Are 2 Radiographic Views As Good as 3 Views to Diagnose Ankle Fractures in Children and Adolescents?

OBJECTIVES: Ankle radiographs are among the most commonly obtained trauma images in the pediatric population, with the standard 3 views (AP/mortise [M]/lateral [L]) routinely ordered in the emergency department. The purpose of this study was to compare the diagnostic accuracy, sensitivity, and specificity of sets of 2 views (AP/L or M/L) with the standard 3 views. METHODS: One hundred twenty sets of ankle radiographs of skeletally immature patients obtained in the emergency department of a level 1 pediatric trauma center were used. These included sets with and without fractures. Sets of 3 and 2 views were reviewed by pairs of pediatric-trained orthopedic surgeons, radiologists, and emergency physicians. Each completed 3 randomized viewing sessions where all possible combinations for each set of radiographs were reviewed. Diagnoses for the 3 sets of views were compared for accuracy, sensitivity, and specificity. RESULTS: Overall accuracy, sensitivity, and specificity for all reviewers were as follows: AP/M/L 74%, 94%, and 90%, AP/L 71%, 90%, and 94%, as well as M/L 69%, 90%, and 91%. P values for accuracy, sensitivity, and specificity of AP/L and M/L compared with 3 views were 0.34, 0.04, and 0.52, as well as 0.04, 0.004, and 1.00, respectively. CONCLUSIONS: In skeletally immature patients, statistically significant differences in accuracy were obtained when comparing the standard 3 AP/M/L views with more limited M/L views, suggesting that this set of 2 views is not as accurate. Differences in sensitivity of limited views were also statistically significant. Conversely, differences in accuracy between the standard 3 views and AP/Lateral views were not statistically significant. While more limited AP/L views may be comparable in accuracy and specificity and lead to dramatically decreased radiation and costs, this can be at the expense of less diagnostic sensitivity and increased risk of misdiagnosing or missing certain fractures. LEVEL OF EVIDENCE: Level III.

Efficacy of surgical skin preparation solutions in hip arthroplasty: a prospective randomized trial.

BACKGROUND: The use of an effective antimicrobial preoperative skin preparation solution is essential in preventing infections after surgery, but the findings in the literature regarding efficacy are not necessarily applicable to surgery involving the hip. The purpose of the present study was twofold: 1) to examine the native bacteria on the skin at the hip and 2) to determine the efficacy of 2 surgical skin preparation solutions at eliminating bacteria from the hip site in patients undergoing total hip arthroplasty. METHODS: We conducted a prospective randomized controlled trial in consecutive adult patients who underwent primary total hip arthroplasty at a single institution from October 2014 to December 2015. Each patient was randomly allocated to be treated with 1 of 2 commonly used surgical skin preparation solutions: ChloraPrep (2% chlorhexidine gluconate and 70% isopropyl alcohol) or DuraPrep (0.7% iodophor and 74% isopropyl alcohol). Aerobic and anaerobic samples were obtained for culture before skin preparation, immediately after skin preparation and after skin closure. RESULTS: Full data were obtained for 105 patients: 54 in the ChloraPrep group and 51 in the DuraPrep group. Staphylococcus epidermidis, Corynebacterium and Micrococcus luteus were the organisms most commonly isolated from the hip before skin preparation. Positive bacterial culture results were obtained in 50 patients (93%) in the ChloraPrep group and 48 patients (94%) in the DuraPrep group. Immediately after skin preparation, the overall proportion of positive culture results was significantly lower in the DuraPrep group than the ChloraPrep group (14% v. 35%, adjusted relative risk 0.40, 95% confidence interval 0.18-0.85). After wound closure, there was no significant difference in the rate of positive culture results between the 2 groups. CONCLUSION: DuraPrep was more effective than ChloraPrep at eliminating skin flora at the hip initially on application, but the 2 solutions were equally effective at the time of closure. Further study with larger samples is required to identify any influence of skin preparation solution on the incidence of prosthetic joint infection.

Treatment for Clubfoot: Stockinette Versus Webril Cast Padding in the Ponseti Method.

BACKGROUND: The Ponseti method of serial manipulation and casting revolutionized the treatment of one of the most common congenital orthopaedic conditions-clubfoot-resulting in less surgical morbidity and better functional results. Several studies have examined aspects of nonoperative treatment but none have explored the effect of different types of undercast padding. METHODS: The authors performed a randomized controlled trial comparing cotton Stockinette and Webril undercast padding using the Ponseti method. They included 56 patients under the age of 6 months who had an untreated idiopathic clubfoot. For treatment, the padding was randomized to double-layer Stockinette (29 patients) or standard 2- to 3-layer Webril (27 patients). The primary analysis consisted of a 2-sample t test comparing the mean number of casts required for correction in each group. Secondary outcomes included initial and final standardized clubfoot scores (Pirani and Dimeglio scores) and adverse events. RESULTS: Baseline demographics were not statistically different between groups, with respect to mean age, sex, and side being treated, nor were the baseline Dimeglio and Pirani scores. The primary outcome analysis revealed an equivalent number of casts (about 4) required before tenotomy. The secondary analysis on complications did not show any significant difference, with 10 events documented in the Webril group and 9 in the Stockinette group (P=1.00). At the end of the study, the mean Dimeglio (3.9±2.1 vs. 3.9±1.8, P=0.99) and Pirani (2.1±0.8 vs. 2.2±0.8, P=0.70) scores were not significantly different. Subjectively, parents and doctors indicated a substantially more positive experience for the Stockinette group. CONCLUSIONS: Webril and Stockinette paddings provide equivalent clubfoot deformity correction while applying a similar number of casts before tenotomy. Although minor skin complications were observed, these were not significantly different between groups.

Indications for surgical management of osteochondritis dissecans of the knee in the pediatric population: a systematic review.

Several case series have been published exploring the surgical management of osteochondritis dissecans (OCD) of the knee in pediatric patients. This systemic review was performed to identify the surgical indications for this condition. A search of the Embase and Ovid Medline databases was performed to identify clinical studies reporting outcomes of surgical management of OCD in the knee in this patient population. A quality assessment of the included articles was conducted independently by two reviewers using a quality assessment tool developed by Yang et al. A total of 25 articles met the eligibility criteria and were reviewed; 40% of studies did not clearly describe their surgical indications. The remainder of the studies had a failure of nonoperative management with or without the concomitant use of imaging as their indication for surgery, or used lesion stability itself as the indication for surgery. This review outlines several surgical indications presented in the literature for the treatment of OCD lesions of the knee in the pediatric population. The most common indication for surgery was a failure of a trial of nonoperative treatment with or without the concomitant use of serial imaging. Although the quality of the case series was high, inconsistencies in reporting radiographic and arthroscopic classification of the OCD lesion were common.