Associated Factor and Long-Term Clinical Outcomes for Patients with Postoperative Rotational Malreduction in Pediatric Supracondylar Humeral Fractures.

Background and Objectives: Long-term outcomes of immediately postoperative rotational malreduction in the axial plane after operative treatment of supracondylar humeral fractures (SCHF) are unknown. This study aimed to investigate the long-term clinical outcomes and associated factors for immediately postoperative rotational malreduction of SCHF. Materials and methods: In this retrospective case-control study, 88 patients who underwent surgery for Gratland type III SCHF were enrolled between January 2012 and January 2020. Among them, 49 patients had immediately postoperative malrotational reduction (rotational malreduction group) and 39 patients had no rotational deformity (control group). To evaluate the associated factors for immediately postoperative rotational malreduction, demographic data, fracture patterns, physical examination signs, and preoperative radiological parameters were analyzed. To compare the clinical outcomes, operation time, range of motion of the elbow, time from operation to full range of motion, and Flynn criteria were evaluated. The Oxford elbow score was used to investigate long-term clinical outcomes for patients five years after operation. Results: The mean age was 5.7 ± 2.3 years and mean follow-up period was 15.7 ± 4.0 months. The rotational malreduction group had significantly more patients with oblique fracture pattern (p = 0.031) and Pucker sign (p = 0.016) and showed a significantly longer operative time (p = 0.029) than the control group. Although there was no significant difference in the range of elbow motion and the Flynn criteria, the Kaplan-Meier survival curve showed a longer time to recover the full range of elbow motion in the rotational malreduction group (p = 0.040). There were no significant differences in the long-term clinical outcomes assessed using the Oxford elbow score (p = 0.684). Conclusions: Oblique fracture pattern and Pucker sign may be associated with immediately postoperative rotational malreduction in the axial plane. Although patients with immediately postoperative rotational malreduction showed favorable results of long-term clinical outcomes, they required more weeks to recover the full range of elbow motion.

Is the May-Thurner Syndrome a Major Risk Factor for Deep Vein Thrombosis in Total Hip Arthroplasty?

Background: May-Thurner syndrome (MTS) is iliac vein compression syndrome associated with postoperative deep vein thrombosis (DVT) resulting from chronic compression of the left iliac vein against lumbar vertebrae by the overlying right or left common iliac artery. MTS is not well known as a risk factor for DVT after total hip arthroplasty (THA). We evaluated the incidence of DVT after THA and analyzed if the MTS is a risk factor for DVT after THA. We hypothesized that MTS would be associated with an increased risk of developing DVT after THA. Methods: All patients > 65 years of age who underwent THA between January 1, 2009, and January 12, 2017, were identified. Among them, the patients who presented for postoperative DVT of the lower extremity were reviewed with medical record data. MTS was diagnosed with computed tomography (CT) angiography of the lower extremity. We analyzed the demographic data, symptoms, diagnoses, and treatment of MTS patients. Results: A total of 492 consecutive patients aged > 65 years who underwent operation for THA were enrolled. Among them, 5 patients (1.0%) presented for postoperative DVT of the lower extremity. After reviewing the CT angiography of the lower extremity, 4 out of 5 DVT patients (80%) were identified as having MTS. All MTS patients were female and presented with pain and swelling of the left leg. All MTS patients were treated with systemic anticoagulation, aspiration thrombectomy, and percutaneous transluminal angioplasty. Complete resolution of thrombus was observed in all patients. Conclusions: If the diagnosis of MTS is delayed, the morbidity and mortality rates are significantly increased. Orthopedic surgeons should be aware of MTS as a risk factor for DVT after THA. Moreover, preoperative evaluation with duplex sonography or CT angiography to confirm MTS should be considered. In this regard, this study is considered to have sufficient clinical value for early diagnosis and appropriate treatment of MTS after THA.

Is there a difference between preoperative and postoperative delirium in elderly hip fracture patients?: A retrospective case control study.

Delirium is associated with greater morbidity, higher mortality, and longer periods of hospital day after hip fracture. There are number of studies on postoperative delirium after a hip fracture. However, few studies have made a distinction between preoperative and postoperative delirium. The purpose of this study is to compare risk factors and clinical outcome between preoperative and postoperative delirium in elderly patients with a hip fracture surgery. A total of 382 consecutive patients aged > 65 years who underwent operation for hip fracture were enrolled. Among them, the patients diagnosed with delirium were divided into 2 groups (a preoperative delirium group and a postoperative delirium group) according to the onset time of delirium. To evaluate risk factors for preoperative and postoperative delirium, we analyzed demographic data, preoperative laboratory data, and perioperative data. To compare clinical outcomes between preoperative and postoperative delirium, we analyzed postoperative complications, KOVAL score, regression, readmission, and 2-year survival rate. Delirium was diagnosed in 150 (39.3%) patients during hospitalization. Preoperative and postoperative delirium occurred in 67 (44.6%) and 83 (55.4%) patients, respectively. Independent risk factors of preoperative delirium included age (odds ratio: 1.47, 95% confidential interval [CI]: 1.13-2.23, P = .004), stroke (odds ratio [OR]: 2.70, 95% CI: 1.11-6.01, P = .015), American Society of Anesthesiologist (OR: 1.68, 95% CI: 1.137-2.24, P = .033), and time from admission to operation (OR: 1.08, 95% CI: 1.01-1.16, P = .031). There was no significant difference in preoperative KOVAL score between the 2 groups. However, postoperative KOVAL score (5.1 ±â€…2.0 vs 4.4 ±â€…2.1, P = .027) and regression rate (68.7% vs 44.6%, P = .029) were significantly higher in the preoperative delirium group than in the postoperative delirium group. Moreover, the 2-year survival rate was significantly lower in the preoperative delirium group than in the postoperative delirium group (62.7% vs 78.3%, P = .046). Characteristics, risk factors, and prognosis are different for patients with preoperative delirium and postoperative delirium. Preoperative delirium patients showed different risk factors with poorer prognosis and higher mortality. Therefore, hip fracture patients with risk factors for preoperative delirium should be monitored more carefully due to their greater risk of mortality.

Superior Capsular Reconstruction Versus Middle Trapezius Tendon Transfer for Isolated Irreparable Supraspinatus Tendon Tears: Static Versus Dynamic Reconstruction.

BACKGROUND: Both superior capsular reconstruction (SCR) and middle trapezius tendon (MTT) transfer can be performed in nonarthritic young and active patients with isolated irreparable supraspinatus tendon tears (IISTTs). However, to our knowledge, no comparative clinical studies have been conducted on these procedures. PURPOSE: To evaluate and compare the clinical and radiological outcomes of SCR and arthroscopic-assisted MTT transfer in patients with IISTTs. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 60 patients with IISTTs were categorized into 2 groups according to the surgical procedure-Group S underwent SCR (n = 34); Group M underwent MTT transfer (n = 26). The clinical outcomes included the visual analog scale score for pain, active shoulder range of motion, American Shoulder and Elbow Surgeons score, and University of California, Los Angeles, shoulder score. Radiological outcomes included the assessment of the acromiohumeral distance, progression of cuff tear arthropathy (Hamada grade), subacromial bone erosion, and graft failure. RESULTS: The mean follow-up time was 39.3 ± 5.2 months (range, 26-59 months) and 37.6 ± 9.8 months (range, 27-54 months) in Group S and Group M, respectively. Significant improvements in clinical outcomes were observed in both groups, while the active forward flexion (148.2°± 24.1° vs 165.9°± 8.7°; P = .003) and abduction (131°± 37.3° vs 152.5°± 17.9°; P = .035) were significantly higher in Group M at the final follow-up. No significant differences were found in the postoperative Constant, American Shoulder and Elbow Surgeons, and University of California, Los Angeles, shoulder scores between the 2 groups. Radiologically, although no difference was found in the Hamada grade at the final follow-up between the 2 groups (P = .143), the rates of acromial wear (58.8% vs 15.4%; P < .001) and graft retear (47.1% vs 7.7%; P < .001) were significantly higher in Group S than in Group M. CONCLUSION: Both SCR and MTT transfer improved the overall clinical outcomes of IISTTs postoperatively, whereas MTT transfer was superior to SCR in terms of active forward flexion and abduction range of motion. Although higher rates of graft failure and subacromial bone erosion were observed in Group S, no difference was found in the clinical scores between the 2 groups at the short-term follow-up. However, further well-structured, prolonged comparative trials should be conducted in the future.

METAL ION RELEASE ACCORDING TO LEG LENGTH DISCREPANCY IN CERAMIC-ON-METAL HIP ARTHROPLASTY.

Objective: The ceramic-on-metal (CoM) bearing has the theoretical advantages over ceramic-on-ceramic (CoC) and metal-on-metal bearings. This study aimed to analyze factors affecting the metal ion release of CoM bearings and compare clinical performance with CoC bearings. Methods: The 147 patients were divided into 96 patients in group 1 (CoM group) and 51 patients in group 2 (CoC group). Additionally, within group1, 48 patients and 30 patients were sub-categorized into group 1-A with leg length discrepancy (LLD) less than 1cm and group 1-B greater than 1 cm. The level of serum metal ions, functional scores and plain radiographs were obtained for the analysis. Results: The level of cobalt (Co) 2-years after surgery and chromium (Cr) 1-year after surgery showed significantly higher in the group1 than the group2. LLD indicated statistically significant positive correlation between serum metal ion levels among CoM bearing THAs. In comparison of the average metal ions level changes, group 1-B showed higher level of metal ion than group 1-A. Conclusion: In patients underwent THA with CoM bearings, large LLD have a higher risk of complications associated to metal ions. Therefore, it is critical to reduce the LLD to 1 cm or less in using CoM bearing. Level of Evidence III; Case Control Study.

Objetivo: Uma superfície metalocerâmica (CoM) apresenta vantagens teóricas sobre as superfícies cerâmica-cerâmica (CoC) e metal-metal. Este estudo teve como objetivo analisar os fatores que afetam a liberação de íons metálicos das superfícies CoM e comparar o desempenho clínico com as superfícies CoC. Métodos: Os 147 pacientes foram divididos em 96 pacientes no grupo 1 (grupo CoM) e 51 pacientes no grupo 2 (grupo CoC). No grupo 1, 48 pacientes foram subcategorizados em grupo 1-A, com discrepância de comprimento das pernas (LLD) menor que 1 cm; e 30 pacientes no grupo1-B maior que 1 cm. O nível de íons metálicos séricos, escores funcionais e radiografias foram obtidas para a análise. Resultados: Os níveis de cobalto (Co) 2 anos após a cirurgia e de cromo (Cr), após o primeiro ano da cirurgia mostraram-se significativamente mais altos no grupo 1 do que no grupo 2. A LLD indicou correlação positiva estatisticamente significativa entre os níveis de íons do soro metálico entre os portadores de THA de CoM. Em comparação com as alterações médias dos níveis de íons metálicos, o grupo 1-B revelou um nível de íons metálicos mais alto do que o grupo 1-A. Conclusão: Em pacientes submetidos a THA com superfícies CoM e elevada LLD têm um maior risco de complicações associadas a íons metálicos. Sendo fundamental reduzir LLD para 1 cm ou menos no uso de superfícies CoM. Nível de Evidência III; Estudo de Controle de Caso.

Reinforced technique of tension band wiring for tibial tuberosity fracture in adolescents: a case report for surgical technique.

Most of the fractures had been previously treated with open reduction and internal fixation. Although there are a number of fixation methods, a consensus on the treatment options has not been reached yet. Case presentation: We demonstrated the reinforced technique of tension band wiring and its surgical outcomes in the tibial tuberosity fracture of a 14-year-old male basketball player. For the modified technique, the wire was inserted between the patellar tendon and tibial tuberosity (insertion site of patellar tendon) and passed distally through the 2-mm-sized predrill cortical hole. Tightening the figure of the eight loops draws the fractured fragments together and anatomically reduces under appropriate compression. This technique can achieve the reduction and fixation of the fracture simultaneously. We confirmed the fixation stability with a range of knee joint motions. The patient was able to return back to the pre-injury level of sports activity at postoperative 2 months. Clinical discussion: The original technique of tension band wiring utilized the Kirschner wire to make a figure-of-eight loop. However, we used the patellar tendon and its insertion site of the tibial tuberosity for making a figure-of-eight loop. Moreover, the reduction and fixation of fracture were achieved simultaneously by tightening the tension band wire. This reinforced technique was firm enough for postoperative rehabilitation. Conclusion: The most certain advantage of this technique was to be able to reduce anatomically and fixate firmly with appropriate compression simultaneously. We recommend open reduction internal fixation with the reinforced technique of tension band wiring for displaced tibial tuberosity fracture in adolescent athletes.

Osteoid Osteoma of the Proximal Phalanx of the Great Toe in a 13-Year-Old Female Patient.

Osteoid osteoma (OO) is a benign osteoblastic bone tumor typically involving the diaphysis or metaphysis in long tubular bones. OO in phalanges of the great toe has been rarely reported, and it is often challenging to differentiate with subacute osteomyelitis, bone abscess, or osteoblastoma. This case report describes an uncommon case of a 13-year-old female patient with subperiosteal OO in the proximal phalanx of the great toe. The atypical location of OO should be familiarized to include appropriate differential diagnosis and to ensure accurate diagnosis by radiologic evaluations. Surgical excision remains the benchmark for the treatment of OO with its advantages on direct visualization and histologic confirmation for the diagnosis.

Metal ion release according to leg length discrepancy in ceramic-on-metal hip arthroplasty / Liberação de íons metálicos segundo discrepância no comprimento da perna após artroplastia metal-cerâmica total de quadril

ABSTRACT Objective The ceramic-on-metal (CoM) bearing has the theoretical advantages over ceramic-on-ceramic (CoC) and metal-on-metal bearings. This study aimed to analyze factors affecting the metal ion release of CoM bearings and compare clinical performance with CoC bearings. Methods The 147 patients were divided into 96 patients in group 1 (CoM group) and 51 patients in group 2 (CoC group). Additionally, within group1, 48 patients and 30 patients were sub-categorized into group 1-A with leg length discrepancy (LLD) less than 1cm and group 1-B greater than 1 cm. The level of serum metal ions, functional scores and plain radiographs were obtained for the analysis. Results The level of cobalt (Co) 2-years after surgery and chromium (Cr) 1-year after surgery showed significantly higher in the group1 than the group2. LLD indicated statistically significant positive correlation between serum metal ion levels among CoM bearing THAs. In comparison of the average metal ions level changes, group 1-B showed higher level of metal ion than group 1-A. Conclusion In patients underwent THA with CoM bearings, large LLD have a higher risk of complications associated to metal ions. Therefore, it is critical to reduce the LLD to 1 cm or less in using CoM bearing. Level of Evidence III; Case Control Study.

RESUMO Objetivo Uma superfície metalocerâmica (CoM) apresenta vantagens teóricas sobre as superfícies cerâmica-cerâmica (CoC) e metal-metal. Este estudo teve como objetivo analisar os fatores que afetam a liberação de íons metálicos das superfícies CoM e comparar o desempenho clínico com as superfícies CoC. Métodos Os 147 pacientes foram divididos em 96 pacientes no grupo 1 (grupo CoM) e 51 pacientes no grupo 2 (grupo CoC). No grupo 1, 48 pacientes foram subcategorizados em grupo 1-A, com discrepância de comprimento das pernas (LLD) menor que 1 cm; e 30 pacientes no grupo1-B maior que 1 cm. O nível de íons metálicos séricos, escores funcionais e radiografias foram obtidas para a análise. Resultados Os níveis de cobalto (Co) 2 anos após a cirurgia e de cromo (Cr), após o primeiro ano da cirurgia mostraram-se significativamente mais altos no grupo 1 do que no grupo 2. A LLD indicou correlação positiva estatisticamente significativa entre os níveis de íons do soro metálico entre os portadores de THA de CoM. Em comparação com as alterações médias dos níveis de íons metálicos, o grupo 1-B revelou um nível de íons metálicos mais alto do que o grupo 1-A. Conclusão Em pacientes submetidos a THA com superfícies CoM e elevada LLD têm um maior risco de complicações associadas a íons metálicos. Sendo fundamental reduzir LLD para 1 cm ou menos no uso de superfícies CoM. Nível de Evidência III; Estudo de Controle de Caso.

Differences in Acetabular Morphology Related to Sex and Side in South Korean Population.

Background: The normal references for acetabular parameters are important for the diagnosis of hip diseases and planning of total hip arthroplasty. There are wide interindividual differences in acetabular morphology in the normal population, and little is known about differences in acetabular morphology in the average South Korean population. The purpose of this study was to evaluate side and sex differences in acetabular morphology in the South Korean population. Methods: The acetabular parameters, including anteversion angle, abduction angle, center-edge angle, acetabular width and depth, and acetabular-head index, were measured on three-dimensional computed tomography images in 197 healthy Korean adults. Differences in acetabular parameters according to side and sex were evaluated. Results: The mean acetabular anteversion angle of men and women was 17.3° ± 5.2° and 20.1° ± 3.5°, respectively. The mean acetabular width of men and women was 61.5 ± 4.6 cm and 56.5 ± 4.0 cm, respectively. There were significant sex differences in acetabular anteversion angle (p = 0.001) and acetabular width (p = 0.036) when adjusted for age, body height, and weight. The mean acetabular width of the right side and the left side was 60.2 ± 5.2 cm and 57.8 ± 4.5 cm, respectively. There were significant side differences in acetabular width (p = 0.007) when adjusted for age, body height, weight, and sex. Conclusions: Differences and reference ranges of acetabular parameters are important for the diagnosis of acetabular deformity, such as femoroacetabular impingement and acetabular dysplasia. Moreover, these differences and reference ranges are useful for preoperative planning and safe positioning of acetabular components in total hip arthroplasty.

Tension band wiring versus suture anchor technique in patellar inferior pole fracture: Novel double row suture anchor technique.

Introduction: Patellar inferior pole fractures are challenging to obtain sufficient fixation. The purpose of this retrospective, case-controlled study was to compare the clinical and radiological outcomes between tension band wiring (TBW) and our novel double-row suture anchor (SA) technique in patellar inferior pole fractures. Materials and methods: This retrospective study included patients who underwent TBW or SA fixation for patellar inferior pole fractures from 2015 to 2019. A total of 63 patients were divided into two groups according to the surgical procedure: the TBW group (n = 35) and the SA fixation group (n = 28). The visual analog scale score, range of motion of the knee, Lysholm score, Kujala patellofemoral score, and patient satisfaction score were evaluated for clinical and functional outcomes. Radiological outcomes included the time to radiological union, loss of reduction, and the Insall-Salvati (IS) ratio. Results: Significant improvements in clinical outcomes were observed in both groups with no significant differences. Bone union was achieved in all patients, and there was no significant difference in the time to radiological union and the IS ratio between the two groups. All patients in the TBW group underwent additional surgeries for implant removal. However, none of the patients in the SA group underwent implant removal or experienced skin irritation. Conclusion: Our novel double-row SA technique could provide comparable fixation strength and good clinical outcomes, with fewer complications in patellar inferior pole fractures. This novel SA technique is a satisfactory alternative treatment for patellar inferior pole fractures.

Identification of Stem Cell Related Gene Expression from the Osteosarcoma Cell Core Side.

Osteosarcoma is the most frequent primary malignant bone tumor with higher incidences in children and adolescents. Despite clinical evolutions, patients with osteosacoma have had a poor prognosis. There has been increasing evidence that cancer is a stem cell disease. This study sought to isolate and characterize cancer stem cells from human osteosarcoma with relevant literature reviews. Here we show that the emerging evidence suggests osteosarcoma should be regarded as a differentiation disease such as stem cell disease. Two human osteosarcoma cell lines were cultured in non-adherent culture conditions as sarcospheres. Sarcospheres were observed using histomorphology and alkaline phosphatase (ALP) staining. Expression of the embryonic stem cell marker was analyzed with use of reverse transcriptase-PCR. Sarcospheres could be reproduced consistently throughout multiple passages and produced adherent osteosarcoma cell cultures. Expression of stem cell-associated genes such as those encoding Nanog, octamer-binding transcription factor 3/4, sex determining region Y box 2 , c-Myc and ALP indicated pluripotent stem-like cells. These results support the extension of the cancer stem cell theory to include osteosarcoma. Understanding the cancer stem cell derived from human osteosarcoma could lead to the evolution of diagnosis and treatment for osteosarcoma patients.

Superior Capsular Reconstruction Versus Lower Trapezius Transfer for Posterosuperior Irreparable Rotator Cuff Tears With High-Grade Fatty Infiltration in the Infraspinatus.

BACKGROUND: Superior capsular reconstruction (SCR) and lower trapezius transfer (LTT) have recently been utilized to treat irreparable rotator cuff tears (IRCTs). There is still no clear guideline on which treatment method is a better fit for posterosuperior IRCTs with high-grade 4 fatty infiltration in the infraspinatus. PURPOSE: To compare the clinical and radiological outcomes between arthroscopic-assisted SCR (aSCR) and arthroscopic-assisted LTT (aLTT) in patients with posterosuperior IRCTs with high-grade (Goutallier grade 4) fatty infiltration in the infraspinatus muscle. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This retrospective study included patients who underwent aSCR or aLTT for posterosuperior IRCTs with high-grade 4 fatty infiltration in the infraspinatus and had a minimum follow-up of 2 years between 2017 and 2019. A total of 58 patients were divided into 2 groups according to the surgical procedure: aSCR group (n = 22) and aLTT group (n = 36). Clinical outcomes comprised the visual analog scale score for pain, active shoulder range of motion (ROM), the American Shoulder and Elbow Surgeons (ASES) score, and patient satisfaction. Radiological outcomes comprised the acromiohumeral distance (AHD). The progression of arthritis was evaluated via the Hamada grade. Graft integrity was assessed on postoperative magnetic resonance imaging scans. RESULTS: Significant improvements in clinical outcomes were observed in both groups. However, active shoulder ROM (forward elevation: 165.7°± 22.3° vs 145.5°± 32.3°, respectively [P = .015]; external rotation: 51.7°± 10.9° vs 41.1°± 7.0°, respectively [P < .001]), the postoperative ASES score (84.8 ± 7.6 vs 76.8 ± 20.3, respectively; P = .045), and patient satisfaction (8.9 ± 1.2 vs 6.4 ± 2.1, respectively; P = .041) were significantly higher with aLTT than with aSCR. There was no significant difference between the groups in AHD at 2 years postoperatively. However, the rate of progression of arthritis was significantly higher with aSCR (22.7%) than with aLTT (2.8%) (P = .027). Moreover, the graft retear rate was significantly higher with aSCR (63.6%) than with aLTT (8.3%) at 2 years postoperatively (P < .001). CONCLUSION: Although aSCR and aLTT both provided improvements in overall clinical outcomes for posterosuperior IRCTs with high-grade 4 fatty infiltration in the infraspinatus, aLTT was superior in terms of functional improvement, patient satisfaction, progression of arthritis, and graft integrity. Therefore, we prefer aLTT for posterosuperior IRCTs under the condition of high-grade 4 fatty infiltration in the infraspinatus.

Stable internal fixation with dual plate technique for osteoporotic distal femur fractures.

BACKGROUND: Osteoporotic distal femur fractures are difficult in terms of fracture treatment and recovery. We hypothesized that the minimally invasive plate osteosynthesis (MIPO) with dual plate technique increased fixation stability and encouraged early mobilization and return to pre-fracture activity. MATERIAL AND METHODS: Between 2016 and 2019, 22 patients were treated with the dual plate technique for osteoporotic distal femur fractures. To evaluate the clinical outcome, the modified Western Ontario and McMaster Universities (WOMAC) score, Tegner activity score, knee range of motion (ROM), time to pain free full weight bearing from operation and patient satisfaction score were used. To evaluate the radiological outcome, the time to radiological union and varus or valgus angulation were measured. RESULTS: The mean modified WOMAC score was 37.0 ± 6.5 (range, 26-42). There was no significant difference between preoperative and postoperative Tegner activity score (p = 0.436). Among 22 patients, 16 patients (72.7%) achieved preoperative activity level. The mean knee ROM was 106.1° ± 16.8° (range, 80-135). The time to pain free weight bearing was 7.4 ± 1.5 (range, 5-10) weeks. In patient satisfaction, 20 patients (90.9%) were very satisfied or somewhat satisfied. Bone union was achieved in all patients at 16.4 ± 4.3 (range, 13-22) weeks. The final follow-up valgus angle was 3.6° ± 4.0° (range, -2.5° - 10.9). CONCLUSION: MIPO with the dual plate technique can provide rigid fixation for osteoporotic distal femur fractures. This stable and rigid fixation may allow early mobilization and return to pre-fracture activity.

Patellar Osteomyelitis in a 9-Year-Old Patient with Chronic Granulomatous Disease: A Case Report.

Hematogenous osteomyelitis is commonly reported in long tubular bones in the pediatric population. Acute osteomyelitis involving the patella is extremely uncommon in children, and its diagnosis is frequently delayed due to its rarity and variable clinical manifestations. Chronic granulomatous disease (CGD) is a rare genetic immunodeficiency disorder characterized by severe recurrent bacterial and fungal infections. The most commonly affected sites of infection are the lungs, lymph nodes, skin, liver, and gastrointestinal tract. Acute hematogenous osteomyelitis of the patella associated with CGD has never been reported. Our report describes the first case of acute hematogenous patellar osteomyelitis in a pediatric patient with CGD. Her clinical manifestations were similar to other possible differentials such as septic arthritis; however, use of advanced imaging confirmed the diagnosis, and the patient was successfully managed surgically. Since hematogenous osteomyelitis in children is uncommon, a high index of suspicion and advanced imaging may help with its diagnosis, and in cases where antibiotic treatment proves to be insufficient, prompt surgical management is imperative.

Preoperative Vitamin D Deficiency is Associated with Postoperative Functional Recovery and Complications after Hip Fracture Surgery.

BACKGROUND: Low concentrations of vitamin D are considered one of the risk factors for hip fracture and are associated with worse outcomes. The purpose of this retrospective study was to compare vitamin D deficient group and vitamin D sufficient group and assess the association preoperative vitamin D deficiency and postoperative walking ability after hip fracture surgery. METHODS: Between January 2014 and January 2020, 1,029 elderly patients with hip fracture (243 in men and 785 in women) were measured preoperative serum 25-hydroxy-vitamin D3 levels. Among 1,029 elderly patients, 702 patients were classified as Vitamin D deficient group (<20 ng/mL). Outcome parameters for functional recovery were the length of the hospital stay and KOVAL score, and those for complications were delirium, pneumonia, and thromboembolism. RESULTS: The mean length of the hospital stay in the vitamin D deficient group was significantly longer than in the vitamin D sufficient group (27.7±17.8 vs. 2.9±11.8 days; odds ratio [OR], 1.03; 95% confidence interval [CI], 1.02-1.05; P=0.001). The mean postoperative KOVAL score in the deficient group was significantly higher than in the sufficient group (4.0±2.1 vs. 3.1±1.9 days; OR, 1.21; 95% CI, 1.11-1.32; P=0.001). Vitamin D deficiency was significantly associated with a higher risk of delirium and pneumonia in deficiency group. CONCLUSIONS: Preoperative vitamin D deficiency in hip fractures patients was associated with prolonged duration of hospital stay and decrease of postoperative ambulatory status, and may increase the risk of delirium and pneumonia. Therefore, it is necessary to evaluate the preoperative vitamin D level and recommend vitamin D supplementation in elderly patients with a high probability of hip fracture.

Prospective study of epigenetic alterations responsible for isolated hemihyperplasia/hemihypoplasia and their association with leg length discrepancy.

BACKGROUND: Hemihyperplasia and hemihypoplasia result in leg length discrepancy (LLD) by causing skeletal asymmetry. Beckwith-Wiedemann syndrome (BWS) and Silver-Russell syndrome (SRS) are opposite growth-affecting disorders caused by opposite epigenetic alterations at the same chromosomal locus, 11p15, to induce hemihyperplasia and hemihypoplasia, respectively. Because of their somatic mosaicism, BWS and SRS show a wide spectrum of clinical phenotypes. We evaluated the underlying epigenetic alterations and potential epigenotype-phenotype correlations, focusing on LLD, in a group of individuals with isolated hemihyperplasia/hemihypoplasia. RESULTS: We prospectively collected paired blood-tissue samples from 30 patients with isolated hemihyperplasia/hemihypoplasia who underwent surgery for LLD. Methylation-specific multiplex-ligation-dependent probe amplification assay (MS-MLPA) and bisulfite pyrosequencing for differentially methylated regions 1 and 2 (DMR1 and DMR2) on chromosome 11p15 were performed using the patient samples. Samples from patients showing no abnormalities in MS-MLPA or bisulfite pyrosequencing were analyzed by single nucleotide polymorphism (SNP) microarray and CDKN1C Sanger sequencing. We introduced a metric named as the methylation difference, defined as the difference in DNA methylation levels between DMR1 and DMR2. The correlation between the methylation difference and the predicted LLD at skeletal maturity, calculated using a multiplier method, was evaluated. Predicted LLD was standardized for stature. Ten patients (33%) showed epigenetic alterations in MS-MLPA and bisulfite pyrosequencing. Of these, six and four patients had epigenetic alterations related to BWS and SRS, respectively. The clinical diagnosis of hemihyperplasia/hemihypoplasia was not compatible with the epigenetic alterations in four of these ten patients. No patients showed abnormalities in SNP array or their CDKN1C sequences. The standardized predicted LLD was moderately correlated with the methylation difference using fat tissue (r = 0.53; p = 0.002) and skin tissue (r = 0.50; p = 0.005) in all patients. CONCLUSIONS: Isolated hemihyperplasia and hemihypoplasia can occur as a spectrum of BWS and SRS. Although the accurate differentiation between isolated hemihyperplasia and isolated hemihypoplasia is important in tumor surveillance planning, it is often difficult to clinically differentiate these two diseases without epigenetic tests. Epigenetic tests may play a role in the prediction of LLD, which would aid in treatment planning.

Effective and Rapid Microbial Identification in Pediatric Osteoarticular Infections Using Blood Culture Bottles.

BACKGROUND: The detection and identification of pathogenic microorganisms are essential for the treatment of osteoarticular infection. However, obtaining a sufficient amount of specimen from pediatric patients is often difficult. Herein, we aimed to demonstrate the effectiveness of the blood culture bottle (BCB) system in pediatric osteoarticular infections. We hypothesized that our BCB culture method is superior to the conventional swab and tissue culture methods in terms of required specimen size, incubation time, and microbial identification rate. METHODS: We analyzed the prospectively collected data of pediatric patients who underwent surgical treatment for osteoarticular infections between August 2016 and October 2019. Four needles were dipped in the infected fluid or tissue during the surgical procedure as soon as the infected area was exposed and were used to inoculate 2 aerobic pediatric BCBs and 2 anaerobic general BCBs. We also collected 2 conventional swab samples and 2 tissue samples from the identical area. The microbial identification rate and the time required for identification were compared between BCB, swab, and tissue cultures. RESULTS: Forty patients constituted the study group; 13 patients had osteomyelitis, 17 patients had septic arthritis, and 10 patients had both. Of these 40 patients, the microbial identification rate was higher with BCB cultures (27 [68%]) than with swab cultures (18 [45%]; p = 0.004) or tissue cultures (15 [38%]; p < 0.001). Nine samples (9 patients [23%]) were only positive in the BCB culture. Positive microbial growth was not detected with conventional culture methods when microorganisms did not grow on the BCB culture. Compared with swab culture (4.3 ± 1.1 days; p < 0.001) or tissue culture (4.4 ± 1.1 days; p < 0.001), the BCB culture reduced the time required for microbial identification (3.5 ± 0.9 days). CONCLUSIONS: In pediatric osteoarticular infections, the BCB culture system improved the microbial identification rate, reduced the time to identification, and permitted a smaller-volume specimen, compared with traditional culture systems. LEVEL OF EVIDENCE: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Which Acetabular Landmarks are the Most Useful for Measuring the Acetabular Index and Center-edge Angle in Developmental Dysplasia of the Hip? A Comparison of Two Methods.

BACKGROUND: The acetabular index and center-edge angle are widely used radiographic parameters. However, the exact landmarks for measuring these parameters are not clearly defined. Although their measurement is straightforward when the lateral osseous margin of the acetabular roof coincides with the lateral end of the acetabular sourcil, where these two landmarks disagree, recommendations have differed about which landmark should be used. Using a radiographic parameter with high reliability for predicting residual hip dysplasia helps avoid unnecessary treatment. QUESTIONS/PURPOSES: We aimed to (1) compare two landmarks (the lateral osseous margin of the acetabular roof and the lateral end of the acetabular sourcil) for measuring the acetabular index and center-edge angle with respect to intraobserver and interobserver reliability and the predictability of residual hip dysplasia in patients with developmental dysplasia of the hip (DDH) and (2) evaluate longitudinal change in the acetabular edge's shape after closed reduction with the patient under general anesthesia. METHODS: Between February 1985 and July 2006, we performed closed reduction with the patient under general anesthesia as well as cast immobilization in 116 patients with DDH. To be included in this study, a patient had to have dislocated-type DDH. We excluded patients with a hip dislocation associated with neuromuscular disease, arthrogryposis, or congenital anomalies of other organs or systems (n = 9); hips that underwent osteotomy within 1 year since closed reduction (n = 8); hips that underwent open reduction because of re-dislocation after closed reduction (n = 4); and hips with Type III or IV osteonecrosis according to Bucholz-Ogden's classification (n = 4). Ninety-one patients were eligible. We excluded 19% (17 of 91) of the patients, who were lost to follow-up before they were 8 years old, leaving 81% (74 of 91 patients) with full preoperative and most-recent data. Ninety-seven percent (72 patients) were girls and 3% (two patients) were boys. The mean ± standard deviation age was 14.0 months ± 6.4 months (range 3-40 months) at the time of closed reduction and 12.1 years ± 2.3 years (range 8.0-16.0 years) at the time of the latest follow-up examination, the duration of which averaged 11 years ± 2.2 years (range 6.5-15.4 years). To investigate whether longitudinal change in the acetabular edge's shape differed among hips with DDH, contralateral hips, and control hips, we identified control participants after searching our hospital's database for patients with a diagnosis of congenital idiopathic hemihypertrophy from October 2000 to November 2006 who had AP hip radiographs taken at 3 years old and then at older than 8 years. From 29 patients who met these criteria, we randomly excluded two male patients to match for sex because girls were predominant in the DDH group. We excluded another female patient from the control group because of a hip radiograph that revealed unacceptable rotation. Eventually, 26 patients were assigned to the control group. Control patients consisted of 24 girls (92%) and two boys (8%). The demographic characteristics of control patients was not different from those of 67 patients with unilateral DDH, except for laterality (left-side involvement: 64% [43 of 67] in the DDH group versus 38% [10 of 26] in the control group; odds ratio 1.7 [95% confidence interval, 1.0-2.8]; p = 0.035). The acetabular index and center-edge angle at 3 years old were measured using the lateral osseous margin of the acetabular roof (AIB and CEAB) and the lateral end of the acetabular sourcil (AIS and CEAS). The treatment outcome was classified as satisfactory (Severin Grade I or II) or unsatisfactory (Grade III or IV). The intraclass correlation coefficient (ICC) was used to compare the intraobserver and interobserver reliability of each method. We compared the predictability of residual hip dysplasia of each method at 3 years old as a proxy using the area under the receiver operating characteristic (AUC) curve. To evaluate longitudinal change in the acetabular edge's shape, we compared the proportion of hips showing coincidence of the two landmarks between 3 years old and the latest follow-up examination. To investigate whether the longitudinal change in the acetabular edge's shape differs among hips with DDH, contralateral hips, and control hips, we compared the proportion of coincidence among the three groups at both timepoints. RESULTS: Intraobserver and interobserver reliabilities were higher for the CEAB (ICC 0.96; 95% CI, 0.94-0.98 and ICC 0.88; 95% CI, 0.81-0.92, respectively) than for the CEAS (ICC 0.81; 95% CI, 0.70-0.88 and ICC 0.69; 95% CI, 0.55-0.79, respectively). The AIB (AUC 0.88; 95% CI, 0.80-0.96) and CEAB (AUC 0.841; 95% CI, 0.748-0.933) predicted residual hip dysplasia better than the AIS (AUC 0.776; 95% CI, 0.67-0.88) and CEAS (AUC 0.72; 95% CI, 0.59-0.84) (p = 0.03 and p = 0.01, respectively). The proportion of hips showing coincidence of the two landmarks increased from 3 years old to the latest follow-up examination in hips with DDH (37% [25 of 67] to 81% [54 of 67]; OR = 8.8 [95% CI, 3.1-33.9]; p < 0.001), contralateral hips (42% [28 of 67] to 85% [57 of 67]; OR = 16.5 [95% CI, 4.2-141.9]; p < 0.001), and control hips (38% [10 of 26] to 88% [23 of 26]; OR = 14 [95% CI, 2.1-592.0]; p = 0.001). The proportion of coincidence in hips with DDH was not different from that in the contralateral hips and control hips at both timepoints. CONCLUSIONS: Measuring the acetabular index and center-edge angle at 3 years old using the lateral osseous margin of the acetabular roof has higher reliability for predicting residual hip dysplasia than that using the lateral end of the acetabular sourcil in patients with DDH treated with closed reduction. Measuring the acetabular index and center-edge angle at an early age using the lateral end of the sourcil may lead to overdiagnosis of residual hip dysplasia and unnecessary treatment. LEVEL OF EVIDENCE: Level III, diagnostic study.

Functional Outcomes of Hip Arthroscopy for Pediatric and Adolescent Hip Disorders.

BACKGROUND: There is a paucity of literature on the use of hip arthroscopy for pathologic conditions in skeletally immature patients. Thus, the indications and safety of the procedure are still unclear. The purpose of this study was to investigate the safety and functional outcomes of hip arthroscopy for pediatric and adolescent hip disorders. We further attempted to characterize arthroscopic findings in each disease. METHODS: We retrospectively reviewed 32 children and adolescents with hip disorders who underwent 34 hip arthroscopic procedures at a tertiary care children's hospital from January 2010 to December 2016. We evaluated functional limitations and improvement after operation by using the modified Harris hip score (HHS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), subjective pain assessment with a visual analog scale (VAS), and range of hip motion as well as the complications of hip arthroscopy. Arthroscopic findings in each disease were recorded. RESULTS: Hip arthroscopy was performed for Legg-Calvé-Perthes disease (n = 6), developmental dysplasia of the hip (n = 6), slipped capital femoral epiphysis (n = 5), idiopathic femoroacetabular impingement (n = 6), sequelae of septic arthritis of the hip (n = 3), hereditary multiple exostosis (n = 2), synovial giant cell tumor (n = 3), idiopathic chondrolysis (n = 2), and posttraumatic osteonecrosis of the femoral head (n = 1). Overall, there was a significant improvement in the modified HHS, WOMAC, VAS, and range of hip motion. Symptom improvement was not observed for more than 18 months in four patients who had dysplastic acetabulum with a labral tear (n = 2) or a recurrent femoral head bump (n = 2). There were no complications except transient perineal numbness in five patients. CONCLUSIONS: Our short-term follow-up evaluation shows that hip arthroscopy for pediatric and adolescent hip disorder is a less invasive and safe procedure. It appears to be effective in improving functional impairment caused by femoroacetabular impingement between the deformed femoral head and acetabulum or intra-articular focal problems in pediatric and adolescent hip disorders.

Diagnosis and Management of Hip Dislocation in Patients with Kabuki Syndrome.

BACKGROUND: Kabuki syndrome is a rare genetic disorder characterized by distinct dysmorphic facial features, growth deficiency, intellectual disabilities, unusual dermatoglyphic patterns, and skeletal abnormalities. The incidence of hip dislocation in Kabuki syndrome ranges from 18% to 62%. We reviewed the outcomes of management of hip dislocations in patients with Kabuki syndrome with special attention to the diagnostic processes for hip dislocation and Kabuki syndrome. METHODS: Among 30 patients with mutation-confirmed Kabuki syndrome, we selected six patients who had hip dislocations and reviewed their medical records and plain radiographs. The modes of presentation and diagnostic processes for both hip dislocations and Kabuki syndrome were investigated. The management and treatment outcomes of hip dislocations in patients with Kabuki syndrome were evaluated. RESULTS: The average age of patients at the time of diagnosis of hip dislocation was 7.7 months (range, 1 week to 22 months). None of the patients were diagnosed as having Kabuki syndrome at that time. Two patients were treated with a Pavlik harness; one, with closed reduction; two, with open reduction and later pelvic and/or femoral osteotomies; and one, with open reduction combined with pelvic osteotomy. The patients were followed up for 5.8 years on average (range, 2.0 to 10.5 years). The radiologic outcome was graded as Severin IA or IB for three patients who were older than 6 years at the latest follow-up (mean age, 9.9 years; range, 7.8 to 12.4 years). In the remaining three patients younger than 6 years (mean age, 3.8 years; range, 2.7 to 5.3 years), the lateral center edge angle was more than 15°. The clinical diagnosis of Kabuki syndrome was made during follow-up after hip dislocation treatment and confirmed by mutational analysis at a mean age of 4.7 years. The mean interval between the diagnosis of hip dislocation and Kabuki syndrome was 4.0 years. CONCLUSIONS: The management of hip dislocation by conservative or surgical method showed successful results. Awareness of Kabuki syndrome could lead to an early diagnosis of this rare disease in patients with hip dislocation and allow for early detection of other underlying conditions and multidisciplinary management.