Focal selective dorsal rhizotomy and concurrent deformity correction: a combined approach.

OBJECTIVE: Selective dorsal rhizotomy (SDR) is a neurosurgical procedure to reduce spasticity in children with cerebral palsy and spastic diplegia. The authors developed a procedure called focal SDR for children with spasticity predominantly in the L5 or S1 motor distribution, which can be combined with orthopedic correction of fixed soft-tissue or bony deformity. The authors describe in detail the technique of minimally invasive focal SDR and propose selection criteria. METHODS: The authors conducted a retrospective study of patients who underwent focal SDR at their institution and underwent baseline and 1-year postoperative 3D gait analysis. Modified Ashworth scale (MAS) and Gait Deviation Index (GDI) scores were the primary outcome measures. RESULTS: Ten patients met the study criteria, all with an underlying diagnosis of cerebral palsy. All underwent focal SDR at the unilateral or bilateral S1 level, and 4 additionally underwent focal SDR at the L5 level unilaterally or bilaterally. All but 1 patient underwent concurrent orthopedic surgery. The improvement in spasticity of the plantar flexors, as measured by the MAS score, was 2.2 (p < 0.001). In the patients who underwent L5 focal SDR, there was an improvement in the hamstring MAS score of 1.4 (p = 0.004). The mean improvement in the GDI score following focal SDR was 11 (range -6 to 29, p < 0.001). CONCLUSIONS: Focally impairing spasticity in the gastrocsoleus complex and/or hamstrings muscle group in the setting of less functionally impactful proximal tone is extremely common in cerebral palsy. The novel technique of focal SDR, combined with orthopedic intervention, improves spasticity scores and overall gait mechanics. Further investigation is warranted to define the ideal candidacy and outcomes.

Tibial derotational osteotomy for idiopathic tibial torsion: A systematic review of surgical indications based on clinical presentation and measurement technique.

PURPOSE: The aim of this systematic review was to identify the surgical indications of tibial derotational osteotomy (TDO) in patients with idiopathic external tibial torsion (ETT) and identify common measurement thresholds for surgical correction. METHODS: A systematic search of MEDLINE and Embase via Ovid, Cochrane Library via Wiley, Web of Science, Scopus, SPORTDiscus via EBSCOhost, ClinicalTrials.gov, WHO ICTRP and Global Index Medicus databases was performed with search terms reflecting the concepts of idiopathic tibial torsion, TDOs, and surgical indications. Studies reporting surgical indications and measurement methods of idiopathic tibial torsion in patients who underwent TDO were included. Two authors independently screened articles and extracted data that was characterized with descriptive statistics. RESULTS: Seventeen studies were identified for inclusion, with 460 tibias and 351 patients. Nearly all patients who underwent surgery had either anterior knee pain or patellar instability, even if other indications were present. Of all included patients, the most common surgical indications for TDO were anterior knee pain (88%), patellar instability (59%), gait dysfunction (41%) and cosmetic deformity (12%). Twelve studies (71%) cited multiple of these indications as reasons for surgery. On physical exam, tibial torsion was measured most commonly by thigh-foot angle (59%) (TFA) and transmalleolar axis (24%) (TMA). In terms of TFA, the most frequently reported cut-off for ETT was >30° (35%). Computerized tomography (CT) was used by nine studies (53%). The most common CT axes used to measure ETT were the TMA with respect to the posterior tibia condylar axis or the bicondylar tibia axis. CONCLUSION: Anterior knee pain and/or patellar instability are common indications for TDO in patients with idiopathic tibial torsion. Standardized TFA thresholds (>30°) and CT measurement methods (TMA and posterior tibia condylar or bicondylar tibial axis) may help further establish objective surgical indications. LEVEL OF EVIDENCE: IV.

A Telemedicine Solution to Minimize Unnecessary Emergency Department Transfers for Low-acuity Pediatric Orthopaedic Patients: A Model for Cost Minimization.

INTRODUCTION: Unnecessary emergency department (ED) transfers represent a notable source of excess costs and misutilization of healthcare resources, particularly with management of acute pediatric musculoskeletal injuries. This study used institutional data to create a model investigating the expected costs of a formal peer-to-peer telemedicine intervention designed to triage pediatric orthopaedic transfers, which we hypothesized would decrease healthcare costs by minimizing unwarranted ED-to-ED transfers. METHODS: In this retrospective modeling analysis, 350 pediatric orthopaedic trauma patients transferred to two in-network referral hospitals from outside facilities were identified and stratified into three groups representing how patients theoretically optimally could have been treated. Group 1 patients required ambulance transfer, group 2 patients required ED-level care but no ambulance transfer, and group 3 patients did not require ED-level care. Base case estimates for the proportions of patients in each group, probability of ambulance transport, and direct costs of care for each patient were derived from the database. A decision tree was developed to evaluate the expected costs of two triaging strategies: (1) transfer everyone or (2) triage first using e-consultation. Probabilistic sensitivity analyses were used to determine how the results of the decision analysis varied across ranges of cost and probability estimates. RESULTS: In the base case analysis, the telemedicine triage strategy was cheaper than the transfer-all strategy ($4,858 versus $6,610). In a 2-way sensitivity analysis comparing cost of a telemedicine visit and proportion of telemedicine triaged patients requiring ambulance transport, the telemedicine triage strategy remained cheaper than the transfer-all strategy across almost all possibilities for both variables. Additional potential benefits of triage before transfer, such as decreased length of time to completion of ED visit, cost to the family, and patient comfort and satisfaction, were not incorporated into this analysis. The potential for misdiagnosis related to telehealth and its potential costs were not included. DISCUSSION: We revealed substantial cost savings for the healthcare system from implementing a telehealth platform for peer-to-peer consultation when considering patient transfer for musculoskeletal trauma. Initial peer-to-peer e-consultations cost less than reflexive ambulance transfer in most situations. LEVEL OF EVIDENCE: Economic Level II.

Sliding Hip Screw and Side Plate for Intertrochanteric Hip Fractures.

For stable intertrochanteric hip fractures, treatment commonly involves the use of a sliding hip screw. Intertrochanteric hip fractures are increasingly common as the population ages and lives longer. More than 250,000 hip fractures occur per year in the United States1. The mortality rate within the first year following operative treatment ranges from 14% to 27.3%2,3. Early surgical repair within 48 hours of injury is associated with a lower risk of mortality2,4,5. The goals of surgical treatment are restoration of coronal plane alignment without varus angulation and early patient mobilization. Description: The sliding hip screw procedure can be divided into (1) preoperative planning; (2) patient positioning; (3) C-arm setup; (4) closed reduction of fracture; (5) sterile preparation and draping; (6) lateral hip approach; (7) guide pin insertion; (8) triple-reaming the proximal aspect of the femur; (9) sliding hip screw insertion into the femoral neck and head; (10) side plate insertion, engaging the sliding hip screw, and fixation to the femur; (11) lag compression screw insertion (if appropriate); and (12) final fluoroscopic images and wound closure. Alternatives: Intertrochanteric hip fractures must be surgically treated to avoid morbidity and increased risk of mortality. Nonoperative treatment is occasionally indicated in nonambulatory patients or those with high perioperative risk. If treated surgically, a common alternative implant option includes the intramedullary nail. Finally, for severely comminuted fractures or failed internal fixation, total hip arthroplasty may be necessary. Rationale: Sliding hip screws are as effective as intramedullary nails and often less costly6. In general, the quality of fracture reduction is more critical than the choice of implant7. A prospective study found no significant difference in walking ability with either sliding hip screws or intramedullary nails for stable intertrochanteric fractures8. Expected Outcomes: By 6 months, the majority of fractures will have healed; according to a prospective randomized study, 91% of stable fractures and 85% of unstable fractures had achieved radiographic union by that time9. Another study showed radiographically healed fractures in all 106 patients treated with sliding hip screws at median follow-up of 13.6 months8. Important Tips: Watch out for comminution of the greater or lesser trochanter, which may require supplemental fixation.Prior to completely reflecting the vastus lateralis muscle, control the bleeding from any perforators with use of 2-0 silk ties. This prevents recurrent bleeding, which often occurs if only cautery is utilized to coagulate these vessels.Utilize a 4.5-mm drill hole in the lateral cortex of the femur in order to allow for minor adjustments of the anterior femoral neck guide pin; otherwise, the pin will be held tightly and continue to be bound in the same direction by the lateral cortex on repeated attempts.If the guide pin is inadvertently withdrawn along with the reamer after reaming, a lag screw may be placed backward in the newly reamed hole and the guide pin passed back through the lag screw to reposition it.Extracapsular hip fractures should be carefully scrutinized for signs of instability, such as lateral wall comminution or reverse obliquity. The fracture may displace posteriorly when the patient is supine on the fracture table.While placing the guidewire, multiple entry attempts can weaken the lateral cortex and propagate the fracture into the subtrochanteric region.Superior placement of the lag screw results in poor tip-apex distance and a higher chance of screw cut-out.Be careful to prevent guidewire penetration into the hip joint.Loss of reduction or femoral head malrotation may occur during lag screw insertion. Acronyms & Abbreviations: AP = anteroposteriorfx's = fracturesIMN = intramedullary nailIV = intravenousPDS = polydioxanone sutureSHS = sliding hip screwTFL = tensor fascia lata.

Biomechanical evaluation of sacroiliac joint fixation with decortication.

BACKGROUND CONTEXT: Fusion typically consists of joint preparation, grafting, and rigid fixation. Fusion has been successfully used to treat symptomatic disruptions of the sacroiliac joint (SIJ) and degenerative sacroiliitis using purpose-specific, threaded implants. The biomechanical performance of these systems is important but has not been studied. PURPOSE: The objective of this study was to compare two techniques for placing primary (12.5 mm) and secondary (8.5 mm) implants across the SIJ. STUDY DESIGN: This is a human cadaveric biomechanical study of SIJ fixation. MATERIALS AND METHODS: Pure-moment testing was performed on 14 human SIJs in flexion-extension (FE), lateral bending (LB), and axial rotation (AR) with motion measured across the SIJ. Specimens were tested intact, after destabilization (cutting the pubic symphysis), after decortication and implantation of a primary 12.5-mm implant at S1 plus an 8.5-mm secondary implant at either S1 (S1-S1, n=8) or S2 (S1-S2, n=8), after cyclic loading, and after removal of the secondary implant. Ranges of motion (ROMs) were calculated for each test. Bone density was assessed on computed tomography and correlated with age and ROM. This study was funded by Zyga Technology but was run at an independent biomechanics laboratory. RESULTS: The mean±standard deviation intact ROM was 3.0±1.6° in FE, 1.5±1.0° in LB, and 2.0±1.0° in AR. Destabilization significantly increased the ROM by a mean 60%-150%. Implantation, in turn, significantly decreased ROM by 65%-71%, below the intact ROM. Cyclic loading did not impact ROM. Removing the secondary implant increased ROM by 46%-88% (non-significant). There was no difference between S1-S1 and S1-S2 constructs. Bone density was inversely correlated with age (R=0.69) and ROM (R=0.36-0.58). CONCLUSIONS: Fixation with two threaded rods significantly reduces SIJ motion even in the presence of joint preparation and after initial loading. The location of the secondary 8.5-mm implant does not affect construct performance. Low bone density significantly affects fixation and should be considered when planning fusion constructs. Findings should be interpreted in the context of ongoing clinical studies.

The utility of ultrasound for diagnosing purulent infections of the upper extremity.

BACKGROUND: The purpose of this study was to determine the test characteristics of formal ultrasound when used to diagnose upper extremity soft tissue abscess in the setting of suspected infection. METHODS: We completed a retrospective chart review of all patients who had formal ultrasounds at our institution for the indication of diagnosing upper extremity abscess between July 2010 and July 2013. Using presence of purulence as the gold standard for diagnosis of abscess, we calculated the test characteristics of ultrasound. We then performed a series of logistic regression models with ultrasound being the independent variable of interest. RESULTS: Using search criteria consistent with upper extremity abscess, we identified 512 patients who underwent ultrasound examinations during our study period. Of these, 178 met the enrollment criteria. Ultrasound reports revealed 110 negative findings, 37 definitively positive findings, and 31 ambiguous findings. Forty-four patients had a final diagnosis of abscess, and 15 of these patients had negative or ambiguous ultrasounds. The sensitivity of definitively positive ultrasound was 65.9 %. The specificity was 94.0 %. Positive predictive value (PPV) of a definitively positive ultrasound result was 78.4 %, and negative predictive value (NPV) of a definitively negative result was 90 %. Logistic regression demonstrated a statistically significant association between definitively positive ultrasound and abscess, but no association between ambiguous ultrasound and abscess after adjustment for significant covariates. CONCLUSIONS: Ultrasound is not a sensitive method to detect the presence of abscess in the setting of upper extremity infection. However, in this population of patients with suspected abscess, the negative predictive value was high with and without the inclusion of ambiguous results, suggesting reasonable utility of ultrasound as a rule-out test. LEVEL OF EVIDENCE: Diagnostic study, Level II.

Biomechanical diversity despite mechanobiological stability in tissue engineered vascular grafts two years post-implantation.

Recent advances in vascular tissue engineering have enabled a paradigm shift from ensuring short-term graft survival to focusing on long-term stability and growth potential. We present the first experimental-computational study of a tissue-engineered vascular graft (TEVG) effectively over the full lifespan of the recipient. We show that grafts implanted within the venous circulation of mice remained patent over 2 years without thrombus, stenosis, or aneurysmal dilatation. Moreover, the gross appearance and mechanical properties of the grafts evolved to be similar to the host vein within 24 weeks, with mean neovessel geometry and properties remaining unchanged thereafter despite a continued turnover of extracellular matrix. Biomechanical diversity manifested after 24 weeks, however, via two subsets of grafts despite all procedures being the same. Computational modeling and associated immunohistological analyses suggested that this diversity likely resulted from a differential ratio of collagen types I and III, with lower I to III ratios promoting grafts having a compliance similar to the native vein. We submit that TEVGs can exhibit the desired long-term mechanobiological stability; hence, we must now focus on evaluating growth potential and optimizing scaffold properties to achieve compliance matching throughout neovessel development.