Operative Treatment of Distal Tibial Fractures in Children Managed With Epiphyseal Screws: A Comparison of Outcomes When Screws Are Retained Versus Removed Following Fracture Union.

BACKGROUND: Fractures of the distal tibial epiphysis in children are often accompanied by articular surface disruption. With increased displacement, internal fixation is frequently performed with an epiphyseal screw to close the fracture gap. Despite limited, high-level clinical evidence to support implant removal, epiphyseal screws are commonly removed after fracture healing due to potentially increased contact forces on the tibiotalar joint. The purpose of this study was to investigate and compare outcomes and complications in children that underwent surgical treatment of distal tibial epiphyseal fractures with placement of an epiphyseal screw(s) and had the implant(s) retained versus removed at a minimum of 2-year postoperative follow-up. METHODS: Children younger than 18 years from two urban tertiary care centers who underwent operative management of distal tibia Salter-Harris III and IV fractures using epiphyseal screws (2013-2020) were divided into two cohorts: retained epiphyseal screws and implant removed. Demographics, intraoperative, postoperative, and radiographic data were collected. Patient-reported outcomes (PROs) using the Foot and Ankle Ability Measure (FAAM) and Single Assessment Numeric Evaluation (SANE) questionnaires were collected at the final follow-up. Statistical analysis, including power analysis, was performed. RESULTS: Fifty-two children were included (30 males, 22 females) with a mean age of 13.3 years at the time of injury (range, 7.7-16.4 years). Thirty-five children retained the implants; seventeen had implants removed. All completed the FAAM questionnaires at a mean follow-up of 4.4 ± 1.9 years, while 29 completed the SANE questionnaire at a mean follow-up of 4.4 ± 1.7 years. No statistically significant difference in patient demographics, surgical variables, or PROs was observed. Six children experienced complications from the initial surgery, including infections and complex regional pain syndrome, with no difference in complication rates between the cohorts ( P =0.08). Furthermore, no complication was observed as a result of implant removal. CONCLUSIONS: Children with retained epiphyseal implants have similar functional outcomes as compared with those who had implants removed after distal tibial epiphyseal fracture fixation and union. LEVEL OF EVIDENCE: Level III-Retrospective comparative study.

An Overview of Pediatric Knee Arthroscopy With Use of the NeedleScope.

As sports-related injuries are becoming more common among children, there has been an increased need for knee arthroscopies in the pediatric population. Nevertheless, pediatric knee arthroscopy exposure is varied among orthopaedic surgeons, especially during residency training. There is a considerable difference in knee arthroscopy case volume between the adult and the pediatric population among orthopaedic residents. Although the fundamentals of adult knee arthroscopy have been well delineated, there is a paucity of literature surrounding basic pediatric knee arthroscopy. Our goal is to further explain the fundamentals needed to perform successful arthroscopic surgery in the pediatric knee. Through discussing proper patient positioning, instrumentation, including the utility of the 1.9-mm small-bore needle arthroscope (NanoScope; Arthrex, Naples, FL), subtle tips and tricks, as well as advantages and disadvantages of arthroscopy in children, this Technical Note along with the corresponding video are designed to help elucidate the intricacies of the pediatric knee. It will serve as educational material targeted to the resident trainee or any orthopaedic practitioner interested in gaining an introductory foundation to pediatric knee arthroscopy.

Efficacy of DIY Cast Covers: An In Vivo Study.

BACKGROUND: Casting is routinely used in orthopaedics. Preventing a wet cast is crucial for maintaining structural integrity and reducing unwanted complications like unnecessary skin irritation/ulceration, bacterial overgrowth, and unnecessary emergency department visits. Using experimental models, studies have tested various contemporary methods to prevent a wet cast. One such study found that in comparison the most effective and cost-conscious approach was to use a Do-It-Yourself cast cover using a double-bag technique sealed with tape. There is a paucity of literature on the utility of this technique in vivo. The purpose of this study was to investigate the efficacy of the Do-It-Yourself cast cover on human test subjects. METHODS: Ten volunteers for the study were obtained. Each received one short arm cast and one short leg cast. Each cast was removed after they were deemed dry. These casts were subsequently weighed until they achieved a stable weight. Each cast was then reapplied to the subject's arm and held together with Scotch tape. A trash bag was then applied around the cast and then secured with Duct tape to the skin. This was repeated to create a double seal. These covered, reapplied casts were submerged under water for 2 minutes. After submersion, the cover was removed, and the cast was reweighed. The casts were then submerged completely without any protection for 2 minutes and their fully saturated weight was recorded. Efficacy was determined by comparing the postsubmersion and full-submersion weights. Data was analyzed using the Mann-Whitney test. RESULTS: The percentage of water absorption prevention ranged from 96.8% to 99.9%, with an average of 99.6% across the entire study sample ( P <0.0001). No adverse effects were reported. CONCLUSION: Our findings conclude that the double-bag with Duct-tape method is effective at preventing external water absorption. This in vivo study demonstrates that almost all external water absorption can be prevented using this simple and inexpensive technique. LEVEL OF EVIDENCE: Level II, prospective comparative study.

The Pressure Is on: Dorsal Versus Volar Univalves for Long-arm Casts.

BACKGROUND: Fiberglass casts are routinely used to treat fractures of the upper extremity. When posttraumatic edema is anticipated, the cast is often valved to hopefully prevent potential complications, especially compartment syndrome. Due to volar forearm compartments being most involved with upper extremity compartment syndrome, volar skin surface pressures (SSP) are paramount. Despite past literature showing that a univalved cast will retain a 3-point mold better than a bivalved cast, there is a paucity of information analyzing the effects of univalving on the volar SSP. We hypothesized that a volar univalve technique would have a greater decrease in the volar skin surface pressures compared to a dorsal univalve in long-arm casts. METHODS: A 100-mL saline bag attached to an arterial line pressure transducer was placed between a long-arm cast and the skin along the volar forearm of a single adult volunteer. Fourteen casts were applied by a single certified orthopaedic technologist with 30 years of experience and assigned randomly to receive either a volar or dorsal univalve. We calculated the change in volar forearm SSP on each cast in 4 stages: isolated univalve, with a 3-mm cast spacer, with a 6-mm spacer, and with bivalve. Statistical analysis of the data was performed using a Mann-Whitney U test. RESULTS: When comparing volar versus dorsal univalve, volar SSP significantly dropped by a mean of 32.00 versus 20.43 mm Hg ( P value=0.001) in stage I, 45.14 versus 38.00 mm Hg in stage II ( P value=0.026), and 56.53 versus 49 mm Hg in stage III ( P value=0.001). There was no significant difference between the 2 groups after a bivalve was performed at stage IV ( P value=0.318). CONCLUSION: Our findings support that a volar univalve with a 6-mm spacer will provide the greatest reduction of skin surface pressure while theoretically maintaining the cast's structural integrity and biomechanical properties when compared to a bivalved cast. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Lumbar Plexus Nerve Blocks for Perioperative Pain Management in Cerebral Palsy Patients Undergoing Hip Reconstruction: More Effective Than General Anesthesia and Epidurals.

BACKGROUND: Hip reconstruction in patients with cerebral palsy (CP) is associated with. significant postoperative pain. However, adequate analgesia can be difficult to achieve. in this population due to spasticity, communication barriers, and postoperative. spasticity. Recently, multimodal pain management techniques such as epidurals and. regional nerve blocks have been described for postoperative pain control, but it is unclear if 1 technique is more beneficial. The purpose of this study was to compare the outcomes of different perioperative pain management techniques. METHODS: This study is a retrospective review of a consecutive series of children with CP over a 5-year period at a single pediatric tertiary-care hospital who underwent hip reconstruction (proximal femoral osteotomy with or without a pelvic osteotomy). Patients were subdivided based on their anesthetic protocol into the following groups: general anesthesia alone (G), general anesthesia with an epidural (E), and general anesthesia with lumbar plexus block (LPB). Our primary outcome was cumulative postoperative narcotic consumption (converted to morphine equivalents). Secondary outcomes included length of stay (LOS), average postoperative heart rate, and pain scores. analysis of variance testing was utilized to compare differences between the groups. RESULTS: Fifty-four patients who underwent hip reconstruction were included: 19 in the G group, 18 in the E group, and 17 in the LPB group. LOS was significantly higher in the E group compared with the G and LPB groups: F(2,51)=3.58, P=0.04. The average pain score was significantly lower in the LPB group compared with the others: F(2,51)=4.26, P=0.02. The average postoperative heart rate was significantly lower in the LPB group: F(2,51)=7.08, P<0.01. Postoperative narcotic consumption was significantly lower in the LPB group: F(2,51)=11.57, P<0.01. CONCLUSION: The LPB patients required the least amount of narcotics compared with the other groups. This, combined with a lower perioperative heart rate and shorter LOS would suggest these patients experienced less pain over the time of their in-patient stay. In comparison to general anesthesia alone and epidural anesthesia, lumbar plexus nerve blocks are an effective pathway for postoperative pain control after hip reconstruction in a CP population. LEVEL OF EVIDENCE: Level III-Case control or retrospective comparative study.

The Perioperative Surgical Home in Pediatrics: Improve Patient Outcomes, Decrease Cancellations, Improve HealthCare Spending and Allocation of Resources during the COVID-19 Pandemic.

Cancellations or delays in surgical care for pediatric patients that present to the operating room create a great obstacle for both the physician and the patient. Perioperative outpatient management begins prior to the patient entering the hospital for the day of surgery, and many organizations practice using the perioperative surgical home (PSH), incorporating enhanced recovery concepts. This paper describes changes in standard operating procedures caused by the COVID-19 pandemic, and proposes the expansion of PSH, as a means of improving perioperative quality of care in pediatric populations.

Stereospecific modulation of dimeric rhodopsin.

The classic concept that GPCRs function as monomers has been challenged by the emerging evidence of GPCR dimerization and oligomerization. Rhodopsin (Rh) is the only GPCR whose native oligomeric arrangement was revealed by atomic force microscopy demonstrating that Rh exists as a dimer. However, the role of Rh dimerization in retinal physiology is currently unknown. In this study, we identified econazole and sulconazole, two small molecules that disrupt Rh dimer contacts, by implementing a cell-based high-throughput screening assay. Racemic mixtures of identified lead compounds were separated and tested for their stereospecific binding to Rh using UV-visible spectroscopy and intrinsic fluorescence of tryptophan (Trp) 265 after illumination. By following the changes in UV-visible spectra and Trp265 fluorescence in vitro, we found that binding of R-econazole modulates the formation of Meta III and quenches the intrinsic fluorescence of Trp265. In addition, electrophysiological ex vivo recording revealed that R-econazole slows photoresponse kinetics, whereas S-econazole decreased the sensitivity of rods without effecting the kinetics. Thus, this study contributes new methodology to identify compounds that disrupt the dimerization of GPCRs in general and validates the first active compounds that disrupt the Rh dimer specifically.-Getter, T., Gulati, S., Zimmerman, R., Chen, Y., Vinberg, F., Palczewski, K. Stereospecific modulation of dimeric rhodopsin.