Teaching Cardiopulmonary Resuscitation to Later Elementary School Students.

STUDY OBJECTIVE: Bystander cardiopulmonary resuscitation (CPR) rates remain low in the United States. Training children is a proposed method to increase this rate, but data on the compression efficacy of US elementary school-aged children are scarce. We hypothesized that fourth and fifth graders could learn how to respond to cardiac arrests and provide effective chest compressions. METHODS: We conducted a nonrandomized before-and-after study with fourth- and fifth-grade elementary students. Two 2-hour CPR educational sessions were held. Two weeks later, skills were assessed using a de novo checklist, and manikin-analyzed compression effectiveness (dichotomized at 50% efficacy) was analyzed using Chi-squared tests. We used paired t tests to evaluate knowledge change on identical pre- and post-tests. Secondary analysis evaluated associations between compression effectiveness and grade, age, sex, and body mass index (BMI) using Chi-squared tests. RESULTS: Three hundred fifty-six students completed the study. The mean change in test scores measuring CPR knowledge increased from 8.2 to 9.3 (1.1, 95% confidence interval [CI] 0.9 to 1.2). Self-reported adequate CPR knowledge increased from 44% to 97% (odds ratio [OR] 44.17, 95% CI 12.62 to 154.62). Seventy-two percent of students completed >7/11 predefined resuscitation steps, and 76% delivered ≥50% effective compressions. Grade was significantly associated with achieving ≥50% effective compression (OR 2.02, 95% CI, 1.19 to 3.43). Age, BMI, and sex were not significantly associated with greater compression efficacy. CONCLUSION: Most students were able to learn hands-only CPR, apply their knowledge during a simulated cardiac arrest scenario, and deliver effective chest compressions. Students' confidence and willingness to perform CPR increased after the intervention.

Gait Analysis in Orthopaedic Surgery: History, Limitations, and Future Directions.

Gait analysis has expanding indications in orthopaedic surgery, both for clinical and research applications. Early work has been particularly helpful for understanding pathologic gait deviations in neuromuscular disorders and biomechanical imbalances that contribute to injury. Notable advances in image acquisition, health-related wearable devices, and computational capabilities for big data sets have led to a rapid expansion of gait analysis tools, enabling novel research in all orthopaedic subspecialties. Given the lower cost and increased accessibility, new gait analysis tools will surely affect the next generation of objective patient outcome data. This article reviews the basic principles of gait analysis, modern tools available to the common surgeon, and future directions in this space.

Hybprinting for musculoskeletal tissue engineering.

This review presents bioprinting methods, biomaterials, and printing strategies that may be used for composite tissue constructs for musculoskeletal applications. The printing methods discussed include those that are suitable for acellular and cellular components, and the biomaterials include soft and rigid components that are suitable for soft and/or hard tissues. We also present strategies that focus on the integration of cell-laden soft and acellular rigid components under a single printing platform. Given the structural and functional complexity of native musculoskeletal tissue, we envision that hybrid bioprinting, referred to as hybprinting, could provide unprecedented potential by combining different materials and bioprinting techniques to engineer and assemble modular tissues.

Köhler Disease: Avascular Necrosis in the Child.

Köhler disease is a childhood condition of pain and swelling of the medial midfoot with associated osteochondrosis or avascular necrosis of the tarsal navicular. The age at presentation is between 2 and 10 years, with boys more likely to be affected than girls. Radiographs show increased sclerosis and sometimes flattening and fragmentation of the navicular. Long-term outcomes for Köhler disease are favorable regardless of the type of treatment, although a short period of immobilization with a short leg walking cast may reduce the duration of symptoms.

A Structured Review Instrument Improves the Quality of Orthopaedic Journal Club.

OBJECTIVE: We asked the following questions: 1. Does the use of an structured review instrument (SRI) at journal club increase presentation quality, as measured objectively by a standardized evaluation rubric? 2. Does SRI use increase the time required to prepare for journal club? 3. Does SRI use positively impact presenter perceptions about confidence while presenting, satisfaction, and journal club effectiveness, as measured by postparticipation surveys? DESIGN: A prospective study was designed in which a grading rubric was developed to evaluate journal club presentations. The rubric was applied to 24 presentations at journal clubs prior to introduction of the SRI. An SRI was developed and distributed to journal club participants, who were instructed to use it to prepare for journal club. The grading rubric was then used to assess 25 post-SRI presentations and scores were compared between the pre- and post-SRI groups. Presentations occurred at either trauma, pediatrics, or spine subspecialty journal clubs. Participants were also surveyed regarding time requirements for preparation, perceptions of confidence while presenting, satisfaction, and perceptions of overall club effectiveness. SETTING: A single academic center with an orthopaedic surgery residency program. PARTICIPANTS: Resident physicians in the department of orthopaedic surgery. RESULTS: Mean presentation scores increased from 14.0 ± 5.9 (mean ± standard deviation) to 24.4 ± 5.2 after introduction of the SRI (p < 0.001). Preparation time decreased from a mean of 47 minutes to 40 minutes after SRI introduction (p = 0.22). Perceptions of confidence, satisfaction, and club effectiveness among trainees trended toward more positive responses after SRI introduction (confidence: 63% positive responses pre-SRI vs 72% post-SRI, p = 0.73; satisfaction: 64% vs 91%, p = 0.18; effectiveness: 64% vs 91%, p = 0.19). CONCLUSIONS: The use of a structured review instrument to guide presentations at orthopaedic journal club increased presentation quality, and there was no difference in preparation time. There were trends toward improved presenter confidence, satisfaction, and perception of journal club effectiveness. SRI utilization at orthopaedic journal club may be an effective method for increasing the quality of journal club presentations. Future work should examine the relationship between presentation quality and overall club effectiveness.

Trans-Metaphyseal Screws Placed in Children: An Argument for Monitoring and Potentially Removing the Implants.

BACKGROUND: Surgeons frequently use trans-metaphyseal screws in children to achieve osteosynthesis after fractures or stability after reconstructive osteotomies. Screws that were initially inserted below the cortex of bone can become prominent and symptomatic due to the process of funnelization that narrows the wide metaphysis to the diameter of the thinner diaphysis. METHODS: Case series presentation of 11 children who presented with screw prominence after the cutback process range in age from 19 to 169 months. We used the screws as radiographic markers to quantitate the amount of bone "cutback" or lost during the process of funnelization. RESULTS: The average length of screw protrusion beyond the edge of the bone when symptomatic was 8.7 mm (range, 3.3 to 14.3 mm). Time from implantation to the last radiograph averaged 40 months (range, 19 to 84 mo). The average loss of bone width at the time of presentation was 21% (range, 7% to 36%). CONCLUSIONS: These cases suggest that orthopaedic surgeons should consider monitoring children after implantation of trans-metaphyseal screws and informing parents and patients about the possibility of screw prominence necessitating removal due to the process of metaphyseal funnelization. LEVEL OF EVIDENCE: Level IV.

Fast comprehensive single-sequence four-dimensional pediatric knee MRI with T2 shuffling.

PURPOSE: To develop and clinically evaluate a pediatric knee magnetic resonance imaging (MRI) technique based on volumetric fast spin-echo (3DFSE) and compare its diagnostic performance, image quality, and imaging time to that of a conventional 2D protocol. MATERIALS AND METHODS: A 3DFSE sequence was modified and combined with a compressed sensing-based reconstruction resolving multiple image contrasts, a technique termed T2 Shuffling (T2 Sh). With Institutional Review Board (IRB) approval, 28 consecutive children referred for 3T knee MRI prospectively underwent a standard clinical knee protocol followed by T2 Sh. T2 Sh performance was assessed by two readers blinded to diagnostic reports. Interpretive discrepancies were resolved by medical record chart review and consensus between the readers and an orthopedic surgeon. Image quality was evaluated by rating anatomic delineation, with 95% confidence interval. A Wilcoxon rank-sum test assessed the null hypothesis that T2 Sh structure delineation compared to conventional 2D is unchanged. Intraclass correlation coefficients were calculated for interobserver agreement. Imaging time of the conventional protocol and T2 Sh was compared. RESULTS: There was 81% and 87% concordance between T2 Sh reports and diagnostic reports, respectively, for each reader. Upon consensus review, T2 Sh had 93% sensitivity and 100% specificity compared to clinical reports for detection of clinically relevant findings. The 95% confidence interval of diagnostic or better rating was 95-100%, with 34-80% interobserver agreement. There was no significant difference in structure delineation between T2 Sh and 2D, except for the retinaculum (P < 0.05), where 2D was preferred. Typical imaging time for T2 Sh and the conventional exam was 7 and 13 minutes, respectively. CONCLUSION: A single-sequence pediatric knee exam is feasible with T2 Sh, providing multiplanar, reformattable 4D images. LEVEL OF EVIDENCE: 2 J. MAGN. RESON. IMAGING 2017;45:1700-1711.

Caput valgum associated with developmental dysplasia of the hip: management by transphyseal screw fixation.

PURPOSE: A late finding of some hips treated for developmental dysplasia of the hip (DDH) is a growth disturbance of the lateral proximal femoral physis, which results in caput valgum and possibly osteoarthritis. Current treatment options include complete epiphysiodesis of the proximal femoral physis or a corrective proximal femoral osteotomy. Alternatively, a transphyseal screw through the inferomedial proximal femoral physis that preserves superolateral growth might improve this deformity. METHODS: This study evaluates the effect of such a transphyseal screw on both femoral and acetabular development in patients with caput valgum following open treatment of DDH. These patients were followed clinically and radiographically until skeletal maturity. Preoperative and postoperative radiographs were assessed, measuring the proximal femoral physeal orientation (PFPO), the head-shaft angle (HSA), Sharp's angle and the center edge angle of Wiberg (CE angle). RESULTS: Thirteen hips of 11 consecutive patients were followed prospectively. The age at the time of transphyseal screw placement was between 5 and 14 years. The mean improvement of the PFPO and HSA was 14° (p < 0.01) and 11° (p < 0.001), respectively. The mean improvement of Sharp's angle and CE angle was 4.7° (p < 0.01) and 5.8° (p < 0.02), respectively. Five patients underwent screw revision. CONCLUSIONS: A transphyseal screw across the proximal femoral physis improved the proximal femur and acetabular geometry.

Comparison of electromagnetic shielding with polyaniline nanopowders produced in solvent-limited conditions.

Nanoparticle synthesis (~10-50 nm) of HCl-doped polyaniline elucidates the impact of limiting solvent (water) and oxidizing agent (ammonium peroxydisulfate) on morphology (XRD and TEM), chemical structure (FTIR), conductivity (two-point DC) and electromagnetic shielding effectiveness (SE) in microwave frequencies (i.e., X-band S-parameter measurements). Detailed comparison of these properties with respect to three distinct polymerization environments indicate that a solvent-free or limited solvent polymerization accomplished through a wet grinding solid-phase reaction produces superior conductivity (27 S/cm) with intermediate crystallinity (66%) for the highest EM shielding-an order of magnitude improvement over conventional polymerization with respect to EM power transmission reduction for all loadings per shielding area (0.04 to 0.17 g/cm(2)). By contrast, the classic oxidation of aniline in a well-dispersed aqueous reaction phase with an abundance of available oxidant in free solution yielded low conductivity (3.3 S/cm), crystallinity (54%), and SE, whereas similar solvent-rich reactions with limiting oxidizer produced similar conductivity (2.9 S/cm) and significantly lower SE with the highest crystallinity (72%). This work is the first to demonstrate that limiting solvent and oxidizer enhances electromagnetic interactions for shielding microwaves in polyaniline nanopowders. This appears connected to having the highest overall extent of oxidation achieved in the wet solid-phase reaction.

Management of the knee in spastic diplegia: what is the dose?

This article discusses the sagittal gait patterns in children with spastic diplegia, with an emphasis on the knee, as well as the concept of the "dose" of surgery that is required to correct different gait pathologies. The authors list the various interventions in the order of their increasing dose. The concept of dose is useful in the consideration of the management of knee dysfunction.

Remodeling of birth fractures of the humeral diaphysis.

BACKGROUND: Birth fractures of the humeral diaphysis are encountered at most pediatric medical centers and pediatric orthopaedic practices. The treatment strategy of these fractures is uniformly nonoperative. However, we have not found sufficient studies in the literature demonstrating the extent to which remodeling is possible and therefore how much deformity is acceptable in the treatment of these fractures. METHODS: We reviewed the records of our institution's Orthopaedic Surgery Clinic and identified all children seen for birth fractures of the humerus from 2001 to 2005. The angulation and displacement at presentation and at follow-up were measured. RESULTS: All patients were treated nonoperatively, and most were managed by swaddling. In 9 patients with more than 4 months of radiographic follow-up, the mean initial angulation was 26 degrees in the coronal plane and 25 degrees in the sagittal plane. The mean angulation at final follow-up was 5 degrees in the coronal plane and 7 degrees in the sagittal plane. The maximum angulation at presentation was 66 degrees, which remodeled to 5 degrees at 7.3 months' follow-up. CONCLUSIONS: Our findings suggest that attempts to obtain an anatomical reduction or the use of more than the simplest immobilization methods are not necessary given the tremendous capacity for remodeling of these fractures in infants.

Vague Upper-Extremity Symptoms?

In brief Thoracic outlet syndrome is a brief commonly missed cause of upper-extremity pain and musculoskeletal symptoms. Understanding the anatomy of the cervicoaxillary canal and proximal limb, etiology of the syndrome, evaluation of clinical symptoms, and differential diagnosis of thoracic outlet pain can lead to proper rehabilitation of the disorder.