Intraoperative 3D Fluoroscopy During Open Reduction for DDH: An Effective Alternative to Postoperative CT/MRI.

BACKGROUND: Computed tomography CT or magnetic resonance imaging (MRI) has been the most used imaging modality to assess hip reduction in developmental dysplasia of the hip (DDH) after open reduction (OR). In 2015, intraoperative 3D fluoroscopy (3D) was introduced at our center as an alternative to CT/MRI. 3D offers the advantage that if hip reduction is insufficient, it can be addressed at the time of surgery. The purpose of this study was to assess the efficacy of 3D in comparison to CT/MRI. METHODS: This was a single-centre, retrospective comparative study of two consecutive cohorts: those with OR and 3D between 2015 and 2017 and those with OR and CT/MRI between 2012 and 2014. Time to imaging, re-imaging, length of stay (LOS), re-operation, and redislocation or subluxation after cast removal were evaluated. RESULTS: Forty-two patients (46 hips) had 3D, and 30 patients (32 hips) had CT/MRI. Significant differences were found between groups in time to imaging, cast changes, and LOS. All 3D was intraoperative (46 hips), and only 69% (22 hips) of CT/MRI was on the day of surgery ( P <0.01). In the 3D group, 1 hip (2%) had a cast change under the same anesthetic, and 4 hips (13%) from CT/MRI had cast changes in subsequent surgery ( P =0.03). The mean LOS in days for 3D was 1.72 and 2.20 for CT/MRI ( P =0.03). There were no statistically significant differences between groups in further imaging and subluxations or re-dislocations at cast removal. Two hips (4%) in the 3D group had MRI, but with no further intervention ( P =0.51), and at cast removal, there were 3 subluxations in each group ( P =0.69) and 1 redislocation in the 3D group ( P =1.00). CONCLUSIONS: Intraoperative 3D improved time to imaging, allowed for cast changes at surgery and had a shorter LOS. Moreover, there were no significant differences found in adverse outcomes between those who underwent 3D versus CT/MRI. 3D should thus be considered an effective alternative to CT/MRI for assessing hip reduction during OR for DDH. LEVEL OF EVIDENCE: Diagnostic Study, level II.

Long-term Outcomes Following Multilevel Surgery in Cerebral Palsy.

BACKGROUND: This long-term consecutive, retrospective single-center cohort study evaluates long-term outcomes of single-event multilevel surgery in diplegic cerebral palsy with respect to functional status, gait, and patient satisfaction. METHODS: All patients with diplegic cerebral palsy who underwent single-event multilevel surgery >10 years previously were included. Retrospective gait assessment was performed using the Edinburgh Visual Gait Score (EVGS) and Gillette Functional Assessment Questionnaire Walking Scale (FAQWS) preoperatively and at midterm postoperative follow-up (median 2.6 y) and prospectively at most recent review [median 18 y, interquartile (IQ) range: 14.4 to 20.5 y]. The Short Form-36 (SF-36) was used prospectively to evaluate outcome compared with population norms for adults from the UK. RESULTS: The complete assessment was possible in 26 of 39 patients who met the inclusion criteria. There was a statistically significant improvement at most recent follow-up compared with the preoperative assessment for EVGS and FAQWS [Wilcoxon Matched Pairs Signed Rank test -4.42 (P<0.0001) and 3.98 (P=0.0001), respectively]. The median Physical Health and Mental Health Component Summary scores for the SF-36 were 43.0 (IQ range: 32.8 to 46.8) and 55.3 (IQ range: 46.1 to 61.1), respectively. CONCLUSIONS: This study demonstrates significant long-term improvements in function, independence and patient satisfaction that continue into adulthood. This will inform discussions with patients and families considering this treatment option. LEVEL OF EVIDENCE: Level IV-Retrospective cohort study.

Long-term patient-centred outcomes of periacetabular osteotomy in a large consecutive series.

Aims: We assessed the long-term outcomes of a large cohort of patients who have undergone a periacetabular osteotomy (PAO), and sought to validate a patient satisfaction questionnaire for use in a PAO cohort. Methods: All patients who had undergone a PAO from July 1998 to February 2013 were surveyed, with several patient-reported outcome measures (PROMs) and radiological measurements of preoperative acetabular dysplasia and postoperative correction also recorded. Patients were asked to rate their level of satisfaction with their operation in achieving pain relief, restoration of activities of daily living, ability to perform recreational activity, and their overall level of satisfaction with the procedure. Results: A total of 143 PAOs were performed between 1998 and 2013. Of those, 90 postoperative surveys were returned. Only 65 patients (73 hips) had both pre- and postoperative radiographs available for measurement. The mean time to follow-up was 15 years (6.5 to 20). Most patients were female (91%), with a mean age of 26.4 years (14.9 to 48.3) at the time of their surgery. A statistically significant improvement in radiological correction was detected in all hips (p < 0.001). A total of 67 patients (92.3%) remained either very satisfied or satisfied with their PAO. The internal consistency of the patient satisfaction questionnaire, measured using Cronbach's α, ranged from 0.89 to 0.94 indicating 'good' to 'excellent' reliability. Conclusion: Outcomes of importance to patients undergoing a PAO include several key domains: pain relief, improve activities of daily living, and improve recreational ability. Our study demonstrates high rates of long-term patient satisfaction in all domains, and found the patient satisfaction questionnaire to be a valid and reliable instrument for use in this cohort.

A comprehensive nonoperative treatment protocol for developmental dysplasia of the hip in infants.

Aims: Brace treatment is the cornerstone of managing developmental dysplasia of the hip (DDH), yet there is a lack of evidence-based treatment protocols, which results in wide variations in practice. To resolve this, we have developed a comprehensive nonoperative treatment protocol conforming to published consensus principles, with well-defined a priori criteria for inclusion and successful treatment. Methods: This was a single-centre, prospective, longitudinal cohort study of a consecutive series of infants with ultrasound-confirmed DDH who underwent a comprehensive nonoperative brace management protocol in a unified multidisciplinary clinic between January 2012 and December 2016 with five-year follow-up radiographs. The radiological outcomes were acetabular index-lateral edge (AI-L), acetabular index-sourcil (AI-S), centre-edge angle (CEA), acetabular depth ratio (ADR), International Hip Dysplasia Institute (IHDI) grade, and evidence of avascular necrosis (AVN). At five years, each hip was classified as normal (< 1 SD), borderline dysplastic (1 to 2 SDs), or dysplastic (> 2 SDs) based on validated radiological norm-referenced values. Results: Of 993 infants assessed clinically and sonographically, 21% (212 infants, 354 abnormal hips) had DDH and were included. Of these, 95% (202 infants, 335 hips) successfully completed bracing, and 5% (ten infants, 19 hips) failed bracing due to irreducible hip(s). The success rate of bracing for unilateral dislocations was 88% (45/51 infants) and for bilateral dislocations 83% (20/24 infants). The femoral nerve palsy rate was 1% (2/212 infants). At five-year follow-up (mean 63 months (SD 5.9; 49 to 83)) the prevalence of residual dysplasia after successful brace treatment was 1.6% (5/312 hips). All hips were IHDI grade I and none had AVN. Four children (4/186; 2%) subsequently underwent surgery for residual dysplasia. Conclusion: Our comprehensive protocol for nonoperative treatment of infant DDH has shown high rates of success and extremely low rates of residual dysplasia at a mean age of five years.

The role of physiotherapy in the treatment of whiplash associated disorders: a prospective study.

OBJECTIVES: Prospective longitudinal study to evaluate the effect of physiotherapy on whiplash associated disorders (WAD). MATERIALS AND METHODS: A total of 141 patients suffering from grades I-III WAD after a road traffic accident were employed. Validated neck Bournemouth Questionnaire was used in order to look at the effect of treatment on the symptoms. RESULTS: The mean age was 40 (+/-14) years. The mean length of the treatment was 6 (+/-3.4) weeks. The mean individual effect size was 0.97 (95% CI 0.8-1.2). A total of 67% of the patients who started their treatment in the first 3 months post-injury improved compared to 48% in those who started physiotherapy after 3 months (P = 0.025). In both groups the applied treatment almost halved the number of patients taken sick leave. CONCLUSION: Physiotherapy is effective in the treatment of whiplash injury, especially in order to get the patients fit to go back to their previous employment.

Establishing Safe Zones to Avoid Nerve Injury in the Approach to the Humerus in Pediatric Patients: A Magnetic Resonance Imaging Study.

BACKGROUND: The surgical anatomy of upper-extremity peripheral nerves in adults has been well described as "safe zones" or specific distances from osseous landmarks. In pediatrics, relationships between nerves and osseous landmarks remain ambiguous. The goal of our study was to develop a model to accurately predict the location of the radial and axillary nerves in children to avoid iatrogenic injury when approaching the humerus in this population. METHODS: We conducted a retrospective review of 116 magnetic resonance imaging (MRI) scans of entire humeri of skeletally immature patients; 53 of these studies met our inclusion criteria. Two independent observers reviewed all scans. Arm length was measured as the distance between the lateral aspect of the acromion and the lateral epicondyle. We then calculated the distances (defined as the percentage of arm length) between the radial nerve and distal osseous landmarks (the medial epicondyle, transepicondylar line, and lateral epicondyle) as well between the axillary nerve and the most lateral aspect of the acromion. RESULTS: The axillary nerve was identified at a distance equaling 18.6% (95% confidence interval [CI], ±0.62%) of arm length inferior to the lateral edge of the acromion. The radial nerve crossed (1) the medial cortex of the posterior part of the humerus at a distance equaling 63.19% (95% CI: ±0.942%) of arm length proximal to the medial epicondyle, (2) the middle of the posterior part of the humerus at a distance equaling 53.9% (95% CI: ±1.08%) of arm length proximal to the transepicondylar line, (3) the lateral cortex of the posterior part of the humerus at a distance equaling 45% (95% CI: ±0.99%) of arm length proximal to the lateral epicondyle, and (4) from the posterior to the anterior compartment at a distance equaling 35.3% (95% CI: ±0.92%) of arm length proximal to the lateral epicondyle. A strong linear relationship between these distances and arm length was observed, with an intraclass correlation coefficient of >0.9 across all measurements. CONCLUSIONS: The positions of the radial and axillary nerves maintain linear relationships with arm lengths in growing children. The locations of these nerves in relation to palpable osseous landmarks are predictable. CLINICAL RELEVANCE: Knowing the locations of upper-extremity peripheral nerves as a proportion of arm length in skeletally immature patients may help to avoid iatrogenic injuries during surgical approaches to the humerus.

Primed PMNs in healthy mouse and human circulation are first responders during acute inflammation.

Polymorphonuclear neutrophils (PMNs) are the most abundant circulating leukocytes, and the first cells recruited to sites of tissue inflammation. Using a fixation method to preserve native CD marker expression prior to immunophenotyping, we identified a distinct population of "primed for recruitment" PMNs in healthy mouse and human blood that has high expression of adhesion and activation markers compared with the bulk resting-state PMNs. In response to acute tissue inflammation, primed PMNs (pPMNs) were rapidly depleted from the circulation and recruited to the tissue. One hour after acute peritoneal insult, pPMNs became the dominant PMN population in bone marrow (BM) and blood, returning to baseline levels with resolution of inflammation. PMN priming was induced by the granulopoietic factors granulocyte-macrophage-colony-stimulating factor (GM-CSF) and granulocyte-colony-stimulating factor (G-CSF). High levels of pPMNs were observed in neutropenic mice and in pediatric neutropenic patients who were resistant to infection, highlighting an important role of this population in innate immune function.

Informal regionalization of pediatric fracture care in the Greater Toronto Area: a retrospective cross-sectional study.

BACKGROUND: Operative management of pediatric fractures is an expected competency in the specialty of Orthopedic Surgery. However, specialized pediatric centres may be providing care for increasing numbers of patients with fractures previously treated at community hospitals. The primary objective of this study was to examine trends in presentation of children with fractures to a specialized pediatric centre. METHODS: We performed a detailed chart review to examine trends in presentation of children aged 14 years or less with supracondylar humerus or femur fractures to a specialized pediatric centre (Hospital for Sick Children, Toronto) from anywhere in the Greater Toronto Area between Apr. 1, 2008, and Mar. 31, 2015. Consecutive patients admitted to hospital and requiring operative intervention for a supracondylar humerus or femur fracture were considered. We calculated changes in operation incidence rates per year using multivariable negative binomial regression models. RESULTS: A total of 945 children with supracondylar humerus fractures and 421 with femur fractures underwent operative intervention during the study period. The baseline characteristics of the 2 groups were similar irrespective of which year fixation occurred. The annual incidence rate of supracondylar humerus fractures increased from 108 to 169 (56.5%) over the study period, at an adjusted rate of 7.5% per year (adjusted incidence rate ratio [IRR] 1.075, 95% confidence interval [CI] 1.072-1.079, p < 0.001). The annual incidence rate of femur fractures increased from 49 to 69 (40.8%), at an adjusted rate of 5.3% per year (adjusted IRR 1.053, 95% CI 1.044-1.062, p < 0.001). Significant increases were observed independent of fracture classification, stabilization method, whether patients were transferred from an outside hospital or presented directly, patient geographic location or the season in which the fracture occurred. INTERPRETATION: Adjusted annual incidence rates of supracondylar humerus and femur fractures increased significantly over the study period. Further work is needed to assess the clinical impact of informal regionalization of care and to determine whether the phenomenon occurs in other specialties.

A form of autosomal dominant spondyloepiphyseal dysplasia is caused by a glycine to alanine substitution in the COL2A1 gene.

We report a family with an unusual form of autosomal dominant spondyloepiphyseal dysplasia characterized by infantile-onset disproportionate short stature with relative shortening of the spine, thoracic kyphosis, lumbar lordosis, scoliosis and premature osteoarthritis of the joints especially of the hips. Radiological findings include mild platyspondyly, vertebral end plate irregularity, irregular femoral necks, and dysplasia of the capital femoral epiphyses with flattening and irregularity present from childhood and mild variable epiphyseal dysplasia elsewhere in the skeleton. Intrafamilial variability is observed in the degree of short stature, severity of spinal and hip involvement and the age of onset of symptoms and complications. We demonstrate that this dysplasia is due to a glycine to alanine substitution in the COL2A1 gene (p.Gly862Ala), thereby expanding the phenotypic spectrum of dysplasias associated with defects in type II collagen.