HSS Presents New Findings Impacting Pediatric Orthopedic Care Recommendations at AAOS Annual Meeting

At this year's American Academy of Orthopedic Surgeons (AAOS) annual meeting, investigators at Hospital for Special Surgery(HSS) presented several significant studies, two of which could lead to changes in how surgeons counsel families of young patients facing serious orthopedic conditions.

What follows are highlights from these studies:

Surgery Unnecessary for Most Adolescent Athletes with Lumbar Spine Stress Fracture

A new study by researchers at HSS shows that 95 percent of adolescent athletes who are diagnosed with acute spondylolysisheal with just rest, bracing, and physical therapy. These findings support treating patients with a conservative, non-operative approach and reserving surgery as a last-resort option.

"These results are important because when we sit with families to discuss treatment options, we can confidently tell them that the vast majority of patients do have resolution of their pain and are able to return to sports without having to undergo surgery," explains Jessica H. Heyer, MD, a pediatric orthopedic and spine surgeon at HSS and senior author of the study.

Spondylolysis is a stress injury or fracture of the pars (a bone structure in the vertebrae located at the bottom of the lumbar spine) that often causes lower back pain. It is prevalent among teenage and pre-teen athletes, especially those who repeatedly bend backwards (hyperextend or twist the lower back) such as soccer players, rowers, baseball players, gymnasts, and football players.

The retrospective review included 179 children and teenagers diagnosed with spondylolysis between February 2016 and August 2024. According to the findings, 95% of the patients were free of pain and able to return to their activities after three months of rest, bracing, and physical therapy. Only 5% of this group went on to require surgery, which can involve either a direct repair of the pars with a screw, or a fusion around the pars injury.

"We saw an excellent rate of return to sports and resolution of pain among the patients in our study," notes Dr. Heyer, adding that the protocols for non-operative management of spondylolysis vary across the country.

"These results support our recommendation to restrict activity for a full three months and initiate physical therapy after 4 to 6 weeks of rest," she says. "This period of restricted activity is important to allow for clinical improvement of pain and healing before deciding on whether surgery is needed."

Growth Hormone Therapy May Increase Risk of Fractures in Children and Teens

A new study by researchers at HSS shows a strong association between growth hormone (GH) therapy and an increased risk of physeal fractures, a pediatric bone injury affecting the growth plate near the ends of long bones such as the wrist, fingers, and lower legs. These fractures are responsible for 15% to 30% of all childhood fractures and are common among adolescents who are active in sports.

"We found that GH therapy was associated with an increased rate of physeal fractures in the upper and lower extremities," says Emily Dodwell, MD, MPH, a pediatric orthopedic surgeon at HSS and senior author of the study. "These findings are important because they provide more data to consider as we help families weigh the risks and benefits of GH therapy."

Previous research has yielded contradictory findings about whether exposure to GH therapy increases the risk of physeal fractures.

"With prior studies being inconclusive, we wanted to investigate the potential association between GH and pediatric physeal fractures on a national basis," explains Dr. Dodwell.

GH therapy is used to treat children who are diagnosed with GH deficiency[EN1] , certain genetic syndromes, short stature, and small for gestational age. GH therapy can help increase a child's height, growth rate, and bone mineral density, and improve their body composition and key bloodwork parameters used to test for metabolic syndrome, diabetes risk, and overall cardiovascular health. However, it has also been linked to orthopedic complications, such as progression of scoliosis(curvature of the spine) and increased risk of slipped capital femoral epiphysis (a painful hip condition).

Dr. Dodwell and her colleagues used a nationwide insurance claims database to identify prevalence of pediatric physeal fractures in the upper and lower extremities with and without GH exposure. Their database search included 34,196 patients aged 4 to 18 years old who were given GH therapy for at least one month between 2010 and 2022 and were followed for two or more years. The researchers compared this group to the same number of patients who did not receive GH therapy during that time, taking into account age, sex, and weight.

The analysis found that GH therapy was associated with a higher rate of physeal fractures. These included fractures at the proximal humerus (arm near the shoulder), proximal radius (forearm near the elbow), distal radius (forearm near the wrist), distal ulna (wrist joint), distal femur (thigh bone above the knee joint), proximal tibia (upper shin bone below the knee), and distal tibia (lower shin bone near the ankle).

"This retrospective study was not designed to determine whether GH actually causes these fractures," notes Dr. Dodwell. "Physicians should bear that in mind when counseling patients regarding the risks and benefits of GH therapy."

Further research is needed to confirm these findings, she adds.