Factors influencing correction rate following hemiepiphysiodesis using tension band plates for deformities around the knee: a multivariate analysis study.

PURPOSE: The aim of this study was to appraise various factors influencing the correction rate in temporary hemiepiphysiodesis (THE) around the knee joint. Specifically, the study analysed the relationship of correction rate with age, gender, aetiology, type and location of deformity. METHODS: The retrospective study included children who underwent THE for a coronal plane deformity (genu valgus or varum) around the knee joint (distal femur or proximal tibia) over a ten year period (2010-2020). The primary outcome of interest was the correction rate of the deformity. RESULTS: Thirty-three children (27 females and 6 males) with a mean age of 8.1 years involving 86 plates were included in the study. The mean correction achieved was 12.2° over a treatment period of 13.3 months. Subgroup analysis showed significant differences between the type (varus (0.8° per month), valgus (1.1° per month)) and the location of deformity femur (1.2° per month) and tibia (0.7° per month)]. On multivariate analysis, the location and the duration of treatment showed significant associations with the correction rate. CONCLUSION: The correction of coronal deformities following temporary hemiepiphysiodesis is influenced by several factors. Valgus, femoral and deformities in younger children correct at a faster rate. Location of deformity and duration of treatment emerged as potential factors affecting the correction rate.

Perspective of medical undergraduates in India towards the LGBTQIA+ population: a short insight into changes in the medical curriculum.

BACKGROUND: Understanding the attitudes of medical students towards individuals from the lesbian, gay, bisexual, transgender, queer, questioning, intersex and asexual (LGBTQIA+) community is a prerequisite for informing competencies-based medical education (CBME) guidelines to make them LGBTQIA+ inclusive. The present study was conducted to assess the attitudes of medical undergraduate students from Indian medical colleges towards the LGBTQIA+ community. METHODS: An online cross-sectional survey was conducted in medical undergraduate students across India, which measured the opinions, beliefs, and acceptance of LGBTQIA+ people using a structured questionnaire uploaded on Google Forms. After data collection, the datasheet was downloaded, cleaned, and anonymised before being imported into RStudio for analysis. RESULTS: A total of 273 valid entries were assessed from the online survey. There was significant gender-based differences on most traditional opinions and beliefs regarding the LGBTQIA+ population (P <0.05). The female participants appeared to be more accepting of and comfortable with all denominations of LGBTQIA+. Many of the participants believed that members of the LGBTQIA+ community are more prone to sexually transmitted diseases, especially HIV/AIDS. However, a few participants also opined that the increased susceptibility to HIV/AIDS may be due to increased prevalence of intravenous drug abuse in the LGBTQIA+ community. CONCLUSIONS: There are some misconceptions about the LGBTQIA+ community among medical students. Therefore, in order to ensure LGBTQIA+ sensitive healthcare provision, there needs to be a concerted, informed effort to incorporate necessary changes in the CBME curriculum.

Efficacy of 2 Nonpharmaceutical (Non-nutritive Sucking and Human Care Contact) Pain Relief Measures for Idiopathic Clubfoot Casted Using Ponseti Technique.

PURPOSE: This study aimed at exploring the pain and physiological responses exhibited during Ponseti manipulation and casting in clubfoot infants. In addition, we compared the efficacy of 2 nonpharmaceutical techniques (non-nutritive sucking and human care contact) for tackling these responses. METHODS: The study included children with unilateral and bilateral idiopathic clubfeet between 15 days to 6 months of age. For comparisons, children were divided into control group without any intervention (group A), non-nutritive sucking group (group B), and human care contact group (group C). Pain score (Neonatal Infant Pain Score), heart rate (HR), and oxygen saturation (SpO2) was assessed before, during and 1 minute after casting. These measurements were compared using statistical methods. RESULTS: There were 16 children (11 bilateral) in group A, 17 (10 bilateral) in group B, and 18 (8 bilateral) in group C. Before casting, the baseline parameters (Neonatal Infant Pain Score, HR, and SpO2) of the 3 groups were comparable. Groups B and C had a significant reduction in pain score at casting and in postcasting period when compared with group A (P<0.05). Group B (at casting-mean: 174.1/min, postcasting-mean: 168.2/min) had the lowest HR both during and after cast application. Group B had the highest SpO2 among all the 3 groups, both during casting (mean: 95.7%) and after casting (mean: 97.4%) (P<0.05). CONCLUSIONS: Infants exhibit moderate pain response and altered physiological responses during and after Ponseti casting. Non-nutritive sucking emerged as a better method to lessen these parameters when compared with the conventional technique and human care contact. LEVEL OF EVIDENCE: Level II.

What exactly is "foot abduction" during management of idiopathic clubfoot in clinical practice?

PURPOSE: There is however gross ambiguity regarding the use of term "foot abduction" in clubfoot treatment. We measured below defined angles at different stages of clubfoot treatment to decipher their precise interpretation. METHODS: In a prospective evaluation of 25 unilateral clubfeet in infants' age less than six months treated with Ponseti technique, clinical leg foot and thigh foot angle were measured at talar head reduction (LHT0), pre-tenotomy, and post-tenotomy stage. A "normal" reference was available in the form of measurements of contralateral limb. RESULTS: Talar head (LHT0) was reduced at mean leg foot angle of 26 degrees. The corresponding pre- and post-tenotomy angles were 42.6 and 50.0 degrees, respectively. The reference leg foot angles for contralateral limb were 49.8 degrees. The thigh foot angle for LHT0, pre-tenotomy, post-tenotomy, and contralateral side were, respectively, 39.2, 56, 68, and 65.6 degrees. There was an additional tibial external rotation component of mean 13.4 degrees (SD 4.5) in the thigh foot angle when compared to the leg foot angle at tenotomy. This increased to 18 degrees (SD 3.4) post-tenotomy. CONCLUSIONS: The study suggested that the foot abduction described in the "Ponseti Manual" probably intends thigh foot rather than leg foot angles. There was a significant difference in the angles when talar head reduced and tenotomy was decided. The foot abduction is an ambiguous term which should be replaced by the more specific leg or thigh foot abduction angle.

Pain behavior of children with bilateral idiopathic clubfoot undergoing Ponseti casting and the effect of non-pharmaceutical pain-relieving agents.

INTRODUCTION: This study prospectively investigated the pain response and physiological parameters [heart rate (HR) and oxygen saturation (SpO2)] during sequential casting in bilateral clubfoot. Additionally, it explored the role of non-nutritive sucking and human care contact on the observed responses during casting. METHODS: Subjects were allotted to control group (Group A with no intervention) and two intervention groups (Group B: non-nutritive sucking intervention, Group C: human care contact intervention). Neonatal Infant Pain Score (NIPS), heart rate (HR), and oxygen saturation (SpO2) were used to assess the response. RESULTS: The three groups matched in age and gender characteristics of the participants. Pain response was noted across all groups. The left foot demonstrated a statistically significant preexisting tachycardia which rose further during casting (p < 0.01). Intergroup comparisons revealed that the alteration for NIPS during casting was in following sequence (Group A > C > B, p < 0.00001). The effect of interventions offered in Group B and C lasted in the post-cast period as well (B > C). CONCLUSION: The clubfoot child exhibited moderate pain response during casting of both feet. A tachycardia was noted prior to initiation of second cast which further exaggerated with subsequent cast. Pacifier (non-nutritive sucking) intervention produced better control of pain response than human care contact during casting for both feet.

Comparison of above elbow and below elbow immobilisation for conservative treatment of distal end radius fracture in adults: A systematic review and meta-analysis of randomized clinical trials.

PURPOSE: The aim of this study was to analyze if any difference exists on the type of immobilisation (above elbow vs. below elbow) in the conservative treatment of distal end radius fractures in adults. METHODS: The study was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses. An electronic literature search was performed up to 1st October 2021 in Medline, Embase, Ovid and Cochrane database using the search terms, "distal end radius fractures OR fracture of distal radius", "conservative treatment OR non-surgical treatment", "above elbow immobilisation" and "below elbow immobilisation". Randomized clinical trials written in English, describing outcome of distal end radius fractures in adults by conservative or non-surgical means using above elbow immobilisation or below elbow immobilisation were included and assessed according to the risk of bias assessment (RoB2) tool by Cochrane collaboration. Non-randomized clinical trials, observational studies, retrospective studies, review articles, commentaries, editorials, conference presentations, operative techniques and articles without availability of full text were excluded from this review. The meta-analysis was performed using Review Manager version 5.4.1 (The Cochrane Collaboration, Copenhagen, Denmark). RESULTS: Six randomized clinical trials were included for quantitative review. High heterogeneity (I2 > 75%) was noted among all the studies. The standard mean difference (MD) between the disability of the arm, shoulder and hand scores in both the groups was 0.52 (95% CI: -0.28 to 1.32) which was statistically non-significant. There was no statistical difference in the radial height (MD = 0.10, 95% CI: -0.91 to 1.12), radial inclination (MD = 0.5, 95% CI: -1.88 to 2.87, palmar tilt (MD =1.06, 95% CI: -0.31 to 2.43) and ulnar variance (MD = 0.05, 95% CI: -0.74 to 0.64). It was observed that shoulder pain occurred more commonly as a complication in above elbow immobilisation and the values were statistically significant (above elbow: 38/92, 41.3%; below elbow: 19/94, 20.2%). CONCLUSION: This two-armed systematic review on the above elbow or below elbow immobilisation to be used for conservative treatment of the distal end radius fracture in adults resulted in non-significant differences in terms of functional and radiological scores among the 2 groups but significant increase in the complication rates in the above elbow group.

What has changed in total hip arthroplasty in patients of juvenile idiopathic arthritis since 2000? A systematic review and pooled data analysis.

PURPOSE: The prevalence of juvenile idiopathic arthritis (JIA) is estimated to be 16-150 per 100,000 children worldwide. The hip joint may be involved in over 50% of children leading to significant morbidity which may require surgical intervention in the form of arthroplasty. The literature lacks a concise overview of the outcomes, including complication and implant survival of total hip arthroplasty (THA) in juvenile idiopathic arthritis (JIA). The aim of this study is to systematically analyze the literature and report the outcomes of THA in JIA. METHODS: Search was conducted in the online databases PubMed, Embase and Cochrane database. It included all original studies which evaluated clinical and/or radiological outcomes of THA in JIA with a minimum sample size of 5 patients and published in English. The level of evidence of the included studies was graded according to the Oxford Centre for Evidence Based Medicine. The Institute of Health Economics checklist was used to assess the quality of the studies included. RESULTS: The nine studies included were retrospective in nature with all being Level IV according to Oxford Centre for Evidence Based Medicine. 475 hips in 304 patients with majority of them being females (241/304, 79.2%) were included in this review. All the studies reported the outcome objectively using various scores. The proportion of revision surgeries (92/378), either femoral or acetabular, noted was 22% (95% CI 10-33%). The proportion of acetabular revisions (72/378) was 16% (95% CI 8-25%) as compared to 4% (95% CI 1-6%) for femoral revisions (20/378). There was no difference in survivorship when cemented and uncemented implants were compared. CONCLUSION: JIA patients with advanced hip disease represent a unique population with need for extra-long implant longevity. THA in patients of JIA leads to improved pain relief as well as mobility but the conversion of the same outcomes to functional activity is not proportionally improved. The current trend is the use of uncemented and ceramic-on-ceramic implants. Acetabular implants require earlier revision as compared to femoral implants. Age at surgery can be delayed by early institution of methotrexate which indirectly improves implant survival. LEVEL OF EVIDENCE: IV.

A Systematic Review Comparing Outcomes of Local Flap Options for Reconstruction of Pressure Sores.

INTRODUCTION: Pressure sores are agonizing complications of chronically bedridden patients. The management of these lesions particularly with respect to grades III and IV lesions are chiefly surgical and involves a multidisciplinary approach. Although there are a variety of local flap options, like fasciocutaneous flaps, musculocutaneous flaps, perforator flaps, and combinations of these to choose from, there is a paucity of literature regarding which flap is better among these in terms of complication and recurrence rates. METHODS: The databases searched were as follows: Cochrane Central Register of Controlled trials (January 2000 to July 2020), MEDLINE (January 2000 to July 2020), and EMBASE (January 2000 to August of 2020). Key words used were "pressure ulcer," "flaps," "surgery," "pressure sore" with limits, "human," and "English." Primary outcomes were "overall complication rates" and "recurrence rates." Overall complication was further categorized as flap necrosis, flap dehiscence, infection, and others. RESULTS: Thirty-nine articles were included in the final analysis. There was a statistically significant difference among the various types of flaps for overall complication, flap dehiscence, infection, flap necrosis, and recurrence rates. CONCLUSIONS: Our study indicates that musculocutaneous flaps have lower recurrence rates, and combined flaps have lower complication rates. However, various other factors, like donor site morbidity, initial defect size, operating time, intraoperative blood loss, salvage options in case of recurrence, should also be considered while choosing a flap to reconstruct a defect.

Surgical outcomes following hemivertebrectomy in congenital scoliosis: a systematic review and observational meta-analysis.

BACKGROUND: Hemivertebrectomy is widely used definitive correction surgery in congenital scoliosis due to hemivertebrae. It may be done either as combined anterior and posterior approach or a single-stage posterior approach only. The purpose of this meta-analysis was to compare two techniques with regards to blood loss, operative time, deformity correction and complications. METHODS: The systematic review and meta-analysis were conducted according to PRISMA guidelines among peer-reviewed journals published in English between June 2000 and June 2020. Quality appraisal of all selected articles was done and data extracted. RESULTS: After thorough literature search and excluding, 37 studies were included for review. The commonest location of the hemivertebrae was thoracolumbar spine (51.3%), thoracic (26.2%), lumbar/lumbosacral (21.6%) followed by cervical (0.7%). Pooled data showed a significant difference (p < 0.05) in mean operative time with posterior only approach (227 min, 95% CI 205-250) as compared to Combined Anterior Posterior Approach (CAPA) (316 min 95% CI 291-341). Significant difference (p < 0.05) in mean blood loss was observed in posterior only approach (522 ml, 95% CI 434-611) as compared to CAPA (888 ml, 95% CI 663-1113). No significant difference was noted in mean correction in either of the approaches and overall pooled mean correction rate was 66%, 95% CI 61-72. CONCLUSION: This review and meta-analysis of two surgical techniques of hemivertebrectomy, shows that operative time and blood loss is significantly lower in posterior only approach with no difference in correction rate as compared to CAPA. There was significant correlation between age at surgery and need for revision surgeries. LEVEL OF EVIDENCE: IV.

Is detethering necessary before deformity correction in congenital scoliosis associated with tethered cord syndrome: a meta-analysis of current evidence.

PURPOSE: To compare the clinical and radiological outcomes in patients with congenital scoliosis (CS) and tethered cord syndrome (TCS) undergoing deformity correction with (NI group) versus without (NNI group) prior neurosurgical intervention aimed at detethering the cord. METHODS: A systematic review and meta-analysis were performed. The databases PubMed, Embase and Google Scholar were searched until March 2020. Inclusion criteria was studied describing performance of deformity correction and fusion surgery for congenital scoliosis with tethered cord syndrome with or without prior detethering procedure. Studies describing growth sparing procedures or congenital scoliosis associated with non-tethering pathologies such as syrinx were excluded. Case reports and series with less than 10 subjects were also excluded. NIH quality assessment tool was used for assessing quality of individual study. RESULTS: Sixteen studies were included for analysis of which eight were found to be retrospective case series (level IV evidence) and retrospective case-control studies (level III evidence) each. Overall proportional meta-analysis found no significant difference in correction rate, operative duration, blood loss or complication rate between the NI and NNI groups. However, subgroup analysis performed after inclusion of only level III evidence studies revealed significantly lesser operative duration and blood loss with comparable correction and complication rate in NNI group. CONCLUSION: Deformity correction and fusion surgery may be performed safely and effectively in CS with TCS patients without the need of a prior detethering procedure.

Insight into the changing patterns in clinical and academic activities of the orthopedic residents during COVID-19 pandemic: a cross-sectional survey.

PURPOSE: The COVID-19 pandemic has presented an unprecedented challenge to the orthopedic residency training programs to adapt to a form of a web-based learning process and simulation-based training. This study focusses on the viewpoint of the orthopedic residents to the paradigm shift in clinical care as well as the academic activities. METHODS: An anonymous questionnaire was created in an online survey generator and was sent through e-mail to 227 orthopedic residents of seven tertiary care centres in North India. The questionnaire was divided into three sections, academic activity section, mental health section, and clinical activity section. There were a total of 44 single answer questions with answers according to the increasing difficulty at present situation compared to a previous time before the COVID-19 pandemic. RESULTS: A total of 158 questionnaires were filled by 107 junior residents (67.7%) and 51 senior residents (32.3%). 49 residents (31%) were quarantined and three became positive for COVID-19. Although all of them knew about necessary precautions, personal protective equipment was difficult to avail at times. Increased difficulty in recruiting new patients for research (48.9%) and conducting prospective research (48.7%) was observed. The online-based learning process was reported to be easier (44.2%) by most of the residents. Routine clinical work in the operating room, out-patient department, and inpatient department was found to be difficult according to the majority of the residents along with the anxiety of contracting the infection. CONCLUSION: There are unique opportunities for improvement of residency programs during these times of uncertainty and the findings of this study can help the universities as well as program chairs to develop a robust program that can outlive this pandemic. The web-based learning process might prove to be useful and can be incorporated into the resident training program in the long term. LEVEL OF EVIDENCE: Level V.

Functional outcome in giant cell tumor of distal radius treated with excision and fibular arthroplasty: a case series.

INTRODUCTION: Giant cell tumor (GCT) of bone is a locally aggressive benign neoplasm that is associated with a wide spectrum of biological activity ranging from latent benign to highly recurrent and has occasional metastatic potential. It affects the meta-epiphyseal region of long bones of young adults with most common site involved is the distal femur, followed by the distal radius. Plain radiographs and contrast-enhanced magnetic resonance imaging are the imaging modalities widely used followed by definite histopathology for diagnosis. Surgical treatment with curettage is considered optimal for local tumor control. Tumor excision with tumor-free margins is associated with lesser recurrence rates; however, for periarticular lesions this is usually accompanied with a suboptimal functional outcome. METHODS: Eleven eligible patients (all females, mean age 39.2 years) with Campanacci grade III GCT of the distal radius who were treated by en bloc resection and reconstruction with non-vascularized proximal fibular autografts at a single centre between July 2016 and December 2017 were included in the study. The patients had a clinical and radiographic review every month for the first 6 months, then biannually for minimum of 2 years. The functional, oncologic and radiological outcomes of the patients were analyzed and recorded. RESULTS: The mean duration of follow-up was 31.9 months. Bony union was achieved in all cases. The mean VAS score at 6 months was 1.1 (range 0-2). The mean Mayo Wrist score was 66.36 (range 55-80) with mean MSTS score was 21.09 (range 18-24). The average range of motion of the wrist was: 37.3° ± 6.9° of flexion, 47.1° ± 7.5° of extension, 57.3° ± 7.8° of supination and 63.6° ± 6.4° of pronation. The average graft length used was 15.6 cm. The complications noted were lung metastases which developed preoperatively, local site recurrence, wrist joint subluxation, foot drop and wound complication. DISCUSSION AND CONCLUSIONS: The primary aim of treating GCT distal radius is oncologically sound resection with good functional outcome and cosmesis being secondary. Reconstruction with a non-vascularized proximal fibular autograft is a reasonable option after en bloc resection of the distal radius for giant cell tumor of bone having comparable results with other treatment modalities.

Accelerated Ponseti technique: efficacy in the management of CTEV.

The current standard practice of treatment for congenital talipes equinus varus (CTEV) is the Ponseti method of manipulation and casting which requires great compliance by caregivers for casting as well as bracing. There is inconclusive evidence regarding optimal cast change interval. This was a prospective non-randomized study conducted at a tertiary care hospital in South India over a 2-year period with a minimum follow-up of 5 years. The patients were divided into 2 groups, one with cast change interval of 7 days and the other group at 3 days. Children with CTEV with age less than 1 year with no previous intervention were included in the study. Functional score devised by Ponseti was determined at final follow-up. The average number of casts in standard and accelerated group was 5.23 ± 0.59 and 4.72 ± 0.61 (p < 0.01). The average number of days required for correction of feet was 54.38 ± 8.01 and 33.88 ± 9.03 (p < 0.01) respectively, for standard and accelerated groups. The Pirani score showed a faster reduction in the accelerated group. This study is the longest prospective study published yet in literature, comparing standard and accelerated Ponseti protocols. Complication rate noted in our study was comparable to study by Morcuende but higher than other studies comparing the techniques. It increases compliance as well as reducing treatment and travel costs for parents, more so in developing countries. At 5-year follow-up, there is no significant difference in the functional outcome.