Percutaneous epiphysiodesis using transphyseal screws (PETS) versus tension-band plating (TBP): comparative study of outcomes for correcting limb length discrepancy.

OBJECTIVES: The best effective treatment strategy for limb length discrepancy (LLD) is still being debated. The goal of this study was to compare the efficacy and results of tension-band plating (TBP) and percutaneous epiphysiodesis using transphyseal screws (PETS) for LLD correction. METHODS: From June 2008 to January 2019, children who had lower extremity epiphysiodesis with either TBP or PETS were reviewed retrospectively. At the conclusion of treatment, LLD, angular deformity, and complications were reviewed. The t-test or Wilcoxon rank sum test was used to compare continuous variables. Categorical variables were evaluated using Fisher's exact test or χ2 test. RESULTS: A total of 32 epiphysiodeses with TBP (14 patients, 24 femur/tibias) or PETS (13 patients, 23 femur/tibias) were compared. TBPs were conducted while the patients were younger (11.0 vs. 13.1 years, p = 0.005). The treatment durations were similar in both groups (TBP: 23.5 months vs. PETS: 24 months, p = 0.132). PETS had significantly shorter operative time (p = 0.047), length of hospital stay (p = 0.014), and time to return to full activity (p = 0.043). LLD in the TBP group reduced from 2.64 to 1.38 cm (p = 0.005), while in the PETS group it decreased from 2.76 to 1.08 cm (p = 0.001). During treatment, the rate of LLD correction was 0.49 ± 0.9 cm/year for limbs treated with TBP and 1.0 ± 1.1 cm/year for limbs treated with PETS (p = 0.185). At the end of treatment, 8 TBP cases (47%) and 9 PETS cases (60%) had achieved LLD ≤ 2 cm (p = 0.502), and at the most recent follow-up, this had grown to 11 (65%) in the TBP group and 12 (80%) in the PETS group. There were no significant differences in the total number of complications between groups (p > 0.05). Revision surgery was required in 11 TBP and 3 PETS limbs due to persistent LLD or angular deformity (AD) (p = 0.016). Logistic regression did not reveal any significant association between TBP and the rate of complication or revision surgery. CONCLUSION: PETS and TBP are both effective methods for limb length equalization. PETS, on the other hand, was linked to a shorter operative time, a shorter hospital stay, a faster recovery to pre-operative function, and a lower complication rate. The rate of revision surgery due to persistent LLD or AD was higher in TBP. We advise surgeons against utilizing TBP to correct LLD. LEVEL OF EVIDENCE: III.

Disparities in Pediatric Scoliosis: The Impact of Race and Insurance Type on Access to Nonoperative Treatment for Adolescent Idiopathic Scoliosis.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) has evidence-based, nonoperative treatments proven to be effective with early diagnosis and prompt treatment. The purpose of this study was to identify potential disparities in access to nonoperative treatment for AIS. Specifically, we sought to determine the interaction of socioeconomic factors on a major curve magnitude and recommend treatment at the initial presentation. METHODS: A retrospective review of AIS patients who underwent surgery at a single tertiary pediatric hospital between January 1, 2013 and December 31, 2018 was conducted. Patients were divided into 2 groups for comparison: patients with public insurance (PUB) and those with private insurance (PRV). Primary variables analyzed were patient race, Area Deprivation Index (ADI), major curve magnitude, and treatment recommendation at the initial presentation. Univariate and multivariate analyses were conducted to identify the predictors of the major curve magnitude at presentation. RESULTS: A total of 341 patients met the inclusion criteria; PUB and PRV groups consisted of 182 (53.4%) and 159 (46.6%) children, respectively. Overall, the major curve magnitude at presentation was significantly higher in PUB compared with PRV patients (50.0° vs. 45.1°; P =0.004) and higher in Black patients compared to White patients (51.8 vs. 47.0, P =0.042). Surgery was recommended for 49.7% of the PUB group and 43.7% of the PRV group. A lesser number of PUB patients had curve magnitudes within the range of brace indications (≤40°) compared to PRV patients (22.5% vs. 35.2%, respectively; P =0.010). The odds of having an initial major curve magnitude <40 degrees were 67% lower among Black patients with public insurance compared to Black patients with private insurance (OR=0.33; 95% CI: 0.13-0.83; P =0.019). CONCLUSION: This study demonstrated disparity in access to nonoperative treatment for pediatric scoliosis. Black patients with public insurance were the most at-risk to present with curve magnitudes exceeding brace indications. Future work focused on understanding the reasons for this significant disparity may help to promote more equitable access to effective nonoperative treatment for adolescent idiopathic scoliosis. LEVEL OF EVIDENCE: III.

The Effect of Surgeon Experience on Outcomes Following Growth Friendly Instrumentation for Early Onset Scoliosis.

BACKGROUND: The purpose of this study was to utilize a multicenter, multisurgeon cohort to assess the effect of surgeon experience on outcomes of growth friendly instrumentation (GFI) in early onset scoliosis (EOS). We hypothesized that unplanned return to the operating room (UPROR), estimated blood loss (EBL), and surgical time would be greater amongst early career surgeons (ECSs) when compared with advanced career surgeons (ACSs). METHODS: An international pediatric spine database was queried for patients ages 2 to 10 years treated by posterior distraction-based GFI with at least of 2-year follow up. Two groups were created for analysis based on surgeon experience: ECSs (with ≤10 y of experience) and ACSs (with >10 y of experience). The primary outcome was UPROR. Additional outcomes included: operating room time, EBL, neurological deficits, infection rate, hardware failure, and the Early Onset Scoliosis Questionnaire (EOSQ-24). Subgroup analysis was performed for further assessment based on procedure type, superior anchor type, etiology, and curve severity. RESULTS: A total of 960 patients met inclusion criteria including 243 (25.3%) treated by ECS. Etiology, sex, superior anchor, and EOSQ-24 scores were similar between groups (P>0.05). There were no clinically significant differences in patient age or preoperative major coronal curve. UPROR (35.8% vs. 32.7%, P=0.532), infection (17.0% vs. 15.6%, P=0.698), operating room time (235 vs. 231 min, P=0.755), and EBL (151 vs. 155 mL, P=0.833) were comparable between ECS and ACS groups. The frequency of having at least 1 complication was relatively high but comparable among groups (60.7% vs. 62.6%, P=0.709). EOSQ-24 subdomain scores were similar between groups at 2-year follow-up (P>0.05). Subgroup analysis revealed that ECS had increased surgical time compared with ACS in severe curves >90 degrees (270 vs. 229 min, P=0.05). CONCLUSIONS: This study represents the first multicenter assessment of surgeon experience on outcomes in EOS. Overall, surgeon experience did not significantly influence UPROR, complication rates, EBL, or surgical time associated with GFI in this cohort of EOS patients. LEVEL OF EVIDENCE: Level III.

Survival in patients with carcinomas presenting with bone metastasis at diagnosis: a SEER population-based cohort study.

INTRODUCTION: Carcinoma metastasis to bone is a common reason for consultation to orthopedic surgeons. The presence of bone metastases (BM) is usually associated with poor prognosis which is worsened in the presence of synchronous metastases. The purpose of this study was to: (1) identify the most common carcinomas presenting with BM at diagnosis, to (2) analyze their survival, and (3) compare this against the survival of patients with additional synchronous metastasis based on a large population analysis. MATERIALS AND METHODS: Patients diagnosed with carcinoma between January 2010 and December 2015 were identified from the Surveillance, Epidemiology and End Results (SEER) database. The most common carcinomas presenting with BM at diagnosis were identified. Survival based on the presence of BM and synchronous metastases (lung, brain, liver, lymph nodes) was evaluated with Kaplan-Meier analysis. Five-year survival (%) stratified by carcinoma type was calculated. Hazard ratio (HR) for mortality comparing isolated BM to other synchronous metastases was performed. RESULTS: A total of 4.85% of patients (98,606/2,035,204) with carcinoma presented with BM at diagnosis, most commonly from a lung primary. Five-year survival with isolated BM was lowest in patients with pancreatic carcinoma (5.8%, 95% CI 3.0-9.9%), and highest in patients with breast carcinoma (41.1%, 95% CI 38.6-43.5%). Synchronous metastases increased significantly the risk of mortality within the majority of carcinomas. CONCLUSION: BM at diagnosis has a poor prognosis which is worsened if synchronous metastases are present; a fact to consider when planning orthopedic interventions. LEVEL OF EVIDENCE: Level III, prognostic study.

Meta-Analysis of the Diagnostic Accuracy of Primary Bone and Soft Tissue Sarcomas by 18F-FDG-PET.

OBJECTIVES: The goal of this meta-analysis was to assess the use of FDG-PET in the diagnosis of primary bone and soft tissue sarcomas. SUBJECTS AND METHODS: Several databases, including PubMed, Embase, Cochrane Library, and Web of Science, were searched. In addition to sensitivity and specificity, the diagnostic accuracy region for detecting and grading sarcomas were pooled using bivariate and hierarchical summary receiver-operating characteristic (HSROC) models. Subgroup analysis included pooling soft tissue and bone sarcomas separately, and sensitivity analysis included high-quality studies. The quality of eligible studies was assessed using QUADAS-2. RESULTS: Of the 1,258 papers screened, 21 studies satisfied the inclusion criteria. The pooled sensitivity and specificity of FDG-PET combined with CT for the detection of sarcomas were 89.2 and 76.3%, respectively. These diagnostic accuracy measures were higher when combined with CT than those of PDG-PET alone. Diagnostic accuracy for bone and soft tissue lesions were comparable but slightly better for soft tissue tumors. Pooling only the high-quality studies with low risk of bias yielded a sensitivity of 88.5% and specificity reduced to 65.6%. There was no evidence for publication bias, but significant heterogeneity among the studies was apparent. This study also showed that FDG-PET can efficiently differentiate between benign and malignant tumors, with a mean standard uptake value of maximally 2.52 units in benign and 6.81 units in malignant tumors (89.2% sensitivity and 75.1% specificity). CONCLUSION: Our findings indicate FDG-PET can efficiently differentiate between benign and malignant bone and soft tissue tumors. We also found that FDG-PET improves accuracy in diagnosing soft tissue sarcomas when combined with CT.

Early versus late treatment of paediatric femoral neck fractures: a systematic review and meta-analysis.

PURPOSE: Femoral neck fractures in children represent less than 1% of all paediatric fractures. Osteonecrosis of the femoral head is one of the devastating complications of this fracture. Time to treatment is one of the most important predictors of this outcome with no clear consensus in the literature. The aim of this study was to determine whether early treatment (< 24 hours) of pediatric femoral neck fractures is associated with a lower rate of osteonecrosis of the femoral head compared to late treatment (> 24 hours). METHODS: We searched several databases (PubMed, Embase, and Cochrane library), from January 1966 to November 2017 for any comparative studies that evaluated early (< 24 hours) versus late (> 24 hours) treatment of paediatric femoral neck fractures. We pooled the effect sizes using fixed effects model that compared the rate of osteonecrosis of the femoral head between children undergoing early versus late treatment, open versus closed reduction, displaced versus non-displaced and different Delbet type femoral neck fractures. Descriptive and qualitative data was also extracted. RESULTS: Of the 391 articles identified, six studies (prospective and retrospective cohort studies) were eligible for the meta-analysis, with a total of 231 paediatric femoral neck fractures. The pooled odds ratio (OR) for osteonecrosis of the femoral head did not show any statistically significant difference between early (< 24 hours) versus late (> 24 hours) treatment (OR = 1.19, 95% CI 0.56, 2.51, I2 = 23.6%), nor between open versus closed reduction of paediatric femoral neck fractures (OR = 1.62, 95% CI 0.82, 3.22, I2 = 19.57%). Displaced and Delbet type I/II femoral neck fractures were 3.8 (OR = 3.81, 95% CI 1.49, 9.78, I2 = 0.00%) and 2.4 (OR = 2.43, 95% CI 1.28, 4.61, I2 = 0.57%) times more associated with osteonecrosis of the femoral head compared to non-displaced and Delbet type III/IV fractures respectively. CONCLUSIONS: The cumulative evidence at present does not indicate an association between the time to treatment or method of reduction of femoral neck fractures in children and the risk of osteonecrosis of the femoral head. However, initial expedient treatment of femoral neck fractures in children should always remain the rule especially for displaced and Delbet type I/II femoral neck fractures. LEVEL OF EVIDENCE: II/III.

Open versus closed treatment of distal tibia physeal fractures: a systematic review and meta-analysis.

AIMS: Distal tibia physeal fractures can lead to growth complications such as premature physeal closure (PPC), angular deformity and leg length discrepancy. The aim of our study was to systematically review the literature to assess whether open reduction and internal fixation (ORIF) is associated with lower rates of PPC compared to closed treatment. MATERIALS AND METHODS: We searched several databases from 1966 to 2016 for studies that evaluated ORIF versus closed treatment of distal tibia physeal fractures. We performed a meta-analysis using a random effects model to pool odds ratios (OR) for the comparison of PPC rate between children undergoing ORIF versus closed treatment. We also investigated the PPC rate in Salter-Harris (S-H) type I and II fractures. Descriptive, quantitative and qualitative data were extracted. RESULTS: Out of the 253 articles identified, six retrospective cohort studies were eligible, with a total of 970 distal tibia physeal fractures. The pooled OR of PPC between ORIF and closed treatment showed no statistically significant difference [OR = 0.98, 95% confidence interval (CI) 0.48, 1.97; I 2 = 49.8%, p = 0.076]. No significant difference in the rate of PPC was detected in S-H type I and II fractures with ORIF and closed treatment [OR = 1.25, 95% CI 0.72, 2.16; I 2 = 32.1%, p = 0.22]. CONCLUSIONS: The cumulative evidence at present does not indicate an association between the method of treatment of distal tibia physeal fractures and the risk of PPC. Both treatment types are feasible, but less surgical-related complications are associated with closed treatment. LEVEL OF EVIDENCE: III.

Does Combining Drilling and Curettage to Percutaneous Trans-epiphyseal Screws Improve Correction of Limb Length Discrepancy? A Comparative Study.

Objectives: Physeal drilling and curettage (PDC) and percutaneous epiphysiodesis using transphyseal screws (PETS) are among the most widely used techniques to treat leg-length discrepancy (LLD). This study compared the efficacy and outcomes between PETS alone and PETS combined with PDC (PETS + PDC). Methods: Retrospective study of children who underwent epiphysiodesis of the proximal tibia or distal femur with either PETS or PETS + PDC between 2008 and 2018 at a single institution. Radiographic parameters and complications were reviewed at completion of treatment and most recent follow-up. Results: A total of 23 epiphysiodeses in 15 patients, average age 13.1 years, with either PETS (13 femur/tibias) or PETS + PDC (10 femur/tibias) were included. PETS patients were treated for a longer time (median: 24 months vs 11 months, p = 0.004), however, follow-up time was similar between groups (p = 0.577), on average 2.7 years. In the PETS group, LLD decreased from 2.55 to 0.84 cm at most recent follow-up (p = 0.010), and in the PETS + PDC group from 3.01 to 1.2 cm (p = 0.005), achieving a correction of 1.71 cm for PETS and 1.83 cm for PETS + PDC (p = 0.871). A correction of LLD to ≤ 2 cm was achieved in 8 PETS (89%) and 4 PETS + PDC cases (67%) (p = 0.525). Two PETS patients (22%) and 1 PETS + PDC (17%) patient returned to the OR for further correction due to persistent LLD (p = 1.000). No differences existed in total number of complications, angular deformity or return to physical activity between groups (p ≥ 0.05 for each comparison). Conclusions: This study showed equal efficiency in resolving LLD between the PETS and PETS + PDC procedures with minimal operative complications.Level of Evidence III.

Skeletal Muscle Metastases from Carcinomas: A Review of the Literature.

* Bones are a common site for metastases; however, muscle metastases recently have been more commonly reported, not only as a result of the multidisciplinary approach in the treatment of these patients but also because of more sensitive imaging modalities such as positron emission tomography-computed tomography (PET-CT) that identify these lesions in early stages.* The most common carcinoma is lung carcinoma, with a hematogenous route of spread mainly to the axial region of the body (the psoas muscle, the gluteal muscles, and the paravertebral muscles). * Clinically, skeletal muscle metastases from carcinomas frequently present as painful palpable masses with or without swelling and are commonly found before diagnosis of the primary carcinoma.* Multiple imaging modalities, including radiographs, CT, magnetic resonance imaging (MRI), and PET-CT, have been used for diagnosis and staging, but tissue sampling is needed for a final diagnosis. The most important differential diagnosis of skeletal muscle metastases is with soft-tissue sarcomas.* Treatment is mainly based on chemotherapy and/or radiation; surgery is performed in cases of symptomatic lesions that fail to respond to nonoperative treatment.

Early versus late hip spica casting for paediatric femoral shaft fractures.

The purpose of our study was to evaluate the effectiveness of treating paediatric femoral shaft fractures by early (<48 h) versus late (>48 h) hip spica casting. A retrospective review of 44 patients with 44 femoral shaft fractures treated by either early or late hip spica application with at least 9-month follow-up was undertaken. Both groups were treated on an inpatient basis. The late hip spica group had skin traction applied before the application of a hip spica. The outcome measures involved both clinical [Pediatric Outcomes Questionnaire (POQ) and Activities Scale for Kids (ASK)] and radiological outcomes. Complications were noted. A total of 44 patients with a mean age of 33 months (range: 7-66 months) were evaluated. Overall, 20 patients underwent early and 24 had late hip spica casting. At follow-up, the ASK was similar amongst the two groups (44.2 vs. 44.8, P=0.8). However, the POQ was better in the early hip spica casting group (24.7 vs. 28.9, P=0.01). Length of hospital stay and duration of immobilization in the hip spica were significantly shorter in the early group (P<0.001). There were no differences in leg lengths, lateral distal femoral angles and medial proximal tibia angles between the fractured and nonfractured limbs in both groups. Early hip spica casting is a safe procedure for paediatric femoral shaft fractures and was associated with less time in hospital and hip spica with a better POQ score. However, early hip spica casting was associated with more hip spica changes and required wedging. At follow-up, radiological parameters were similar in both groups. Level of Evidence: III.

Impaired Liver Size and Compromised Neurobehavioral Activity are Elicited by Chitosan Nanoparticles in the Zebrafish Embryo Model.

The use of chitosan nanoparticles (ChNPs) in various biological and environmental applications is attracting great interest. However, potential side effects related to ChNP toxicity remain the major limitation hampering their wide application. For the first time, we investigate the potential organ-specific (cardiac, hepatic, and neuromuscular) toxicity of ChNPs (size 100⁻150 nm) using the zebrafish embryo model. Our data highlight the absence of both acute and teratogenic toxic effects of ChNPs (~100% survival rate) even at the higher concentration employed (200 mg/L). Although no single sign of cardiotoxicity was observed upon exposure to 200 mg/L of ChNPs, as judged by heartbeat rate, the corrected QT interval (QTc, which measures the time between the start of the Q wave and the end of the T wave in the heart's electrical cycle), maximum cardiac arrest, and ejection fraction assays, the same dosage elicited the impairment of both liver size (decreased liver size, but without steatosis and lipid yolk retention) and neurobehavioral activity (increased movement under different light conditions). Although the observed toxic effect failed to affect embryo survival, whether a prolonged ChNP treatment may induce other potentially harmful effects remains to be elucidated. By reporting new insights on their organ-specific toxicity, our results add novel and useful information into the available data concerning the in vivo effect of ChNPs.

Performance evaluation of five commercial assays in assessing seroprevalence of HEV antibodies among blood donors.

INTRODUCTION: Although hepatitis E virus (HEV) is mainly transmitted via the faecal-oral route, the rate of HEV transmission via blood donation is on the rise. However, the seroprevalence of HEV among blood donors is not well established and is thought to be affected by the type of diagnostic assay used. We aimed to evaluate performance and correlation among widely used commercial diagnostic assays for the seroprevalence assessment of HEV-IgM/IgG among blood donors. METHODOLOGY: A total of 1049 blood donor samples were tested for HEV IgG and IgM using different enzyme immunoassays (Wantai, Eruoimmune, MP diagnostics, Mikrogen immunoblot, HEV-IgM rapid test). The performance of each assay was evaluated according to our established silver standard value based on three or more IgG concordant assay results. RESULTS: HEV seroprevalence varied considerably using these assays, ranging from 10.1 % (Euroimmune-ELISA) to 18.0 % (Wanti-ELISA) for HEV-IgG, and from 0.2 % (Wanti-ELISA) to 2.6 % (MP Rapid test) for HEV-IgM. A total of 155 of 216 (71.6%) samples tested positive for HEV-IgG by three or more concordant assays. On the other hand, IgM assays showed poor agreement as only 7.6 % (4/52) of the specimens were positive according to three or more concordant assay test results. All HEV-IgG assays revealed high sensitivity and specificity (ranging 96.5-100 %),and excellent Kappa concordance (0.88-0.95), except for Euroimmun ELISA (sensitivity=61.5 %, kappa=0.63). MP ELISA showed the highest levels of sensitivity (100 %) and specificity (98.5 %). CONCLUSIONS: Due to discrepancies in the performance of various IgG and IgM assays, seroprevalence studies should be based on furher confirmatory testing for decisive conclusions to be reached.

An unusual osteomyelitis caused by Moraxella osloensis: A case report.

INTRODUCTION: Moraxella osloensis is a gram-negative coccobacillus, that is saprophytic on skin and mucosa, and rarely causing human infections. Reported cases of human infections usually occur in immunocompromised patients. PRESENTATION OF CASE: We report the second case of M. osloensis-caused-osteomyelitis in literature, occurring in a young healthy man. The organism was identified by sequencing analysis of the 16S ribosomal RNA gene. Our patient was treated successfully with surgical debridement and intravenous third-generation cephalosporins. DISCUSSION: M. osloensis has been rarely reported to cause local or invasive infections. Our case report is the second case in literature and it is different from the previously reported case in that our patient has no chronic medical problems, no history of trauma, with unique presentation and features on the MRI and intraoperative finding. CONCLUSION: Proper diagnosis is essential for appropriate treatment of osteomyelitis. RNA gene sequence analysis is the primary method of M. osloensis diagnosis. M. osloensis is usually susceptible to simple antibiotics.