for further validation and exploration of psychometric properties.  Read the publication.

Mundy, C., Yao, L., Shaughnessy, K.A., Saunders, C., Shore, E.M., Koyama, E. and Pacifici, M., 2023. Palovarotene Action Against Heterotopic Ossification Includes a Reduction of Local Participating Activin A‐ Expressing Cell Populations. JBMR plus, 7(12), p.e10821.

In an important collaborative investigation led by Dr. Pacifici along with Dr. Koyama, this study focuses on therapeutic action of palovarotene against heterotopic ossification (HO). HO involves the formation of extraskeletal bone in response to physical insults or genetic conditions. The investigation demonstrated a decrease in Inhba-expressing/activin A- producing cells within HO masses after palovarotene administration. The data suggest that palovarotene inhibits canonical BMP signaling, chondrogenesis, and cells participating in HO, emphasizing its multi-level action against HO formation. The study highlights the complexity of activin A biology, its roles in musculoskeletal processes, and the potential of palovarotene as a treatment for disorders like fibrodysplasia ossificans progressiva. Read the publication.

Ji, X., Seeley, R., Li, K., Song, F., Liao, X., Song, C., Angelozzi, M., Valeri, A., Marmo, T., Lee, W.C., Shi, Y., and Long, F. 2023. Genetic activation of glycolysis in osteoblasts preserves bone mass in type I diabetes. Cell Chemical Biology, 30(9), pp.1053-1063.

Dr. Fanxin Long spearheaded this study to examine monogenic type I diabetes mouse model and discovered defective glycolysis in osteoblasts as an underlying cause for diabetic osteopenia. Bone fragility is increasingly recognized as a comorbidity in diabetic patients. Type I diabetes especially is associated with decreased bone mineral density and a notable increase in fracture risks. Currently, the two main classes of bone anabolic therapies are inadequate for diabetic patients due to contraindications of either cardiovascular complications or pediatric patients with open epiphysis. The findings highlight the impact of hypoinsulinemia and hyperglycemia on osteoblast glycolysis as a mechanism for osteopenia in T1D. The results provide a proof of principle that osteoblast glycolysis may be therapeutically activated to minimize bone loss in diabetes. Read the publication.

Strong, A., Behr, M., Lott, C., Clark, A.J., Mentch, F., Da Silva, R.P., Rux, D.R., Campbell, R., Skraban, C., Wang, X. and Anari, J.B., Sinder, J.B., Cahill, P.J., Slieiman, P. Hakon Hakonarson. 2023. Molecular diagnosis and novel genes and phenotypes in a pediatric thoracic insufficiency cohort. Scientific Reports, 13(1), p.991.

Drs. Cahill and Anari collaborated with Dr. Hakonarson & Center for Applied Genomics to elucidate the underlying molecular etiologies of syndromic and non-syndromic thoracic insufficiency and predict extra-skeletal manifestations and disease progression. The research was conducted on a cohort of 42 Thoracic Insufficiency Syndrome (TIS) patients, aiming to understand the genetic and phenotypic landscape of the disorder. Many TIS cases result from underlying genetic diseases affecting skeletal development or connective tissue components. Our team identified a novel association between KIF7 and USP9X variants and thoracic insufficiency. The study utilizes comprehensive phenotyping analysis and whole exome sequencing to uncover the genetic factors contributing to TIS, emphasizing the importance of molecular diagnosis for prognosis and management. Read the publication.