Lateral wall fixation with bone pegs for advanced osteochondritis dissecans of the humeral capitellum.

BACKGROUND AND HYPOTHESIS: It is generally considered that fragment fixation with bone pegs (FFBP) for osteochondritis dissecans (OCD) of the humeral capitellum can be indicated for stages I and II according to the International Cartilage Repair Society (ICRS) classification of OCD and it is difficult to obtain complete bone union for advanced lesions. However, the clinical and radiologic results of FFBP with cancellous bone graft for ICRS-OCD stage III with lateral wall involvement have not been described in detail. Good bone union can be achieved with the lateral wall fragment of the capitellum by FFBP in combination with refreshing the sclerotic surface at the base of the lesion and cancellous bone grafting even in ICRS-OCD stage III lesions. METHODS: In total, 10 adolescent baseball players with a diagnosis of OCD, a median age of 13.5 years at the time of surgery, and 26.7 months of postoperative follow-up were included. Preoperative imaging showed that all patients had lesions in the late detached stage and of the lateral-widespread type based on the site of the focal lesion. The intraoperative ICRS-OCD classification was stage III. We aimed to preserve and fix the lateral wall fragment with cancellous bone grafting if the condition of the articular cartilage was good and the size and thickness of the segment could withstand fixation. RESULTS: Bone union of the lateral wall fragment was achieved in all cases. The elbow extension range of motion was -3.9° ± 9.7° before surgery and was eventually -0.4° ± 6.7° at the final assessment. Flexion range of motion ranged from 138.1° ± 10.5° to 142.4° ± 6.2°. The Timmerman and Andrews score significantly improved from 165.5 ± 10.9 points before surgery to 197.0 ± 6.3 points after surgery, demonstrating excellent results in all patients. All patients were able to return to competitive baseball. CONCLUSION: The radiographic and clinical outcomes of FFBP for lateral wall fragments with cancellous bone graft were satisfactory, showing that the indications for this procedure could be extended to ICRS-OCD stage III.

Mechanical prophylaxis is a heparin-independent risk for anti-platelet factor 4/heparin antibody formation after orthopedic surgery.

Platelet-activating antibodies, which recognize platelet factor 4 (PF4)/heparin complexes, induce spontaneous heparin-induced thrombocytopenia (HIT) syndrome or fondaparinux-associated HIT without exposure to unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH). This condition mostly occurs after major orthopedic surgery, implying that surgery itself could trigger this immune response, although the mechanism is unclear. To investigate how surgery may do so, we performed a multicenter, prospective study of 2069 patients who underwent total knee arthroplasty (TKA) or hip arthroplasty. Approximately half of the patients received postoperative thromboprophylaxis with UFH, LMWH, or fondaparinux. The other half received only mechanical thromboprophylaxis, including dynamic (intermittent plantar or pneumatic compression device), static (graduated compression stockings [GCSs]), or both. We measured anti-PF4/heparin immunoglobulins G, A, and M before and 10 days after surgery using an immunoassay. Multivariate analysis revealed that dynamic mechanical thromboprophylaxis (DMT) was an independent risk factor for seroconversion (odds ratio [OR], 2.01; 95% confidence interval [CI], 1.34-3.02; P = .001), which was confirmed with propensity-score matching (OR, 1.99; 95% CI, 1.17-3.37; P = .018). For TKA, the seroconversion rates in patients treated with DMT but no anticoagulation and in patients treated with UFH or LMWH without DMT were similar, but significantly higher than in patients treated with only GCSs. The proportion of patients with ≥1.4 optical density units appeared to be higher among those treated with any anticoagulant plus DMT than among those not treated with DMT. Our study suggests that DMT increases risk of an anti-PF4/heparin immune response, even without heparin exposure. This trial was registered to www.umin.ac.jp/ctr as #UMIN000001366.

Twenty-degree-tilt radiography for evaluation of lateral humeral condylar fracture in children.

OBJECTIVE: To investigate the efficacy of '20 degrees -tilt anteroposterior (A-P) radiography' in the assessment of lateral condylar fractures of the distal humerus. MATERIALS AND METHODS: Eighteen children with lateral humeral condylar fractures were studied. Every child underwent conventional A-P and lateral radiography, and six children underwent multi-detector computed tomography (MDCT). For the investigation of 20 degrees -tilt radiography, ten children with lateral humeral condylar fractures had conventional and 20 degrees -tilt A-P and lateral radiography both preoperatively and postoperatively. Fragment dislocation was measured at the lateral and medial margins of the fracture on both the conventional A-P and 20 degrees -tilt A-P radiographs. RESULTS: The lateral condylar fragment was triangular and was most prominent posteriorly. The fracture line was typically tilted approximately 20 degrees to a reference line perpendicular to the long axis of the humerus in the lateral view. The extent of dislocation at the lateral and medial margins of the fracture site by 20 degrees -tilt A-P radiography (9.3 +/- 3.6 mm and 5.6 +/- 2.5 mm) was significantly wider than that measured by the conventional method (6.8 +/- 4.1 mm and 2.0 +/- 1.5 mm ), which may influence treatment. CONCLUSION: Twenty-degree-tilt A-P radiography may more precisely demonstrate fragment dislocation than standard radiographs and may influence patient treatment.