The Role of Obesity in Pediatric Orthopedics

Sports and Weight Control in Children

Pediatric obesity is a global concern with distressing comorbid conditions, including mood disturbance, cardiovascular changes, endocrine imbalance, liver disease, sleep apnea, and orthopedic conditions. The primary treatment of this condition includes physical activity. Participating in organized sports has been shown to reduce weight and the complications of pediatric obesity more effectively than individual exercise.

Metabolic, behavioral health, and disordered eating comorbidities associated with obesity in pediatric patients: An Obesity Medical Association (OMA) Clinical Practice Statement 2022

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) details metabolic, behavioral health, and disordered eating comorbidities associated with obesity in children. This CPS will be followed by a companion CPS covering further comorbidities, including genetics and social consequences related to overweight and obesity. These CPSs are intended to provide clinicians with an overview of clinical practices applicable to children and adolescents with body mass indices greater than or equal to the 95th percentile for their ages, particularly those with adverse consequences resulting from increased body mass. The information in this CPS is based on scientific evidence, supported by the medical literature, and derived from the clinical experiences of members of the OMA.

Methods

The scientific information and clinical guidance in this CPS is based upon referenced evidence and derived from the clinical perspectives of the authors.

Results

This OMA statement details metabolic, behavioral health, and disordered eating comorbidities associated with obesity in children. It provides clinical information regarding identifying and treating metabolic, behavioral health, and disordered eating comorbidities associated with obesity in children over the 95th percentile of weight/height for age.

Conclusions

This OMA clinical practice statement details metabolic, behavioral health, and disordered eating comorbidities associated with obesity in children and provides an overview of current recommendations. These recommendations lay out a roadmap to the improvement of the health of children and adolescents with obesity, especially those with metabolic, physiological, and psychological complications.

The Effect of Obesity on Pediatric Tibia Fractures

BACKGROUND

Childhood obesity affects nearly one fifth of all children in the United States. Understanding the unique injury characteristics and treatment of tibia fractures in this population has become increasingly important. This study aims to explore the different injury characteristics between tibia fractures in obese and non-obese children.

METHODS

215 skeletally immature children aged 2-18 who sustained tibia fractures between 2007.2019 were retrospectively reviewed. Patients were analyzed by weight group: underweight, normal weight, overweight, and obese as defined by body mass index (BMI) percentile based upon age. Analyses were performed on dichotomized groups: underweight and normal weight versus overweight and obese. Chi-square or Fisher's exact test was used to compare differences in categorical outcome between the 2-category BMI class variables; Wilcoxon test was used to compare continuous outcomes. A multivariate logistic regression model was used to evaluate BMI associations while controlling for age, sex, race, and mechanism of injury.

RESULTS

Distribution of BMI in the cohort included 6.5% underweight, 45.6% normal weight, 16.7% overweight and 31.2% obese. Overweight and obese children sustained fractures from low energy mechanisms at more than double the rate of normal and underweight children (20.5% versus 9.7%, p=0.028). Overweight and obese children sustained physeal fractures at a rate of 54.4% in comparison with 28.6% in their normal and underweight peers (p<0.0001, OR 2.50 (95% CI, 1.26-4.95)). Overweight and obese children sustained distal 1/3 tibia fractures at a higher rate of 56.9% compared to under and normal weight children at 33.9% (p=0.003, OR 2.24 (95% CI, 1.17-4.30)). Overweight and obese children underwent unplanned changes in treatment at a lower rate than normal and underweight children at 1% versus 8% rates of treatment change, respectively (p=0.013, OR 0.076 (95%CI, 0.009-0.655)). No significant differences were found in the rates of operative treatment, repeat reduction, post treatment complications, or physical therapy.

CONCLUSION

Overweight children sustain tibia fractures from low energy mechanisms at higher rates than their peers. Similarly, obese and overweight patients have higher rates of physeal injuries and higher rates of distal 1/3 tibia fractures. Complication rates are similar between obese and non-obese children undergoing treatment for tibia fractures. Level of Evidence: III.

Legg-Calvé-Perthes disease overview

Background

Legg–Calvé–Perthes Disease (LCPD) is a necrosis of the femoral head which affects the range of motion of the hips. Its incidence is variable, ranging from 0.4/100,000 to 29.0/ 100,000 children. Although LCPD was first described in the beginning of the past century, limited is known about its etiology. Our objective is to describe the main areas of interest in Legg–Calve–Perthes disease.

Methods

A review of the literature regarding LCPD etiology was performed, considering the following inclusion criteria: Studies reporting clinical or preclinical results. The research group carried out a filtered search on the PubMed and Science Direct databases. To maximize the suitability of the search results, we combined the terms ‘‘Perthes disease” OR “LCPD” OR “children avascular femoral head necrosis” with “diagnostic” OR “treatment” OR “etiology” as either key words or MeSH terms.

Results

In this article been described some areas of interest in LCPD, we include topics such as: history, incidence, pathogenesis, diagnosis, treatment and possible etiology, since LCPD has an unknown etiology.

Conclusions

This review suggests that LCPD has a multifactorial etiology where environmental, metabolic and genetic agents could be involved.

Altered IGF-I activity and accelerated bone elongation in growth plates precede excess weight gain in a mouse model of juvenile obesity

Nearly one-third of children in the United States are overweight or obese by their preteens. Tall stature and accelerated bone elongation are characteristic features of childhood obesity, which cooccur with conditions such as limb bowing, slipped epiphyses, and fractures. Children with obesity paradoxically have normal circulating IGF-I, the major growth-stimulating hormone. Here, we describe and validate a mouse model of excess dietary fat to examine mechanisms of growth acceleration in obesity. We used in vivo multiphoton imaging and immunostaining to test the hypothesis that high-fat diet increases IGF-I activity and alters growth plate structure before the onset of obesity. We tracked bone and body growth in male and female C57BL/6 mice (n = 114) on high-fat (60% kcal fat) or control (10% kcal fat) diets from weaning (3 wk) to skeletal maturity (12 wk). Tibial and tail elongation rates increased after brief (1-2 wk) high-fat diet exposure without altering serum IGF-I. Femoral bone density and growth plate size were increased, but growth plates were disorganized in not-yet-obese high-fat diet mice. Multiphoton imaging revealed more IGF-I in the vasculature surrounding growth plates of high-fat diet mice and increased uptake when vascular levels peaked. High-fat diet growth plates had more activated IGF-I receptors and fewer inhibitory binding proteins, suggesting increased IGF-I bioavailability in growth plates. These results, which parallel pediatric growth patterns, highlight the fundamental role of diet in the earliest stages of developing obesity-related skeletal complications and validate the utility of the model for future studies aimed at determining mechanisms of diet-enhanced bone lengthening.NEW & NOTEWORTHY This paper validates a mouse model of linear growth acceleration in juvenile obesity. We demonstrate that high-fat diet induces rapid increases in bone elongation rate that precede excess weight gain and parallel pediatric growth. By imaging IGF-I delivery to growth plates in vivo, we reveal novel diet-induced changes in IGF-I uptake and activity. These results are important for understanding the sequelae of musculoskeletal complications that accompany advanced bone age and obesity in children.

Tendency towards operative treatment is increasing in children's fractures: results obtained from patient databases, causes, impact of evidence-based medicine

Results of numerous studies assessing the national or the local patient databases in several countries have indicated that the overall rate of operative treatment in fractures, as well as the rate in certain upper and lower limb fractures, has significantly increased in children. The most prominent increase in the rate of operative treatment was observed in forearm shaft fractures.

Results of several survey studies have revealed that there was not a high level of agreement among paediatric orthopaedic surgeons concerning treatment preferences for several children’s fractures.

The reasons for the increasing tendency towards operative treatment are multifactorial and patient-, parent- and surgeon-dependent factors as well as technological, economic, social, environmental and legal factors seem to have an impact on this trend.

It is obvious that evidence-based medicine is not the only factor that leads to this tendency. A high level of scientific evidence is currently lacking to support the statement that operative treatment really leads to better long-term outcomes in children’s fractures. Properly designed multicentre clinical trials are needed to determine the best treatment options in many fractures in children.

Cite this article: EFORT Open Rev 2020;5:347-353. DOI: 10.1302/2058-5241.5.200012