AM Op List:
(1) Child X, 7 years old. Varus Osteotomy for Perthes’ (or perhaps a spica, or brace, or nothing?).
(2) Child Y, 12 years old. In-situ Pinning Severe Stable SCFE (or perhaps an osteotomy?).
(3) Child Z, 5 years old. Cross-wiring of Supracondylar Humerus Fracture (or perhaps lateral wires?).
Uncertainty prevails in many aspects of children’s orthopaedic surgery, with even the most common diseases lacking a surgical approach that is universally adopted. Children’s orthopaedic practice has largely developed through an experiential approach, with successful wisdom ‘passed on’ in the surgical apprenticeship. Such ‘wisdoms’ are often justified by case series, but rarely do these challenge preconceived ideas. Even the most highly regarded papers may lack the scientific rigor required to challenge, or indeed change, current practice. Patient enrollment to intervention trials is a rarity. ...
Perhaps the primary barrier to research in children’s orthopaedics is the case volume. In many diseases of adult orthopaedic surgery, a single-centre’s workload may generate enough case-volume to overcome this barrier and produce high quality research output,1 yet in children’s orthopaedics high case-volumes are rare. For this reason prospective studies may take many years to adequately power, and support from funding bodies and academia may be difficult to acquire. Other barriers include unclear outcome measures, the necessity for lengthy follow-up in order to record outcomes at skeletal maturity and a reluctance to randomise patients. Some attempts have been made to embark upon large-scale collaborative children’s orthopaedic studies to overcome the problem of ‘volume’, but all too often the barriers have been to great to overcome.2Uncertainty prevails in many aspects of children’s orthopaedic surgery, with even the most common diseases lacking a surgical approach that is universally adopted. Children’s orthopaedic practice has largely developed through an experiential approach, with successful wisdom ‘passed on’ in the surgical apprenticeship. Such ‘wisdoms’ are often justified by case series, but rarely do these challenge preconceived ideas. Even the most highly regarded papers may lack the scientific rigor required to challenge, or indeed change, current practice. Patient enrollment to intervention trials is a rarity.
The specialty to most successfully overcome challenges similar to those faced by paediatric orthopods is paediatric oncology. Case volumes are similarly small, with just 12,500 new malignancies in individuals under 20 each year in the USA. However, cancer research in childhood malignancy has been so successful that survival has improved from < 10%, to > 80% over the last 60 years. This achievement has largely been made by a collaborative approach, involving pooling patients and cross-fertilising ideas. This collaborative ethos, has attracted a raft of support, has proven success, and even the most rare tumors are now usually eligible for trial recruitment. Funding bodies accept that for rare tumours trial recruitment may have to be extended over many years, and the collaborative ethos is so strong that malignancies with an annual frequency of just 5-6 UK cases per year are recruited into international collaborative trials.3 The research culture is so ingrained in paediatric oncology, that > 70% of those with a childhood cancer are enrolled in a trial, and most of the remainder are usually treated according to protocols established through trials.4 Trials, by definition, seek to find the more successful method of treatment, but paediatric oncology has demonstrated that both arms of the trial generally have improved outcomes compared to those treated outside a trial – the so-called ‘inclusion benefit’. Currently, surgeons may be firm in their belief that their treatment regimen is optimal, and consider randomization unethical. However, the ‘inclusion benefit’ is a compelling argument to overcome concerns of randomization, further supporting patient involvement in trials.
In the UK there has been a recent surge in interest in collaborative networks amongst paediatric orthopaedics. The recent meeting of the British Society for Children’s Orthopaedic Surgery (BSCOS-2013) included discussion amongst members who had joined to investigate two of the most common elective diseases in paediatric orthopaedics, Developmental Dysplasia of the Hip and Slipped Femoral Epiphysis (the British Orthopaedic SCFE Surgery trial group). These networks are been run through academic units, and will be funded externally through grant support. It is hoped that the close-knit nature of the paediatric orthopaedic community, and the active support of the representative bodies, particularly EPOS and BSCOS, may allow collaborative research networks to flourish, and research to form a routine part of practice. The government drive for the nationwide collection of surgeon-level data may help to provide a universal mechanism by which to collect outcome data – perhaps via a mechanism similar to trauma (TARN) or hip fractures (NHFD).
Paediatric orthopaedic surgeons are learning from the paediatric oncologists, with a growing determination to emulate their research successes. The passion and drive that exists amongst surgeons, along with academic input, support from the funding bodies and possible assistance from government initiatives, may soon reach the ‘tipping-point’ with study recruitment, and high quality research-outputs being commonplace in children’s orthopaedic surgery.
Mr Daniel Perry, NIHR Clinical Lecturer in Trauma and Orthopaedic Surgery, Warwick Orthopaedics, University of Warwick, UK
1. Costa ML, Achten J, Parsons NR, et al. Total hip arthroplasty versus resurfacing arthroplasty in the treatment of patients with arthritis of the hip joint: single centre, parallel group, assessor blinded, randomised controlled trial. BMJ 2012;344:e2147.
2. Dietz FR. Reflections on the failure of the POSNA-sponsored multicenter trial for treatment of unstable slipped capital femoral epiphysis. J Pediatr Orthop2010;30:386-89.
3. Le Deley MC, Rosolen A, Williams DM, et al. Vinblastine in children and adolescents with high-risk anaplastic large-cell lymphoma: results of the randomized ALCL99-vinblastine trial. J Clin Oncol 2010;28:3987-93.
4. Unguru Y. The successful integration of research and care: how pediatric oncology became the subspecialty in which research defines the standard of care. Pediatr Blood Cancer 2011;56:1019-25.