A prediction model for treatment decisions in distal radial physeal injuries: A multicenter retrospective study.

Background: There are no clearly defined guidelines for the management of distal radial physeal injuries. We aimed to identify the risk factors for patients with distal radial physeal trauma for the risk of deformity, physeal closure, and revision procedure and develop a predictive model. Methods: The retrospective study included patients less than 16 years old with displaced distal radial physeal injuries treated between 2011 and 2018 across five centers in the United Kingdom. Deformity was defined as a volar angulation of >11°, dorsal angulation of >15°, a radial inclination of <15° or >23°, or positive ulnar variance. Presence of a bony bar spanning the physis was considered physeal closure. Results: This study comprised of 479 patients. In that, 32 (6.6%) patients had a second procedure. Also, 49 (10.2%) patients had closure of physis, and 28 (6%) patients had deformity at the end of follow-up. The occurrence of deformity had a strong correlation with age (p = 0.04) and immobilization duration (p = 0.003). Receiver operating characteristic analysis showed that age >12.5 years (p = 0.006) and sagittal angulation of >21.7° (p = 0.002) had a higher odd of deformity. Immobilization for <4.5 weeks (p = 0.01) had a higher revision rate. The nomograms showed good calibration, with a sensitivity of 70% and specificity of 75%. Interpretation: The nomograms provide accurate, pragmatic multivariate predictive models. Anatomical reduction is recommended in patients >12.5 years of age with >22° of dorsal angulation with cast immobilization for no less than 4.5 weeks. Any revision procedure should be performed within 11 days from the date of injury to reduce the risk of physeal damage.

Leiomyosarcoma in the extremities and trunk wall: systematic review and meta-analysis of the oncological outcomes.

BACKGROUND: Leiomyosarcomas are aggressive malignancies which can occur on the trunk and extremities whose pathogenesis is poorly understood. We aim to quantify the prognostic impact of various clinical and pathological markers on survival and recurrence of leiomyosarcomas. METHODS: We conducted a systematic review as per PRISMA protocol. Survival, local recurrence, and metastasis were the outcome measures. Data were extracted from the studies for the outcome variables; the resultant odds ratios (OR) and 95% confidence interval (CI) were used for the synthesis of a forest plot. RESULTS: Our search revealed thirteen studies comprising 1380 patients. Seven of these 13 publications were since 2012. Our analysis showed that tumor size larger than 5 cm adversely affected the outcome with an OR 3.39 (2.26-5.10, p < 0.01). Other factors which reduced the overall survival were positive margins of excision OR 2.12 (1.36-3.32, p < 0.01). A reduced risk of metastasis has strongly associated the use of radiotherapy with OR 10.84 (4.41-26.61, p < 0.01). Only a few studies analyzed the impact of factors on local recurrence. CONCLUSIONS: Size larger than 5 cm and positive margins of excision are associated with poor overall survival. In comparison, the use of adjuvant radiotherapy was associated with a lower metastatic rate. There is a need for methodically high-quality studies with more uniform study design and reporting to evaluate the impact of various risk factors on local recurrence and metastases. LEVEL OF EVIDENCE: Level 1 Prognostic.

A Multicenter Retrospective Cohort Study of First Metatarsophalangeal Joint Arthrodesis.

In this multicenter study, we evaluated commonly used methods of fixation and 2 methods of joint preparation for first metatarsophalangeal joint fusion, in terms of radiological union and revision rates. Included were 409 consecutive fusions in 385 patients. The overall union rate was 91.4% (34/409). About 29.4% (10/34) of our nonunions were symptomatic. Preoperative hallux valgus showed a statistically significant relation to nonunion (odds ratio [OR] = 9.33, p = .017). Other potential contributing factors like gender (OR 1.9, p = .44), diabetes (OR = 0, p = .99), steroid use (OR = 2.07, p = .44), inflammatory arthritis (OR = 0, p = .99), and smoking (OR = 2.69, p = .34) did not attain statistical significance. Further, the methods of fixation like solid screws (OR = 0, p = .99), plate (OR = 3.6, p = .187), or cannulated screws (OR = 0.09, p = .06) showed no correlation with incidence of nonunion. We compared 2 techniques of joint preparation and found no significant difference in union rates (chi-square = 1.0426, p = .30). Our crude comparison of costs showed the average saving to the trust per year could be 33,442.50£ by choosing screws over plates. To conclude, only hallux valgus had a statistically significant relation to nonunion. All other variables had no significant impact on the union. Solid screw seems to be economically the most viable option and a valid alternative.

Current surgical management of metastatic pathological fractures of the femur: A multicentre snapshot audit.

AIMS: We aimed to find out: the typical workload for metastatic bone disease, the conventional treatment for femoral metastases and whether there is a trend for arthroplasty and endoprosthetic reconstruction. MATERIALS AND METHODS: All sequential patients undergoing surgery for femoral metastatic lesions (both pathological fracture and impending pathological fracture) of any age patient were included in the multicenter snapshot audit. Data on demographics, institutions and operative procedures were recorded. RESULTS: 24 UK Institutions were enrolled, including 7 Major Trauma Centres (MTCs). It was a 2 month audit from 1stMarch 2018. 95 cases were recorded. The mean age was 71 and 65% were female. 66 patients had a fracture at presentation and 23 an impending fracture. Breast carcinoma was the primary tumour at 23%. The mean Mirel's score is 9. The commonest fixation was with a long cephalomedullary nail (38%). Endoprostheses accounted for 24%. None of the endoprostheses were implanted at MTCs. CONCLUSION: This audit revealed large numbers of cases of femoral metastases. Although the use of endoprostheses may be increasing in Trauma Units, intramedullary nailing still predominates. Future pathways may benefit from directing resources to allow greater arthroplasty.

Comparative Biomechanical Characteristics of Modified Side-to-Side Repair and Modified Pulvertaft Weaving Repair - In vitro Study.

BACKGROUND: Strong surgical repair is the mechanical basis of early mobilization and prerequisite for biological healing following tendon grafting. Side to side and pulvertaft repairs were developed to meets these demands. However, these techniques have later been modified to improve the strength of repair but their characteristics have not been compared. METHODS: We compared biomechanical strength of the modified side-to-side (SS) repair with the modified Pulvertaft (PT) repair technique in turkey tendons keeping overlap length, anchor points, type of suture, suture throw and amount of suture similar. Two investigators performed 34 repairs during one summer month to test the tensile strength of the repair using mechanical strength testing machine. Variables measured were maximum load, load to first failure, modulus, load at break, mode of failure, site of failure, tensile strain, tensile stress. The statistical comparison was carried by Levene's test and T test for means. RESULTS: The mean maximum load for modified SS repair was 50.3 (SD 13.7) N and modified PT repair was 46.9 (SD 16.4) N. The tensile stress at maximum load for SS and modified PT repair was 4.7 (SD 4) MPa and 4.2 (SD 3) MPa respectively. The suture cut through was the commonest mode of failure. CONCLUSIONS: We found no statistical difference between 2 repairs in load at which they started failing (p = 0.16), and maximum load repairs could withstand (p = 0.35). Our study uniquely compares two techniques under standard conditions, and contrary to existing evidence found no difference. However, in our opinion the number of anchor points may have a greater impact than number of weaves on the strength.

A Consecutive Case Series of 166 First Metatarsophalangeal Joint Fusions Using a Combination of Cup and Cone Reamers and Crossed Cannulated Screws.

Fusion of the first metatarsophalangeal joint (MTPJ) is the reference standard surgery for significant hallux rigidus. A number of different techniques for first MTPJ fusion have been reported. We describe our technique of first MTPJ fusion using cup and cone reamers for joint surface preparation and 2 crossed cannulated screws for fixation. To the best of our knowledge, this is the single largest series using this technique. The present study reports on a single-surgeon, consecutive series of 166 consecutive cases in 147 patients who had undergone first MTPJ fusion. The demographic data and comorbidities of the patients were collected from the digital medical records, and the radiographs were evaluated by 2 of us (S.Q., M.A.) independently to document fusion status. Radiologic nonunion was seen in 11 of 166 cases (6.6%). The mean duration of follow up was 60 ± 29.5 (minimum 26, maximum 183) days. However, only 4 of the 11 cases (36%) of nonunion were clinically symptomatic and underwent revision using a bone graft and locking plate. A statistically significant difference was found in union rates among males and females (p = .01). Other factors, such as diabetes (p = .2), inflammatory arthritis (p = .5), steroids (p = .6), smoking (p = .5), hallux valgus deformity (p = .5), and concomitant forefoot surgery, did not have a statistically significant (p = .3) effect on union in our study. The union rate of first MTPJ fusion with our technique was comparable to that of others, with the advantage of being simple and less expensive compared with the use of a plate.

A systematic review of management of scapular fractures.

There is no agreement within literature regarding management of scapula fractures. Our aim was to carry out a systematic review of literature on management of the scapular fractures. Our search across multiple medical databases for studies on the scapular fractures until February 2014 yielded 32 studies. We have excluded case series <7 patients, case reports, review articles, articles without abstract, observational studies and articles on fractures following shoulder arthroplasty. There were 8 prospective case series and one cohort study, however, majority of the included studies were retrospective studies. There were 1237 patients, follow up data were available for 941 patients who underwent either conservative (629) or operative management (512). Non-operative management scapular body fractures had satisfactory results. The scapular neck fractures displaced <10mm have satisfactory outcome following non-operative management. Operative management of displaced glenoid fossa fractures and scapular neck fractures displaced >10mm lead in a better functional outcome.

Tuberculosis of the pubic symphysis: four unusual cases and literature review.

BACKGROUND: The incidence of extrapulmonary tuberculosis (TB) has increased in the chemotherapeutic era owing to the increasing presence of immunodeficiency disorders. Pubic symphysis TB, although uncommon, is again important as these infections once were in the prechemotherapeutic era. CASE DESCRIPTION: We present the cases of four patients with pubic symphysis TB in which one patient had a horseshoe-shaped abscess in the pubic region and another had a double lesion of the pelvis leading to vertical shear-type pathologic displacement. Three patients were diagnosed by cytology and PCR. These patients were treated successfully with antituberculosis treatment with or without minimal surgical intervention despite their late presentation and advanced disease. The fourth patient remains under treatment and followup. LITERATURE REVIEW: We identified 40 patients with TB of the pubic symphysis in the English language medical literature. Of these 40 patients, only five are from India despite TB being endemic in this country. Followup information is available for 32 of the 40 patients with followups ranging from 1 to 84 months (mean of approximataly 20 months). PURPOSES AND CLINICAL RELEVANCE: We suspect TB of the pubic symphysis is increasing in frequency owing to drug resistance, use of biologics, immunomodulating drugs, and anticancer drugs. Therefore, it is important for clinicians to have a high index of suspicion in patients at risk. Initially patients may be asymptomatic or present with adductor region pain or spasm, sacroiliac strain, limp, or a hypogastric, inguinal, or thigh mass that mimics an inguinal hernia, genitourinary, abdominal, or thigh tumor. CONCLUSION: It is important to diagnose and treat pubic TB early in the course of the disease before the destructive stage. After relevant investigations most patients can be treated with antitubercular drugs with or without a minor surgical procedure.