Treatment Strategies and Outcomes for Osteochondritis Dissecans of the Capitellum.

BACKGROUND: The optimum management of osteochondritis dissecans (OCD) of the capitellum is a widely debated subject. PURPOSE: To better understand the efficacy of different surgical modalities and nonoperative treatment of OCD as assessed by radiological and clinical outcomes and return to sports. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review of all treatment studies published between January 1975 and June 2020 was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 76 clinical studies, including 1463 patients, were suitable for inclusion. Aggregate analysis and subgroup analysis of individual patient data were performed to compare the functional and radiographic outcomes between the various nonoperative and surgical treatment options for capitellar OCD. A unified grading system (UGS; grades 1-4) was developed from existing validated classification systems to allow a comparison of patients with similar-grade OCD lesions in different studies according to their treatment. Patient-level data were available for 352 patients. The primary outcome measures of interest were patient-reported functional outcome, range of motion (ROM), and return to sports after treatment. The influences of the capitellar physeal status, location of the lesion, and type of sports participation were also assessed. Each outcome measure was evaluated according to the grade of OCD and treatment method (debridement/microfracture, fragment fixation, osteochondral autograft transplantation [OATS], or nonoperative treatment). RESULTS: No studies reported elbow scores or ROM for nonoperatively treated patients. All surgical modalities resulted in significantly increased postoperative ROM and elbow scores for stable (UGS grades 1 and 2) and unstable lesions (UGS grades 3 and 4). There was no significant difference in the magnitude of improvement or overall scores according to the type of surgery for stable or unstable lesions. Return to sports was superior with nonoperative treatment for stable lesions, whereas surgical treatment was superior for unstable lesions. Patients with an open capitellar physis had superior ROM for stable and unstable lesions, but there was no correlation with lesion location and the outcomes of OATS versus fragment fixation for high-grade lesions. CONCLUSION: Nonoperative treatment was similar in outcomes to surgical treatment for low-grade lesions, whereas surgical treatment was superior for higher grade lesions. There is currently insufficient evidence to support complex reconstructive techniques for high-grade lesions compared with microfracture/debridement alone.

Lengthening Nails for Distraction Osteogenesis: A Review of Current Practice and Presentation of Extended Indications.

PURPOSE: Circular frames have been the gold standard of treatment for complex deformity corrections and bone loss. However, despite the success of frames, patient satisfaction has been low, and complications are frequent. Most recently, lengthening nails have been used to correct leg length discrepancies. In this article, we review the current trends in deformity correction with emphasis on bone lengthening and present our case examples on the use of lengthening nails for management of complex malunions, non-unions, and a novel use in bone transport. MATERIALS AND METHODS: A nonsystematic literature review on the topic was performed. Four case examples from our institute, Brighton and Sussex University Hospitals, East Sussex, England, UK, were included. RESULTS: New techniques based on intramedullary bone lengthening and deformity correction are replacing the conventional external frames. Introduction of lengthening and then nailing and lengthening over a nail techniques paved the way for popularization of the more recent lengthening nails. Lengthening nails have gone through evolution from the first mechanical nails to motorized nails and more recently the magnetic lengthening nails. Two case examples demonstrate successful use of lengthening nails for management of malunion, and two case examples describe novel use in management of non-unions, including the first report in the literature of plate-assisted bone segment transport for the longest defect successfully treated using this novel technique. CONCLUSION: With the significant advancement of intramedullary lengthening devices with lower complications rates and higher patient satisfaction, the era of the circular frame may be over. HOW TO CITE THIS ARTICLE: Barakat AH, Sayani J, O'Dowd-Booth C, et al. Lengthening Nails for Distraction Osteogenesis: A Review of Current Practice and Presentation of Extended Indications. Strategies Trauma Limb Reconstr 2020;15(1):54-61.

The use of red wristbands for allergy documentation in day case surgery.

In England over six million day case surgical procedures are performed each year. Many of these patients have an allergy and are given a red armband to notify staff of this. This audit compared the use of red armbands to indicate allergy at two institutions undertaking day case surgery. The presence of wristbands, the allergies recorded on them and the correlation to allergies documented in the patient notes were analysed.

Developmental dysplasia of the hip in the newborn: A systematic review.

Developmental dysplasia of the hip (DDH) denotes a wide spectrum of conditions ranging from subtle acetabular dysplasia to irreducible hip dislocations. Clinical diagnostic tests complement ultrasound imaging in allowing diagnosis, classification and monitoring of this condition. Classification systems relate to the alpha and beta angles in addition to the dynamic coverage index (DCI). Screening programmes for DDH show considerable geographic variation; certain risk factors have been identified which necessitate ultrasound assessment of the newborn. The treatment of DDH has undergone significant evolution, but the current gold standard is still the Pavlik harness. Duration of Pavlik harness treatment has been reported to range from 3 to 9.3 mo. The beta angle, DCI and the superior/lateral femoral head displacement can be assessed via ultrasound to estimate the likelihood of success. Success rates of between 7% and 99% have been reported when using the harness to treat DDH. Avascular necrosis remains the most devastating complication of harness usage with a reported rate of between 0% and 28%. Alternative non-surgical treatment methods used for DDH include devices proposed by LeDamany, Frejka, Lorenz and Ortolani. The Rosen splint and Wagner stocking have also been used for DDH treatment. Surgical treatment for DDH comprises open reduction alongside a combination of femoral or pelvic osteotomies. Femoral osteotomies are carried out in cases of excessive anteversion or valgus deformity of the femoral neck. The two principal pelvic osteotomies most commonly performed are the Salter osteotomy and Pemberton acetabuloplasty. Serious surgical complications include epiphyseal damage, sciatic nerve damage and femoral neck fracture.

A Rare Presentation of Concurrent Scedosporium apiospermum and Madurella grisea Eumycetoma in an Immunocompetent Host.

Mycetoma is a disfiguring, chronic granulomatous infection which affects the skin and the underlying subcutaneous tissue. We present an atypical case of recurrent mycetoma without ulceration, in a 35-year-old immunocompetent male caused by Scedosporium apiospermum sensu stricto and Madurella grisea, occurring at two separate anatomical sites.

Articular surface remodeling of the hip after periacetabular osteotomy.

PURPOSE: Periacetabular osteotomies are a family of surgical procedures used to treat hip dysplasia. In a periacetabular osteotomy, the operating surgeon aims to increase acetabular coverage of the femoral head. The surgical correction has mechanical goals of increasing the stability of the joint and to improving the pressure distribution across the acetabulum. Although it is known that bone will remodel under changing load at the microstructural level, it is unclear whether there is any gross remodeling of the acetabulum or the femoral head in response to the change in loading following a periacetabular osteotomy. This observational study aims to quantify the shape of operative and contralateral hip joint surfaces pre and postoperatively to determine whether there are gross morphological changes in the shape of any of the bony articular surfaces of the joint. METHODS: Preoperative and postoperative computed tomography (CT) scans were segmented as triangulated meshes. The bony articular surfaces of these meshes were then isolated. The vertices of these surfaces were fit to spheres and to general ellipsoids and, in the case of the acetabulum, examined in anatomical coordinate frames to look for changes between pre and postoperative segmentations. RESULTS: Spherical fit results were consistent preoperatively and postoperatively, with small changes in the radii of the spheres of best fit for both operative and nonoperative hips. Ellipsoid fitting showed variations between preoperative and postoperative scans in both eccentricity and orientation. CONCLUSIONS: Because there is no clear evidence of gross articular surface remodeling, periacetabular osteotomy for an adult should be planned with the expectation that the patient's existing articular structure will be preserved.