Hydrotherapy for Patients With External Fixation: Effect on Infectious Events.

BACKGROUND: Surgery to achieve long bone lengthening and deformity correction in skeletally immature patients is traditionally performed through external fixators. The incidence of infection during treatment is high. Hydrotherapy is highly beneficial during external fixation management, but the infection rates may impact its utilization. The objective of this paper is to document the incidence and duration of infection in patients who participated in a full hydrotherapy program when performed under medical supervision and in accordance with strict follow-up protocols. METHODS: In this retrospective study, we documented the key characteristics of patients who participated in hydrotherapy after lower limb external fixation surgery including age, sex, diagnosis and surgery site, the incidence and duration of pin site infections, and the percentage of cases, which were able to comply with a full hydrotherapy protocol. RESULTS: The hydrotherapy pool met all daily water quality metrics. Thirty-four children (19 males and 15 females) had a mean±SD age of 10.9±4.6 years. Of the cases, 80% were unilateral and 20% were bilateral. Diagnoses included congenital hereditary (eg, achondroplasia), congenital nonhereditary conditions (eg, fibular hemimelia), and acquired conditions (eg, traumatic). The location of osteotomy site was quite evenly spread between the femur and the tibia/fibula. Three out of the 34 patients were unable to receive hydrotherapy due to continuous secretions; 2 patients did not miss any sessions. The mean number of treatments was 3 per week. During the entire period, a total of 1200 treatments were performed for these patients with only 32 cancellations (about 3%) due to secretions or other signs of infection. Spearman correlation coefficients showed significantly high correlations between the duration of external fixation and the duration of hydrotherapy. There are no significant correlations between infections and other factors (sex, age segment, whether the problem is unilateral or /bilateral, diagnosis, and duration of treatment). CONCLUSIONS: This is the first report, to our knowledge, that documents the low prevalence of infectious events during hydrotherapy treatment and demonstrates its feasibility. LEVEL OF EVIDENCE: Level III; retrospective, comparative study.

Capitellum and Capitellar-Trochlear Shear Injury in Children.

OBJECTIVES: We report our clinical results following surgical intervention for capitellar fractures in a pediatric population, highlighting approaches, surgical instruments, and possible prognostic factors. DESIGN: Retrospective descriptive case-series study. SETTING: A tertiary referral hospital. PATIENTS: Twelve pediatric patients with capitellar or capitellar-trochlear injuries were treated between 2017 and 2021. INTERVENTION: Open reduction and internal fixation primarily using cannulated headless screws. MAIN OUTCOME MEASUREMENTS: The mean follow-up period was 22 months (range: 10-35 months). Functional outcomes were assessed using the Mayo Elbow Performance Score. Post-traumatic elbow arthrosis was assessed using the Bromberg and Morrey rating system. RESULTS: All fractures healed within 5-7 weeks. The mean Mayo Elbow Performance Score value was 98 (range, 85-100). Three patients developed arthrosis, and one had capitellar osteonecrosis. CONCLUSIONS: Based on our experience, the Kocher approach and fixation of 2-3 retrograde cannulated screws together represent an appropriate surgical technique for isolated capitellar fractures, whereas good functional outcomes are attainable for capitellar-trochlear shear fractures using the transolecranon approach with 3 cannulated screw fixations. Further injuries to the osseoligamentous structures around the elbow joint are suspected to be an unfavorable prognostic factor. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Orthotic hip brace as an alternative for treatment of femoral fractures in children under the age of 3 years: a retrospective study.

Femoral fractures are among the most common reasons for orthopedic-related hospital admissions in children. While spica cast is recommended for most children younger than 5 years, in the last decades, Pavlik harness was proven to be a safe alternative for young children. The objective is to assess the safety, outcomes and complications of a hip abduction brace (HAB) for the treatment of femoral fractures in children under the age of 3 years. This 7-year retrospective study was conducted in a single tertiary hospital. Children aged 6-36 months diagnosed with a femoral fracture, which did not necessitate operative treatment, were included. HAB has been used as the treatment of choice for nondisplaced or minimally displaced fractures of the proximal femur as well as for both displaced and nondisplaced femoral shaft fractures. The database was composed of a total of 102 children under the age of 3 with femoral fractures. Twenty-nine (28.4%) patients were treated with HAB and the others with a spica cast. The average age (±SD) at presentation was 21.5 ± 6.1 months. The length of stay was 0.96 ± 1 day. The complication rate was 6.9%. A satisfactory outcome in terms of fracture alignment and union was reported in 100% of the patients treated with HAB. When compared with patients treated with a spica cast, the HAB group were younger, had less severe injuries, shorter lengths of stay, lower complication rates and no need for surgical intervention. HAB can be considered a safe and comfortable alternative in selected children aged 6-36 months with nondisplaced/mildly displaced proximal and diaphyseal femoral fractures.

Case series: Factors of mortality in pediatric patients with pelvic fractures.

OBJECTIVE: No algorithm exists to guide the orthopedic treatment of pediatric patients with pelvic fractures, as most analytic studies have been conducted in adults. The goal of this study was to identify prognostic factors of pelvic fractures, and suggest whether early total care can be safely provided. METHODS: A retrospective trauma database for pediatric pelvic fractures from 2002-2018 was gathered, and patient charts were reviewed. RESULTS: A total of 128 patients were evaluated for pelvic trauma; 99 injuries were secondary to motor vehicle accidents (MVA) (77%), and 19 were secondary to falls (15%). Patients were more likely to be male (71%), older (33% aged 15-16 years, 2% aged 0-1 years), to experience a head trauma (55%), to be treated conservatively (70%), and to survive their trauma (91%). About half of the patients (49%) experienced an additional extremity trauma. When exploring the prognostic factors, mortality was associated with thoracic trauma (72% vs. 27%, p<0.05); a lower reduction of neutrophils levels 48 hours after the initial trauma (-1.34 vs. -7.7, p<0.05); a more significant reduction upon arrival of Prothrombin Time (72% vs. 37%, p<0.01), and an increment of International Normalized Ratio (2.29 vs. 1.26, p<0.01) and Partial Thromboplastin Time (79 vs 28, p<0.01). There was also a higher demand for Fresh Frozen Plasma (24% vs. 9%, p<0.05); Upon presentation, there was a higher Injury Severity Score (49 vs. 21, p<0.001), and a lower systolic Blood Pressure (96 vs. 118, p<0.05); The deceased did not have a very prolonged stay in the hospital (3 days vs. 12 days, P<0.01); Mortality was not significantly associated with either Early Total Care or Damage Control Orthopedics. CONCLUSIONS: Prognostic factors in pediatric patients with pelvic fractures parallel those of the adult population. Pediatric patients tendentiously outlive their pelvic trauma, whether the course of action taken by their surgeons is Conservative by nature, Early Total Care or Damage Control Orthopedics.

Hemiepiphysiodesis for coronal angular knee deformities: tension-band plate versus percutaneous transphyseal screw.

INTRODUCTION: Pediatric coronal plane knee deformities can be treated surgically using hemiepiphysiodesis. The two leading techniques used for hemiepiphysiodesis are: tension-band plates (TBP) and percutaneous transphyseal screws (PETS). We hypothesized that PETS would lead to faster guided correction of angular knee deformities than TBP. MATERIALS AND METHODS: A retrospective cohort of 35 patients treated with either TBP or PETS in one medical institution was established. The cohort included both genu varum and genu valgum of both primary and secondary etiologies. We first compared the treatment groups for differences in demographic and malalignment characteristics. Then, we compared the treatment groups for differences in operation-related outcomes, radiological mechanical correction and complication rates. RESULTS: We found that the use of PETS, compared to TBP, was associated with a faster implantation surgery and a shorter interval between implantation and removal, i.e., faster correction. Furthermore, PETS were associated with faster correction rates of the mechanical axis deviation, lateral distal femoral angle and medial proximal tibial angle. No significant differences in complication rates were found between the two treatments. CONCLUSION: PETS provided a faster correction of angular knee deformities compared to TBP at similar complication rates. Hence, PETS could be considered a superior technique for hemiepiphysiodesis.

Measuring pupil size and light response through closed eyelids.

Monitoring pupillary size and light-reactivity is a key component of the neurologic assessment in comatose patients after stroke or brain trauma. Currently, pupillary evaluation is performed manually at a frequency often too low to ensure timely alert for irreversible brain damage. We present a novel method for monitoring pupillary size and reactivity through closed eyelids. Our method is based on side illuminating in near-IR through the temple and imaging through the closed eyelid. Successfully tested in a clinical trial, this technology can be implemented as an automated device for continuous pupillary monitoring, which may save staff resources and provide earlier alert to potential brain damage in comatose patients.

Universal neonatal foot orthotics-a novel treatment of infantile metatarsus adductus.

Approximately one in 100 babies has metatarsus adductus) MTA(. Although most deformities may resolve spontaneously, moderate and severe deformities might cause future discomfort and are therefore often treated. Common treatment alternatives include stretching, serial casting, and orthoses. Surgery is reserved for severe cases that are unresponsive to conservative management. The purpose of this study was to present our experience with a novel orthosis designed to correct and maintain correction of MTA in infants. Seventy-three children between the ages of 4 and 11.5 months with moderate to severe MTA were treated using the Universal Neonatal Foot Orthosis (UNFO). Treatment was started in cases of rigid deformity when the child was first seen in the clinic, or after the age of 5 months in children with moderate or severe but flexible deformity that failed to improve spontaneously. The orthosis was applied for 23 h daily. Weaning was started after a complete correction of the deformity was achieved. Follow-up was continued at least until walking age. Results were assessed utilizing the heel bisector line (HBL) as a measure of foot deformity before, during, and after treatment completion, and at the end of follow-up. Seventy-one patients (114 feet (were followed from the time of diagnosis to at least walking age. There were 102 severe (HBL at, or lateral to, the 4TH toe) and 12 moderate MTA (HBL between 3rd and 4th toes). Average age at the beginning of treatment was 6.58 months (range 4-11.5). Of the study population, 56 patients (98 feet) improved significantly by the end of the follow-up. In 11 children (11 feet), no change was noted, and in 3 children (3 feet), worsening of the deformity was observed at the end of follow-up. In one child who discontinued treatment after 6 weeks, there was no change in one foot and worsening in the other. Minor side effects were observed in 11 patients, all resolved uneventfully.Conclusion: UNFO is an effective treatment for moderate and severe MTA in children younger than10 months, with only infrequent minor side effects. What is Known: • Debate exists as to which patient warrants treatment since spontaneous improvement is the rule. However, some deformities persist to adulthood and may be esthetically unpleasing. • Treatment modalities available vary from benign neglect, special shoe ware that are either static or need special tools, and knowledge to adjust or casting by an orthopedic surgeon What is New: • This is a description of the results of treatment with a new orthotics which may be applied by pediatricians to treat this very common neonatal deformity. The orthotics provides an excellent, short duration solution, easy for the baby and caregiver with results comparable to those of more elaborate orthotics and casting • The use of digital pictures to assess forefoot adduction deformity severity instead of radiographs is a reliable measurement method.

Skeletal Changes After Hematopoietic Stem Cell Transplantation in Osteopetrosis.

Osteopetrosis is a rare skeletal dysplasia resulting from an osteoclast defect leading to increased bone mass and density. Hematopoietic stem cell transplantation can rescue the disease phenotype and prevent complications. However, little is known about the skeletal changes hematopoietic stem cell transplantation induces in patients with this disease. The purpose of this study was to describe the skeletal changes after hematopoietic stem cell transplantation in a retrospective cohort of patients diagnosed with osteopetrosis in one medical center over 13 years. For this purpose, all available epidemiological, hematological, biochemical, and radiographic data were collected and quantitatively analyzed. We found a significant early change in bone metabolism markers coinciding with hematopoietic recovery after stem cell transplantation. Hematopoietic stem cell transplantation induced a later significant improvement in both skeletal mineral distribution and morphology but did not lead to complete radiological normalization. Presumably, changes in bone metabolism, skeletal mineral distribution, and morphology were the result of renewed osteoclast function enabling bone remodeling. We propose that biochemical bone metabolism markers and radiological indices be routinely used to evaluate response to hematopoietic stem cell transplantation in patients with osteopetrosis. © 2020 American Society for Bone and Mineral Research.

Characteristics of ataxic gait in familial dysautonomia patients.

INTRODUCTION AND OBJECTIVES: Progressive ataxic gait is a common symptom in individuals with Familial Dysautonomia (FD). At least 50% of adults with FD require assistance with walking. Our aims were to describe the medical condition of individuals with FD (ii) compare their gait characteristics to healthy individuals, and (iii) assess correlations between gait measures, presence of unstable gait pattern and frequency of falls. METHODS: Twelve subjects with FD (7 males, age 25.3±10.6 years) and 16 healthy participants (6 males, age 35.9±11.9 years) were recruited. Gait kinematics, gait symmetry, dynamic muscle activity, and foot deep vibration sensation were recorded. RESULTS: Ataxic gait degrees were: severe (6 out of 12), moderate (4 out of 12) and low (2 out of 12). The number of falls correlated with base width asymmetry. Crouch gait was noted in 3 out of 12 of the subjects. CONCLUSIONS: In-depth quantitative gait analysis of individuals with FD revealed ataxic gait. The ataxic pattern might be a result of combined neurological deficiencies and osseous deformities. Increasing the base of support of patients with FD might increase the symmetry of the base width during gait and decrease the number of falls. Additionally, perturbation treatment and dynamic balance exercises may be recommended in order to improve compensatory strategies. Future investigation of this population should include quantification of osseous rotations of the lower limb in order to fully understand its effect on their gait pattern and falls.

Prophylactic Postoperative Antibiotics May Not Reduce Pin Site Infections After External Fixation.

BACKGROUND: Pin infection continues to be a nuisance when using definitive external fixation. Prophylactic antibiotic treatment has been proposed in an effort to decrease pin complications. QUESTIONS/PURPOSES: We performed a prospective, randomized, single-blinded study to answer the following questions: (1) what was the effect of a 10-day course of oral prophylactic antibiotics administered immediately after external fixation surgery on the incidence of a subsequent pin infection, (2) what was the effect on the severity of a subsequent pin infection, and (3) what was the effect on the timing of a subsequent pin infection? METHODS: Patients were randomized into antibiotic treatment and control groups, and incidence, severity, and time of onset of pin infection were recorded. RESULTS: The incidence of pin infection for the entire cohort during the 90-day observation period was 46/58 (79%) without a statistically significant difference (p = 0.106). There was no statistical difference found (p = 0.512) in pin infection severity. There was no significant difference in the time of onset of infection between the two groups from the date of surgery (p = 0.553). CONCLUSIONS: Our randomized data do not suggest that oral antibiotics alter the incidence, timing, or severity of pin infection. This study does not support the use of prophylactic oral antibiotics in healthy patients.

The outcome of early revision of malaligned pediatric supracondylar humerus fractures.

BACKGROUND: Supracondylar humerus fractures (SCHF) are the most common elbow fractures requiring surgical treatment in the pediatric age group. Most fractures are reduced and stabilised adequately. Yet, post-surgical malunion may occur. The purpose of this study is to evaluate our results of early revision surgery in 21 surgically treated pediatric SCHF with immediate postoperative loss of alignment and compare them with previous reports of late corrective osteotomies. METHODS: Twenty-one pediatric SCHF patients that underwent revision surgery for malalignment within 3 weeks of the initial reduction and fixation consisted the study group. Indications for revision were unacceptable radiographic alignment diagnosed within the first 3 weeks after the index surgery. Clinical outcome included pain, range of motion (ROM) and appearance of the elbow. Radiographic outcome was defined as fracture healing and final alignment, assessed in both coronal and sagittal planes. RESULTS: The average time interval between index and revision surgery was 7.6 days (range 3-18). In revision surgery, closed reduction was performed in 17 out of 21 patients, and open reduction was required in four. In one patient, an external fixator was added. In the most recent follow up, all patients but three regained full ROM. The remaining three had a deficit of 10° or less. Two patients had cubitus varus of 10° or less. All patients had a marked radiographic improvement after revision, especially in the sagittal plane increasing the humero-capitaller flexion angle by an average of 20°. DISCUSSION: Malunion after reduction and Kirschner wires (KW) fixation of SCHF is an uncommonly reported phenomenon. When malunion is recognised after fracture healing, corrective osteotomies may carry a significant complications rate. We describe our favourable experience with early diagnosis and revision surgery of malaligned SCHF.

Leukocyte adhesion deficiency type III: clinical features and treatment with stem cell transplantation.

Leukocyte adhesion deficiency type III (LADIII) is an autosomal recessive disorder that presents with a severe leukocyte adhesion defect and a Glanzmann-type thrombocytopathy. Hematopoietic stem cell transplantation (HSCT)--the only definitive treatment for LADIII--appears to have a high rate of complications. In this study, we describe a new group of patients with LADIII, highlighting further clinical and immunologic aspects of this disease, and reevaluating the effectiveness of HSCT for its treatment. The patients had clinical and laboratory findings consistent with LADIII. Molecular analysis confirmed the presence of a mutation in the kindlin-3 gene. HSCT was carried out in 3 patients and was successful in 2. The diagnosis of LADIII should be considered in all patients who present with recurrent infections and a bleeding diathesis, regardless of the leukocyte count. LADIII is a primary immune deficiency, which can be successfully corrected by bone marrow transplantation if applied early in the course of the disease using appropriate conditioning.

Circular external fixator-assisted ankle arthrodesis following failed total ankle arthroplasty.

BACKGROUND: Failed total ankle arthroplasty (TAA) often results in significant bone loss and requires salvage arthrodesis. This study quantified the bone loss following failed TAA and reports the outcome of seven arthrodesis reconstructions using the Ilizarov method. METHODS: A retrospective review of ankle fusions was performed for failed TAA to collect the mode of implant failure, presenting limb length discrepancy (LLD), total bone defect, postarthrodesis LLD, and treatment type (shoe lift versus distraction osteogenesis) and amount (shoe lift or lengthening). RESULTS: Four mechanical failures and three infections were found. Four of seven cases had prior revision TAAs. Four of seven patients were treated with tibiotalar arthrodesis; three of the seven patients required talar resection and tibiocalcaneal arthrodesis. The mean presenting LLD was 2.2 (range, 1.2 to 3.5) cm. The mean time in frame was 197 (range, 146 to 229) days. With a mean postexplantation total bone defect of 5.1 (range, 3.7 to 8.5) cm, four of seven patients elected tibial lengthening following fusion [mean lengthening 4.6 (range, 2.5 to 8.0) cm; external fixation index (EFI) 42.6 (range, 16.5 to 55.6) days/cm)]. Three of seven patients were treated with a shoe lift [mean lift height 2.9 (range 2.5 to 3.2) cm]. There was no failure of fixation, refracture, or infection. All patients had a stable plantigrade foot and walked with minimal limp. Association for the Study and Application of the Method of Ilizarov (ASAMI) functional scores were six good and one fair. ASAMI bone scores were four excellent and three good. CONCLUSIONS: Ankle arthrodesis following failed TAA results in large LLDs secondary to bone loss during implant failure and subsequent explantation. External fixation can produce an excellent fusion rate in complex, possibly infected, failed TAAs. Limb length equalization (by either distraction osteogenesis or shoe lift) provides a means of obtaining good functional outcomes following failed TAA.

Advances in growth plate modulation for lower extremity malalignment (knock knees and bow legs).

PURPOSE OF REVIEW: Lower extremity angular deformities are among the most common nontraumatic conditions in children being referred to pediatric orthopedists. Understanding of this abnormality is essential for pediatricians and primary caregivers. There is a development in the surgical management of these problems that has improved the quality of care of affected children and adolescents. RECENT FINDINGS: In recent years, we have improved our understanding of consequences of lower limb angular deformities on knees. New treatment options for angular deformity include the method of 'guided growth' using small, extraphyseal tension band plates. SUMMARY: The development of this surgical technique for growth plate manipulation for the treatment of angular deformities of knees has expanded the indications for surgical management and has a potential to decrease the incidence and the severity of complications.

Posttraumatic painful hip: sonography as a screening test for occult hip fractures.

OBJECTIVE: Nondisplaced hip fractures may be radiographically occult and require magnetic resonance imaging (MRI) or bone scintigraphy for diagnosis. Both examinations are expensive and are not readily available in many hospitals. Our objective was to evaluate sonography as a screening tool for occult hip fractures in posttraumatic painful hips in elderly patients. METHODS: We prospectively evaluated 30 patients (mean age, 73 years), who were admitted for painful hips after having low-energy trauma with nondiagnostic hip radiographs. After inclusion, patients underwent sonography of both hips for signs of injury. After completion of the sonographic examination and analysis of the results, patients underwent MRI of both hips. The sonographic findings were compared with the MRI findings, which served as the reference standard for accurate detection of a hip fracture. RESULTS: Ten hip fractures were diagnosed by MRI. Sonography showed trauma-related changes in all of those patients and in 7 additional patients, 3 of whom had pubic fractures. Sonography correctly identified 13 patients without hip fractures. The sensitivity of sonography was found to be 100%, whereas the specificity for hip fractures was 65%. CONCLUSIONS: Sonography for posttraumatic hip pain with negative radiographic findings did not result in a single missed hip fracture. Therefore, sonography may serve as an effective screening tool, mandating MRI only for cases with positive findings, whereas patients with negative sonographic findings need no further investigation. Sonography may therefore be very useful in hospitals around the world, where MRI may not be readily affordable or available.

Sciatic nerve palsy due to hematoma after thrombolysis therapy for acute pulmonary embolism after total hip arthroplasty.

Sciatic nerve paralysis as a complication of bleeding due to hip surgery is a rare entity. The use of thrombolysis and full-dose heparin administration for the treatment of massive pulmonary embolism increase the risk for developing major bleeding. Prompt recognition and intervention in this condition are warranted. A case of sciatic nerve palsy due to expanding thigh hematoma as a complication of thrombolytic therapy for pulmonary embolism after total hip arthroplasty is presented with a literature review. Although rare, this complication should be promptly recognized and immediate decompression should take place because of the favorable results of the early treatment.