Infection in osteotomy around the knee: Incidence, management and outcomes in a high-volume case series.

PURPOSE: Current evidence around the management of osteotomy-related infection is insufficient to robustly underpin the expert statements formulated by a recent European consensus statement. We present a review of a large case series in a high-volume osteotomy practice to contribute to the understanding of the incidence, management and outcome of infection in this subspecialty area. METHODS: Analyses of two prospectively collected databases for all osteotomy around the knee and infections related to osteotomy were performed, along with a review of hospital readmission data to capture all osteotomy-related infections. Clinical notes were reviewed to assess patient demographics, incidence of infection, how infection was managed and clinical outcome. RESULTS: In a series of 822 osteotomies in 755 patients, there were 21 (2.8%) cases of suspected infection. Twelve (1.6%) were contemporaneously deemed 'superficial' and nine confirmed 'deep' infections (1.2%). Deep infections were all successfully managed with wound debridement, with or without plate removal, depending on union and time from initial surgery. One of these infections was noted during a revision procedure, but no revision was carried out as a direct result of infection, no external fixation was required and no infected nonunions were experienced. CONCLUSION: All of the cases in this series were managed successfully with debridement ± removal of the plate, without the need for revision or external fixation. Any potential signs of infection around an osteotomy, especially in the case of medial high tibial osteotomy, should raise awareness for deep infection and the need for further surgery due to the limited overlying soft tissue cover. This evidence supports the recent European Society of Sports Traumatology, Knee Surgery and Arthroscopy algorithm. LEVEL OF EVIDENCE: Level IV, case series.

What Can We Learn From COVID-19 Protocols With Regard to Management of Nonoperative Pediatric Orthopaedic Injuries?

INTRODUCTION: The COVID-19 pandemic has resulted in significant changes to normal practice in pediatric outpatient orthopaedics, with the instigation of telephone fracture clinic appointments, and the use of self-removable casting. We aim to determine any beneficial or detrimental short-term effects of these changes. METHODS: All patients referred to fracture clinic from the emergency department during the period March 24, 2020 to May 10, 2020 (national lockdown) were assessed for number of face to face and telephone appointments, number of radiographs performed, time to discharge, use of a removable cast, any cast complications, other complications, reattendance or re-referral after discharge. They were compared with patients referred in the same period in 2019. Follow-up was to 6 months for every patient. RESULTS: In 2019, 240 patients were reviewed and 110 in 2020. Changes in practice resulted in significant differences in the number of face to face appointments per patient [2 (1 to 6) 2019 vs. 1 (0 to 5) 2020 (P<0.00001)] and increase in telephone appointments [0 (0 to 1) 2019 vs. 1 (0 to 2) 2020]. Number of radiographs per patient [1 (1 to 7) 2019 vs. 1 (1 to ) 2020 (P=0.0178)] and time to discharge [29 d (0 to 483) 2019 vs. 16 d (0 to 216) 2020 (P<0.00001)] also reduced significantly. Use of a self-removable casting technique increased significantly (2.4% of casts in 2019 vs. 91.8% in 2020 (P<0.00001). There were no significant differences in complications related to cast or otherwise, unplanned attendance or reattendance after discharge. Use of self-removable casts for supracondylar fractures and for simple injuries (including distal radius, forearm, Toddler's, and ankle fractures) also demonstrated no change in complication rate. Significant potential cost savings of >£185 000 per annum could be demonstrated through clinic appointment and cast removal reductions. DISCUSSION: Changes to the normal management of pediatric orthopaedic trauma brought about by the COVID-19 pandemic have been demonstrated to be safe in the short term with no increase in complications demonstrated. Potential cost savings are possible both to the health care provider and also to the patient because of reduced hospital attendance. It is feasible to continue these practices for the potential benefits as they appear safe in the short term. LEVEL OF EVIDENCE: Level III-therapeutic study-retrospective comparative study.

Clinical presentation, MRI and clinical outcome scores do not accurately predict an important meniscal tear in a symptomatic discoid meniscus.

PURPOSE: Discoid menisci can be symptomatic from instability or a tear. A torn discoid meniscus is likely to require repair to preserve meniscal function and should not be missed. This is the first study to evaluate a range of pre-operative methods to predict the likelihood of a torn discoid meniscus. METHODS: A retrospective analysis of prospectively collected data was performed. Clinical, radiographic and operative data were reviewed. Patients were grouped based on the presence of a tear or not during surgery. All patients underwent MRI scans pre-operatively which were validated with arthroscopy findings to calculate sensitivity. All patients completed Pedi-KOOS and Pedi-IKDC pre-operative scores. RESULTS: There were 32 discoid menisci in 27 patients. Mean age at surgery was 10.4 years (6-16). Nineteen patients were female. Seventeen menisci were identified as torn at time of arthroscopy (53%), 15 were unstable but not torn. Clinical findings did not differentiate between the torn or unstable menisci. MRI was only 75% sensitive and 50% specific at identifying a torn discoid meniscus. There was no statistical difference between KOOS-child (n.s.) and Pedi-IKDC (n.s.) scores between the groups. CONCLUSION: MRI is neither sensitive nor specific at identifying tears in discoid menisci. There is no difference in pre-operative outcome scores for patients with a torn or unstable discoid meniscus; pre-operative PROMs are a poor predictor of a meniscal tear. This study emphasises that pre-operative tests and clinical findings are not conclusive for identifying a meniscal tear and the operating surgeon should be vigilant in identifying and repairing tears at the time of surgery. Pre-operative findings poorly correlate to arthroscopic findings and potential surgical interventions required. Patients and parents/carers should, therefore, be appropriately counselled prior to surgery that post-operative measures are dependent on intra-operative findings and not pre-operative findings in patients. LEVEL OF EVIDENCE: III.

Paediatric orthopaedics in lockdown: A study on the effect of the SARS-Cov-2 pandemic on acute paediatric orthopaedics and trauma.

AIMS: To determine the impact of COVID-19 on orthopaediatric admissions and fracture clinics within a regional integrated care system (ICS). METHODS: A retrospective review was performed for all paediatric orthopaedic patients admitted across the region during the recent lockdown period (24 March 2020 to 10 May 2020) and the same period in 2019. Age, sex, mechanism, anatomical region, and treatment modality were compared, as were fracture clinic attendances within the receiving regional major trauma centre (MTC) between the two periods. RESULTS: Paediatric trauma admissions across the region fell by 33% (197 vs 132) with a proportional increase to 59% (n = 78) of admissions to the MTC during lockdown compared with 28.4% in 2019 (N = 56). There was a reduction in manipulation under anaesthetic (p = 0.015) and the use of Kirschner wires (K-wires) (p = 0.040) between the two time periods. The median time to surgery remained one day in both (2019 IQR 0 to 2; 2020 IQR 1 to 1). Supracondylar fractures were the most common reason for fracture clinic attendance (17.3%, n = 19) with a proportional increase of 108.4% vs 2019 (2019 n = 20; 2020 n = 19) (p = 0.007). While upper limb injuries and falls from play apparatus, equipment, or height remained the most common indications for admission, there was a reduction in sports injuries (p < 0.001) but an increase in lacerations (p = 0.031). Fracture clinic management changed with 67% (n = 40) of follow-up appointments via telephone and 69% (n = 65) of patients requiring cast immobilization treated with a 3M Soft Cast, enabling self-removal. The safeguarding team saw a 22% reduction in referrals (2019: n = 41, 2020: n = 32). CONCLUSION: During this viral pandemic, the number of trauma cases decreased with a change in the mechanism of injury, median age of presentation, and an increase in referrals to the regional MTC. Adaptions in standard practice led to fewer MUA, and K-wire procedures being performed, more supracondylar fractures managed through clinic and an increase in the use of removable cast.Cite this article: Bone Joint Open 2020;1-7:424-430.

Malreduction of tibial articular width in bicondylar tibial plateau fractures treated with circular external fixation is associated with post-traumatic osteoarthritis.

OBJECTIVES: We aimed to report outcomes of Bicondylar Tibial Plateau (BTP) fractures treated using Ilizarov fixation, and identify risk factors for developing post-traumatic radiographic osteoarthritis (ROA). METHODS: Retrospective study of 80 BTP fractures managed with Ilizarov fixation. RESULTS: All fractures united, with only 3 cases of deep infection. ROA was evident in 12.5% at average 13 months post-injury. Increased tibial articular-widening associated with risk of developing ROA (p = 0.02). CONCLUSION: Ilizarov fixation is safe and reliable in the management of BTP fractures. Restoration of tibial articular-width at fixation associated with reduced risk of developing radiographic OA.

Accuracy and reliability of knee goniometry methods.

BACKGROUND: Measuring knee range of motion is important in examination and as a post-operative outcome. It is therefore important that measurements are accurate. Knee angles can be measured by traditional goniometers, smartphone apps are readily available and there are also purpose made digital devices. Establishing the minimum difference between methods is essential to monitor change. The purpose of this study was to assess reliability and minimum significant difference of visual estimation, short and long arm goniometers, a smartphone application and a digital inclinometer. METHODS: Knee angles were assessed by 3 users: one consultant orthopaedic surgeon, one orthopaedic surgical trainee and an experienced physiotherapist. All 5 methods were used to assess 3 knee angles, plus full active flexion and extension, on 6 knees. The subjects had knee angles fixed using limb supports during measurement, whilst maintaining appropriate clearance to allow a reproduction of assessment in clinic. Users were then blinded to their results and the test was repeated. A total of 300 measurements were taken. RESULTS: Inter-rater and intra-rater reliabilities were high for all methods (all > 0.99 and > 0.98 respectively). The digital inclinometer was the most accurate method of assessment (6° minimum significant difference). The long arm goniometer had a minimum significant different of 10°, smartphone app 12° and both visual estimation and short arm goniometry were found to be equally inaccurate (14° minimum significant difference). CONCLUSION: The digital inclinometer was the most accurate method of knee angle measurement, followed by the long arm goniometer. Visual estimation and short goniometers should not be used if an accurate assessment is required.

Osteochondroma arising from a lumbar facet joint in a 16-year-old.

Osteochondromas are benign tumours of bony or cartilaginous origin, which may be solitary or multiple. They are rare in the axial skeleton and have previously been reported to arise from facet joints only in four cases in the English literature. We report the case of a 16-year-old girl who presented with a palpable bony lump and a short history of back pain. Imaging showed a bony lesion arising from a left-sided facet joint in the lumbar spine. Following excision biopsy, there was complete resolution of symptoms. The literature on the origin and management of spinal osteochondromas is discussed.