Validation of a Novel Smartphone-Based Electronic Data Capture System Following Surgical Fixation of Distal Radial Fractures.

BACKGROUND: Large prospective institutional data provide the opportunity to conduct level II and III studies using robust methodologies and adequately powered sample-sizes, while circumventing limitations of retrospective databases. We aimed to validate a prospective data collection tool, the Orthopaedic Minimal Data Set Episode of Care (OME), implemented at a tertiary North American health care system for distal radial fracture (DRF) open reduction and internal fixation (ORIF). METHODS: The first 100 DRF ORIFs performed after OME inception (February 2015) were selected for this validation study. A blinded review of the operative notes and charts was performed, and extracted data of 75 perioperative DRF ORIF procedure variables were compared with OME collected data for agreement. Outcomes included completion rates and agreement measures in OME versus electronic medical record (EMR)-based control datasets. Data counts were evaluated using raw percentages and McNemar tests. Cohen (κ) and concordance correlation coefficient analyzed categorical and numerical variable agreement, respectively. RESULTS: Overall, OME demonstrated superior completion and agreement parameters versus EMR-based retrospective review. Nine data points (12.0%) demonstrated significantly higher completion rates within the OME dataset (P < .05, each), and 88% (66/75) of captured variables demonstrated similar completion rates. Up to 80.0% (60/75) of variables either demonstrated an agreement proportion of ≥0.90 or were solely reported in the OME. Of 33 variables eligible for agreement analyses, 36.4% (12/33) demonstrated almost perfect agreement (κ > 0.80), and 63.6% (21/33) exhibited almost perfect or substantial agreement (κ > 0.60). CONCLUSIONS: The OME is a valid and accurate prospective data collection tool for DRF ORIF that is reliably able to match or supersede traditional retrospective chart review. Future investigations could use this tool for large-scale analyses investigating peri/intraoperative DRF ORIF variables.

The "Fight Bite" Saline Joint Loading Test: Effectiveness in Detecting Simulated Traumatic Metacarpophalangeal Arthrotomies.

Background: The saline load test is routinely used to recognize other joints' traumatic arthrotomies; however, there are currently no studies evaluating the novelty of this test for metacarpophalangeal joints (MCPJs). This study aimed to investigate the effectiveness and sensitivity of saline load testing in identifying the traumatic arthrotomies of the MCPJs using human cadavers. Methods: This was a cadaveric study of 16 hands (79 MCPJs). Traumatic arthrotomies were created using 11-blade stab-incisions, followed by blunt probing into the joint on the radial or ulnar side of the flexed MCPJs. A 3-mL syringe was used to inject intra-articular methylene-blue-dyed saline from the contralateral side. The volume at saline extravasation was recorded. Test sensitivity and factors influencing extravasation volume were assessed. Results: The mean (range) volume injected to identify arthrotomy of all MCPJs was 0.18 mL (0.1-0.4 mL). The mean volume to identify MCPJ arthrotomy of the thumb, index, long, ring, and small fingers was 0.16 mL (0.1-0.3 mL), 0.19 mL (0.1-0.3 mL), 0.21 mL (0.1-0.4 mL), 0.17 mL (0.1-0.3 mL), and 0.16 mL (0.1-0.3 mL), respectively. Cadaver age, laterality, and joint range of motion were not significantly associated with the injected volume at extravasation(P > .05, each). Injection volumes of 0.3 and 0.32 mL were required to detect arthrotomies at 95% and 99% sensitivities across all MCPJs. None of the MCPJs required > 0.4 mL to detect arthrotomy. Conclusions: Saline joint loading volumes to detect traumatic arthrotomy were similar for all MCPJs. Injection volumes of 0.32 mL is suggested for 99% sensitivity. Our findings provide the first report, to our knowledge, on intra-articular injection volumes expected to detect an arthrotomy of MCPJ. This is critical for further validation using in vivo clinical studies.

Wrist Arthrotomy Saline Load Test.

BACKGROUND: Failure to recognize a potential wrist arthrotomy may lead to missed septic arthritis and devastating sequelae. The saline load test is routinely used to recognize traumatic arthrotomies of other joints; however, there are limited data optimizing this test for the wrist. The purpose of this study was to investigate and perform saline load testing to identify traumatic arthrotomies of the wrist. METHODS: This was a cadaveric study of 15 wrists. Traumatic arthrotomies were created using a blunt trocar through the 3-4 portal. A 3-mL syringe with 0.1 mL markings was used to inject methylene blue dyed saline into the wrist through the 1-2 portal. Once extravasation was visible from the atherectomized site, the volume was recorded. RESULTS: The mean (range) volume injected to identify the arthrotomy of all wrists was 1.22 mL (range, 0.1-3.1 mL). Multivariate regression demonstrated that cadaver age, laterality, and extension range of motion were not significantly associated with the injected saline volume at extravasation (P > .05, each). Greater joint range of motion was independently associated with higher saline volume load for extravasation (odds ratio: 1.049; 95% confidence interval: 1.024-1.075; P = .003). CONCLUSIONS: We found that 2.68 and 3.02 mL of methylene blue dyed saline offered 95% and 99% sensitivity, respectively, for diagnosing traumatic wrist arthrotomy. The maximum volume of saline needed to recognize an arthrotomy was 3.1 mL. We recommend this be the minimum volume used to evaluate a traumatic wrist arthrotomy.

Validation of a Smartphone-Based Institutional Electronic Data Capture System for Thumb Carpometacarpal Joint Arthroplasty.

BACKGROUND: The Orthopaedic Minimal Data Set (OrthoMiDaS) Episode of care (OME) is a prospectively collected database enabling capture of patient and surgeon-reported data in a more efficient, comprehensive, and dependable manner than electronic medical record (EMR) review. We aimed to assess and validate the OME as a data capture tool for carpometacarpal (CMC) arthroplasty compared to traditional EMR-based review. Specifically, we aimed to: (1) compare the completeness of the OME versus EMR data; and (2) evaluate the extent of agreement between the OME and EMR data-based datasets for carpometacarpal (CMC) arthroplasty. METHODS: The first 100 thumb CMC arthroplasties after OME inception (Febuary, 2015) were included. Blinded EMR-based review of the same cases was performedfor 48 perioperative variables and compared to their OME-sourced counterparts. Outcomes included completion rates and agreement measures in OME versus EMR-based control datasets. RESULTS: The OME demonstrated superior completion rates compared to EMR-based retrospective review. There was high agreement between both datasets where 75.6% (34/45) had an agreement proportion of >0.90% and 82.2% (37/45) had an agreement proportion of >0.80. Over 40% of the variables had almost perfect to substantial agreement (κ > 0.60). Among the 6 variables demonstrating poor agreement, the surgeon-inputted OME values were more accurate than the EMR-based review control. CONCLUSIONS: This study validates the use of the OME for CMC arthroplasty by illustrating that it is reliably able to match or supersede traditional chart review for data collection; thereby offering a high-quality tool for future CMC arthroplasty studies.

Upper Extremity Free Flap Transfers: An Analysis of the National Surgical Quality Improvement Program Database.

Introduction We evaluated the demographics, flap types, and 30-day complication, readmission, and reoperation rates for upper extremity free flap transfers within the National Surgical Quality Improvement Program (NSQIP) database. Materials and Methods Upper extremity free flap transfer patients in the NSQIP from 2008 to 2016 were identified. Complications, reoperations, and readmissions were queried. Chi-squared tests evaluated differences in sex, race, and insurance. The types of procedures performed, complication frequencies, reoperation rates, and readmission rates were analyzed. Results One-hundred-eleven patients were selected (mean: 36.8 years). Most common upper extremity free flaps were muscle/myocutaneous (45.9%) and other vascularized bone grafts with microanastomosis (27.9%). Thirty-day complications among all patients included superficial site infections (2.7%), intraoperative transfusions (7.2%), pneumonia (0.9%), and deep venous thrombosis (0.9%). Thirty-day reoperation and readmission rates were 4.5% and 3.6%, respectively. The mean time from discharge to readmission was 12.5 days. Conclusion Upper extremity free flap transfers could be performed with a low rate of 30-day complications, reoperations, and readmissions.

Prolonged Operative Time Associated with Increased Healthcare Utilization after Open Reduction and Internal Fixation of Intra-Articular and Extra-Articular Distal Radial Fractures: An Analysis of 17,482 Cases.

Background The current literature does not contain a quantitative description of the associations between operative time and adverse outcomes after open reduction and internal fixation (ORIF) of distal radial fractures (DRF). Questions/Purpose We aimed to quantify associations between DRF ORIF operative time and 1) 30-day postoperative health care utilization and 2) the incidence of local wound complications. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for DRF ORIF cases (January 2012-December 2018). A total of 17,482 cases were identified. Primary outcomes included health care utilization (length of stay [LOS], discharge dispositions, 30-day readmissions, and reoperations) per operative-time category. Secondary outcome was incidence of wound complications per operative-time category. Multivariate regression was conducted to determine operative-time categories associated with increased risk while adjusting for demographics, comorbidities, and fracture type. Spline regression models were constructed to visualize associations. Results The 121 to 140-minute category was associated with significantly higher risk of a LOS > 2 days (odds ration [OR]: 1.64; 95% confidence interval [CI]:1.1-2.45; p = 0.014) and nonhome discharge (OR: 1.72; 95% CI:1.09-2.72; p = 0.02) versus 41 to 60-minute category. The ≥ 180-minute category exhibited highest odds of LOS > 2 days (OR: 2.08; 95%CI: 1.33-3.26; p = 0.001), nonhome discharge disposition (OR: 1.87; 95% CI: 1.05-3.33; p = 0.035), and 30-day reoperation occurrence (OR: 3.52; 95% CI: 1.59-7.79; p = 0.002). There was no association between operative time and 30-day readmission ( p > 0.05 each). Higher odds of any-wound complication was first detected at 81 to 100-minute category (OR: 3.02; 95% CI: 1.08-8.4; p = 0.035) and peaked ≥ 181 minutes (OR: 9.62; 95% CI: 2.57-36.0; p = 0.001). Spline regression demonstrated no increase in risk of adverse outcomes if operative times were 50 minutes or less. Conclusion Our findings demonstrate that prolonged operative time is correlated with increased odds of health care utilization and wound complications after DRF ORIF. Operative times greater than 60 minutes seem to carry higher odds of postoperative complications.

Outcomes of gracilis free-flap muscle transfers and non-free-flap procedures for restoration of elbow flexion: A systematic review.

PURPOSE: Elbow flexion is one of the most important functions to restore following brachial plexus damage. The authors sought to systematically review available evidence to summarize outcomes of free gracilis and non-free muscle transfers in restoring elbow flexion. METHODS: MEDLINE, EMBASE, and Cochrane were searched to identify articles reporting on elbow flexion reanimation in terms of transfer failure rates, strengths, range of motion (ROM), and/or Disabilities of the Arm, Shoulder and Hand (DASH) scores. A systematic review was chosen to select studies and reported according to PRISMA guidelines. RESULTS: Forty-six studies met the inclusion criteria for this study. A total of 432 cases were gracilis free-flap muscle transfers (FFMT), and 982 cases were non-free muscle transfers. FFMT were shown to have higher Medical Research Council (MRC) strength scores than non-free muscle transfer groups. However, 42 studies, totaling 1,266 cases, were useful in evaluating graft failure, showing failure (MRC<3) in 77/419 (∼18.4%) of gracilis free-flap transfers and 215/847 (∼25.4%) of non-free muscle transfers. Sixteen articles, 285 cases, were useful to evaluate ROMs (total range: 0-140°), and eight articles, 215 cases, provided DASH scores (total range: 8-90.8). CONCLUSIONS: Of patients who underwent gracilis FFMT procedures, higher mean strength scores and lower failure rates were observed when compared with non-free muscle transfers. Articles reporting non-free muscle transfer procedures (pectoralis, pedicled, Steindler, vascularized ulnar nerve grafts, Oberlin, single/double nerve transfers) provided comprehensive insight into outcomes and indicated that they may result in pooerer poorer DASH scores and ROM.

Disseminated Intravascular Coagulation in Pediatric Scoliosis Surgery: A Systematic Review.

BACKGROUND: Disseminated intravascular coagulation (DIC) is a rare but serious complication of pediatric scoliosis surgery; sparse current evidence warrants more information on causality and prevention. This systematic review sought to identify incidence of DIC in pediatric patients during or shortly after corrective scoliosis surgery and identify any predictive factors for DIC. METHODS: Medline/PubMed, EMBASE, and Ovid databases were systematically reviewed through July 2017 to identify pediatric patients with DIC in the setting of scoliosis surgery. Patient demographics, medical history, surgery performed, clinical course, suspected causes of DIC, and outcomes were collected. RESULTS: Eleven studies met inclusion criteria. Thirteen cases from 1974 to 2012 (mean age: 15.3 ± 4.3 years, 72% women) were identified, with neuromuscular (n = 7; 54%) scoliosis as the most common indication. There were no prior bleeding disorder histories; all preoperative labs were within normal limits. Procedures included 8 posterior segmental fusions (54%), 3 Harrington rods (31%), 1 Cotrel-Dubousset, and 1 unit rod. Eight patients experienced DIC intraoperatively and 5 patients experienced DIC postoperatively. Probable DIC causes included coagulopathy following intraoperatively retrieved blood reinfusion, infection from transfusion, rhabdomyolysis, hemostatic matrix application, heparin use, and hypovolemic shock. Most common complications included increased intraoperative blood loss (n = 8) and hypotension (n = 7). The mortality rate was 7.69%; one fatality occurred in the acute postoperative period. CONCLUSIONS: Prior bleeding disorder status notwithstanding, this review identified preliminary associations between variables during corrective scoliosis surgery and DIC incidence among pediatric patients, suggesting multiple etiologies for DIC in the setting of scoliosis surgery. Further investigation is warranted to quantify associated risk. CLINICAL RELEVANCE: This study brings awareness to a previously rarely discussed complication of pediatric scoliosis surgery. Further cognizance of DIC by scoliosis surgeons may help identify and prevent causes thereof.

Malpractice Litigation in Hand Surgery: A Comprehensive Nationwide Analysis.

BACKGROUND: The circumstances surrounding claims against hand surgeons have not been elucidated in the literature. The purpose of this study was to analyze trends in malpractice litigation regarding hand surgery through a nationwide legal database. METHODS: The Westlaw legal research database was queried for verdicts and settlements between 1985 and 2017 for hand surgery-related malpractice cases. Cases were included if the hand surgeon was sued for malpractice. Procedure type and complications and/or adverse events that resulted in litigation were recorded. Patient characteristics, state, date of case, case outcomes, and indemnity payment were also noted. All dollar amounts were adjusted to 2017 values using the Consumer Price Index. RESULTS: In all, 171 cases (35 states) were included. The most frequently litigated surgeries were carpal tunnel releases followed by fracture treatment. Nerve injury was the predominant cause of litigation. The median nerve was predominantly injured, followed by the ulnar and radial nerves. In fracture surgery, malunion was the predominant cause, followed by weakness, nerve injury, and infection. In total, 72.5% of cases yielded verdicts in favor of the defense, 21.6% favored the plaintiff, and 5.9% were settled. Indemnity varied between $7800 and $8.99 million, averaging $570,397 for cases when the jury ruled in favor of the plaintiffs. Settled cases averaged $1,140,527. CONCLUSIONS: Malpractice litigation has substantial financial implications on surgeons and the health care system. Litigation arises most commonly from routine procedures (carpal tunnel release and fracture fixation) rather than complex surgical cases, potentially due to the high variability in operating surgeon subspecialization, with discrepant training.

Scapulothoracic fusion using nonabsorbable suture fixation: surgical technique and review of the literature.

Background: Historically, scapulothoracic fusion (STF) is performed using steel wire and plate construct fixation. The purpose of this study is to report a recent fusion achieved through ultra-high-molecular-weight polyethylene-reinforced suture fixation as well as to perform a systematic literature review of techniques, fusion rates, complications, and reoperation. Methods: Patient data were gathered from chart review and clinical encounters. For the review, MEDLINE, Embase, and Ovid databases were queried for STF cases. Thirty articles reporting on 386 fusion procedures were included. Results: Including this patient, 5 of 387 (1.3%) STFs have been attempted with fiber suture. Fusion rates of metal-only constructs is 90.8% (346 of 381) with 11.3% (43 of 381) requiring wire removal or trimming because of symptomatic hardware and 7% (27 of 381) causing a postoperative pneumothorax. Although a small sample size, all fiber-suture constructs have achieved union without implant removal and without pneumothorax development. In this patient, fusion was determined radiographically at 6 months with substantial improvement in pain level and function. Conclusion: Scapulothoracic fusion has benefit to patients to have failed other management options for winged scapula, most commonly those with neurologic trauma or facioscapulohumeral muscular dystrophy. With advancements in surgical options, fiber-suture offers an alternative to steel wire to achieve fusion. Further cases with longer term follow-up are needed to determine if significant differences in outcomes exist between constructs.

Acute compartment syndrome of the deltoid: a case report and systematic review of the literature.

BACKGROUND: Deltoid compartment syndrome is a rare entity. The purpose of this study was to report a recent case and perform a systematic literature review. METHODS: Patient data were gathered from chart review and clinical encounters. For the review, the MEDLINE, Embase, and Ovid databases were queried for deltoid compartment syndrome cases. Seventeen articles reporting on 18 patients with deltoid compartment syndrome were included. RESULTS: Including our patient, 9 of 19 patients (47.4%) presented with compartment syndrome limited to the deltoid. Most patients presented with additional affected compartments, most commonly in the ipsilateral arm (7 of 19, 37%). Isolated deltoid involvement often resulted from iatrogenic injury; of 10 iatrogenic reports, 8 involved only the deltoid. Of 19 cases, 5 (26%) occurred in powerlifters, climbers, or anabolic steroid or testosterone injectors. In 13 of 19 cases (68%), the patients were men aged 18-36 years, and only 1 female case (5%) was reported. Prolonged recumbence owing to substance abuse was documented in 6 of 19 cases (32%). CONCLUSION: Deltoid compartment syndrome is rare, with only 19 reported cases, including our patient. Men are more commonly affected, and isolated deltoid compartment syndrome occurs in about 50% of reported cases. More than half of cases are iatrogenic, secondary to prolonged lateral decubitus positioning, injections, and surgical interventions about the shoulder. Prolonged recumbence from intoxication is also a common etiology. Providers should be aware of and recognize deltoid compartment syndrome to facilitate urgent surgical management.

Single-Cell RNA Sequencing of Calvarial and Long-Bone Endocortical Cells.

Single-cell RNA sequencing (scRNA-Seq) is emerging as a powerful technology to examine transcriptomes of individual cells. We determined whether scRNA-Seq could be used to detect the effect of environmental and pharmacologic perturbations on osteoblasts. We began with a commonly used in vitro system in which freshly isolated neonatal mouse calvarial cells are expanded and induced to produce a mineralized matrix. We used scRNA-Seq to compare the relative cell type abundances and the transcriptomes of freshly isolated cells to those that had been cultured for 12 days in vitro. We observed that the percentage of macrophage-like cells increased from 6% in freshly isolated calvarial cells to 34% in cultured cells. We also found that Bglap transcripts were abundant in freshly isolated osteoblasts but nearly undetectable in the cultured calvarial cells. Thus, scRNA-Seq revealed significant differences between heterogeneity of cells in vivo and in vitro. We next performed scRNA-Seq on freshly recovered long bone endocortical cells from mice that received either vehicle or sclerostin-neutralizing antibody for 1 week. We were unable to detect significant changes in bone anabolism-associated transcripts in immature and mature osteoblasts recovered from mice treated with sclerostin-neutralizing antibody; this might be a consequence of being underpowered to detect modest changes in gene expression, because only 7% of the sequenced endocortical cells were osteoblasts and a limited portion of their transcriptomes were sampled. We conclude that scRNA-Seq can detect changes in cell abundance, identity, and gene expression in skeletally derived cells. In order to detect modest changes in osteoblast gene expression at the single-cell level in the appendicular skeleton, larger numbers of osteoblasts from endocortical bone are required. © 2020 American Society for Bone and Mineral Research.

Free Gracilis Muscle Transfers Compared with Nonfree Muscle Flaps for Reanimation of Elbow Flexion: A Meta-Analysis.

Objectives Elbow flexion loss is a debilitating upper extremity injury. Surgical treatment options include nonfree muscle transfers (tendon transfers, nerve transfers, Steindler procedure, Oberlin transfers, and pedicled muscle transfers) or free muscle transfers. We sought to determine if free muscle transfers and nonfree muscle transfers have similar outcomes for elbow flexion reanimation. Materials and Methods A literature search for studies evaluating free and nonfree muscle transfers for elbow flexion reanimation was performed. Included studies reported on transfer failure (strength

The Outcomes of Posterior Arthrodesis for Atlantoaxial Subluxation in Down Syndrome Patients: A Meta-Analysis.

STUDY DESIGN: This is a meta-analysis. OBJECTIVE: To establish rates of (1) neurological complications, (2) bony-related complications, (3) complications delaying recovery, (4) reoperation, and (5) fatalities following posterior cervical arthrodesis in Down syndrome (DS) patients with atlantoaxial subluxation. To determine if presenting symptoms had any relationship to postoperative complications. SUMMARY OF BACKGROUND DATA: Posterior arthrodesis is commonly utilized to correct cervical instability secondary to atlantoaxial instability in DS patients. However, there has never been a global evaluation of postoperative complications associated with posterior cervical spinal arthrodesis in DS patients. METHODS: A comprehensive search of Medline/PubMed, EMBASE, and Ovid databases between January 1980 and July 2017 was utilized to identify DS patients with atlantoaxial subluxation who underwent posterior cervical arthrodesis. Data were sorted by neurological complications, complications delaying recovery, bony-related complications, reoperations, and fatalities. Patients were sorted into 2 groups based on presentation with or without neurological deficits. RESULTS: Twelve studies met inclusion criteria, including 128 DS patients. Mean age was 13.8 years (range: 6.7-32.7 y; 47.8% male). Mean follow-up was 31.7 months (range: 14.9-77 mo). All patients underwent primary posterior cervical arthrodesis with an average of 2.5 vertebrae fused. A total of 39.6% of patients had bony-related complications [95% confidence interval (CI), 31.4%-48.5%], 23.3% had neurological deficits (95% CI, 16.6%-31.6%), and 26.4% experienced complications delaying recovery (95% CI, 19.4%-34.9%). The reoperation rate was 34.9% (95% CI, 25.5%-45.6%). The mortality rate was 3.9% (95% CI, 1.5%-9.7%). Neurological complications were 4-fold (P<0.05) and reoperation was 5.5-fold (P<0.05) more likely in patients presenting with neurological deficits compared with those without. CONCLUSIONS: This study detailed global complication rates of posterior arthrodesis for DS patients, identifying bony-related complications and reoperations among the most common. Patients presenting with neurological symptoms and cervical instability have increased postoperative rates of neurological complications and reoperations than patients with instability alone. Further investigation into how postoperative complications effect patient independence is warranted.

Intracranial and hierarchical perspective on dietary plasticity in mammals.

The effect of dietary properties on craniofacial form has been the focus of numerous functional studies, with increasingly more work dedicated to the importance of phenotypic plasticity. As bone is a dynamic tissue, morphological variation related to differential loading is well established for many masticatory structures. However, the adaptive osteogenic response of several cranial sites across multiple levels of bony organization remains to be investigated. Here, rabbits were obtained at weaning and raised for 48 weeks until adulthood in order to address the naturalistic influence of altered loading on the long-term development of masticatory and non-masticatory elements. Longitudinal data from micro-computed tomography (µCT) scans were used to test the hypothesis that variation in cortical bone formation and biomineralization in masticatory structures is linked to increased stresses during oral processing of mechanically challenging foods. It was also hypothesized that similar parameters for neurocranial structures would be minimally affected by varying loads as this area is characterized by low strains during mastication and reduced hard-tissue mechanosensitivity. Hypotheses were supported regarding bone formation for maxillomandibular and neurocranial elements, though biomineralization trends of masticatory structures did not mirror macroscale findings. Varying osteogenic responses in masticatory elements suggest that physiological adaptation, and corresponding variation in skeletal performance, may reside differentially at one level of bony architecture, potentially affecting the accuracy of behavioral and in silico reconstructions. Together, these findings underscore the complexity of bone adaptation and highlight functional and developmental variation in determinants of skull form.

The Outcomes of Nonelongating Intramedullary Fixation of the Lower Extremity for Pediatric Osteogenesis Imperfecta Patients: A Meta-analysis.

BACKGROUND: Osteogenesis imperfecta is usually due to autosomal dominant mutations in type I collagen, leading to an increase in fractures and bone deformities, especially in the long bones of the lower extremities. The use of nonelongating intramedullary rods is an established surgical intervention to address such deformities. The rate of surgical complications has been reported to be as high as 187%, with revision rates as high as 90%, although exact global rates are unknown. As such, we sought to determine the published rates of (1) bone-related complications (including both fracture and deformity), (2) rod migration, and (3) complications that require reoperation. METHODS: Following the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines, 1295 studies were evaluated. After cross-referencing, and applying specific inclusion and exclusion criteria, a total of 7 studies were included in the final cohort. Data were extracted from the studies and analyzed. Random effect models determined the complication rates of intramedullary nonelongating rod procedures. RESULTS: A total of 359 primary nonelongating intramedullary rod procedures of tibiae and femurs, in patients with a mean age of 6 years (5.2 to 7.3 y), at a mean follow-up of 63 months (24 to 118 mo), were evaluated. 60% of the surgical procedures were on femurs, and 40% were on tibiae. The reoperation rate was 39.4%. The most common complication was rod migration, with a rate of 25.7%. The rate of bone-related complications was 19.5% including fractures (15.0%) and worsening bone deformity (4.3%). CONCLUSIONS: This is the first meta-analysis to identify the rates of complication and reoperation in lower limb intramedullary fixation for pediatric osteogenesis imperfecta patients. This study has shown that rod migration is the most common complication, followed by bone-related complications including fractures and deformity. Reoperations occur after nearly 40% of all procedures due to rod migration or bone-related complications. LEVEL OF EVIDENCE: Level IV-retrospective meta-analysis.

Betwixt and Between: Intracranial Perspective on Zygomatic Arch Plasticity and Function in Mammals.

The zygomatic arch is morphologically complex, providing a key interface between the viscerocranium and neurocranium. It also serves as an attachment site for masticatory muscles, thereby linking it to the feeding apparatus. Though morphological variation related to differential loading is well known for many craniomandibular elements, the adaptive osteogenic response of the zygomatic arch remains to be investigated. Here, experimental data are presented that address the naturalistic influence of masticatory loading on the postweaning development of the zygoma and other cranial elements. Given the similarity of bone-strain levels among the zygoma and maxillomandibular elements, a rabbit and pig model were used to test the hypothesis that variation in cortical bone formation and biomineralization along the zygomatic arch and masticatory structures are linked to increased stresses. It was also hypothesized that neurocranial structures would be minimally affected by varying loads. Rabbits and pigs were raised for 48 weeks and 8 weeks, respectively. In both experimental models, CT analyses indicated that elevated masticatory loading did not induce differences in cortical bone thickness of the zygomatic arch, though biomineralization was positively affected. Hypotheses were supported regarding bone formation for maxillomandibular and neurocranial elements. Varying osteogenic responses in the arch suggests that skeletal adaptation, and corresponding variation in performance, may reside differentially at one level of bony architecture. Thus, it is possible that phenotypic diversity in the mammalian zygoma is due more singularly to natural selection (vs. plasticity). These findings underscore the complexity of the zygomatic arch and, more generally, determinants of skull form. Anat Rec, 299:1646-1660, 2016. © 2016 Wiley Periodicals, Inc.