Perioperative blood loss reduction using a sterile exsanguination tourniquet for orthopedic femoral-related surgeries in children: a randomized controlled study.

OBJECTIVES: The sterile exsanguination tourniquet (SET) could be an alternative for providing bloodless surgeries in orthopedic femoral-related surgeries in pediatric patients where the standard pneumatic tourniquet would not be feasible. This randomized-controlled study aimed to evaluate the efficacy of SET in decreasing total perioperative blood loss and blood transfusion. METHODS: We conducted an unplanned interim analysis of data from a randomized-controlled trial. At the time of the analysis, 31 pediatric patients had been randomly assigned to undergo surgery with the SET application (the SET group, 15 patients) and without the SET application (the control group, 16 patients). An intention-to-treat analysis was performed to evaluate the total perioperative blood loss, postoperative blood transfusion, estimated intraoperative blood loss, total drainage volume, postoperative hemoglobin level, and operative time according to the significance level adjusted for multiplicity (p < 0.029). RESULTS: There was a borderline statistically significant lower body weight-adjusted TBL in the SET group (SET = 14.1 (7.7, 16.9) ml/kg vs. control 18.3 (14.8, 37.2) ml/kg, p-value = 0.027). The body weight-adjusted transfusion volume was statistically significantly greater in the control group (SET = 0.0 (0.0, 0.0) ml/kg vs. control = 2.1 (0.0, 9.7) ml/kg, p = 0.017). Body weight-adjusted estimated intraoperative blood loss was significantly lower in the SET group (SET = 0.8 (0.2, 3.5) ml/kg vs. control = 5.6 (3.4, 21.5) ml/kg, p < 0.001). In addition, the operative time was lower in the SET group with borderline statistical significance (SET = 105 (85.0, 125.0) vs. control = 130 (101.3, 167.5), p = 0.039). CONCLUSION: Utilization of a sterile exsanguination tourniquet (SET) significantly reduced an estimated intraoperative blood loss while preventing the need for blood transfusion after pediatric orthopedic femoral-related surgeries. Trial registration TCTR20220412003.

Predictive factors for recurrence after lower limb deformity correction in hypophosphatemic rickets.

BACKGROUND: Surgical treatment for severe lower limb deformities in patients with hypophosphatemic rickets has shown satisfactory outcomes. However, the rates of recurrence of deformities after surgical correction were high, and studies on predictive factors of recurrence were limited. This study aimed to determine the predictive factors for the recurrence of lower limb deformities after surgical correction in patients with hypophosphatemic rickets, and the effects of each predictor on the recurrence of deformities. METHODS: We retrospectively reviewed the medical records of 16 patients with hypophosphatemic rickets aged 5-20 years and who had undergone corrective osteotomies between January 2005 and March 2019. Demographic data from the patients, biochemical profiles, and radiographic parameters were collected. Univariable Cox proportional hazard analyses of recurrence were performed. Kaplan-Meier failure estimation curves for deformity recurrences of potential predictors were created. RESULTS: A total of 38 bone segments were divided into 2 groups: 8 segments with recurrent deformities and 30 segments without recurrent. The average follow-up time was 5.5 ± 4.6 years. Univariable Cox proportional hazard analyses of recurrence found that an age < 10 years (hazard ratio [HR], 5.5; 95% CI, 1.1-27.1; p = 0.04), and gradual correction by hemiepiphysiodesis (HR, 7.0; 95% CI, 1.2-42.7; p = 0.03) were associated with recurrence after surgery. The Kaplan-Meier failure estimation for deformity recurrences by age at the time of surgery also achieved a statistically significant difference between ages < 10 years and those > 10 years (p = 0.02). CONCLUSIONS: Identifying predictive factors for the recurrence of lower limb deformities after surgical correction in hypophosphatemic rickets can assist in early recognition, proper intervention, and prevention. We found that an age < 10 years at the time of surgery was associated with recurrence after deformity correction and gradual correction with hemiepiphysiodesis may also be a potential factor affecting the recurrence.

A long-term outcome (up to 29 years) of bilateral iliac wings "bayonet osteotomies" for closure of bladder exstrophy.

BACKGROUND: Several types of pelvic osteotomy techniques have been reported and employed by orthopedic surgeons to enhance the approximation of symphyseal diastasis in bladder exstrophy patients. However, there is limited evidence on a long-term follow-up to confirm which osteotomy techniques provide the most suitable and effective outcomes for correcting pelvic deformities. This study aimed to describe the surgical technique of bilateral iliac bayonet osteotomies for correcting pelvic bone without using fixation in bladder exstrophy and to report on the long-term clinical and radiographic outcomes following the bayonet osteotomies. METHODS: We retrospectively reviewed patients with bladder exstrophy who underwent bilateral iliac bayonet osteotomies with the closure of bladder exstrophy between 1993 and 2022. Clinical outcomes and radiographic pubic symphyseal diastasis measurements were evaluated. From a total of 28 operated cases, eleven were able to attend a special follow-up clinic or were interviewed by telephone by one of the authors with completed charts and recorded data. RESULTS: A total of 11 patients (9 female and 2 male) with an average age at operation of 9.14 ± 11.57 months. The average followed-up time was 14.67 ± 9.24 years (0.75-29), with the average modified Harris Hip score being 90.45 ± 1.21. All patients demonstrated decreased pubic symphyseal diastasis distance (2.05 ± 1.13 cm) compared to preoperative (4.58 ± 1.37 cm) without any evidence of nonunion. At the latest follow-up, the average foot progression angle was externally rotated 6.25° ± 4.79° with full hips ROM, and no patients reported abnormal gait, hip pain, limping, or leg length discrepancy. CONCLUSIONS: Bilateral iliac wings bayonet osteotomies technique demonstrated a safe and successful pubic symphyseal diastasis closure with an improvement both clinically and radiographically. Moreover, it showed good long-term results and excellent patient's reported outcome scores. Therefore, it would be another effective option for pelvic osteotomy in treating bladder exstrophy patients.

Surgical outcome of scoliosis in patients with Marfan syndrome.

PURPOSE: To evaluate clinical and radiographic outcomes after surgical scoliosis correction and posterior instrumented fusion in SMF patients. METHODS: A single-center medical database was reviewed to identify MF patients who presented with scoliosis from 2000 to 2015. Patients who underwent spinal fusion surgery were included. Demographic, operative and clinical data were reviewed, and the preoperative, postoperative, and latest follow-up radiographic parameters were compared. RESULTS: Twelve patients were identified (2 males, 10 females) with an average age at surgery of 14.4 ± 2.6 years. Comorbidities were found in 84.6%. Most patients (90.9%) presented with a right thoracic curve. The average preoperative Cobb angle was 75.6 ± 15.5 degrees. Posterior instrumented spinal fusion was performed in all patients (1 hook/pedicular screw and 11 pedicle screws only). The average follow-up period was 6.8 ± 3.1 years. The mean postoperative Cobb angle after surgery and at the final follow-up was 33.4 ± 18.0 degrees and 35.5 ± 18.4 degrees, respectively. There was a statistically significant difference among the preoperative and postoperative Cobb angles (p < 0.001), but no significant difference among the sagittal angles. Two perioperative complications including superficial wound infection and broken rods were observed. CONCLUSIONS: Posterior scoliosis correction and instrumented spinal fusion resulted in a satisfactory outcome in MF patients. Perioperative complications are not uncommon; however, no neurological complication or spinal decompensation was observed in this study. LEVEL OF EVIDENCE: IV.

Comparative Evaluation of the Radiographic Parameters for Screening Early Blount Disease.

BACKGROUND: Radiographic findings in young children with physiological bowing sometimes difficult to distinguish from early Blount disease. However, early diagnosis of the disease is critical because of the poor treatment outcomes for Blount disease. In this study, we aim to evaluate the accuracy of the metaphyseal-diaphyseal angle (MDA) compared with the medial metaphyseal beak (MMB) angle for differentiating between physiological bowing and early Blount disease and to determine which parameter to adequately screen for the subsequent development of Blount disease. METHODS: A retrospective study was conducted on children aged 1 to 3 years old who were brought to our outpatient clinic with bowed leg between 2000 and 2017. Data on the patients' age, sex, and affected sides were collected. Radiographic measurements of the femorotibial angle (FTA), MDA, and MMB angle were evaluated from the initial radiographs. An observer repeated the measurements on all the radiographs 2 weeks after they were first done. RESULTS: In total, 158 legs were considered from 79 children (48 males/31 females), whose average age was 26.0±6.1 months old. Eighty-seven legs were diagnosed with Blount disease and 71 legs had physiological bowing. Using single cutoff values of 16 degrees for the MDA showed low sensitivity (50.6%), very high specificity (100.0%), and a very high positive predictive value (PPV); while using MMB angle cutoff values ≥122 degrees showed very high sensitivity (92.0%), high specificity (80.3%), and a high PPV. Considering the MDA and MMB angle simultaneously showed very high sensitivity (93.1%), high specificity (80.3%), and a high PPV. The area under the receiver operating characteristic curve of the MDA and MMB showed excellent (0.89) and outstanding (0.93) discriminative ability, respectively. When combining the MDA and MMB angles, it was also considered outstanding performance (area under the receiver operating characteristic curve=0.95). CONCLUSIONS: The MMB angle represents a potential radiographic screening parameter for predicting early Blount disease in children 1 to 3 years old, offering high sensitivity and specificity. The MDA showed excellent specificity as a confirmation parameter for Blount disease patients. Applying both the MDA and MMB angles is another option to increase early recognition and confirm the diagnosis in early Blount disease patients. LEVEL OF EVIDENCE: Level II.

Percutaneous hamstring lengthening in cerebral palsy and the risk of neurovascular transection.

PURPOSE: Percutaneous hamstring lengthening is increasingly popular due to its simplicity, fast recovery rate, and low morbidity. Neurovascular anatomy changes due to knee flexion contracture and the precise proximity of peroneal nerve and Biceps femoris tendon are not well established. This study examined (1) the coronal distance between the peroneal nerve and lateral hamstring tendon ("PLD"), and (2) the distance between the popliteal vessels and medial hamstring tendons ("VMD") to determine the safe distance for percutaneous hamstring lengthening. METHODS: This prospective study recruited cerebral palsy patients aged under 15 who needed hamstring lengthening. Ultrasonography was performed after the patients were anesthetized. PLDs and VMDs at popliteal angles (PAs) of 40°, 60°, and 80° knee flexions were collected. RESULTS: Sixteen patients (32 knees) were enrolled. The mean minimum PLDs at PAs of 40°, 60°, and 80° were 3.5, 4.1, and 3.1 mm, respectively. The peroneal nerve physically touched the lateral hamstring tendon in 5/32 knees (15.6%). The mean minimum VMDs at PAs of 40°, 60°, and 80° were 19, 18.3, and 16.4 mm, respectively. One spastic diplegic patient had a minimum VMD < 3 mm on both sides. Changing the PAs demonstrated no statistical significance for both PLD and VMD (P value = 0.105 and 0.779, respectively). CONCLUSIONS: Percutaneous medial hamstring lengthening should be done with caution. We recommend open biceps femoris surgery, with preoperative ultrasonography (to check the PLD) or peroneal nerve palpation to reduce the risk of peroneal nerve transection.

Identifying children at high risk for recurrence child abuse.

PURPOSE: To evaluate the characteristics of abused children, families and abusive event and to identify risk factors associated with recurrence of child abuse. METHODS: Retrospective data from 133 children aged between 2 months to 15 years old who were diagnosed as abuse between year 2002 and 2017. Thirteen items related to characteristics of the child, families, abusive event were selected. These factors were analyzed by multivariate logistic regression model for association with repeated child abuse. RESULTS: Total of 133 subjects with average age of 5.25 ± 4.65 years old. There were 54 cases (40.60%) reported of repeated abuse. Majority of repeated abuse type in this study was physical abuse (73.68%). Most perpetrators were child's own parents (45.10%). Factors associated with increased risk of repeated abuse were child age 1-5 years old (AOR = 4.95/95%CI = 1.06-23.05), 6-10 years old (AOR = 6.80/95%CI = 1.22-37.91) and perpetrator was child's own parent (AOR = 21.34/95%CI = 3.51-129.72). Three cases of mortality were found with single-visit children and one case in recurrence. Most of death cases were children less than 1-year-old with average age of 7 months. Causes of death were subdural hematoma with skull and ribs fracture. CONCLUSIONS: Identifying risk factors for repeated child abuse help in recognizing child at risk to provide prompt intervention. This study found two factors associated with higher risk of abuse recurrence: child age 1-10 years old and abusive parents. Children who presented with these risk factors should be recognized and intensively monitored.

Medial Metaphyseal Beak Angle as a Predictor for Langenskiöld Stage II of Blount's Disease.

OBJECTIVE: To determine the medial metaphyseal beak (MMB) cut-off angle predicting Langenskiöld stage II of Blount's disease and to study the intra-observer and inter-observer reliabilities of angle measurements and the influence of the experience level of observers. METHODS: A retrospective study was conducted on children aged 2-4 years from January 2000 to December 2017. Children were identified through a computer-based search. Children with Langenskiöld stage II of Blount's disease who had been initially evaluated at our institution were categorized into Blount group and children who were diagnosed with physiologic bowing were categorized into control group. Data on the patients' ages, genders, and affected sides were collected. The MMB angles were measured on standing anteroposterior radiographs of the knees. The angle was formed between one line drawn parallel to the medial cortex of the proximal tibia, and a second line running from the intersection of the first line with the proximal tibial metaphysis through to the most distal point of the MMB. Measurements were independently performed by six observers. All observers repeated the measurements 2 weeks after they were first done. RESULTS: There were 148 legs from 79 children (48 males and 31 females) with an average age of 28.6 months. The average MMB angle of the Blount group was 128.52° ± 5.38° (P-value <0.001) and of the control group was 114.45° ± 4.89°. The average femorotibial angle of the Blount group was 15.48° ± 6.81° (P-value <0.001) and of the control group was 7.71° ± 7.94°. The receiver operating characteristic curve showed that an MMB angle >122° (sensitivity 92.7%; specificity 97.0%) was associated with Langenskiöld stage II. The intraclass correlation coefficient of the intra-observer reliability ranged from 0.93-0.97, and the inter-observer reliability was 0.93. CONCLUSIONS: By using anteroposterior (AP) radiographs of the knee, the MMB angle is a potential radiographic parameter to distinguish between Langenskiöld stage II of Blount's disease and physiologic bowed legs, with an MMB angle >122° predicting Langenskiöld stage II.

Medial Metaphyseal Slope as a Predictor of Recurrence in Blount Disease.

OBJECTIVE: This study was aimed to find the radiographic parameter predicting recurrence of stage 2 Blount's disease. METHOD: We retrospectively reviewed radiographs of 82 legs from 49 patients diagnosed with stage 2 Blount's disease by Langenskiöld classification who had failed brace treatment and underwent valgus osteotomy between 1998 to 2016. Age ranged from 26 to 47 months. The metaphyseal-diaphyseal angle was measured preoperatively. The medial metaphyseal slope of the proximal tibia and femorotibial angle were measured preoperatively and 3, 6, 12, and 24 months postoperatively in both non-recurrence (group 1) and recurrence (group 2) group. The receiver operating characteristic curve calculated using MedCalc software was used to determine the medial metaphyseal slope predicting risk for recurrence. Statistical analysis was performed using SPSS software. RESULTS: The mean follow-up time was 4.83 ± 0.38 years. The mean age was 34.57 ± 5.76 in group 1 and 33.2 ± 1.48 in group 2 (P = 0.258). The mean preoperative metaphyseal slope was 62.39° ± 9.75° in group 1 and 73.22° ± 6.59° in group 2 (P = 0.02). The mean preoperative femorotibial angle (FTA) was -14.31° ± 8.25° in group 1 and -18.89° ± 7.74° in group 2 (P = 0.1). The mean preoperative metaphyseal diaphyseal angle (MDA) was 14.75° ± 4.21° in group 1 and 20.11° ±5.16° in group 2 (P = 0.001). Demographic data including age, gender, weight, height, and body mass index showed no statistically significant difference between both groups. Out of 82 legs, 9 (10.97%) had recurrence. Preoperatively, the metaphyseal-diaphyseal angle showed statistical significance between both groups. The medial metaphyseal slope showed statistically significant difference between group 1 and group 2 at 3, 6, 12, and 24 months postoperatively. The receiver operating characteristic curve showed that a medial metaphyseal slope more than 70° at 12 months (sensitivity 88.89% and specificity 69.86%) and more than 62° at 24 months postoperatively (sensitivity 100%, specificity 52.3%) was a predictor for recurrence of stage 2 Blount's disease. CONCLUSION: Medial metaphyseal slope more than 62° over the 24-month follow-up was associated with recurrence of varus deformity.

Does the parental stretching programs improve metatarsus adductus in newborns?

BACKGROUND: Metatarsus adductus (MA) is a common pediatric foot deformity. Current recommendations suggest observation until 4-6 months, then casting if the deformity persists. Based on our review of the literatures, no randomized controlled trial has been conducted to study the effectiveness of parental stretching in the correction of MA in newborn. MATERIAL AND METHODS: Ninety-four newborn feet that were diagnosed as MA by clinical examination were enrolled. Feet were randomized into two groups: observation group and stretching group. Outcome measurements were performed to compare success rate between groups. RESULTS: According to Pearson's χ2 test, there were no statistically significant differences between groups with regard to the overall success of the parental stretching program ( p = 0.191). There was also no significant difference between groups for mild degree or moderate-to-severe degree ( p = 0.134, p = 0.274, respectively). A more rapid success rate was observed in the stretching group at the first month follow-up, but rate of improvement then decreased. The stretching group tended to have a lower success rate compared to the observation group in moderate-to-severe feet, but the difference was not statistically significant. CONCLUSIONS: Parental stretching program found no benefit over observation group in this study. Parental stretching program should not be applied for newborn babies with moderate-to-severe MA as the result from the study appeared to have lower success rate compared to observation group. Observe until 4-6 months, then corrective casting for the persisting deformity is recommended.

The Comparison between Computer-Assisted Hexapods and Ilizarov Apparatus in Gradual Tibial Deformity Correction: A Preliminary Study.

Background: The Hexagonal external fixator (Hexapods) is known to have the ability to correct complex multi-planar deformities faster than the Ilizarov apparatus. However, the difficulty of achieving deformity correction by Hexapods seems to limit its popularity. Objective: This study aims to compare the advantages and disadvantages of Hexapods and Ilizarov in the gradual correction of complex tibial deformities. Material and Method: A retrospective review was performed in patients with complex tibial deformities treated with Hexapods or with Ilizarov apparatus from 2000 to 2014. Magnitude of deformity, length of time in Hexapods or Ilizarov apparatus, Lengthening Index, and complications were recorded. Statistical analysis was used to compare the two methods. Results: Six patients were treated with Ilizarov apparatus and seven patients were treated with Hexapods. Patients in Hexapods group had more coronal plane angulation before surgery than in the Ilizarov group with statistical significance (p = 0.02). The differences of the sagittal and the axial plane angulations were not statistically significant. The difference of leg length was also not statistically significant. After completion of treatment, no statistical significance of residual deformities was found between the two methods. Lengthening Index had trends toward significance in Hexapods group (p = 0.051). Conclusion: Computer-assisted Hexapods may reduce the Lengthening Index compared to the conventional Ilizarov method. The hexapods device could be beneficial for faster correction of complex deformity if the patients or family members understand how to manipulate the apparatus.

The Results of Lengthening in Congenital Posteromedial Angulation of Tibia.

Background: Congenital posteromedial bowing of the tibia (PMBT) is a rare deformity with limb length discrepancy (LLD) with or without significant angular deformity. Some patients need only limb length equalization while many patients require additional angular correction. Limb length equalization may be achieved by either limb lengthening, epiphysiodesis or acute shortening of the long leg. Limb lengthening is the preferred treatment option in PMBT patients with significant angular deformity. Objective: The presented study is to evaluate the results of lengthening with Ilizarov fixator in these patients. Material and Method: PMBT patients treated with Ilizarov lengthening were retrospectively reviewed. Progression of angular deformity and LLD were assessed. Residual deformity after Ilizarov lengthening and complications were also evaluated. Results: Limb lengthening with Ilizarov external fixator was performed in 4 PMBT patients. Mean age at surgery was 3.7 years. Expected LLD (using multiplier method) of tibia ranged from 5.1 to 9.9 cm. Younger patients had more angular deformity than older patients. One patient had pin tract infection requiring Ilizarov removal. Lengthening index varied from 1.2 to 2.1 month/centimeter. LLD after the lengthening was -1.4 to 0.4 cm. Mean progression of LLD was 1.8 mm/year. Conclusion: Ilizarov lengthening for posteromedial angulation shown good result with average residual LLD 0.4 to 1.4 cm which is not clinically significant.

Complications Associated with Ponseti Serial Casting and Surgical Correction via Soft Tissue Release in Congenital Idiopathic Clubfoot.

Background: The current standard treatment used worldwide for management of congenital idiopathic clubfoot is serial casting by Ponseti method. Prior to 2006, standard treatment for congenital idiopathic clubfoot at Siriraj Hospital involved major soft tissue release by any of the following release techniques, modified posteromedial release, complete subtalar release, and posterior release. Objective: To evaluate the complications and recurrence of deformity associated with treatment of congenital idiopathic clubfoot by Ponseti serial casting and major soft tissue release at Siriraj Hospital. Material and Method: This retrospective review of medical charts and records was conducted in congenital idiopathic clubfoot patients who underwent primary treatment by either Ponseti serial casting or major surgical soft tissue release between 2000 and 2012 at Siriraj Hospital. Patient demographic, clinical, diagnostic, and surgical procedure-related data were reviewed. All associated complications were recorded and analyzed. Results: One hundred sixty one patients were included, of which 46 had treatment by Ponseti method and 115 had treatment by major soft tissue release. In the Ponseti group, there were 26 males and 20 females (73 feet), with an average age at the beginning of treatment of 10.70 weeks (range 0.86 to 42.86). The complication rate was 17.8% (13 feet in 11 patients). The most common complications were cast loosening in four feet (5.48%) and cast-associated skin irritation in four feet (5.48%). In patients treated with Ponseti method, second surgery for recurrent deformity was performed in 26 feet (35.61%). In the soft tissue release surgical intervention group, there were 69 males and 46 females (171 feet), with an average age at the beginning of treatment at 52.05 weeks (range 9.86 to 248.71). The complication rate was 12.87% (22 feet in 18 patients). The most common complications were wound infection in nine feet (5.26%), followed by cast loosening in seven feet (4.09%). In soft tissue release patients, second surgery for recurrent deformity was performed in 26 feet (15.20%). Conclusion: In this study, complication rates relating to clubfoot treatment by Ponseti serial casting and major soft tissue release were 17.8% and 12.87%, respectively. The two most common complications of Ponseti serial casting were cast loosening (5.48%) and cast-associated skin irritation (5.48%). The most common complication of major soft tissue release was wound infection (5.26%), followed by cast loosening (4.09%).

Results of Primary Talectomy for Clubfoot in Infants and Toddlers with Arthrogryposis Multiplex Congenita.

BACKGROUND: Equinovarus deformity in arthrogryposis multiplex congenita patients is rigid and difficult to treat. Radical soft tissue operations yielded good results though recurrence of deformity was high. Talectomy is a bony procedure recommended as either a salvage procedure or a primary operation. OBJECTIVE: To evaluate the results ofprimary talectomy in infant and toddler patients retrospectively. MATERIAL AND METHOD: Arthrogryposis multiplex congenita patients with rigid equinovarus deformity treated with talectomy initially were retrospectively reviewed. Pain score, residual foot deformity, shoe modification, and ambulatory status were assessed. RESULTS: Talectomy were performed in 19 arthrogrypotic feet in 10 infants and toddlers. There were 6 males and 4 females. The mean age at surgery was 1.3 years old and the mean age of the follow-up time was 4.9 years. All patients had plantigrade foot without pain. One arthrogrypotic foot required posteromedial release 2 years after index surgery due to recurrent deformity. CONCLUSION: Talectomy as theprimaryprocedure in arthrogrypotic infants and toddlers demonstrated good results withfew residual deformities and recurrence. Patients could achieve plantigrade position.

The effect of epidural low-dose morphine-soaked microfibrillar collagen sponge in postoperative pain control after laminectomy and instrumented fusion: a randomized double-blind placebo-controlled study.

OBJECTIVE: To evaluate the postoperative analgesic effect and postoperative nausea and vomiting (PONV) after using epidural low-dose morphine-soaked microfibrillar collagen sponge (MMCS), as compared with placebo. MATERIAL AND METHOD: A prospective randomized double-blind placebo-controlled study was performed on patients under-going single-level posterior lumbar spinal decompression and instrumented fusion at the Department of Orthopedic Surgery, Siriraj Hospital, between August 2012 and December 2013. Patients were randomly allocated into two groups to receive either an epidural MMCS or an epidural normal saline-soaked microfibrillar collagen sponge (placebo). Intensity ofpain, PONV and total amount of morphine were recorded at 4, 24, 48, and 72 hours, postoperatively. RESULTS: The analgesic effect was enhanced significantly in the epidural MMCS group, as the amount ofmorphine used was statistically less than in the placebo group at 4 and 24 hours (p < 0.05). CONCLUSION: A single low-dose epidural MMCS is effectiveforpain control after posterior lumbar spinal surgery with a low incidence of PONV.

Incidence of symptomatic pulmonary embolism in spinal surgery.

BACKGROUND: Pulmonary embolism (PE) is a serious condition in orthopedic surgery. The incidence of PE, which is a sequelae of VTE in spinal surgery, is quite low. In the limited available published data, incidence rates of PE in spinal surgery are comparable to that of hip or knee arthroplasty surgery. The role of pharmacologic thomboprophylaxis remains controversial in spinal surgery. OBJECTIVE: The present study was designed to evaluate the incidence of symptomatic pulmonary embolism in spinal surgery at a single tertiary care institute. MATERIAL AND METHOD: A retrospective study of the medical records of patients that were diagnosed with symptomatic pulmonary embolism in spinal surgery from 2002-2012. The reviewed data were retrieved from the database of the Faculty of Medicine Siriraj Hospital, Mahidol University in Bangkok, Thailand. RESULTS: Three cases of symptomatic pulmonary embolism were found from 9,184 spinal surgery cases. The incidence rate was 0.033%. There were two patients with lumbar spine surgery and one case with thoracolumnbar surgery. All three cases had different underlying conditions, operations, and clinical course. One case of fatal pulmonary embolism was found in our study. CONCLUSION: Although there is a very low incidence of symptomatic pulmonary embolism, this is a catastrophic condition for affected patients and their families. PE can occur in spinal surgery cases at all levels of severity and complexity, even with no apparent risk factors.

Results of surgical treatment of coxa vara in children: valgus osteotomy with angle blade plate fixation.

BACKGROUND: Coxa vara is a rare condition. Surgical correction of coxa vara has been challenging. A few reports present correction coxa vara in multiple causes. In this retrospective study, the authors reported the results of surgical treatment of coxa vara by valgus osteotomy with angle blade plate fixation in 11 children with 12 hips. MATERIAL AND METHOD: Since 2002-2011, 11 children with 12 hips with coxa vara were reviewed retrospectively by medical chart and radiographic data after surgical treatment. All of them were operated by valgus osteotomy and fixation with angle blade plate. All of them had been hip spica cast between 8-12 weeks after surgery. Neck-shaft angle, Hilgenreiner-epiphyseal angle, leg-length discrepancy and Harris hip score were evaluated at preoperative, postoperative, and final follow-up. RESULTS: Twelve coxa vara; 4 malunion femeral neck fracture, 4 congenital coxa vara, 2 spondyloepiphyseal dysplasia and 1 multiple epiphyseal dysplasia were operated on in 11 patients. One spondyloepiphyseal dysplasia had bilateral coxa vara. The average age at surgery was 9.5 years (range, 7-12 years). The average time of follow-up was 4.2 years (range, 3-7years). The average neck-shaft angle was changed significantly from 79.8 to 123.7 degrees, the Hilgenreiner-epiphyseal angle was changed significantly from 70 to 39.3 degrees and leg-length discrepancy was changed significantly from 2.2 to 1.7 centimeters at final follow-up. The average Harris Hip score was improved significantly from 68 at preoperative to 96 atfinalfollow-up. No complication or recurrence was found. CONCLUSION: Surgical treatment of coxa vara is uncommon treatment. The aims of treatment were to change the stress in the neck femur from shearing force to compression force and also improving shortening that could reduce incidence of further fracture and osteoarthritis. The Hilgenreiner-epiphyseal angle should be closed to 38-40 degree or less after surgery.

The incidence of common orthopaedic problems in newborn at Siriraj Hospital.

BACKGROUND: The congenital orthopaedic anomalies in Thai population had a limited data and the previously studies are based on only hospital chart records. OBJECTIVE: To determine the incidence of common congenital orthopedic problems by physical examination in newborn at Siriraj Hospital. MATERIAL AND METHOD: A prospective study was conducted by physical examination of 3,396 newborns from June 2009 to September 2009. All orthopaedic abnormalities of newborns were recorded along with maternal age, obstetric history of mother, complications during pregnancy, complications in labour stage, mode of delivery and presentation. Sex of newborn, birth weight, body length and APGAR score were recorded. RESULTS: Incidence of calcaneovalgus was found in 60:1,000 live births following by metatarsus adductus in 7.6:1,000, polydactyly or syndactyly in 2.6:1,000, talipes equninovarus in 2.4:1,000, brachial plexus injury in 1.5:1,000, developmental dysplasia of hip in 0.6:1,000, osteogenesis imperfecta in 0.6:1,000, skeketal dysplasia in 0.6:1,000, congenital vertical talus in 0.3: 1,000 and fracture clavicle at birth in 0.3: 1,000. CONCLUSION: In the present study, the calcaneovalgus was the most common orthopaedic problem followed by metatasus adductus, polydactyly or syndactyly.

Comparison effectiveness of custom-made versus conventional aluminum splint for distal phalange injury.

BACKGROUND: Finger splint is a simple and common method for finger immobilization. The flexible aluminum foam-padded splint is a convenient off-the-shelf inexpensive splint. But there're some studies favor expensively custom-made thermoplastic splint due to its less likely result in treatment failure. Therefore the authors have modified the conventional aluminum finger splint in the foam-padded part to improve the fitting and compliance of the patients. OBJECTIVE: To compare the fitting of custom-made aluminum finger splint with conventional aluminum finger splint. MATERIAL AND METHOD: Sixty volunteers were randomized to apply 30 conventional or custom-made aluminum splints on 4th digit in non dominated hand for one week. The fitting of each splint was measured by displacement of the splint between initial placement and one week later. Patient satisfaction and pain was measured by visual analog score (VAS). RESULTS: The slip and deviation in custom-made group were less than the conventional group significantly (mean of slip 0.86 mm vs. 2.23 mm, p < 0.001, mean of deviation 1.1 degrees vs. 2.23 degrees,p < 0.001) but the longitudinal migration was not significantly difference between both groups (mean 1.6 mm in custom-made group vs. 1.46 mm in conventional group, p = 0.67). The patient satisfaction demonstrated no significant difference between both groups (mean VAS 7.76 in custom-made group vs. 7.3 in conventional group, p = 0.31). Two patients terminated from the present study before one week in custom-made group and one patient in the conventional group (6.67% vs. 3.33%, p = 0.554). CONCLUSION: The custom-made aluminum finger splint can improve the fitting to the finger pulp. However, patient satisfaction and compliance are not significantly different between both groups.

Surgical management of spinal metastases: the postoperative quality of life.

OBJECTIVE: The surgical treatment of spinal metastases remains controversial. Increasing life expectancy has resulted in greater interest in overall quality of life, pain and neurologic improvements. There are few prospective studies on functional and quality of life outcomes in patients with vertebral metastases. Therefore, the authors conducted the prospective study evaluating the clinical, neurologic function and quality of life after surgery in these patients. MATERIAL AND METHOD: Fifty-two patients undergoing surgical treatment for spinal metastases during October 2007 to October 2009 were prospectively evaluated. Surgical intervention included neurological decompression,fusion and spinal instrumentation. Pre- and post-operative assessments at 1st month, 3rd month and 6th month were performed using a visual analog scale, the modified Frankel grade classification and a Shortform-36 (SF-36). RESULTS: Pain scores were improved significantly at all post-operative time points (p < 0.001). The neurological functions were improved at 1st month (p < 0.001), 3rd month (p < 0.001) and 6th month (p = 0.260) postoperatively. At 1st month after surgery, 40 patients (76.9%) had improvement in quality of life. However, at 3rd month postoperatively, there were 31 patients (59.6%) improved. At 6th month postoperatively, only 15 patients (28.8%) were improved. Internal organ metastases was the only factor that related to the reduction of quality of life at 1 month, 3rd month (p < 0.001) and 6th month (p < 0.05). CONCLUSION: Patients with spinal metastases will have benefit from palliative surgery in significant pain reduction and neurological recovery. As the global assessment in the quality of life, the patients may have the improvement at 1st month postoperatively but after 3 months and 6 months postoperatively, selected patients may have benefit from the surgery and the factors such as internal organ metastases and primary site of cancer have great effects on the improvement in the quality of life. This data may be useful for counseling the patients and relatives about the prognosis and expected surgical outcome before surgical intervention is decided.