Long-term patient-centred outcomes of periacetabular osteotomy in a large consecutive series.

Aims: We assessed the long-term outcomes of a large cohort of patients who have undergone a periacetabular osteotomy (PAO), and sought to validate a patient satisfaction questionnaire for use in a PAO cohort. Methods: All patients who had undergone a PAO from July 1998 to February 2013 were surveyed, with several patient-reported outcome measures (PROMs) and radiological measurements of preoperative acetabular dysplasia and postoperative correction also recorded. Patients were asked to rate their level of satisfaction with their operation in achieving pain relief, restoration of activities of daily living, ability to perform recreational activity, and their overall level of satisfaction with the procedure. Results: A total of 143 PAOs were performed between 1998 and 2013. Of those, 90 postoperative surveys were returned. Only 65 patients (73 hips) had both pre- and postoperative radiographs available for measurement. The mean time to follow-up was 15 years (6.5 to 20). Most patients were female (91%), with a mean age of 26.4 years (14.9 to 48.3) at the time of their surgery. A statistically significant improvement in radiological correction was detected in all hips (p < 0.001). A total of 67 patients (92.3%) remained either very satisfied or satisfied with their PAO. The internal consistency of the patient satisfaction questionnaire, measured using Cronbach's α, ranged from 0.89 to 0.94 indicating 'good' to 'excellent' reliability. Conclusion: Outcomes of importance to patients undergoing a PAO include several key domains: pain relief, improve activities of daily living, and improve recreational ability. Our study demonstrates high rates of long-term patient satisfaction in all domains, and found the patient satisfaction questionnaire to be a valid and reliable instrument for use in this cohort.

Myopic regression and recurrent Salzmann nodule degeneration after laser in situ keratomileusis in Ehlers Danlos Syndrome.

PURPOSE: We describe the first case of Ehlers Danlos Syndrome (EDS) reported in the English language ophthalmic literature to have undergone Laser In Situ Keratomileusis (LASIK) surgery. OBSERVATIONS: We review our patient's specific postoperative complications of myopic regression, Salzmann nodular degeneration, and dry eye syndrome, as well as the risks and consequences of performing LASIK on patients with this collagen disorder. CONCLUSIONS AND IMPORTANCE: Refractive errors may prompt EDS patients to seek laser vision correction, placing them at increased risk for complications such as myopic regression, keratectasia, and dry eye syndrome. Aberrant wound healing and collagen dysfunction may have influenced our patient's myopic regression and Salzmann nodule degeneration post-LASIK. Currently, EDS is considered a relative contraindication in LASIK due to a presumed higher risk of postoperative keratectasia; however, we believe it is possible that not all forms of EDS need to be an absolute contraindication to LASIK. More research is warranted to determine preoperative risk stratification for laser vision surgery in each subtype of EDS.

Human allograft refractive lenticular implantation for high hyperopiccorrection.

Hyperopia is a common form of refractive error in the United States. Many refractive errors can be treated with refractive surgery methods such as laser in-situ keratomileusis and photorefractive keratectomy; however, in patients with large degrees of hyperopia (≥+5.0 diopters [D]), these surgical methods are limited because of higher rates of refractive regression. Lenticule Intrastromal Keratoplasty (LIKE) is a surgical procedure that can be used to correct refractive errors in patients with high hyperopia. The authors describe the first intrastromal implantation of an allograft lenticule performed for the primary correction of hyperopia in the United States, and demonstrate that LIKE is potentially an effective procedure for the correction of high hyperopia. Mechanisms for achieving the intended refractive correction and the complications our patient experienced, including epithelial ingrowth and flap necrosis, are discussed.

Comparison of FDA-Reported Visual and Refractive Outcomes of the Toric ICL Lens, SMILE, and Topography-Guided LASIK for the Correction of Myopia and Myopic Astigmatism.

PURPOSE: To compare U.S. Food and Drug Administration (FDA)-reported visual and refractive outcomes following surgical correction of myopia and myopic astigmatism using the Visian Toric Implantable Collamer Lens (STAAR Surgical, Monrovia, CA) (Toric ICL), small incision lenticule extraction (SMILE), and topography-guided laser in situ keratomileusis (TG-LASIK). METHODS: FDA summary of safety and effectiveness data (SSED) were analyzed for each of the three platforms. Primary outcomes measured were efficacy, safety, stability, and accuracy of refractive correction. Stratified mean refractive spherical equivalent (MRSE) data were assessed. RESULTS: One hundred twenty-four Toric ICL patients (210 eyes), 357 SMILE patients (357 eyes), and 212 TG-LASIK patients (249 eyes) were included. SMILE eyes had a significant improvement in postoperative uncorrected distance visual acuity with respect to preoperative corrected distance visual acuity from 3 to 12 months (P < .001), whereas TG-LASIK had no further improvement from 3 to 12 months (P = .79). For preoperative MRSE greater than 10.00 diopters (D), there was a significant difference in the percentage of eyes achieving postoperative MSRE within ±0.50 D between Toric ICL (66%) and SMILE (100%) (P < .001). SMILE was consistently more accurate than Toric ICL for cylinder within ±0.25 D (P < .001), ±0.50 D (P < .001), and ±1.00 D (P = .0014). CONCLUSIONS: All three platforms analyzed in this study had excellent efficacy, safety, stability, and accuracy. Stratified analysis revealed that SMILE may be comparable to Toric ICL for patients with high myopia or myopic astigmatism, and SMILE may have a longer visual recovery compared to TG-LASIK than previously indicated. [J Refract Surg. 2019;35(11):699-706.].

Impact of web-based clinical practice guidelines on paediatric fracture clinics.

BACKGROUND: In an effort to standardize management and reduce over-treatment of uncomplicated paediatric fractures, the Victorian Pediatric Orthopaedic Network and the Royal Children's Hospital, Melbourne, created publically available web-based paediatric fracture pathways. The aim of this study was to determine the impact of web-based fracture pathways on the clinic volume at a tertiary-care paediatric fracture clinic. METHODS: A comparative retrospective review was performed at a large, urban, tertiary-care children's hospital. Fracture clinic data from two 12-week periods before and after implementation of the fracture pathways were compared. For each study period, data collected included: total number of emergency department visits, number of fracture clinic visits, number of fracture clinic visits for patients that presented with upper extremity fractures for which web-based fracture pathways were available, number of radiology department visits for X-rays, and number of fracture clinic visits for patients requiring orthopaedic intervention in the operating room (closed or open reductions). RESULTS: The number of fracture clinic visits for patients with upper extremity fractures decreased 12% post-pathway implementation, from 954 visits to 842 visits. The number of radiology department visits for patients with upper extremity fractures decreased 24% post-pathway implementation, from 714 to 544 visits. CONCLUSION: The implementation of web-based fracture pathways for upper extremity paediatric fractures was associated with a decrease in clinic resource utilization at a tertiary-care children's hospital.

Acetabular coverage after innominate osteotomy.

A criticism of innominate osteotomy is that it may cause relative acetabular retroversion, predisposing to osteoarthritis. This study was designed to address that hypothesis. We had access to standing hip radiographs of 30 patients (36 hips) who had undergone open reduction and innominate osteotomy for late presenting developmental hip dislocation at least 40 years earlier. A single independent investigator used the validated method of Hefti (1995) to measure anterior and posterior acetabular coverage, contact area, and version. Ten operated hips had advanced osteoarthritis obscuring acetabular landmarks. Twenty-six operated hips were readable despite some radiographs showing signs of mild-to-moderate osteoarthritis. Twenty contralateral hips without developmental hip dysplasia formed a comparison group and 21 age-matched and sex-matched "normal hips" were used as a control. A significant difference between the groups was found for contact area (P < 0.001). There was no significant difference between the other 3 outcomes: anterior coverage (P = 0.509), posterior coverage (P = 0.135), and anteversion (P = 0.845). Anteversion in hips with a good outcome after innominate osteotomy and open reduction was not different to a control group of radiographically normal hips. The early osteoarthritic changes seen in these hips may relate to decreased contact area compared with the normal population. In this series, innominate osteotomy before the age of 5 years did not consistently cause acetabular retroversion that persisted into adulthood. Apparently unaffected hips contralateral to the dislocated side display reduced contact area relative to controls indicating probable occult dysplasia.

Avulsion of the perforating branch of the peroneal artery secondary to an ankle sprain: a cause of acute compartment syndrome in the leg.

In this report, we describe the case of an adult male who developed an acute compartment syndrome localized to the anterior compartment of the leg following an ankle sprain. Compartment syndrome in association with ankle sprain is unusual, and has been previously described in association with avulsion of the perforating peroneal artery. Because of the potential for severe morbidity, we feel that it is important to make foot and ankle surgeons aware of this unusual injury.