Pediatric Medial Malleolus Reconstruction and Cartilage Preservation Using Iliac Crest Bone Graft After Ankle Trauma: A Case Report.

CASE: This case report describes cartilage preservation and medial malleolus reconstruction using tricortical iliac crest autograft in a pediatric patient who sustained an ankle injury resulting in near-complete medial malleolus bone loss. CONCLUSION: Medial malleolar bone loss precluding open reduction and internal fixation is a challenging surgical problem, and there are few studies describing treatment. Our case report adds to the literature because our described technique resulted in a successful outcome for this patient.

Biomechanical properties of splint materials while curing.

Many studies have evaluated splint strength at maturity with multiple splint materials, methods, and configurations but none have analyzed splints as they cure. The purpose of this study is to evaluate the properties of different splint materials immediately following activation and as they mature. Splints were dipped for three seconds in two temperatures of water and an additional group of fiberglass with no water was tested as well. Splint weight was taken as an additional measurement to assure homogenous groups. All splints were tested in three-point bending at a constant displacement. The generalized linear model (GLM) including all time frames showed differences in yield load and ultimate loads after three minutes. All ultimate loads occurred at greater than 20° of angulation. Plaster had a much lower displacement at its yield load at all times after 3 min. Plaster had a higher stiffness at 1° of angulation at all time points after six minutes. The GLM that excluded the three-day time showed that the higher temperature increased initial stiffness in the splints at three and six minutes. Fiberglass has a higher yield point and ultimate load when compared to plaster. However, these loads were measured at significant splint angulation for the fiberglass, suggesting that plaster is acting as a true splint. Fiberglass is stronger and faster to cure than plaster. In situations where the surgeon desires the strongest splint, fiberglass may be preferable. However, the initial stiffness of plaster is superior to fiberglass.

The Influence of Computerized Tomography Imaging on Treatment of Periprosthetic Proximal Femur Fractures.

Introduction Periprosthetic femur fractures (PPFF) are increasing in incidence and management of such injuries requires a specialized skill set combined with detailed knowledge of component design. To assist with planning, computed tomography (CT) can be used pre-operatively to give a surgeon more information. No study to date has shown the utility of obtaining preoperative CT. The goal of this study is to show that CT is a useful diagnostic adjunct and report any differences in how subspecialties such as orthopedic traumatologists and arthroplasty surgeons use it. Methods Seventeen PPFF cases met our inclusion criteria. They were shown to six faculty, three trauma and three arthroplasty surgeons. They viewed the plain radiographs and then CTs. After each they filled out the same questionnaire that included their assessment of diagnosis and proposed treatment plan both before and after access to CT imaging. Fleiss and Cohen kappa were used to compare inter- and intra-observer reliability. Results The interobserver kappa values (k) in diagnosis were 0.348 pre- and 0.371 post-CT, while trauma and arthroplasty were 0.328 to 0.260 and 0.821 to 0.881 respectively. The interobserver reliability in treatment was 0.336 pre- and 0.254 post-CT, while trauma and arthroplasty were 0.323 to 0.288 and 0.688 to 0.519. For intraobserver the average k for diagnosis and treatment were 0.818 and 0.671. Broken down by subspecialty they were 0.874 and 0.831 and 0.762 and 0.510 for trauma and arthroplasty. There were 11 diagnostic and 24 treatment changes. Conclusion CT provides diagnostic changes 10% and treatment changes 24% of the time. However, it does not lead to greater agreement among the surgeons on either. Arthroplasty uses CT more to guide both their treatment and the diagnosis, and they agree more than trauma surgeons. Most of the treatment changes come from adding or removing a plate, and the most common diagnostic change was shared by A to B1 and B2 to B3. This suggests fracture extension and bone stock are better evaluated by CT.

Bilateral Slipped Capital Femoral Epiphysis Fixation Failure Including the Prophylactic Side: A Case Report.

Slipped capital femoral epiphysis (SCFE) is a common problem treated by pediatric orthopedic surgeons. A 13-year-old male presented with right-sided hip pain. Both sides, symptomatic and asymptomatic, were treated with a single 7.3-mm screw. The patient returned with symptoms to the bilateral hips 16 months after the procedure. He was treated with removal of hardware and revision fixation with a good outcome. We report a rare case of fixation failure in bilateral SCFE with an excellent outcome. We highlight the importance of quick recognition of failure before displacement and a strategy for hardware removal.

In vitro effects of a kaolin-coated hemostatic dressing on anticoagulated blood.

BACKGROUND: The use of kaolin-coated dressings has become common and have efficacy in normal patients, but their increased use will inevitably include use on bleeding patients taking anticoagulants. We hypothesize that kaolin coating material (KCM) will improve clotting regardless of anticoagulation medication. METHODS: A prospective study was performed on blood from patients who were on a vitamin K antagonist (VKA), unfractionated heparin (UH), an antiplatelet (AP) agent, a Xa inhibitor (Xa), or a direct thrombin inhibitor (DTI). None were on more than one type of anticoagulation medication. Viscoelastic testing was performed with and without KCM. All p values were adjusted for multiple comparisons. RESULTS: The addition of KCM significantly decreased the time for initial clot formation (CT) in all groups. The mean CT for controls was decreased from 692 to 190.8 s (p < 0.0001). KCM decreased the initial clot formation time by about 1.5 times in those on DTI (p = 0.043) and 2.5 times in those taking AP medication (p < 0.001). The most profound effect was seen in those on UH (no KCM 1,602 s vs. KCM 440 s; p < 0.001), VKA (no KCM 1,152 s vs. 232 s; p < 0.01), and Xa (no KCM 1,342 s vs. 287 s; p < 0.001). Analysis of other clot formation parameters revealed that KCM significantly improved the clot formation kinetics (CFT) only in patients taking Xa (p = 0.03). KCM improved maximum clot strength in patients on Xa inhibitors (p = 0.05). Patients on UH had a larger effect size with an increase in clot strength from 24.35 mm to 43.35 mm whereas those on Xa had an increase of 38.7 mm to 49.85 mm. CONCLUSION: In this in vitro analysis, the addition of KCM to the blood of patients taking any of these anticoagulation medications significantly improved the time to initial clot formation, indicating that kaolin-based hemostatic dressings will be effective in initiating clot formation in patients on anticoagulants. LEVEL OF EVIDENCE: Therapeutic, level IV.

Can CT imaging of the chest, abdomen, and pelvis identify all vertebral injuries of the thoracolumbar spine without dedicated reformatting?

BACKGROUND: The main objective of this study was to compare detection rates of clinically significant thoracolumbar spine (TLS) fracture between computed tomography (CT) imaging of the chest, abdomen, and spine (CT CAP) and CT for the thoracolumbar spine (CT TL). METHODS: We retrospectively identified patients at our institution with a TLS fracture over a two-year period that had both CT CAP and reformatted CT TL imaging. The sensitivity of CT CAP to identify fracture was calculated for each fracture type. RESULTS: A total of 516 TLS fractures were identified in 125 patients using reformatted CT TL spine imaging. Overall, 69 of 512 fractures (13%) were missed on CT CAP that were identified on CT TL. Of those, there were no clinically significant missed fractures. CONCLUSIONS: CT CAP could potentially be used as a screening tool for clinically significant TLS injuries.

The Parkland grading scale for cholecystitis.

BACKGROUND: Gallbladders (GBs) with severe inflammation have longer operative times and an increased risk for complications. We propose a grading system using intraoperative images to better stratify GB inflammation. METHODS: After reviewing the intraoperative images of GBs obtained during several hundred laparoscopic cholecystectomies, we developed a five-tiered grading system based on anatomy and inflammatory changes. Fifty intraoperative photographs were taken prior to dissection and then distributed to 11 surgeons who rated each GB's severity per the grading system. The two-way random effects Intraclass Correlation Coefficient (ICC) was used to assess the reliability among the raters. RESULTS: The ICC among the raters of GB severity was 0.804 (95% CI: 0.733 to 0.867; p = 0.0001). Nineteen GB images had greater than 82% agreement and 16 were clustered around GBs with severe inflammation (grades 3-5). CONCLUSION: This study proposes a simple, reliable grading system that characterizes GB complexity based on inflammation and anatomy.