Preoperative vascular assessment of patients with a supracondylar humeral fracture and a perfused, pulseless limb.

The 'pink, pulseless hand' is often used to describe the clinical situation in which a child with a supracondylar fracture of the humerus has normal distal perfusion in the absence of a palpable peripheral pulse. The management guidelines are based on the assessment of perfusion, which is difficult to undertake and poorly evaluated objectively. The aim of this study was to review the available literature in order to explore the techniques available for the preoperative clinical assessment of perfusion in these patients and to evaluate the clinical implications. A systematic literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered prospectively with the International Prospective Register of Systematic Reviews. Databases were explored in June 2022 with the search terms (pulseless OR dysvascular OR ischaemic OR perfused OR vascular injury) AND supracondylar AND (fracture OR fractures). A total of 573 papers were identified as being suitable for further study, and 25 met the inclusion criteria for detailed analysis. These studies included a total of 504 patients with a perfused, pulseless limb associated with a supracondylar humeral fracture. Clinical examination included skin colour (23 studies (92%)), temperature (16 studies (64%)), and capillary refill time (13 studies (52%)). Other investigations included peripheral oxygen saturation (SaO2) (six studies (24%)), ultrasound (US) (14 (56%)), and CT angiogram (two studies (8.0%)). The parameters of 'normal perfusion' were often not objectively defined. The time to surgery ranged from 1.5 to 12 hours. A total of 412 patients (82%) were definitively treated with closed or open reduction and fixation, and 92 (18%) required vascular intervention, ranging from simple release of entrapped vessels to vascular grafts. The description of the vascular assessment of the patient with a supracondylar humeral fracture and a pulseless limb in the literature is variable, with few objective criteria being used to define perfusion. The evidence base for decision-making is limited, and further research is required. We were able, however, to make some recommendations about objective criteria for the assessment of these patients, and we suggest that these are performed frequently to allow the detection of any deterioration of perfusion.

The British Orthopaedic Surgery Surveillance study: Perthes' disease: the epidemiology and two-year outcomes from a prospective cohort in Great Britain.

AIMS: The aim of this study was to evaluate the epidemiology and treatment of Perthes' disease of the hip. METHODS: This was an anonymized comprehensive cohort study of Perthes' disease, with a nested consented cohort. A total of 143 of 144 hospitals treating children's hip disease in the UK participated over an 18-month period. Cases were cross-checked using a secondary independent reporting network of trainee surgeons to minimize those missing. Clinician-reported outcomes were collected until two years. Patient-reported outcome measures (PROMs) were collected for a subset of participants. RESULTS: Overall, 371 children (396 hips) were newly affected by Perthes' disease arising from 63 hospitals, with a median of two patients (interquartile range 1.0 to 5.5) per hospital. The annual incidence was 2.48 patients (95% confidence interval (CI) 2.20 to 2.76) per 100,000 zero- to 14-year-olds. Of these, 117 hips (36.4%) were treated surgically. There was considerable variation in the treatment strategy, and an optimized decision tree identified joint stiffness and age above eight years as the key determinants for containment surgery. A total of 348 hips (88.5%) had outcomes to two years, of which 227 were in the late reossification stage for which a hip shape outcome (Stulberg grade) was assigned. The independent predictors of a poorer radiological outcome were female sex (odds ratio (OR) 2.27 (95% CI 1.19 to 4.35)), age above six years (OR 2.62 (95% CI (1.30 to 5.28)), and over 50% radiological collapse at inclusion (OR 2.19 (95% CI 0.99 to 4.83)). Surgery had no effect on radiological outcomes (OR 1.03 (95% CI 0.55 to 1.96)). PROMs indicated the marked effect of the disease on the child, which persisted at two years. CONCLUSION: Despite the frequency of containment surgery, we found no evidence of improved outcomes. There appears to be a sufficient case volume and community equipoise among surgeons to embark on a randomized clinical trial to definitively investigate the effectiveness of containment surgery. Cite this article: Bone Joint J 2022;104-B(4):510-518.

The British Orthopaedic Surgery Surveillance study: slipped capital femoral epiphysis: the epidemiology and two-year outcomes from a prospective cohort in Great Britain.

AIMS: The aim of this study was to inform the epidemiology and treatment of slipped capital femoral epiphysis (SCFE). METHODS: This was an anonymized comprehensive cohort study, with a nested consented cohort, following the the Idea, Development, Exploration, Assessment, Long-term study (IDEAL) framework. A total of 143 of 144 hospitals treating SCFE in Great Britain participated over an 18-month period. Patients were cross-checked against national administrative data and potential missing patients were identified. Clinician-reported outcomes were collected until two years. Patient-reported outcome measures (PROMs) were collected for a subset of participants. RESULTS: A total of 486 children (513 hips) were newly affected, with a median of two patients (interquartile range 0 to 4) per hospital. The annual incidence was 3.34 (95% confidence interval (CI) 3.01 to 3.67) per 100,000 six- to 18-year-olds. Time to diagnosis in stable disease was increased in severe deformity. There was considerable variation in surgical strategy among those unable to walk at diagnosis (66 urgent surgery vs 43 surgery after interval delay), those with severe radiological deformity (34 fixation with deformity correction vs 36 without correction) and those with unaffected opposite hips (120 prophylactic fixation vs 286 no fixation). Independent risk factors for avascular necrosis (AVN) were the inability of the child to walk at presentation to hospital (adjusted odds ratio (aOR) 4.4 (95% CI 1.7 to 11.4)) and surgical technique of open reduction and internal fixation (aOR 7.5 (95% CI 2.4 to 23.2)). Overall, 33 unaffected untreated opposite hips (11.5%) were treated for SCFE by two-year follow-up. Age was the only independent risk factor for contralateral SCFE, with age under 12.5 years the optimal cut-off to define 'at risk'. Of hips treated with prophylactic fixation, none had SCFE, though complications included femoral fracture, AVN, and revision surgery. PROMs demonstrated the marked impact on quality of life on the child because of SCFE. CONCLUSION: The experience of individual hospitals is limited and mechanisms to consolidate learning may enhance care. Diagnostic delays were common and radiological severity worsened with increasing time to diagnosis. There was unexplained variation in treatment, some of which exposes children to significant risks that should be evaluated through randomized controlled trials. Cite this article: Bone Joint J 2022;104-B(4):519-528.

Orthoplastic management of open tibial fractures in children : a consecutive five-year series from a paediatric major trauma centre.

AIMS: Open tibial fractures are limb-threatening injuries. While limb loss is rare in children, deep infection and nonunion rates of up to 15% and 8% are reported, respectively. We manage these injuries in a similar manner to those in adults, with a combined orthoplastic approach, often involving the use of vascularised free flaps. We report the orthopaedic and plastic surgical outcomes of a consecutive series of patients over a five-year period, which includes the largest cohort of free flaps for trauma in children to date. METHODS: Data were extracted from medical records and databases for patients with an open tibial fracture aged < 16 years who presented between 1 May 2014 and 30 April 2019. Patients who were transferred from elsewhere were excluded, yielding 44 open fractures in 43 patients, with a minimum follow-up of one year. Management was reviewed from the time of injury to discharge. Primary outcome measures were the rate of deep infection, time to union, and the Modified Enneking score. RESULTS: The mean age of the patients was 9.9 years (2.8 to 15.8), and 28 were male (64%). A total of 30 fractures (68%) involved a motor vehicle collision, and 34 (77%) were classified as Gustilo Anderson (GA) grade 3B. There were 17 (50%) GA grade 3B fractures, which were treated with a definitive hexapod fixator, and 33 fractures (75%) were treated with a free flap, of which 30 (91%) were scapular/parascapular or anterolateral thigh (ALT) flaps. All fractures united at a median of 12.3 weeks (interquartile range (IQR) 9.6 to 18.1), with increasing age being significantly associated with a longer time to union (p = 0.005). There were no deep infections, one superficial wound infection, and the use of 20 fixators (20%) was associated with a pin site infection. The median Enneking score was 90% (IQR 87.5% to 95%). Three patients had a bony complication requiring further surgery. There were no flap failures, and eight patients underwent further plastic surgery. CONCLUSION: The timely and comprehensive orthoplastic care of open tibial fractures in this series of patiemts aged < 16 years resulted in 100% union and 0% deep infection, with excellent patient-reported functional outcomes. Cite this article: Bone Joint J 2021;103-B(6):1160-1167.

Predicting translational deformity following opening-wedge osteotomy for lower limb realignment.

An opening-wedge osteotomy is well recognised for the management of limb deformity and requires an understanding of the principles of geometry. Translation at the osteotomy is needed when the osteotomy is performed away from the centre of rotation of angulation (CORA), but the amount of translation varies with the distance from the CORA. This translation enables proximal and distal axes on either side of the proposed osteotomy to realign. We have developed two experimental models to establish whether the amount of translation required (based on the translation deformity created) can be predicted based upon simple trigonometry. A predictive algorithm was derived where translational deformity was predicted as 2(tan α × d), where α represents 50 % of the desired angular correction, and d is the distance of the desired osteotomy site from the CORA. A simulated model was developed using TraumaCad online digital software suite (Brainlab AG, Germany). Osteotomies were simulated in the distal femur, proximal tibia and distal tibia for nine sets of lower limb scanograms at incremental distances from the CORA and the resulting translational deformity recorded. There was strong correlation between the distance of the osteotomy from the CORA and simulated translation deformity for distal femoral deformities (correlation coefficient 0.99, p < 0.0001), proximal tibial deformities (correlation coefficient 0.93-0.99, p < 0.0001) and distal tibial deformities (correlation coefficient 0.99, p < 0.0001). There was excellent agreement between the predictive algorithm and simulated translational deformity for all nine simulations (correlation coefficient 0.93-0.99, p < 0.0001). Translational deformity following corrective osteotomy for lower limb deformity can be anticipated and predicted based upon the angular correction and the distance between the planned osteotomy site and the CORA.

A severe systemic presentation of pigmented villonodular synovitis in a child with underlying Chediak-Higashi syndrome.

Pigmented villonodular synovitis (PVNS), a condition of synovial hyperproliferation that mostly affects large joints, is rare in children and conventionally lacks systemic symptoms. This report describes a complex paediatric patient who underwent bone marrow transplantation to control the accelerated phase of the Chediak-Higashi syndrome. Diffuse PVNS developed in one knee 2.75 years later. Progression of PVNS was accompanied by the development of severe systemic symptoms, which resolved rapidly following subtotal surgical debridement. The patient remains well with minimal elevation of inflammatory marker levels 10.5 years later. As PVNS and Chediak-Higashi syndrome are both very rare diseases we propose a potential unifying hypothesis for this combination.

Cytotoxic agents are detrimental to bone formed by distraction osteogenesis.

UNLABELLED: Distraction osteogenesis can be used to replace segmental bone loss when treating malignant bone tumors in children and adolescents. These patients often receive cytotoxic chemotherapy as part of their treatment regimen. The effect of cytotoxic drugs on the cellular processes during distraction osteogenesis and the structural and mechanical properties of regenerate bone is unknown. We therefore used a rabbit model of distraction osteogenesis to determine that cytotoxic agents had a detrimental effect on regenerate bone formed by this technique. We administered adriamycin and cisplatinum to 20 rabbits using two different simulated chemotherapy regimens. All rabbits underwent an osteotomy at 12 weeks of age. Distraction osteogenesis began 24 h later at a rate of 0.75 mm a day for 10 days, followed by 18 days without correction to allow for consolidation. Regenerate bone was assessed using plain radiographs, bone densitometry, and mechanical testing. Peri-operative chemotherapy decreased the mechanical properties of the regenerate with regard to yield strain (3.7 × 10(-2) vs. 5.2 × 10(-2)) and energy at yield (2.73 × 10(7) vs. 3.92 × 10(7)). Preoperative chemotherapy in isolation reduced bone mineral density (0.38 vs. 0.5 g/cm(2)), bone mineral content (0.24 vs. 0.36 g), and volumetric bone mineral density (0.57 vs. 0.65 g/cm(2)) with no alterations in the mechanical properties. CONCLUSIONS: Preoperative chemotherapy appears to decrease the volume of regenerate bone, without affecting structural integrity, suggesting that the callus formed is of good quality. The converse appears true for peri-operative chemotherapy.