A Comparison Between 3 Functional Hip Scores for Evaluation of the Pediatric Hip.

BACKGROUND: This investigation aimed to determine the degree of correlation among 3 functional scales for evaluating the hip in pediatric patients and determine the correlation between measures of global function and outcome. METHODS: We performed a prospective study of 173 consecutive patients (M age = 13 ± 3 y) being followed for developmental dysplasia of the hip (n = 122, 71%), slipped capital femoral epiphysis (n = 31, 18%), or Legg-Calve-Perthes disease (n = 20, 12%). We evaluated patients clinically, and we compiled scores for the Iowa Hip Score (IHS), Harris Hip Score (HHS), and Children's Hospital Oakland Hip Evaluation Scale (CHOHES). Patients concomitantly completed the Pediatric Outcomes Data Collection Instrument (PODCI) at the same clinic visit. We assessed Global Functioning Scale the and the Sports and Physical Functioning Core Scale of the PODCI. We determined the degree of correlation between the functional hip scales and between each scale and the PODCI scales using Spearman rank correlation coefficients. RESULTS: The correlations between the IHS, HHS, and CHOHES scores were robust (IHS and HHS ρ = 0.991; IHS and CHOHES ρ = 0.933; HHS and CHOHES ρ = 0.938; all P < 0.001). The correlation between the Global Functioning Scale of the PODCI and the 3 hip scores was ρ = 0.343 for the IHS, ρ = 0.341 for the HHS, and ρ = 0.352 for the CHOHES (all P < 0.001). The correlation between the sports and physical functioning core scale of the PODCI and the 3 hip scores was ρ = 0.324 for the IHS, ρ = 0.329 for the HHS, and ρ = 0.346 for the CHOHES (all P < 0.001). CONCLUSIONS: In a pediatric population with diverse hip pathology, there was a very strong correlation between scores on the IHS, HHS, and CHOHES. However, none of these 3 most commonly used hip scores correlated strongly with the global functioning scale or sports and physical functioning core scale of the PODCI. The most frequently used scores to determine the outcome of pediatric patients with hip pathology correlate strongly with each other but do not necessarily relate to global functional results. LEVEL OF EVIDENCE: Level IV.

Impact of tranexamic acid on blood loss and transfusion rate in children with cerebral palsy undergoing hip reconstruction with two or more osteotomies.

PURPOSE: Tranexamic acid (TXA), a synthetic lysine analogue, has been used in orthopedic procedures to limit blood loss and prevent allogeneic blood transfusions. However, data are scarce on its use in hip reconstruction of patients with cerebral palsy (CP). This study examines the effect of TXA on patients with CP undergoing hip reconstruction with at least two osteotomies. METHODS: This is a single-center, retrospective study of patients with CP who underwent hip reconstruction with two or more osteotomies from January 2013 to April 2019. There were 43 patients, with a mean age of 9.9 years. Age, procedure, preoperative and postoperative hemoglobin/hematocrit, estimated blood loss (EBL), transfusions and length of stay were recorded. The patients were split into the following two groups: 24 patients who had received intraoperative TXA and 19 who had not. RESULTS: Age, EBL, mean preoperative and postoperative hemoglobin or hematocrit, preoperative to postoperative hematocrit drop, and length of stay were similar for the two groups (p > 0.05). The risk for intraoperative transfusion (21 vs. 17%), postoperative transfusion (26 vs. 8%), and any transfusion (42 vs. 21%) appeared to be greater in the group that did not receive TXA, but this difference did not achieve statistical significance. CONCLUSION: This pilot study shows patients with CP undergoing hip reconstruction with two or more osteotomies; the use of TXA, while not statistically significant, shows a trend toward a decreased need for allogeneic blood transfusion.

Use of hamstring autograft to reconstruct the patellar tendon after endoprosthetic replacement of the proximal tibia for bone sarcomas.

The surgical treatment of bone sarcoma involves wide surgical resection and endoprosthetic replacement. Surgical resection for proximal tibia bone sarcoma includes the patellar tendon. The secondary extension lag is a common complication and, although many have been described, the options for reconstruction of the patellar tendon are suboptimal. We propose adding a biological reinforcement, the hamstring tendons, to our extensor mechanism reconstruction technique (polyprolene mesh and gastrocnemius flap). We describe the surgical technique and, using an illustrative case, compare the outcome of this technique with the outcome following reconstruction without reinforcement. Level of evidence: Level III.

Primary Total Hip Arthroplasty for Legg-Calvé-Perthes Syndrome: 20 Year Follow-Up Study.

Background: Patients with Legg-Calvé-Perthes Syndrome (LCPS) are at an increased risk for developing osteoarthritis of the hip and undergoing total hip arthroplasty (THA) at an early age. Importantly, this younger age may put them at a higher risk for failure and revision surgery. The purpose of the study was to assess the clinical and radiographic outcomes as well as implant failure rate and risk for revision surgery at an average 20 years follow up. Methods: Data from LCPS patients treated with THA were collected including age, gender, operative date, revision date, as well as reason for and type of revision. Living patients filled the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaires at the time of last follow-up. Radiographs were evaluated for lucencies, debonding, loosening, osteolysis, wear, heterotopic ossification and sclerosis. Results: Nineteen patients (20 hips) treated with THA were followed-up for a mean of 18.3 years (range, 10.1 - 36.2 years). Radiographic evidence of lucency of the acetabular component was seen in 70% of the patients and femoral cortical hypertrophy in 85% at last follow-up. The rate of revision for any reason was 35%, mostly due to aseptic acetabular loosening. Conclusions: Our findings support the use of THA for the treatment of OA in patients with LCPS, bearing in mind the potentially lower survival rate at 20 years as compared those treated with THA for primary OA. Further studies are needed to identify the possible causes of the high rate of cortical hypertrophy seen in this patient population.Level of Evidence: IV Therapeutic.

Effect of Gender on Postoperative Morbidity and Mortality Outcomes: A Retrospective Cohort Study.

Full extent of gender differences on postoperative outcomes has never been studied on large scale, specifically postoperative complications. This study aims to assess the effect of gender on 30-day morbidity and mortality after major surgery. A retrospective cohort study was carried out using data of patients undergoing major surgeries from the American College of Surgeons' National Surgical Quality Improvement Program database between 2008 and 2011. Demographics, pre- and perioperative risk factors, as well as 30-day morbidities, both overall and specific, were reviewed. The 30-day mortality data were also assessed. Multivariate logistic regression analyses, basic (Adj1) and extended (Adj2), were used to assess the association between gender and outcomes. Out of 1,409,131 patients, 57.2 per cent were females. Females had lower prevalence of most system-specific risk variables. Overall morbidities were also lower in females versus males, even after adjustment for variables [total overall morbidity: ORadj2 = 0.9 (0.89-0.92), P < 0.0001] except in some cases such as after cardiac surgeries [ORadj2 = 1.29 (1.14-1.44), P < 0.0001] and vascular surgeries [ORadj2 = 1.14 (1.10-1.18), P < 0.0001], where overall morbidities of females were higher. Specific morbidities were also lower in females than in males in all types of complications except central nervous system-related postoperative complications [ORadj2 = 1.15 (1.08-1.22), P < 0.0001] and return to the operating room [ORadj2 = 1.06 (1.04-1.08), P < 0.0001]. The 30-day mortality rate for females was lower than males [ORadj2 = 0.99 (0.96-1.03), P = 0.94]. Female gender was associated with less perioperative morbidity and mortality versus males, but they did worse after cardiovascular procedures and had more central nervous system-related complications. These outcomes should be taken into consideration by surgeons and should be evaluated further in future studies.

A novel treatment approach to infected nonunion of long bones without systemic antibiotics.

Infected nonunion of long bones may require intravenous antibiotics over a lengthy period which may result in a high rate of complications. This study aims to assess the efficacy of local antibiotics used as a replacement to prolonged intravenous therapy. Thirteen patients with infected nonunion of long bones who failed at least one previous surgery were included. The infection was treated through extensive debridement, application of antibiotic-impregnated calcium sulphate pellets and the bone stabilized with external fixation. These patients were monitored for union and infection by clinical signs, laboratory values, and radiographs over a period of 24 months. The results support an eradication of infection and union in all patients with no antibiotic-associated complications. Local antibiotic delivery using calcium sulphate pellets provides an effective method for treatment of nonunion in long bones and is free of the complications from the intravenous route.

Comparison of Early Adverse Events After Operative Treatment of Bimalleolar and Trimalleolar Fractures Versus Pilon Fractures.

Ankle fractures requiring open reduction and internal fixation vary in severity from unimalleolar fractures to bimalleolar/trimalleolar (BT) fractures to pilon fractures. Consequently, the postoperative outcomes with these surgeries can vary. Most previous studies of these injuries had small sample sizes, studied a single risk factor or adverse event, or did not compare different injuries by severity. The purpose of the present study was to describe and compare the patient characteristics and postoperative outcomes of 2 high-energy ankle fractures: BT and pilon fractures. The relevant patients were identified from the American College of Surgeons National Surgical Quality Improvement Program database using the Current Procedural Terminology codes for BT and pilon fractures. Patient demographics, characteristics, comorbidities, and 30-day mortality and adverse events were recorded and compared between the 2 types of ankle fractures. More than 45% of patients with these fracture types were aged 40 to 65 years. Pilon fractures occurred more frequently in younger patients, were more likely to occur in men, required a longer hospital stay and operative time, were less likely to occur in patients with a body mass index of >30 kg/m2, and conferred a greater risk of wound complications (odds ratio 1.76; p = .048) compared with BT fractures. The findings from the present study help us understand the differences in patient characteristics and potential early adverse events after open reduction and internal fixation of BT fractures versus pilon fractures.

Epithelialization Over a Scaffold of Antibiotic-Impregnated PMMA Beads: A Salvage Technique for Open Tibial Fractures with Bone and Soft Tissue Loss When all Else Fails.

The management of soft tissue defects in tibial fractures is essential for limb preservation. Current techniques are not without complications and may lead to poor functional outcomes. A salvage method is described using three illustrative cases whereby a combination of flaps and antibiotic-impregnated polymethylmethacrylate beads are employed to fill the bony defect, fight the infection, and provide a surface for epithelial regeneration and secondary wound closure. This was performed after the partial failure of all other options. All patients were fully ambulatory with no clinical, radiographic or laboratory sign of infection at their most recent follow-up. Although our findings are encouraging, this is the first report of epithelialization of the skin on a polymethylmethacrylate scaffold. Further studies investigating the use of this technique are warranted.

Back pain: A puzzle in children.

Back pain in children is underdiagnosed and increases incidence in adolescence. A systematic approach can diagnose the most common causes: trauma, structural deformities, inflammatory diseases, infection and malignancy.

Preoperative Pneumonia and Postoperative Venous Thrombosis: A Cohort Study of 427,656 Patients Undergoing Major General Surgery.

BACKGROUND: The literature is sparse regarding the association between pneumonia and venous thrombosis in surgical patients. The aim of this study was to investigate the risk of postoperative venous thrombosis in patients who fit the criteria for preoperative pneumonia using data from the ongoing American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database while adjusting for potential confounders. METHODS: This is a cohort study using data from the ACS NSQIP database participating sites from 2008 (211 sites) and 2009 (237 sites). 427,656 patients undergoing major general surgery were included. The 30-day risk of postoperative venous thrombosis including deep vein thrombosis (DVT) and pulmonary embolism (PE) was evaluated in patients with preoperative pneumonia diagnosed before undergoing major general surgery. RESULTS: Patients with preoperative pneumonia had a higher incidence of both 30-day DVT and PE than patients without preoperative pneumonia. After adjusting for all potential confounders, the effect estimates for the association between preoperative pneumonia and venous thrombosis were DVT, OR: 1.67 (95% CI 1.32-2.11) and PE, OR: 2.18 (95% CI 1.48-3.22). CONCLUSIONS: A large, multicenter database of surgical patients showed that preoperative pneumonia may increase risk for developing venous thrombosis. This adds to our understanding of risk factors for venous thrombosis and suggests a potential benefit of diagnosing preoperative pneumonia in patients undergoing major general surgery.

Bilateral Achilles Tendon Ruptures Associated With Ciprofloxacin Use in the Setting of Minimal Change Disease: Case Report and Review of the Literature.

Fluoroquinolones are widely used antibiotics; however, numerous side effects have been reported in published studies, including a spectrum of tendinopathies, affecting numerous anatomic sites. Several risk factors have been identified, including advanced age (>60 years), corticosteroid use, renal failure or dialysis, female sex, and nonobesity. We present the case of an elderly male with minimal change disease treated with glucocorticoids and acute kidney injury, who sustained spontaneous nontraumatic bilateral Achilles tendon tears 4 days after initiating ciprofloxacin.

Intramuscular myxoma of the tibialis anterior muscle First report in the English literature.

Intramuscular myxoma is a rare entity in itself, and while it has been described in several locations in the body, its presence in the tibialis anterior muscle has only been reported once in the literature. In this case report, we present, to our knowledge, the first case of an intramuscular myxoma in the tibialis anterior muscle in the English literature, which was successfully managed with wide surgical resection.

Correlation of non-mass-like abnormal MR signal intensity with pathological findings surrounding pediatric osteosarcoma and Ewing's sarcoma.

OBJECTIVE: The aim of this work was to determine the role of MRI in interpreting abnormal signals within bones and soft tissues adjacent to tumor bulk of osteosarcoma and Ewing's sarcoma in a pediatric population by correlating MR findings with histopathology. MATERIALS AND METHODS: Thirty patients met the inclusion criteria, which included (1) osteosarcoma or Ewing's sarcoma, (2) MR studies no more than 2 months prior to surgery, (3) presence of abnormal MR signal surrounding the tumor bulk, (4) pathological material from resected tumor. The patients received standard neoadjuvant chemotherapy. Using grid maps on gross pathology specimens, the abnormal MR areas around the tumor were matched with the corresponding grid sections. Histopathology slides of these sections were then analyzed to determine the nature of the regions of interest. The MR/pathological correlation was evaluated using Mann-Whitney U test and Fisher's exact test. RESULTS: Twenty-seven patients had osteosarcoma and three patients had Ewing's sarcoma. Of the studied areas, 17.4% were positive for tumor (viable or necrotic). There was no statistically significant correlation between areas positive for tumor and age, gender, signal extent and intensity on MRI, or tissue type. There was, however, a statistically significant correlation between presence of tumor and the appearance of abnormal soft tissue signals. A feathery appearance correlated with tumor-negative areas whereas a bulky appearance correlated with tumor-positive regions. CONCLUSIONS: MR imaging is helpful in identifying the nature of abnormal signal areas surrounding bone sarcomas that are more likely to be tumor-free, particularly when the signal in the soft tissues surrounding the tumor is feathery and edema-like in appearance.

Relapse after tibialis anterior tendon transfer in idiopathic clubfoot treated by the Ponseti method.

BACKGROUND: The Ponseti method for clubfoot correction has demonstrated excellent results. However, relapses are common and continue to be the most important problem facing clubfoot practitioners. Relapses usually require repeated casting and/or surgical intervention with tibialis anterior tendon transfer (TATT). However, recent data on relapses suggest that performing a successful TATT may not be a definitive cure as there may be other processes, such as neuromuscular deficits, that may result in subsequent relapses. METHODS: The authors reviewed 66 patients (102 clubfeet) treated by TATT for clubfoot relapses after successful initial treatment by the Ponseti method. Ten patients (15 clubfeet) experienced a subsequent relapse. Demographic, clinical, and treatment data was recorded. RESULTS: These patients had a tendency toward a greater number of casts at initial treatment (P=0.14) and they underwent relapse surgery earlier than those who did not relapse after TATT (P=0.05). Two of these patients had a neuromyopathy, diagnosed by muscle biopsy. The treatment of post-TATT relapse included casting (6 patients), ankle foot orthotic (4 patients), physical therapy (2 patients), or bracing (1 patient). One patient was treated by osteotomies of the cuboid and medial cuneiform and 1 patient had a peroneus longus to peroneus brevis tendon transfer. CONCLUSIONS: Performing a TATT may not be the definitive treatment for clubfoot relapses as neuromuscular deficits may be involved. In addition, these patients may be at an increased risk of relapse due to the earlier age at which TATT was performed. When there is a high index of suspicion, prompt diagnosis with muscle biopsy is warranted. LEVEL OF EVIDENCE: Level III (Case-control study).

Value of sagittal fat-suppressed proton-density fast-spin-echo of the knee joint as a limited protocol in evaluating internal knee derangements.

PURPOSE: The aim of the study was to determine the accuracy and observer agreement in the assessment of internal knee derangement using sagittal fat-suppressed proton-density fast-spin-echo (FS PD-FSE) compared with combined sagittal T1-weighted spin-echo, dual-proton-density, and T2-weighted spin-echo sequences and with arthroscopy. METHODS: One hundred eighteen patients undergoing routine knee magnetic resonance (MR) imaging had additional imaging with sagittal FS PD-FSE sequences. Menisci, cruciate ligaments, extensor tendons (ETs), bone marrow, osteoarthritic changes, soft tissue edema, joint effusion, and incidental tumors were analyzed. Magnetic resonance images were independently reviewed by 2 radiologists. Fifty patients underwent knee arthroscopy. Statistical analysis compared both imaging protocols with each other and with arthroscopy. Intrareader and interreader agreements were evaluated using κ analysis. Both protocols were compared with arthroscopy. RESULTS: Intrareader agreement was very high except for readings of the posterior cruciate ligament, ETs, and cartilage. Intrareader agreement did not differ significantly between the 2 readers except for ETs, bone marrow, and cartilage. Interreader percent agreements were high using both protocols and were not significantly different between the 2 readers except for posterior cruciate ligament. Compared with arthroscopy, both methods showed almost identical results regarding sensitivity, specificity, positive predictive value, and negative predictive value, except for cartilage where FS PD-FSE had increased sensitivity, whereas the combined protocol had increased specificity. CONCLUSIONS: Sagittal FS PD-FSE is comparable to our regular MR protocol in assessing internal knee derangement with an overall agreement of at least 93% on all sites except cartilage. It was also comparable to arthroscopy in assessing the cruciate ligaments and menisci, but had a low specificity for cartilaginous derangements. It can replace our 3 sagittal series comprising T1- and T2-weighted and proton-density-spin-echo sequences, hence saving time and cost.

High tibial osteotomy in young adults with constitutional tibia vara.

Frontal plane malalignment of the lower extremity results in abnormal load distribution across the knee joint. Consequences of this increased stress may lead to compartmental osteoarthritis. High tibial osteotomy is well established for early osteoarthritis of the knee joint in middle-aged patients. We hypothesize that earlier realignment of the varus knee can be performed without undue risks and debilitation toward the young active patient and with good results in short-term follow-up. Open-wedge high tibia osteotomy using the Puddu plate was performed on eleven patients (19 knees) under 25 years of age for constitutional high tibia vara. The mechanical femorotibial angle (FTA) and Knee Society Knee Score (KSKS) were compared pre-operatively and 24 months post-operatively. The average FTA improved from +8.8 degrees (+5 - +16) to -0.1 (-2 - +5). The average KSKS improved from 74 (50-100) to 93 (60-100) and the function score improved from 84 (50-100) to 95 (60-100). Special concerns in this age group include unsightly cosmesis, and kneeling pain and discomfort. Open-wedge high tibia osteotomy provides a satisfactory solution for constitutional high tibia vara with minor morbidity on behalf of the patient in the short-term follow-up period.

The risk of local recurrence along the core-needle biopsy tract in patients with bone sarcomas.

INTRODUCTION: We evaluated the local recurrence rate (LRR) of bone sarcoma along the core-needle biopsy (CNB) tract in patients who underwent limb Salvage Surgery (LSS) following a diagnostic CNB performed irrespective of the planned surgical incision site and for which surgery did not involve any biopsy tract removal. METHODS: A retrospective review of 10 pediatric patients diagnosed with bone sarcoma using a computed tomography-guided core-needle biopsy, with evaluation of medical records, pathological specimens and radiological films from the date of diagnosis until the most recent follow-up. RESULTS: None of the patients experienced local recurrence during their follow up, despite the lack of biopsy site resection. CT scans of the involved extremities were negative for any suspicious lesions in all patients up until the most recent follow-up. CONCLUSIONS: Our study and review of the literature suggest that the incidence of tumor seeding the CNB tract in bone sarcoma patients is apparently low, and possibly negligible. CNB should be performed through the most direct approach to the tumor, and LSS can be performed safely through the standard approaches without excision of the biopsy tract.