Unilateral versus bilateral reconstructive hip surgery in children with cerebral palsy: A survey of pediatric orthopedic surgery practice and decision-making.

Purpose: This study explored whether surgeons favor unilateral or bilateral reconstructive hip surgery in children with cerebral palsy who have unilateral hip displacement. Methods: An invitation to participate in an anonymous, online survey was sent to 44 pediatric orthopedic surgeons. The case of an 8 year old at Gross Motor Function Classification System level IV with migration percentages of 76% and 22% was described. Surgeons selected their surgical treatment of choice and provided their rationale. Respondents were also asked to list and rank radiographic parameters used for decision-making and multidisciplinary team members involved in decision-making. Results: Twenty-eight orthopedic surgeons from nine countries with a mean 21.3 years (range, 5-40 years) of experience completed the survey. A "bilateral VDROs with a right pelvic osteotomy (PO) was selected by 68% (19/28) of respondents; risk of contralateral subluxation (9/19; 47%) and maintaining symmetry (7/19; 37%) were the most common rationales for bilateral surgery. The remaining 32% (9/28) chose a 'right VDRO with a right PO'" with most of these (8/9; 89%) stating the left hip was sufficiently covered. Of 31 radiographic parameters identified, migration percentage, acetabular angle/index, Shenton line, neck shaft angle, and presence of open/closed triradiate growth plates were the most common. Physical therapists (68%) and physiatrists (43%) were most likely to be involved in pre-operative surgical consultation. Conclusion: There is a lack of agreement on management of the contralateral hip in children with unilateral hip displacement. Further studies comparing patient important outcomes following unilateral and bilateral surgery are required. Level of Evidence: V.

Arthroscopic rotator cuff repair without antibiotic prophylaxis does not increase the infection rate.

PURPOSE: Rotator cuff repair is a commonly performed shoulder procedure. In the past 20 years, there has been a shift from mini-open towards arthroscopic repair, and many units exclusively use arthroscopic techniques for rotator cuff surgery. The aim of this study was to find out whether withholding antibiotics had any effect on the infection rate in patients undergoing arthroscopic rotator cuff repair. METHODS: A retrospective analysis of 336 consecutive patients with an arthroscopic rotator cuff repair (RCR) and a minimum 2-year follow-up was performed. The control group received prophylactic antibiotics (controls) and the cases of interest did not receive perioperative antibiotics. A power analysis was performed according to literature regarding infection proportions. The primary outcome was an infection (superficial or deep) in the operated shoulder. RESULTS: There were 336 patients who underwent a RCR. Two-hundred-and-twelve in the control group and 124 in the non-antibiotic group. Average ages were 57.3 ± 12.5 and 56.8 ± 13.2 years in each group, respectively. The follow-up times ranged from 24 to 76 months. Equipment used and surgical techniques were identical, only operating times were statistically different between the groups (control 77.2 ± 41.3 min versus no antibiotic cases 52.9 ± 16.7 min) (p = 0.000009). There was no recorded infection in either group. CONCLUSION: Infection following arthroscopic surgery is uncommon. Small incisions, constant lavage with saline, minimal hardware insertion and short operating times all combine to minimise the risks. Current results point towards no detriment in withholding prophylactic antibiotics in low-risk patients undergoing routine rotator cuff repair surgery. Therefore, judicious use of prophylactic antibiotics in patients undergoing this procedure is advocated to prevent potential harm to those it is administered to. LEVEL OF EVIDENCE: Level III.

Extra-articular arthroscopic release of lateral epicondylitis: a prospective study.

Background: Operative management of lateral epicondylitis can be managed with percutaneous, arthroscopic, or open surgical release. Extraarticular arthroscopic release is a new technique, and no study has compared its outcomes and risk profile. Methods: A 26-patient cohort was reviewed before and after extraarticular arthroscopic release, which was performed by the senior author. The Mayo Elbow Performance Scores were used as a functional outcome score and obtained via a phone interview. Results were analyzed using a paired t-test with a statistical significance set at P < .05. Results: Of the 26 patients, 10 were being treated under workers compensation. Preoperative Mayo Elbow Performance Score was 47.5, and the postoperative score was 90.2 with a significant difference of 42.7 (P value = .05). The workers compensation group scored 13.3 points lower postoperatively than the remainder of patients, which was shown to also be significant with a P value of .002. Discussion and Conclusion: The advantage of extraarticular arthroscopic release was better visualization of affected structures, which improved accuracy of debridement, and a small capsulotomy, which decreased the risk of a transient radial nerve palsy. Overall, extraarticular arthroscopic results were found to be good and comparable to the results of other operative techniques with the added advantage of a lower risk profile.

3D - Printed Patient Specific Instrumentation in Corrective Osteotomy of the Femur and Pelvis: A Review of the Literature.

BACKGROUND: The paediatric patient population has considerable variation in anatomy. The use of Computed Tomography (CT)-based digital models to design three-dimensionally printed patient specific instrumentation (PSI) has recently been applied for correction of deformity in orthopedic surgery. This review sought to determine the existing application of this technology currently in use within paediatric orthopaedics, and assess the potential benefits that this may provide to patients and surgeons. METHODS: A review was performed of MEDLINE, EMBASE, and CENTRAL for published literature, as well as Web of Science and clinicaltrials.gov for grey literature. The search strategy revolved around the research question: "What is the clinical impact of using 3D printed PSI for proximal femoral or pelvic osteotomy in paediatric orthopaedics?" Two reviewers, using predetermined inclusion criteria, independently performed title and abstract review in order to select articles for full text review. Data extracted included effect on operating time and intraoperative image use, as well as osteotomy and screw positioning accuracy. Data were combined in a narrative synthesis; meta-analysis was not performed given the diversity of study designs and interventions. RESULTS: In total, ten studies were included: six case control studies, three case series and a case report. Five studies directly compared operating time using PSI to conventional techniques, with two showing a significant decrease in the number of intraoperative images and operative time. Eight studies reported improved accuracy in executing the surgical plan compared to conventional methods. CONCLUSION: Compared to conventional methods of performing femoral or pelvic osteotomy, use of PSI has led to improved accuracy and precision, decreased procedure times, and decreased intra-operative imaging requirements. Additionally, the technology has become more cost effective and accessible since its initial inception and use.

Are Prophylactic Intravenous Antibiotics Required in Routine Shoulder Arthroscopic Surgery? A Systematic Review of the Literature.

Purpose The purpose of this study was to find out from the literature the difference in infection rates between patients who did and patients who did not receive prophylactic antibiotics in arthroscopic shoulder surgery. Methods We conducted a comprehensive search of the literature using Medline Ovid for prospective studies that looked at infection as the primary outcome following shoulder arthroscopy. The articles were then assessed for study design, outcome, and relevance to the specific question as part of the critical appraisal. Results Eight partially relevant articles were obtained from the search, but there were no prospective studies comparing infection in patients who had prophylactic antibiotics versus those who did not in shoulder arthroscopy. Conclusion No compelling evidence exists on the role of prophylactic antibiotics in preventing infections in shoulder arthroscopy. Level of Evidence Level IV, systematic review of level IV studies.

Distal Humeral Fractures-Current Concepts.

BACKGROUND: Distal humerus fractures constitute 2% of all fractures in the adult population. Although historically, these injuries have been treated non-operatively, advances in implant design and surgical technique have led to improved outcomes following operative fixation. METHODS: A literature search was performed and the authors' personal experiences are reported. RESULTS: This review has discussed the anatomy, classifications, treatment options and surgical techniques in relation to the management of distal humeral fractures. In addition, we have discussed controversial areas including the choice of surgical approach, plate orientation, transposition of the ulnar nerve and the role of elbow arthroplasty. CONCLUSION: Distal humeral fractures are complex injuries that require a careful planned approach, when considering surgical fixation, to restore anatomy and achieve good functional outcomes.

Home therapy pathway - safe and streamlined method of initial management of ankle fractures.

BACKGROUND: Ankle fractures requiring operative fixation often swell up after 24h and surgery during this period is not feasible as there are several associated risks including infection and wound breakdown. The affected limb is kept elevated usually in hospital and once the swelling has sufficiently subsided then the operation takes place. We conducted a study looking at the impact of a home therapy ankle pathway on the length of stay and safety of patients with ankle fractures requiring surgical fixation. METHODS: The length of stay of a control group was studied from December 2009 to March 2010. The home therapy ankle pathway was then introduced in August 2010. If patients could not have their operation within 24h then they were placed in a Plaster of Paris back slab in casualty with the ankle reduced, limb care advice given - elevation, cooling and DVT thromboprophylaxis - and the patient was discharged home on crutches after a slot was determined on the trauma list typically six days later. The patient was also given an emergency contact number in case an untoward event occurred, and they were called at least once during their home stay by hospital staff to ensure all was well. Patients who were unsafe to be discharged on home therapy were admitted. This cohort of patients was studied between August 2010 and December 2011 RESULTS: In the control group, 49 ankle fractures required operative intervention. The mean pre-operative length of stay was 2.88 days and the mean post op length of stay was 5 days. Between August 2010 and December 2011, after implementation of the pathway, 176 ankle fractures requiring operative treatment presented to the orthopaedic department. Of these, 105 were eligible for home therapy on the ankle pathway prior to surgery. The average pre-operative length of stay on the pathway was 0.17 days. The average post op length of stay was 1.72 days (P<0.001 in all modalities). Home therapy was carried out for an average of 6.63 days. Challenges of home therapy included persistent swelling and blistering (11), loss of reduction (4), poor pain management whilst at home (4) and cancellation due to lack of availability of a theatre slot (6). CONCLUSION: With patients in whom it is indicated, the home therapy ankle pathway has proved to be a safe and resource sparing method of managing ankle fractures prior to surgery.

A vast increase in the use of CT scans for investigating occult hip fractures.

BACKGROUND: Early diagnosis in neck of femur fractures has been shown to improve outcome. The National Institute for Clinical Excellence recommends if an occult hip fracture is suspected then an MRI should be performed and if not available within 24h a CT should be considered. At our centre, emergency MRI is rarely available and so CT is commonly used. OBJECTIVES: Our study aims to analyse the trends in CT use over a five year period for the diagnosis of neck of femur fractures. METHODS: Both the number of patients with a hip fracture and those undergoing a CT hip to diagnose an occult injury were identified across two district general hospitals between 2006-2007 and 2010-2011. The time from initial radiograph to CT and initial radiograph to operation were calculated. RESULTS: In 2006-2007, of 547 hip fractures, 20 CT hips were performed and 6 reported as a fractured neck of femur (30%). In 2010-2011, of 499 hip fractures, 239 CT hips were performed and 65 fractures were recognised (27%). The mean time from radiograph until CT scan was 2.0 days in 2007 and 3.2 days in 2011, which was a statistically significant difference (p<0.001). For those diagnosed using a CT scan the mean time from admission X-ray to surgery was 1.2 days in 2007 and 3.6 days in 2011. CONCLUSION: Clinicians are becoming increasingly reliant on CT for the diagnosis of hip fractures with our data suggesting further imaging is one factor that can delay time to diagnosis and theatre.

Eccentric Exercise Protocols for Patella Tendinopathy: Should we Really be Withdrawing Athletes from Sport? A Systematic Review.

The 2007 review by Visnes and Bahr concluded that athletes with patella tendinopathy should be withdrawn from sport whilst engaging in eccentric exercise (EE) rehabilitation programs. However, deprivation of sport is associated with a number of negative psychological and physiological effects. Withdrawal from sport is therefore a decision that warrants due consideration of the risk/benefit ratio. The aim of this study was to determine whether sufficient evidence exists to warrant withdrawal of athletes from sport during an eccentric exercise rehabilitation program. A systematic review of the literature was performed to identify relevant randomised trials. Data was extracted to determine whether athletes were withdrawn from sport, what evidence was presented to support the chosen strategy and whether this affected the clinical outcome. Seven studies were included. None of these reported high quality evidence to support withdrawal. In addition, three studies were identified in which athletes were not withdrawn from sport and still benefited from EE. This review has demonstrated that there is no high quality evidence to support a strategy of withdrawal from sport in the management of patella tendinopathy.

Volar locking plates versus K-wire fixation of dorsally displaced distal radius fractures--a functional outcome study.

BACKGROUND: Fractures of the distal radius are common. As the population of the western world ages, their incidence is set to increase further. There are various methods of treating these fractures, but optimal management remains controversial. In the United Kingdom, the most common surgical treatment of closed distal radius fractures is by Kirschner-wires (K-wires) or volar locking plate. In this study, we compared long-term functional outcomes of volar locking plates with those of K-wires. METHODS: A retrospective comparative study of 71 patients with dorsally displaced distal radius fractures treated contemporaneously in two independent hospitals was performed. One group was treated with a volar locking plate (n = 36) and the other group with manipulation and K-wire fixation (n = 35). There was no difference between the two groups in terms of demographics or grade of fracture. Outcome was measured 15 months to 27 months post surgery using the Disabilities of the Arm, Shoulder and Hand score and the Patient-Rated Wrist Evaluation score. RESULTS: We found no statistical difference between the two groups in the Patient-Rated Wrist Evaluation score or Disabilities of the Arm, Shoulder and Hand score at 1 year to 2 years postsurgery. CONCLUSION: We have been unable to demonstrate a clinically relevant advantage of using volar locking plates over K-wires at 1 year to 2 years postoperatively.