Surgeon Recommendations for Physical Activity in Patients With Pediatric Hip Conditions.

BACKGROUND: While physical activity (PA) is important during youth, it is unclear if children and adolescents with developmental dysplasia of the hip (DDH), Legg-Calvé-Perthes disease (LCPD), or slipped capital femoral epiphysis (SCFE) are expected or encouraged to return to PA once they have healed. This study examines the orthopaedic surgeons' role in advising pediatric hip patients on the PA they should engage in, assessing their practice, opinions, and consensus when making recommendations. METHODS: Orthopaedic surgeons were invited from member lists of 4 hip study groups. The survey included demographics, opinions regarding PA, and 10 case scenarios that queried respondents on the duration and intensity of PA as well as the restrictions on activity type that they would recommend for DDH, LCPD, or SCFE patients. Consensus was evaluated on a scale ranging from 0 to 1, with a value of 0 indicating no agreement among respondents and a value of 1 indicating complete agreement. RESULTS: A total of 51 orthopaedic surgeons responded. While 94% agreed that it is important for school-aged hip patients to return to PA after they have healed, 53% believed that PA may compromise the hip and contribute to the development of osteoarthritis. Average standardized consensus was 0.92 for suggesting the patient engage in some amount of PA, 0.44 for suggesting the recommended daily minimum of 60 minutes of moderate-to-vigorous physical activity (MVPA), and 0.33 for suggesting restrictions on activity type. The most frequently selected restrictions included avoiding impact activities (93%, 235/254) and contact activities (58%, 147/254), followed by weight-bearing activities (24%, 62/254). Respondents were not aware of existing PA guidelines, although 57% expressed interest in following guidelines and 39% were uncertain. CONCLUSIONS: While there is consensus among orthopaedic surgeons that children with chronic hip conditions should engage in PA, there is considerable variation when recommending the recommended daily MVPA minimum and placing restrictions on activity type. This study suggests interest among orthopaedic surgeons in developing PA guidelines that optimize outcomes for pediatric hip patients. LEVEL OF EVIDENCE: Level II-Survey study.

Fibrin Glue is a Viable Alternative to Fat Graft for Interposition After Tarsal Coalition Resection.

BACKGROUND: Tarsal coalition is one of the most common foot and ankle pathologies in children, yet there is no consensus regarding what to interpose after resection. Fibrin glue could be considered, but the literature comparing fibrin glue to other interposition types is sparse. The purpose of this study was to evaluate the effectiveness of fibrin glue for interposition compared with fat graft by analyzing the rate of coalition recurrence and wound complications. We hypothesized that fibrin glue would have similar rates of coalition recurrence and fewer wound complications compared with fat graft interposition. METHODS: A retrospective cohort study was performed examining all patients who underwent a tarsal coalition resection at a free-standing children's hospital in the United States from 2000 to 2021. Only patients undergoing isolated primary tarsal coalition resection with interposition of fibrin glue or fat graft were included. Wound complications were defined as any concern for an incision site that prompted the use of antibiotics. Comparative analyses were conducted using χ 2 and Fisher exact test to examine relationships among interposition type, coalition recurrence, and wound complications. RESULTS: One hundred twenty-two tarsal coalition resections met our inclusion criteria. Fibrin glue was used for interposition in 29 cases and fat graft was used in 93 cases. The difference in the coalition recurrence rate between fibrin glue and fat graft interposition was not statistically significant (6.9% vs. 4.3%, P =0.627). The difference in wound complication rate between fibrin glue and fat graft interposition was not statistically significant (3.4% vs 7.5%, P = 0.679). CONCLUSION: Fibrin glue interposition after tarsal coalition resection is a viable alternative to fat graft interposition. Fibrin glue has similar rates of coalition recurrence and wound complications when compared with fat grafts. Given our results and the lack of tissue harvesting required with fibrin glue, fibrin glue may be superior to fat grafts for interposition after tarsal coalition resection. LEVEL OF EVIDENCE: Level III, a retrospective comparative study between treatment groups.

What Is New in Pediatric Bone Health.

BACKGROUND: This review paper aims to report on the last 5 years of relevant research on pediatric bone health in regard to nutrition and obesity, ethnic disparities, common orthopaedic conditions, trauma, spine, and sports medicine. METHODS: A search of the PubMed database was completed using the following terms: bone health, Vitamin D, pediatric, adolescent, sports medicine, fractures, spine, scoliosis, race, ethnicity, obesity, Slipped Capital Femoral Epiphysis, Osteogenesis Imperfecta, Duchenne's Muscular Dystrophy, neuromuscular, and cancer. Resultant papers were reviewed by study authors and determined to be of quality and relevance for description in this review. Papers from January 1, 2015 to August 31, 2020 were included. RESULTS: A total of 85 papers were selected for review. General results include 7 key findings. (1) Obesity inhibits pediatric bone health with leptin playing a major role in the process. (2) Socioeconomic and demographic disparities have shown to have a direct influence on bone health. (3) Vitamin D deficiency has been linked to an increased fracture risk and severity in children. (4) Formal vitamin D monitoring can aid with patient compliance with treatment. (5) Patients with chronic medical conditions are impacted by low vitamin D and need ongoing monitoring of their bone health to decrease their fracture risk. (6) Vitamin D deficiency in pediatrics has been correlated to low back pain, spondylolysis, and adolescent idiopathic scoliosis. Osteopenic patients with AIS have an increased risk of curve progression requiring surgery. Before spine fusion, preoperative screening for vitamin D deficiency may reduce complications of fractures, insufficient tissue repair, loosening hardware, and postoperative back pain. (7) Increasing youth sports participation has resulted in increased bone health related injuries. However, improved understanding of Relative Energy Deficiency in Sport effects on bone health has recently occurred. CONCLUSIONS: Increasing awareness of bone health issues in children will improve their recognition and treatment. Further research is needed on diagnosis, treatment, outcomes, and most importantly prevention of pediatric bone health diseases.

The evolution of primary double-bundle ACL reconstruction and recovery of early post-operative range of motion.

PURPOSE: The aim of this study was to analyse early post-operative range of motion (ROM) as our anatomic double-bundle (DB) anterior cruciate (ACL) reconstruction technique with respect to tunnel placement evolved. It is the hypothesis of this study that more anatomic placement of the femoral insertion site of the anteromedial (AM) bundle of the ACL results in better restoration of early post-operative knee range of motion. METHODS: Two methods of DB ACL reconstruction regarding more accurate placement of the femoral AM tunnel in relation to its anatomic origin were compared. Patients presenting for 1- and 3-month post-operative clinical visits were examined for passive extension and active flexion by members of the clinical staff. Only patients undergoing primary DB reconstruction with allograft were included in the analyses. To determine the effects of the modified AM bundle placement on recovery of post-operative ROM, patients undergoing surgery in the 6 months before July 2006 (Group A, n = 50) were compared to patients undergoing surgery in the 6 months after July 2006 (Group B, n = 49). RESULTS: A total of 99 patients met the inclusion criteria. More accurate placement of the AM bundle of the ACL was associated with a smaller side-to-side difference in flexion at 1 month (n.s.) and at 3 months (3° reduction, p < 0.03) after surgery. There was no effect on extension (n.s.) CONCLUSION: More anatomic placement of the femoral insertion of the AM bundle was associated with improved knee flexion. The study translates the findings of previous anatomic basic science research to demonstrate improved restoration of normal joint motion. This ideally leads to improved long-term clinical outcomes and maintenance of joint and cartilage health. LEVEL OF EVIDENCE: III.

Exercise-induced Pediatric Lumbar Paravertebral Compartment Syndrome: A Case Report.

Acute compartment syndrome is described as an elevation of interstitial pressure in a closed fascial compartment that can lead to damage of the microvasculature with subsequent tissue necrosis. Although paravertebral compartment syndrome has been described there is no case of paravertebral compartment syndrome that has been described in the pediatric population. We report the case of a 17-year-old boy who presented at our institution with severe, acute-onset low back pain that started shortly after a rigorous 4-hour workout. He was diagnosed with acute lumbar paravertebral compartment syndrome and underwent emergent fasciotomy with 2 more debridements.

Global discrepancies in the diagnosis, surgical management, and investigation of femoroacetabular impingement.

PURPOSE: The purpose of this study was to review the global pattern of surgical management of femoroacetabular impingement (FAI), particularly in diagnosis, outcome measurement, and management. METHODS: We performed a systematic search in duplicate for surgical studies addressing FAI published up to June 2013. Study parameters, including sample size, study location, surgical intervention technique, diagnostic imaging, outcome measures used, sex distribution, and level of evidence, were obtained. The number of trials and cumulative sample size were analyzed. The surgical interventions, sex distribution, outcome measures, and diagnostic imaging used were compared between geographic regions. RESULTS: We identified 105 studies reporting surgical interventions for FAI. Most studies were completed in North America (52 studies, 3,629 patients) and in Europe (44 studies, 3,745 patients). Asia (3 studies, 49 patients) and Oceania (6 studies, 394 patients) had smaller contributions. There were no studies from South America or Africa. Most research performed in North America, Europe, and Oceania investigated arthroscopic FAI surgery (55% of studies) followed by surgical dislocation (33%), and miniopen (15%) and combined approaches (8%). Methods of diagnosis were consistent worldwide, with radiography being the mainstay of diagnosis (84% of studies). Case series were the most common type of study globally (75% of studies). Outcome measures varied by region; Harris hip scores were most common in North America, Oceania, and Asia, whereas Non-Arthritic Hip Scores and Western Ontario McMaster scores predominated in Europe. CONCLUSIONS: Global surgical trends for FAI show a predominance of North American and European studies, studies of lower level evidence, and inconsistent use of outcome measures. However, patterns of diagnostic imaging, sex proportions, and predominance of arthroscopic techniques are consistent worldwide. Future research should focus on development of reliable validated outcome measures and international collaboration to conduct high-quality research and improve our understanding of FAI diagnosis and management. LEVEL OF EVIDENCE: Level IV, systematic review of Level I-IV studies.

What is the rate of methicillin-resistant Staphylococcus aureus and Gram-negative infections in open fractures?

BACKGROUND: There have been increasing reports of methicillin-resistant Staphylococcus aureus (MRSA) infections in the community, but it is unclear whether infectious organisms in open fracture infections have changed and if our current regimen of antibiotic prophylaxis is therefore obsolete. QUESTIONS/PURPOSES: We determined the recent incidence of MRSA and Gram-negative organism infections after open fractures. METHODS: We performed a retrospective cohort study on 189 patients with 202 open fractures treated from 2009 to 2010. During the followup, patients were evaluated for signs of infection using the Centers for Disease Control and Prevention criteria. We determined the organisms using routine microbiology culture. The minimum followup was 3 months (median, 47 months; range, 3-108 months). RESULTS: Of the 202 open fractures, 20 (10%) developed infections. The most common organism was Staphylococcus, whereas five (25%) of those infected were positive for MRSA, and 11 (55%) of those with infection were cultured for at least one Gram-negative organism. Six (30%) open fractures had infections that grew out multiple organisms. The incidence of MRSA infections in our open fracture population was 2.5%. CONCLUSIONS: There is a high incidence of MRSA and Gram-negative infections after open fractures, which may indicate that current antibiotic regimens need to be changed. LEVEL OF EVIDENCE: Level IV, retrospective case-series. See the Guidelines for Authors for a complete description of levels of evidence.

International Orthopaedic Volunteer Opportunities in Low and Middle-Income Countries.

ABSTRACT: Globally, the burden of musculoskeletal conditions continues to rise, disproportionately affecting low and middle-income countries (LMICs). The ability to meet these orthopaedic surgical care demands remains a challenge. To help address these issues, many orthopaedic surgeons seek opportunities to provide humanitarian assistance to the populations in need. While many global orthopaedic initiatives are well-intentioned and can offer short-term benefits to the local communities, it is essential to emphasize training and the integration of local surgeon-leaders. The commitment to developing educational and investigative capacity, as well as fostering sustainable, mutually beneficial partnerships in low-resource settings, is critical. To this end, global health organizations, such as the Consortium of Orthopaedic Academic Traumatologists (COACT), work to promote and ensure the lasting sustainability of musculoskeletal trauma care worldwide. This article describes global orthopaedic efforts that can effectively address musculoskeletal care through an examination of 5 domains: clinical care, clinical research, surgical education, disaster response, and advocacy.

Anatomic single- and double-bundle anterior cruciate ligament reconstruction flowchart.

Anatomy is the foundation of orthopaedic surgery, and the advancing knowledge of the anterior cruciate ligament (ACL) anatomy has led to the development of improved modern reconstruction techniques that approach the anatomy of the native ACL. Current literature on the anatomy of the ACL and its reconstruction techniques, as well as our surgical experience, was used to develop a flowchart that can aid the surgeon in performing anatomic ACL reconstruction. We define anatomic ACL reconstruction as the functional restoration of the ACL to its native dimensions, collagen orientation, and insertion sites. A guideline was written to accompany this flowchart with more detailed information on anatomic ACL reconstruction and its pitfalls, all accompanied by relevant literature and helpful figures. Although there is still much to learn about anatomic ACL reconstruction methods, we believe this is a helpful document for surgeons. We continue to modify the flowchart as more information about the anatomy of the ACL, and how to more closely reproduce it, becomes available.

"Anatomic" anterior cruciate ligament reconstruction: a systematic review of surgical techniques and reporting of surgical data.

PURPOSE: The aim of this systematic review was to evaluate studies published on anatomic double-bundle anterior cruciate ligament (ACL) reconstruction. METHODS: A systematic electronic search was performed by use of the Medline and Embase databases. Studies that were published from January 1995 to April 2009 were included. The selection criteria were studies that reported on a surgical technique for "anatomic double-bundle ACL reconstruction" on skeletally mature living human subjects and were written in English. Data collected and analyzed included a variety of surgical data. Tables were created to provide an overview of surgical techniques for anatomic ACL reconstruction. RESULTS: Seventy-four studies were included in this review. Some surgical factors were adequately reported in the majority of the articles: visualizing the native ACL insertion sites, placing the tunnels in the footprint, graft type, and fixation method. However; ACL insertion site measurement, femoral intercondylar notch measurement, individualization of surgery, and intraoperative/postoperative imaging were poorly reported. The most variety was seen in knee flexion angle during femoral tunnel drilling and tensioning pattern of the grafts. CONCLUSIONS: For most surgical data, there was a gross under-reporting of specific operative technique data. We believe that the details of an "anatomic" operative technique are crucial for the valid interpretations of the outcomes. Thus we encourage authors to report their surgical technique in a specific and standardized fashion.

The anatomic approach to primary, revision and augmentation anterior cruciate ligament reconstruction.

The anatomic approach is gaining popularity in anterior cruciate ligament (ACL) reconstruction. It is predominantly applied during primary ACL reconstruction. However, following the same principles as during primary surgery, the anatomic approach can also be applied during revision and augmentation surgery. This paper discusses the surgical technique for anatomic single- and double-bundle ACL reconstruction, for primary, revision and augmentation surgery. During primary reconstruction, the choice for single- or double-bundle reconstruction and graft size should be based on ACL insertion site and femoral intercondylar notch dimensions. When there is an isolated anteromedial (AM) or posterolateral (PL) bundle rupture, augmentation of a single-bundle can be performed while protecting the integrity of the intact bundle. Especially during revision surgery, there are many potential situations the surgeon may encounter when entering the knee. There are multiple possible solutions for all of these different situations leading to an anatomic end result. Three-dimensional computed tomography (CT) scanning should be used to evaluate the current tunnel positions and determine the operative strategy.

Is There a Difference in Graft Motion for Bone-Tendon-Bone and Hamstring Autograft ACL Reconstruction at 6 Weeks and 1 Year?

BACKGROUND: Bone-patellar tendon-bone (BTB) grafts are generally believed to heal more quickly than soft tissue grafts after anterior cruciate ligament (ACL) reconstruction, but little is known about the time course of healing or motion of the grafts within the bone tunnels. HYPOTHESIS: Graft-tunnel motion will be greater in hamstring (HS) grafts compared with BTB grafts and will be less at 1 year than at 6 weeks. STUDY DESIGN: Controlled laboratory study. METHODS: Twelve patients underwent anatomic single-bundle ACL reconstruction using HS or BTB autografts (6 per group) with six 0.8-mm tantalum beads embedded in each graft. Dynamic stereo x-ray images were collected at 6 weeks and 1 year during treadmill walking and stair descent and at 1 year during treadmill running. Tibiofemoral kinematics and bead positions were evaluated. Graft-tunnel motion was based on bead range of motion during the loading response phase (first 10%) of the gait cycle. RESULTS: During treadmill walking, there was no difference in femoral tunnel or tibial tunnel motion between BTB or HS grafts at 6 weeks (BTB vs HS: 2.00 ± 1.05 vs 1.25 ± 0.67 mm [femoral tunnel]; 1.20 ± 0.63 vs 1.27 ± 0.71 mm [tibial tunnel]), or 1 year (BTB vs HS: 1.62 ± 0.76 vs 1.08 ± 0.26 mm [femoral tunnel]; 1.58 ± 0.75 vs 1.68 ± 0.53 mm [tibial tunnel]). During stair descent, there was no difference in femoral or tibial tunnel motion between BTB and HS grafts at 6 weeks or 1 year. With running, there was no difference between graft types at 1 year. For all results, P values were > .05. Knee kinematics were consistent with the literature. CONCLUSION: During walking and stair descent, ACL reconstruction using suspensory fixation yielded no difference between graft types in femoral or tibial tunnel motion at 6 weeks or 1 year. All subjects were asymptomatic with knee kinematics similar to that of the literature. The significance of persistent, small (1 to 3 mm) movements at 1 year for healing or graft performance is unknown. CLINICAL RELEVANCE: These study results may have significant implications for graft choice, rehabilitation strategies, and timing for return to sports.

The timing of definitive fixation for major fractures in polytrauma--a matched-pair comparison between a US and European level I centres: analysis of current fracture management practice in polytrauma.

PURPOSE: Early definitive stabilisation is usually the treatment of choice for major fractures in polytrauma patients. Modifications may be made when patients are in critical condition, or when associated injuries dictate the timing of surgery. The current study investigates whether the timing of fracture treatment is different in different trauma systems. MATERIALS AND METHODS: Consecutive patients treated a Level I trauma centre were documented (Group US) and a matched-pair group was gathered from the German Trauma Registry (Group GTR). INCLUSION CRITERIA: New Injury Severity Score (NISS)>16, >2 major fractures and >1 organ/soft tissue injury. The timing and type of surgery for major fractures was recorded, as were major complications. RESULTS: 114 patients were included, n=57 Group US (35.1% F, 64.9% M, mean age: 44.1 yrs±16.49, mean NISS: 27.4±8.65, mean ICU stay: 10±7.49) and n=57 Group GTR (36.8% F, 63.1% M, mean age: 41.2 yrs±15.35, mean NISS: 29.4±6.88, mean ICU stay: 15.6±18.25). 44 (57.1%) out of 77 fractures in Group US received primary definitive fracture fixation compared to 61 (65.5%) out of 93 fractures in Group GTR (n.s.). The average duration until definitive treatment was comparable in all major extremity fractures (pelvis: 5 days±2.8 Group US, 7.1 days±9.6 Group GTR (n.s.), femur: 7.9 days±8.3 Group US, 5.5 days±7.9 (n.s.), tibia: 6.2 days±5.6 Group US, 6.2 days±9.1 Group GTR (n.s.), humerus: 5 days±3.7 Group US, 6.6 days±6.1 Group GTR (n.s.), radius: 6 days±4.7 Group US, 6.1 days±8.7 Group GTR (n.s.). CONCLUSION: The current matched-pair analysis demonstrates that the timing of initial definitive fixation of major fractures is comparable between the US and Europe. Certain fractures are stabilised internally in a staged fashion regardless the trauma system, thus discounting previous apparent contradictions.

Anatomic Double-bundle ACL Reconstruction.

Rupture of the anterior cruciate ligament (ACL) is one of the most frequent forms of knee trauma. The traditional surgical treatment for ACL rupture is single-bundle reconstruction. However, during the past few years there has been a shift in interest toward double-bundle reconstruction to closely restore the native ACL anatomy. This paper evaluates the basis for double-bundle ACL reconstruction including anatomy, biomechanics and kinematics, describes our surgical technique, and discusses why we prefer anatomic double-bundle ACL reconstruction, as well as its outcome, the choices, and the controversies of double-bundle ACL reconstruction. Pitfalls of traditional ACL surgery are also discussed, the recognition of which is the key to performing anatomic ACL reconstruction.