Distal Scaphoid Excision for Chronic and Nonchronic Scaphoid Fracture Nonunion.

Purpose: The indications for distal scaphoid excision are limited to localized wrist arthritis surrounding the scaphoid, as a result of scaphoid nonunion advanced collapse or scapho-trapezio-trapezoid joint arthritis. The procedure historically has led to relief of symptoms and improvement in strength. Our aim was to examine the outcomes of this procedure in patients with scaphoid fracture nonunion. Methods: This is a single-center retrospective case series of 12 consecutive patients who underwent distal scaphoid excision after scaphoid fracture nonunion. Patients were divided into the following two groups based on nonunion chronicity: chronic (more than a year) and nonchronic (less than a year). Clinical and radiographic data were examined using descriptive statistics. Results: Our cohort consisted of 12 patients, 10 men (83%) and 2 women (17%), with a mean age of 37.6 ± 13.6 years. Eight patients had a chronic scaphoid fracture nonunion (six had a neglected scaphoid fracture and two had a nonunion after scaphoid open reduction and internal fixation with bone graft), and four patients had a nonchronic fracture nonunion (two had failed cast treatment and two had nonunion after scaphoid open reduction and internal fixation with bone graft). Before surgery, all patients complained of pain and four had numbness (all in the chronic group). After an average of 21 weeks after surgery, seven patients (58%) reported continued pain, two patients reported ulnar side pain, and one underwent arthroscopic synovectomy. All patients who started with a normal radiolunate angle continued to have a normal angle, whereas patients who had dorsal intercalated segmental instability prior to surgery persisted with it after surgery, except for a patient who underwent midcarpal fusion and had their radiolunate angle corrected. Conclusions: Distal scaphoid excision is an effective procedure for carefully selected patients with periscaphoid wrist arthrosis. Patients with recent scaphoid fractures that failed treatment may also be treated with distal scaphoid resection. Type of study/level of evidence: Therapeutic V.

The Feasibility of Utilizing Malunion Criteria to Limit Radiographs After Spica Casting for Pediatric Femur Fractures.

BACKGROUND: There are no existing guidelines regarding the timing or frequency of postoperative radiographs following spica casting for pediatric femur fractures. The purpose of this study was to evaluate established femoral malunion criteria as a potential screening tool to limit postoperative radiographs by identifying patients at risk for unacceptable alignment in the early treatment period. METHODS: A retrospective chart review was conducted for pediatric femoral shaft fractures presenting to a tertiary pediatric referral hospital from 2012 to 2017. Pediatric femur malunion criteria were applied to radiographs at initial presentation, first follow-up visit, and final follow-up visit. The primary outcome was a change in management based on radiographic findings in the early postoperative period. Secondary outcomes included radiographic measures, number of follow-up visits, and complications. RESULTS: Of 449 consecutive pediatric femur fractures treated at our center, 149 patients aged 1 to 4 years (mean age: 2.5±1.6 y) met inclusion criteria. At initial presentation, 36.9% (55/149) of patients met malunion criteria. Only 4.0% (6/149) of patients had a change in management following initial closed reduction and spica cast application due to radiographic findings at subsequent follow-up. Of these patients, 67% (4/6) were identified on preoperative imaging, and 83.3% (5/6) were identified by their first clinic appointment. Four of the 149 patients were converted to definitive surgical fixation, and 2 patients required cast wedging due to either unacceptable fracture shortening or coronal/sagittal angulation. CONCLUSIONS: Routine early postoperative radiographs may not be necessary for all pediatric femur fractures managed with closed reduction and spica casting. The value of this study is that it is the first to demonstrate the feasibility of limiting postoperative radiographs using a preoperative screening tool. However, the established femoral malunion criteria utilized in this study were limited in their predictive value, and further work is necessary to improve the sensitivity and specificity before widespread clinical application. LEVEL OF EVIDENCE: Level IV.

Enhanced Recovery After Pediatric Scoliosis Surgery: Key Components and Current Practice.

With the goal of safety and efficiency in health care delivery, enhanced recovery protocols (ERPs) continue to gain traction throughout various surgical disciplines, including in pediatric scoliosis surgery. The growing body of literature reporting decreased length of stay and cost with no change in readmissions or complications has brought these protocols to the forefront. The key components of ERPs include preoperative patient counseling, perioperative pain management, and early patient mobilization. In this review, the authors aim to describe the foundational history and major components of ERPs following pediatric spine deformity surgery. [Orthopedics. 2020;43(5):e338-e344.].

VEPTR Treatment of Early Onset Scoliosis in Children Without Rib Abnormalities: Long-term Results of a Prospective, Multicenter Study.

BACKGROUND: In 2007, this prospective study on vertical expandable prosthetic titanium rib (VEPTR) treatment of early onset scoliosis in children without rib abnormalities was initiated. Two-year follow-up results have previously been reported. This study examines whether, at 5-year follow-up, VEPTR continues to control scoliosis and allow spinal growth. METHODS: A prospective, multicenter, observational cohort design was used. Patients underwent traditional VEPTR implantation ≥5 years before analysis. Preimplantation and last available images were compared, regardless of whether VEPTR remained in vivo. Additional analysis was performed if VEPTR was in vivo ≥5 years. RESULTS: This study included 59 patients (mean age at VEPTR implantation, 6.1±2.4 y; mean follow-up, 6.9±1.4 y). Currently, 24 patients still have VEPTR, whereas 24 have converted (13 fusions, 6 MCGR, 3 growing rods, 1 hybrid, and 1 Shilla). Three have had VEPTR explanted, 6 are unknown, and 2 have deceased. On last available imaging (n=59; mean follow-up, 4.8±1.9 y), scoliosis improved from 71.8±18.0 degrees preoperatively to 60.9±20.3 degrees (P<0.001) and T1- T12 height increased (15.8±3.2 to 19.3±3.8 cm, P<0.001). T1-S1 height also increased (24.8±4.4 to 31.2±5.3 cm, P<0.001), representing 119% age-matched growth. Composite improvement of scoliosis, T1-T12, and T1-S1 height was achieved in 79% of patients. A subset of 29 patients with VEPTR was analyzed at most recent follow-up ≥5 years while VEPTR remained in vivo (24 patients with VEPTR above, and 5 who later converted to other devices). Mean age at implantation was 5.0±2.2 years, with a mean VEPTR treatment duration of 6.2±1.1 years. Scoliosis improved from preoperatively (69.3±14.5 to 61.6±16.1 degrees, P=0.006), with mild recurrence from postoperative to 5 years. T1-T12 height increased (15.0±3.3 to 18.7±3.3 cm, P<0.001) and T1-S1 height increased (23.7±4.5 to 30.1±4.6 cm, P<0.001), representing 83% age-matched growth. Composite improvement was achieved in 83% of patients. Instrumented sagittal length also increased during this period (21.8±4.2 to 30.3±5.1 cm, P<0.001). CONCLUSION: At a 5-year follow-up, VEPTR continues to control scoliosis and allow spinal growth. LEVEL OF EVIDENCE: Level II-prospective cohort, therapeutic study.

Prevalence and correlation of glycemic control achievement in patients with type 2 diabetes in Iraq: A retrospective analysis of a tertiary care database over a 9-year period.

BACKGROUND: This study was designed to assess the achievement of a glycated hemoglobin (HbA1c) target in Iraqi type 2 diabetes mellitus (T2DM) patients via retrospective analysis of a tertiary care database over a 9-year period. METHODS: A total of 12,869 patients with T2DM with mean (SEM) age: 51.4(0.1) years, and 54.4% were females registered into Faiha Specialized Diabetes, Endocrine and Metabolism Center(FDEMC) database between August 2008 and July 2017 were included in this retrospective study. Data were recorded for each patient during routine follow-up visits performed at the center every 3-12 months. RESULTS: Patients were under oral antidiabetic drugs (OAD; 45.8%) or insulin+ OAD (54.2%) therapy. Hypertension was evident in 42.0% of patients, while dyslipidemia was noted in 70.5%. Glycemic control (HbA1c <7%) was achieved by 13.8% of patients. Multivariate analysis revealed <55 years of age, female gender, >3 years duration of diabetes, HbA1c >10% at the first visit, presence of dyslipidemia, and insulin treatment as significant determinants of an increased risk of poor glycemic control. BMI <25 kg/m2 and presence of hypertension were associated with a decreased risk of poor glycemic control. CONCLUSION: Using data from the largest cohort of T2DM patients from Iraq to date, this tertiary care database analysis over a 9-year period indicated poor glycemic control. Younger patient age, female gender, longer disease duration, initially high HbA1c levels, dyslipidemia, insulin treatment, overweight and obesity, and lack of hypertension were associated with an increased risk of poor glycemic control in Iraqi T2DM patients.

Predictors of Open Reduction in Pediatric Femur Fractures Treated With Flexible Nails.

BACKGROUND: Closed reduction (CR) is sufficient to reduce the majority of femur fractures treated with flexible intramedullary nailing (FIN). No previous study has examined factors associated with failed CR of pediatric femoral shaft fractures treated with FIN. We sought to determine preoperative factors associated with failed CR. We hypothesized that fracture, patient, and surgeon characteristics would impact the need for open reduction (OR). METHODS: A retrospective review of children treated for femur fracture between 2012 and 2017 at a tertiary pediatric hospital was performed. Comparisons were made between 2 groups: FIN with CR group and FIN that required OR group. Demographic and baseline characteristics were compared between treatment groups using either χ tests or Fisher exact tests for categorical variables and general linear models for continuous variables. Odds ratios with 95% confidence intervals were calculated using univariate logistic regression tests. RESULTS: Of 449 consecutive pediatric femur fractures treated at our center, 85 children were treated with FIN and constituted the study cohort. CR failed in 14 patients (16.5%) necessitating OR of the fracture site. Significant differences between study groups were found in fracture location (P=0.018), the mechanism (P=0.003), and displacement on the anteroposterior radiograph (P=0.027). Surgical time was found to be longer in the OR group (P=0.010). We identified 3 preoperative predictors of OR for FIN including fractures caused by high energy mechanisms (odds ratio=7.5), distal third fractures (odds ratio=15.3), and fracture displacement on the anteroposterior view (odds ratio=1.06). Surgeon years in practice, patient weight, age, and time from injury to surgery were not associated with OR. CONCLUSIONS: This study presents 3 preoperative risk factors that predict the need for OR of femur fractures treated with FIN. Surgical time was longer in cases that required OR. Our findings suggest that surgeons should avoid lengthy attempts at CR and consider a lower threshold for OR of at-risk fractures or use another technique other than flexible nails. LEVEL OF EVIDENCE: Level III-prognostic.

Clinical and radiographic presentation of pelvic sarcoma in children.

INTRODUCTION: Pelvic sarcomas may present with vague symptoms. The aim of this study was to examine the characteristics and clinical presentations of different types of pelvic sarcoma in children. METHODS: This is a retrospective cohort study of patients up to 21 years of age with the diagnosis of pelvic sarcoma between January 2000 and June 2013. Data on demographics, tumor type and location, and clinical presentation were collected from the medical records. RESULTS: A total of 59 patients [37 males (62.7%) and 22 females (37.3%)] were examined in this study. Mean age at presentation was 11.3 ± 5 years (range 0.8-21 years). Thirty-six patients had Ewing sarcoma (61%), 9 osteosarcoma (6.8%), 4 undifferentiated sarcoma (6.8%), 2 (3.4%) rhabdomyosarcoma, 2 synovial cell sarcoma, and one (1.7%) of each fibrosarcoma, dermatofibrosarcoma, fibromyxoid sarcoma, chondrosarcoma, chordoma, and epithelioid sarcoma. Pain at presentation was reported in 41 patients, 13 mass, 8 limping, and 5 neurologic symptoms. Most of the bony tumors were painful (77%), while most of the soft tissue tumors were painless (70%). Nine patients presented with constitutional symptoms. Most patients presented within 4-12 months from symptoms beginning. Twenty-one patients (35.6%) presented with metastases (14 Ewing sarcoma, 6 osteosarcoma, and 1 synovial cell sarcoma). Pelvic radiographs showed lytic lesion in 11 patients, 4 sclerotic lesions, 6 mixed lesion, 6 had only soft tissue mass, 1 radiograph showed osteopenia, and 2 radiographs were reported normal. CONCLUSION: Ewing sarcoma was the most common pelvic sarcoma tumor in children. In most cases, pelvic sarcoma in children presented with pain mimicking other benign conditions. Some patients presented with metastatic disease with no prognostic clinical or radiographical signs or symptoms. Pelvic sarcoma should be considered a differential diagnosis as part of children work up.

Spectrum of Pituitary disorders: A retrospective study from Basrah, Iraq.

Background: Sellar and parasellar region lesions spectrum includes a wide variety of diseases. This study aimed at providing a comprehensive overview of such lesions in patients from  Faiha Specialized Diabetes, Endocrine and Metabolism Center (FDEMC) in Basrah (Southern Iraq). Methods: Retrospective data analysis from FDEMC for the period January 2012 through June 2017. We included all patients with sellar and parasellar region lesions who received a MRI scan on their pituitary region Results: The total enrolled patients were 232 (84 men and 148 women),with age range 15-75 years.Pituitary disease and adenoma were more common among women. Those with macroadenoma were older than those with microadenoma, with nearly equal gender prevalence of macroadenoma. Pituitary adenoma constituted the bulk of pituitary disease in this setting (67.2%). Growth hormone secreting adenoma were the most common adenoma seen in 41.0%, followed by clinically non-functioning pituitary adenoma (NFPA) in 31.4% and prolactinoma in 26.9%. About 64.8% of pituitary adenoma was macroadenoma. Macroadenoma was seen in 73.4% of growth hormone secreting adenoma (acromegaly), 61.2% in NFPA and 62.0% of prolactinom a(of them six were giant prolactinoma). Conclusion: Pituitary adenoma constituted the bulk of sellar and parasellar region lesions, growth hormone secreting adenoma is the the most common adenoma followed by NFPA and prolactinoma due to referral bias. A change  in  practice of adenoma treatment is needed.

Guided growth for angular correction in children: a comparison of two tension band plate designs.

This retrospective cohort study examined 20 patients (48 physes), 11 boys and nine girls, who were treated with hinge-plate or eight-plate. The mean age of the patients at surgery was 11.9±2.6 years. The mean follow-up duration was 13±2.7 months. The radiographic measurement of both distal femoral and proximal tibial deformity showed significant correction, with no difference between the hinge-plate and the eight-plate. Both screw divergence angle and the hinge angle showed significant changes at the last follow-up. The deformity correction of the distal femoral physis was quicker than the proximal tibial physis. The rate of mechanical femoral-tibial angle correction was 0.97°/month if both femoral and tibial physes were treated. LEVEL OF EVIDENCE: III.

Surgical treatment of pelvic sarcoma in children: outcomes for twenty six patients.

PURPOSE: Pelvic sarcoma is uncommon in children and challenging to treat. This study examined different surgical approaches to treat pelvic sarcoma with the aim of assessing the oncologic, and functional outcomes. METHODS: We retrospectively examined the medical records of patients younger than 21 years of age who underwent surgery for pelvic sarcoma at our institution from 1992 to 2010. The functional status of the patients was examined after a minimum follow-up of two years. RESULTS: Twenty-six patients were included in the analysis. Nineteen (73%) patients were male and seven (27%) were female. Mean age at presentation was 12.0 ± 3.9 years. Nineteen patients had Ewing sarcoma (73%), five had osteosarcoma (19%), one had chondrosarcoma (4%) and one had rhabdomyosarcoma (4%). Iliac wing resection with no reconstruction was done in three patients. Reconstruction with free fibular graft A-frame was performed in four patients, saddle endoproshtesis in five patients, iliac autoclave in one patient, and internal hemipelvectomy in nine patients. Hindquarter amputation was performed in five patients. Median follow-up was 4.6 years (range, 2.6-16 years). Nineteen patients were alive (73%); of those, 13 were known to be without disease, three were with disease and three did not have known tumor status. Six patients were reported deceased, three had osteosarcoma and three had Ewing sarcoma. Function was assessed in 17 patients; 64% were asymptomatic and ambulatory and 36% were symptomatic and ambulatory. CONCLUSIONS: Salvage reconstruction for pelvic sarcoma can be performed through various procedures on the extent of necessary bony resection. Survival rate and functional outcomes were promising in the performed study.

VEPTR Implantation to Treat Children With Early-Onset Scoliosis Without Rib Abnormalities: Early Results From a Prospective Multicenter Study.

BACKGROUND: Thoracoplasty and insertion of vertical expandable prosthetic titanium rib (VEPTR) for thoracic and spine distraction has been found to be effective in the treatment of early-onset scoliosis (EOS) with ribs anomalies and congenital vertebral anomalies. The aim of this study was to evaluate the efficacy of VEPTR in preventing further progression of scoliosis without impeding spinal growth in children with progressive EOS without rib abnormalities. METHODS: This is a prospective, multicenter, observational cohort study. Erect radiographs were analyzed for coronal and sagittal curve and height measurements at preimplant, immediate postoperative, and at 2-year follow-up. RESULTS: Sixty-three patients met inclusion: 35 males and 28 females. Mean age at time of implantation was 6.1±2.4 years. Etiologies included congenital (n=6), neuromuscular (n=36), syndromic (n=4), and idiopathic (n=17). The mean follow-up was 2.2±0.4 years. Scoliosis (72±18 degrees) decreased after implant surgery (47±17 degrees) followed by slight increase at 2-year follow-up (57±18 degrees), P<0.0001. Kyphosis (48±22 degrees) also showed significant decrease after implantation (40±14 degrees), but increased after 2 years (48±16 degrees), P<0.0001. Coronal spine height measurements including T1-T12 (15.7±3 cm) and T1-S1 (25±6 cm) showed significant increases after implantation surgery (17.7±4 cm and 28.6±6 cm, respectively) and at 2 years (18.4±4 cm and 29.1±5 cm, respectively), P<0.0001. The increase in coronal spine height represented 144% of expected age-matched T1-T12 growth and 193% of expected age-matched T1-S1 growth. Similarly, sagittal spine length of T1-T12 and T1-S1 increased from 16.9±2.7 cm and 27.1±3.9 cm, respectively preoperatively to 19.7±3.5 cm and 31.9±5.1 cm, respectively at 2-year follow-up, P<0.0001. The instrumented spine segment continued growth from 25.8±5.2 cm after implantation to 27.4±5.3 cm at 2-year follow-up, P<0.0001. Thirty-one patients (49%) had at least 1 complication with total of 58 complications. CONCLUSIONS: At 2-year follow-up, VEPTR was effective in treating EOS without rib abnormalities with 86% of patients having an improvement in scoliosis and 94% of patients having an increased spinal height as compared with preoperative values. This study proved that spine continues to grow after VEPTR instrumentation during the distraction phase. This amount of growth represents about 40% for T1-T12 and 31% for T1-S1 spine of the expected age-matched growth based on Dimeglio reference numbers. We find this growth important as it proves continuous spine growth with VEPTR treatment. LEVEL OF EVIDENCE: Level II.

Treatment Options for Nonunion With Segmental Bone Defects: Systematic Review and Quantitative Evidence Synthesis.

OBJECTIVES: To determine which reconstruction treatment of long bones nonunion with segmental bone defects (SBDs) is effective to restore bone length and union with good function. DATA SOURCES: PubMed was used to identify published literature on treatment of SBD caused by fracture nonunion regardless of infection between January 1975 and December 2014. STUDY SELECTION: We included retrospective cohort studies with a minimum sample size of 10 consecutive patients with minimum follow-up of 18 months and available data on radiographic and functional outcomes. DATA EXTRACTION: Literature review revealed 24 publications with a sample size of 504 patients (395 males, 109 females). Data on bone union and functional outcome and complications were collected and analyzed based on validated classification systems. DATA SYNTHESIS: Two outcome groups were categorized for bone union and functional outcome, success, and failure. We then performed heterogeneity test to examine the variability or differences in the methods used by these studies and based on that we determined whether the fixed effect or random effect method is appropriate in examining the summary or pool estimate. Pool estimate was examined for bone union and functional outcome in each surgical modality and in each anatomic location when data were available. CONCLUSIONS: Treatment of SBD can be challenging. This quantitative evidence synthesis shows that bone union was achieved by different procedures with variable bone union and functional outcomes. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Paper #24: VEPTR Treatment of Early Onset Scoliosis (EOS) in Children without Rib Abnormalities: Long-Term Results of a Prospective, Multicenter Study.

A prospective, multicenter study demonstrating the long-term efficacy of VEPTR treatment in EOS without rib abnormalities.

Surgical resection of osteoid osteoma and osteoblastoma of the spine.

Intraoperative radiographic guidance has traditionally been utilized in orthopedic surgery through 2-D navigation with the C-arm and recently with 3-D navigation with the O-arm. The aim of this study was to describe the outcome of surgical treatment of spinal osteoblastoma and osteoid osteoma with the utilization of the O-arm and conventional C-arm guidance. This is a retrospective cohort study of patients with spinal osteoid osteoma and or osteoblastoma who were treated at our institution between 2002 and 2011. Seventeen patients were examined in this study including seven with spinal osteoblastoma and 10 with spinal osteoid osteoma. The mean age of the patients at surgery was 11.5±3.9 years. The O-arm was used in seven patients and the C-arm in 10 patients. The C-arm failed to identify the tumor in one case and needed transport to perform a computed tomographic-scan. The length of surgery was shorter when the O-arm was used, especially in the osteoblastoma group. Thirteen patients were pain free at the last follow-up visit and two patients developed recurrence. Radiographs at the last follow-up did not show signs of vertebral instability following tumor resection. Safe and effective localization of spine tumors and confirmation of tumor removal during surgery was achieved by intraoperative radiographic guidance specifically with the O-arm 3-D navigation system. LEVEL OF EVIDENCE: III.

Hallux valgus deformity correction without fusion in children with cerebral palsy.

This study aimed to evaluate the outcomes of nonarthrodesis surgical treatment of hallux valgus (HV) deformity in children with cerebral palsy using radiographic and gait analysis parameters. There were 25 patients who had hallux valgus correction in 39 feet. The mean age at surgery was 15±2.8 years and the mean follow-up duration was 14.6 months. The first metatarsal osteotomy was performed in nine feet, bunionectomy in 25 feet, and Aiken osteotomy in 32 feet. None had metatarsophalangeal joint fusion. We observed a significant correlation between HV correction and other foot and ankle gait parameters. Our study showed correction of HV deformity at short-term follow-up without fusion of the metatarsophalangeal joint. LEVEL OF EVIDENCE: Level IV Therapeutic Studies.

Solid screw insertion for tension band plates: a surgical technique tip.

PURPOSE: Growth modulation with tension band plates (TBPs) and cannulated screws is the current mainstay of treatment for pediatric lower extremity angular deformities. Solid screws have been used as an alternative to cannulated screws to decrease the risk of screw failure, particularly in obese children. The downside of solid screws is the decrease in precision of placement. This study describes a surgical technique to insert solid TBP screws accurately. METHODS: TBP insertion starts with the same conventional steps by inserting the guidewires into the epiphysis and metaphysis, straddling the physis. After fluoroscopic confirmation of the position of the guidewires, the cannulated drill bit is used to broach the cortex to a depth of 5 mm in the bone. A standard 4.5-mm cannulated screw from the TBP set is used to tap the screw tract over the guidewires for approximately three-quarters of the planned screw length. After removing the guidewires, the solid screws are then inserted in each hole to follow the tapped tracts. RESULTS: This technique was used in five patients including four with Blount disease and one with bilateral genu varum. CONCLUSION: It is recommended to use solid screws with TBPs in patients with a high body mass index to avoid screw fracture. Our technique describes using a cannulated screw as a tap to create a tract to ease accurate insertion of the solid screws, and prevent the solid screw from deviating outside the desired path.

Do Surgical Times and Efficiency Differ Between Inpatient and Ambulatory Surgery Centers That are Both Hospital Owned?

PURPOSE: The aim of this study was to examine the differences in primary anterior cruciate ligament reconstruction (ACLR) surgical time and operation room (OR) work efficiency between inpatient and ambulatory facilities within the same institution. METHODS: Patients studied included those who underwent primary ACLR at either the inpatient hospital or the ambulatory facility by a single orthopaedic surgeon on elective surgery days. Time variables were calculated for ACLR to compare the 2 facilities. The OR work efficiency was calculated as the percentage of work that was completed before mid-day that was determined by the midpoint of the surgical day at each facility. RESULTS: Two hundred twenty-seven ACLR surgeries were performed on 187 elective surgery days, 153 surgeries at the inpatient facility and 74 at the outpatient facility. The mean age at the time of surgery was 14.9±2.2 years. The ACLR surgeries at the ambulatory facility were of shorter duration than those at the inpatient facility (P<0.0001). One OR was most commonly utilized and 2 to 3 surgeries were performed on most surgery days at both facilities. Seven nurses served as alternating circulators at the ambulatory facility compared with 41 nurses serving in the same capacity at the inpatient facility. The median turnover time was longer at the inpatient facility compared with the ambulatory facility. OR work efficiency (work done before mid-day) was 72.5% at the ambulatory facility and 49.5% at the inpatient facility, P<0.0001. If 2 ACLR surgeries were performed consecutively, the surgery day lasted for 6 hours at the hospital-owned ambulatory surgery center compared with 9 hours at the inpatient hospital. CONCLUSIONS: Despite the common variables of the same surgeon performing the same surgery at facilities owned by the same institution primarily working in a single OR, differences exist in OR procedure time and work efficiency. LEVEL OF EVIDENCE: Level III.

Unicameral Bone Cysts in the Humerus: Treatment Outcomes.

BACKGROUND: Several treatment modalities have been described for the treatment of unicameral bone cysts (UBC). The aim of this study was to examine the outcome of various treatment modalities of UBC in a specific anatomic location, the humerus. METHODS: This study is a retrospective case-only study of patients with humeral UBC with minimum follow-up of 1 year. Medical records and radiographs were assessed and UBC healing status was determined based on most recent follow-up radiographs and divided into 3 groups (healed, partially healed, and not healed). Descriptive statistics were utilized to summarize study outcome. RESULTS: Sixty-eight patients (54 boys and 14 girls) with humeral UBC comprised the study population. Sixty-four cases (94.1%) presented with a pathologic fracture. Fifty-one cases were in the proximal metaphysis and 17 were in the diaphysis. Mean age at diagnosis was 9.2±3.7 years, and mean follow-up was 4.0±2.6 years. Twenty-five patients were treated with observation, 38 by injection (27 with steroids and 11 with bone marrow), and 5 by open surgery. Patients who underwent open surgery had relatively larger cyst length, width, and cyst index, and all healed or partially healed at last follow-up. UBC persistence was observed in 29% of diaphyseal and 27.5% of metaphyseal cysts. Of the 19 patients with persistence, 8 were treated with observation, 9 with steroid injection, and 2 with bone marrow injection. Inner wall disruption before injection was performed in 17 patients (24% did not heal), whereas 21 patients did not have inner wall disruption (33% did not heal). Twenty patients received >1 injection. Eleven patients complained of pain at the last visit (8 had a persistent cyst, 2 were partially healed, and 1 had a healed UBC). CONCLUSIONS: Complete healing of humeral UBC is challenging to achieve irrespective of treatment modality. UBCs treated with open surgery tended to heal better. Unhealed cysts were more likely to be associated with pain. LEVEL OF EVIDENCE: Level III-a retrospective comparative study.

Melorheostosis: segmental osteopoikilosis or a separate entity?

PURPOSE: Melorheostosis is a progressive hyperostotic bone disease that commonly affects the appendicular skeleton. Melorheostosis has a significant degree of overlap with other hyperostosis conditions including osteopoikilosis and likely represent varying degrees of a clinical spectrum. METHODS: This is a report of 2 patients with melorheostosis who presented with different clinical presentations and involvement of different anatomic locations. RESULTS: One of the patients presented with foot size asymmetry along with intermittent foot pain and limping. This patient also had irregular nonblanching yellow plaque-like lesion on the forehead. The second patient presented with abnormal gait but no pain. Radiographs demonstrated endosteal hyperostosis, which were consistent with a mixed picture of melorheostosis and osteopoikilois. Genetic testing of the LEMD3 gene from a blood sample was negative in both cases. CONCLUSIONS: The diagnosis of melorheostosis can be made based on the clinical and radiographic features and can be challenging to differentiate from other hyperostosis conditions. LEVEL OF EVIDENCE: Level V.

Late-onset superior mesenteric artery syndrome four years following scoliosis surgery - a case report.

BACKGROUND: Superior mesenteric artery (SMA) syndrome has been reported as an uncommon condition of external vascular compression of the SMA particularly after rapid weight loss, body casts, or after corrective surgery for spinal deformities, usually within the first few weeks after surgery. METHODS: This is a retrospective report of a case of a non-verbal autistic female patient who started to develop SMA syndrome at the age of 16, 4 years after posterior spinal fusion surgery for scoliosis. She was treated conservatively by increasing oral caloric intake, which resulted in increased body weight and relief of symptoms. RESULTS: Seen at 10 years' follow up, the patient is doing well, and is functional within the limits of her suboptimal cognitive and verbal conditions. She maintains good trunk balance with solid spinal fusion and intact instrumentation at latest follow up. CONCLUSION: Spinal surgeons should maintain a high index of suspicion for diagnosis of SMA syndrome even years after scoliosis surgery, especially for patients with communication problems, like the case we present here. Appropriate conservative measures can succeed in relieving the symptoms, increasing body weight, and preventing complications including the risk of death.