Is an Orthopaedic Surgery Resident's Previous Case Experience Associated with Success of Initial Treatment of Pediatric Forearm Fractures?

Redisplacement and subsequent intervention are common for pediatric forearm fractures. We investigated associations between the success of closed reduction and the treating provider's experience. We identified patients aged 4-16 years with forearm fractures treated by closed reduction and cast immobilization. Clinical data and radiographs of 130 patients treated by 30 residents were reviewed to determine the treating resident's pediatric forearm fracture reduction experience and the incidence of initial treatment failure (ITF). ITF was defined as subsequent intervention before union or malunion. ITF occurred in 32 of 130 patients (25%), comprising 12 of 23 patients (52%) treated by residents with no previous experience and 20 of 107 patients (19%) treated by residents who had logged ≥ 1 previous reduction (odds ratio, 4.7). ITF was more likely to occur in pediatric forearm fractures treated by residents with no previous forearm reduction experience compared with those performed by residents who had such experience. Level of Evidence: Level III, therapeutic. (Journal of Surgical Orthopaedic Advances 32(1):032-035, 2023).

Characterization of lipomatous tumors with high-resolution 1H MRS at 17.6T: Do benign lipomas, atypical lipomatous tumors and liposarcomas have a distinct metabolic signature?

Background: Distinguishing between some benign lipomas (BLs), atypical lipomatous tumors (ALTs), and dedifferentiated liposarcomas (DDLs) can be challenging due to overlapping magnetic resonance imaging characteristics, and poorly understood molecular mechanisms underlying the malignant transformation of liposarcomas. Purpose: To identify metabolic biomarkers of the lipomatous tumor spectrum by examining human tissue specimens using high-resolution 1H magnetic resonance spectroscopy (MRS). Materials and methods: In this prospective study, human tissue specimens were obtained from participants who underwent surgical resection for radiologically-indeterminate lipomatous tumors between November 2016 and May 2019. Tissue specimens were obtained from normal subcutaneous fat (n=9), BLs (n=10), ALTs (n=7) and DDLs (n=8). Extracts from specimens were examined with high-resolution MRS at 17.6T. Computational modeling of pattern recognition-based cluster analysis was utilized to identify significant differences in metabolic signatures between the lipomatous tumor types. Results: Significant differences between BLs and ALTs were observed for multiple metabolites, including leucine, valine, branched chain amino acids, alanine, acetate, glutamine, and formate. DDLs were distinguished from ALTs by increased glucose and lactate, and increased phosphatidylcholine. Multivariate principal component analysis showed clear clustering identifying distinct metabolic signatures of the tissue types. Conclusion: Metabolic signatures identified in 1H MR spectra of lipomatous tumors provide new insights into malignant progression and metabolic targeting. The metabolic patterns identified provide the foundation of developing noninvasive MRS or PET imaging biomarkers to distinguish between BLs, ALTs, and DDLs.

Do contrast-enhanced and advanced MRI sequences improve diagnostic accuracy for indeterminate lipomatous tumors?

PURPOSE: Benign, intermediate-grade and malignant tumors sometimes have overlapping imaging and clinical characteristics. The purpose of this study was to evaluate the added value of contrast-enhanced sequences (dynamic contrast enhancement (DCE)), diffusion-weighted imaging (DWI), and chemical shift imaging (CSI) to noncontrast MRI sequences for the characterization of indeterminate lipomatous tumors. MATERIALS AND METHODS: Thirty-two consecutive patients with histologically proven peripheral lipomatous tumors were retrospectively evaluated. Two musculoskeletal radiologists recorded the MRI features in three sessions: (1) with noncontrast T1-weighted and fluid-sensitive sequences; (2) with addition of static pre- and post-contrast 3D volumetric T1-weighted sequences; and (3) with addition of DCE, DWI, and CSI. After each session, readers recorded a diagnosis (benign, intermediate/atypical lipomatous tumor (ALT), or malignant/dedifferentiated liposarcoma (DDL)). Categorical imaging features (presence of septations, nodules, contrast enhancement) and quantitative metrics (apparent diffusion coefficient values, CSI signal loss) were recorded. RESULTS: For 32 tumors, the diagnostic accuracy of both readers did not improve with the addition of contrast-enhanced sequences, DWI, or CSI (53% (17/32) session 1; 50% (16/30) session 2; 53% (17/32) session 3). Noncontrast features, including thick septations (p = 0.025) and nodules ≥ 1 cm (p < 0.001), were useful for differentiating benign tumors from ALTs and DDLs, as were DWI (p = 0.01) and CSI (p = 0.009) metrics. CONCLUSION: The addition of contrast-enhanced sequences (static, DCE), DWI, and CSI to a conventional, noncontrast MRI protocol did not improve diagnostic accuracy for differentiating benign, intermediate-grade, and malignant lipomatous tumors. However, we identified potentially useful imaging features by DCE, DWI, and CSI that may help distinguish these entities.

Preoperative Considerations for Teenagers Undergoing Orthopaedic Surgery: VTE Prevention, Mental Health Assessment, Vaping, and Drug Addiction.

INTRODUCTION: Adolescents undergoing pediatric orthopaedic surgery typically experience an uncomplicated postoperative course. However, adolescence represents a unique transition period from pediatric to adult physiology. As a result, the astute pediatric orthopaedic surgeon will be aware of unique medical and social scenarios which are relevant to adolescents during the perioperative course including the risk of venous thromboembolism (VTE), prevalence of mental health conditions, and rising use of electronic cigarettes or "vaping" to consume nicotine and cannibas. DISCUSSION: Adolescents are at a greater risk of VTE after pediatric orthopaedic surgery. In particular, adolescent females with a family history of blood clotting disorders and those with a change in mobility after surgery should be considered for prophylaxis. The prevalence of adolescent mental health conditions including anxiety, depression, and behavioral issues is increasing in the United States. Higher levels of preoperative anxiety and the presence of mental health pathology are associated with slower recovery, higher levels of postoperative pain, and the increased likelihood for chronic pain. Several quick screening instruments are available to assess adolescents for preoperative anxiety risk, including the Visual Analogue Scale for Anxiety or the Amsterdam Perioperative Anxiety Information Scale. Unfortunately, electronic cigarettes have become increasingly popular for the consumption of nicotine and cannabis among adolescents. Preoperative use of combustive cigarettes (nicotine/cannabis) represents perioperative risks for induction/anesthesia, postoperative pain, and analgesia requirements and issues with delayed wound and fracture healing. CONCLUSIONS: VTE, underlying mental health conditions, and usage of nicotine and cannabis are clear detriments to the recovery and healing of adolescent patients following orthopaedic surgery. Therefore, standardized screening for adolescents before orthopaedic surgery is indicated to identify perioperative risk factors which have negative impacts on functional outcomes.

Knee Scooter-Related Injuries: A Survey of Foot and Ankle Orthopedic Surgeons.

BACKGROUND: Knee scooters ("scooters") are a commonly used device to facilitate postoperative adherence to weightbearing restrictions. Although high rates of falls have been reported, little is known about injuries related to scooter use. METHODS: We analyzed survey responses from 316 of 2046 members (15%) of the American Orthopaedic Foot & Ankle Society in May-June 2019 describing (1) frequency of scooter recommendation; (2) indications for which they recommended scooters; (3) characteristics of patients for whom they recommended scooters; (4) prevalence, anatomic locations, mechanisms, and sequelae of scooter-related injuries; and (5) characteristics of patients with scooter-related injuries. Descriptive statistics and χ2 goodness-of-fit tests were performed (alpha = .05). RESULTS: Mean frequency with which respondents recommended scooters in particular was 69%. Respondents most often recommended scooters after hindfoot arthrodesis (97% [305/316]), ankle arthrodesis (96% [302/316]), and for total nonweightbearing (64% [202/316]) and to patients who were overweight (vs obese) or aged 45-75 years. Mean prevalence of scooter-related injuries was 2.5%. The most common injury mechanism was making a sharp turn (reported by 62% [103/166]). Thirty-four percent (56/166) of respondents with injured patients said patients underwent surgery to treat scooter-related injuries. Patients with scooter-related injuries were more often women, >44 years old, obese, and sedentary. CONCLUSION: Scooters were commonly recommended postoperatively, most often for total nonweightbearing after hindfoot or ankle arthrodesis, and most often in overweight adults or those aged 45-75 years. Mean reported prevalence of scooter-related injuries was 2.5%. Female sex, older age, obesity, and sedentary lifestyle were associated with scooter-related injury. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Surgical Hip Dislocation Using the Modified Hardinge Approach for Excision of Osteocartilaginous Lesions of the Acetabulum and Femoral Neck in an Adult: A Case Report.

CASE: A 20-year-old woman presented with hip pain related to an osteocartilaginous lesion arising within the cotyloid fossa. She also had a lesion along the inferior femoral neck. Resection of both lesions was performed with surgical hip dislocation through a modified Hardinge approach. CONCLUSIONS: This unusual location for an osteocartilaginous lesion can lead to substantial pain and disability. Surgical dislocation through a modified Hardinge approach is an excellent option to concurrently resect these benign lesions of the cotyloid fossa and femoral neck without the need for trochanteric osteotomy.

Treatment of a Pediatric T-type Intercondylar Humerus Fracture With Hybrid Percutaneous Pinning and External Fixation.

T-type intercondylar fractures of the distal humerus are rare injuries in skeletally immature patients. Few studies are available to guide the treatment of these injuries. Small case series and expert recommendations suggest superiority of the open approach for direct reduction of the articular surface. This approach poses risks of vascular compromise and elbow stiffness. However, success with percutaneous intercondylar screw fixation has been described for simple split patterns. The authors present a case that illustrates a novel percutaneous technique to treat this fracture type. A healthy 8-year-old boy sustained a T-type intercondylar fracture of the distal humerus (AO 13-C1). Excellent reduction was noted after closed reduction and crossed percutaneous pinning. Compression was applied across the pins through a small external fixator bar to address the intercondylar split component. At the 6-week postoperative clinic visit, the pins and fixator were removed uneventfully, and normal healing with full range of elbow motion was noted. This case report describes a simple, minimally invasive technique to treat uncomplicated T-type intercondylar fractures of the distal humerus in skeletally immature patients. Practitioners familiar with percutaneous fixation of supracondylar fractures can easily perform this technique. The described technique spares an open dissection and avoids permanent implants around the joint. Further multicenter research is warranted to determine the long-term outcomes and safety of the described technique. [Orthopedics. 2017; 40(6):e1096-e1098.].

Evaluation and management of the pregnant patient with suspected primary musculoskeletal tumor or metastatic carcinoma to bone.

Primary musculoskeletal cancer and metastatic disease to bone in pregnant patients presents major treatment challenges. Although uncommon, musculoskeletal malignancies in pregnant women have been reported. When diagnosing and treating these patients, the mother's health must be managed appropriately while ensuring that fetal development is not deleteriously affected. Extensive radiographic imaging and more advanced techniques are often necessary to fully characterize the extent of disease. When possible, magnetic resonance imaging should be used instead of computed tomography to limit exposure of the conceptus to radiation. If treatment is needed, therapeutic radiation, chemotherapy, and surgery should be considered. Surgical resection is the foundation of treatment of early-stage primary bone tumors and soft-tissue sarcomas during pregnancy. With surgery, anesthesia and thromboprophylaxis are important considerations. If chemotherapy is required, administration should be avoided in the first trimester to limit harm to the fetus. Therapeutic radiation should similarly be avoided during the first trimester and often can be postponed until after delivery.