Obesity in Paediatric Orthopaedics: Challenges of a Supersized Epidemic

Lise Leveille, M.D.
University of British Columbia
Vancouver, BC

Harish Hosalkar M.D.
Consultant Orthopaedic Surgeon
Paediatric, Adolescent and Young Adult Hip and Trauma Specialist
AO-North America Faculty for Paediatric Orthopaedic Traumatology
Rady Children's Hospital
San Diego, CA

"Childhood obesity isn't some simple, discrete issue. There's no one cause we can pinpoint and no one program we can fund to make it go away. Rather, it's an issue that touches on every aspect of how we live and how we work" Michelle Obama, 9/15/2010

Sadly but truly, childhood obesity has become a well-recognized public health epidemic. Within the last three decades, the prevalence of obesity has tripled among school-age children and adolescents1. In 2010, the number of obese and overweight children worldwide reached forty-three million, with a prevalence of 6.7%2.

 

Body mass index (BMI) is the measure most commonly used to quantify obesity in adults. Obesity in children and adolescents is described with use of the Centre for Disease Control sex-specific BMI-for-age growth charts1. Overweight children are defined as those between the 85th and 95th percentile and obese children are those at or above the 95th percentile.

Obesity places children at risk for both short-term health consequences3 and long-term sequelae.4 Orthopaedic concerns are well defined among this spectrum of problems. Overweight children report a greater prevalence of musculoskeletal discomfort and mobility impairment compared to their peers5. Obesity in children is strongly associated with some common orthopaedic conditions and adversely affects the management of many others. In this review, we will outline many of these problems supported by evidence in the literature and discuss some of the important considerations in managing overweight children and adolescents.

Slipped Capital Femoral Epihpysis (SCFE)
The exact cause of SCFE remains unknown, but there is a strong association with obesity6-9. Prevalence of obesity in patients presenting with a SCFE has been reported to be as high as 81%8. In addition, obese patients presenting with a SCFE have an increased risk of bilateral disease and of progression from unilateral to bilateral disease6. With rising prevalence of adolescent and childhood obesity, an associated increased incidence of SCFE has been observed further supporting the relationship between these two conditions7, 9.

HOSALKAR_Figure1
Figure 1: Pelvis radiograph of a 130 kilogram 12-year-old male who presented with a three-month history of left knee pain. Note the severe SCFE of the left proximal femur. An increased incidence of this condition should be anticipated as the prevalence of adolescent obesity continues to increase in Canada.

Blount Disease
The pathogenesis of Blount disease is likely multifactorial with a strong mechanical component. Increased loads placed across the medial compartment of the knee cause growth inhibition of the medial side of the proximal tibial physis and subsequent genu varum deformity. There is a positive correlation between high BMI and the magnitude of genu varum in children with untreated early onset Blount disease10. In the less common adolescent variety of Blount disease, African Americans that are morbidly obese comprise more than 90% of reported cases11. Obese patients with Blount disease are more likely to require surgical intervention when compared to their non-obese counter parts12. They have an increased risk of complications related to the surgical intervention, including implant failure13, 14.

Fracture Management
Prevalence of extremity fractures is higher in obese children and adolescents than in non-obese controls15-17. This may be related to potential variations in their bone mineral density, serum leptin levels, or altered balance and gait18.

Obese children with operatively-treated femur fractures have a significantly increased incidence of complications including re-fracture, pin-site infection, loss of alignment, wound infection, malunion, osteomyelitis, wound dehiscence, compartment syndrome, and hardware failure19. Implant selection is an important component of preoperative planning. Greater mechanical demand is placed on the chosen construct when compared to non-obese children. For example, children greater than 49 kilograms are five times more likely to have a poor outcome with flexible titanium elastic nailing of femoral shaft fractures20, 21. The American Acadamy of Orthopaedic Surgeons recently released treatment guidelines that recommend children greater than 49 kilograms be treated with rigid trochanteric entry nails or submuscular plating to avoid these complications22.

Perioperative Considerations
Careful preoperative planning is important for all patients but is of even greater importance in the obese patient. Any given surgical procedure will likely be more technically difficult due to positioning and exposure challenges related to patient size and depth of subcutaneous tissue. Obese patients often require larger incisions to achieve adequate exposure of the local anatomy. This results in longer operative times, which subsequently contributes to increased postoperative complications.

There is a higher prevalence of critical events during anaesthesia in obese children23, and increased prevalence of obstructive sleep apnea and asthma in obese patients can complicate postoperative patient care18. Wound dehiscence and infection is of great concern to the paediatric surgeon treating obese and overweight patients as these complications have been found to be significantly higher in this population24. Primary incisional wound vac therapy following major surgical procedures (such as hip and pelvis operations) has been shown to decrease the risk of postoperative infections and wound complications in this population25.

HOSALKAR_Figure2
Figure 2: Incisional vac therapy used for an obese patient to decrease risk of postoperative infection or wound complication.

Summary
Childhood and adolescent obesity is a global problem with significant impact on diagnosis and treatment of orthopaedic conditions in this unique population. We are likely going to see an increasing trend in conditions such as SCFE and Blount disease as the epidemic continues to spread. We should also anticipate increased complexity in operative interventions and recognize the need to plan appropriately with operating room resources and orthopaedic implants.

References

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  2. De Onis M., Blossner M., Borghi E. Global prevalence and trends of overweight and obesity among preschool children. Am J Clin Nutr. 2010;92:1257-1264.
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  21. Weiss. Complications with flexible nailing of femur fractures more than double with child obesity and weight >50 kg. Journal of Children's Orthopaedics. 2009;3:53-58.
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  25. Venkatadass M.S., Bittersohl B., Fornari E.D., Bomar J.D., Harish H. Does Incisional Wound VAC after Major Hip Surgery in Obese Pediatric Patients Reduce Wound Infection and Scar Formation? A Pilot Study. Clinical Orthopaedics and Related Research. In press.

 

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