Single-Stage versus Multi-Stage Intramedullary Nailing for Multiple Synchronous Long Bone Impending and Pathologic Fractures in Metastatic Bone Disease and Multiple Myeloma.

PURPOSE: Determine whether perioperative outcomes differ between patients who have undergone single or multi-stage IMN procedures for impending or completed pathologic fractures. METHODS: Patients were classified into single-stage single-bone (SSSB), single-stage multiple-bone (SSMB), and multi-stage multiple-bone (MSMB) based on procedure timing and number of bones involved. Outcome variables compared included length of stay (LOS), in-hospital mortality and survival, initiation of rehabilitation and adjuvant therapy, and perioperative complications. RESULTS: There were 272 IMNs placed in 181 patients (100 males, 81 females, 55.2% and 44.8%, respectively) with a mean age of 66.3 ± 12.1 years. MSMB had significantly longer LOS (24.3 ± 14.2 days) and rehabilitation initiation (3.4 ± 2.5 days) compared to SSSB (8.5 ± 7.7 and 1.8 ± 1.6 days) and SSMB (11.5 ± 7.6 and 2.0 ± 1.6 days) subjects, respectively (both; p < 0.01). Although total perioperative complication rates in SSMB and MSMB were comparable (33.3% vs. 36.0%), they were significantly higher than SSSB (18%) (p = 0.038). MSMB had significantly more (20%) cardiopulmonary complications than SSMB (11.1%) and SSSB (4.5%) (p = 0.027). All groups exhibited comparative survivorship (8.1 ± 8.6, 7.1 ± 7.2, and 11.4 ± 11.8 months) and in-hospital mortality (4.5%, 8.9%, and 4.0%) (all; p > 0.05). CONCLUSION: In comparison to MSMB, SSMB intramedullary nailing did not result in higher perioperative complication or in-hospital mortality rates in select patients with synchronous long-bone metastases but led to earlier postoperative discharge and initiation of rehabilitation.

Trends and epidemiology of radial head subluxation in the United States from 2004 to 2018.

BACKGROUND: Increased body mass may predispose children to a greater risk for radial head subluxation (RHS). Recent studies in the literature have reported a plateau in obesity prevalence among infants and toddlers. This study sought to examine recent epidemiological trends in RHS incidence from 2004 to 2018 using the National Electronic Injury Surveillance System database to determine how obesity patterns may affect RHS incidence. METHODS: The National Electronic Injury Surveillance System (NEISS) database was queried for patients 6 years of age or younger presenting with radial head subluxation between January 1, 2004 and December 31, 2018. Patient demographics, mechanisms of injury, and location of injury were recorded. RESULTS: An estimated total 253,578 children 6 years or younger were treated for RHS with 14,204 (95% CI = 8124-20,284) in 2004 to 21,408 (95% CI = 12,882-29,934) in 2018. The overall annual rate of RHS per 10,000 children ≤ 6 years was 6.03 (95% CI = 4.85-7.58). The annual rate of RHS per 10,000 children ≤ 6 years increased (m = 0.200, ß = 0.802, p < 0.001) from 5.18 (95% CI 2.96-7.39) in 2004 to 7.69 (95% CI = 4.63-10.75) in 2018. The most common mechanism associated with RHS was falls (39.4%) with 103,466 (95% CI 74,806-132,125) cases. Pulls accounted for the second most common mechanism of injury, accounting for 90,146 (95% CI 68,274-112,018) cases or 36.2%. Yearly RHS incidence was compared to obesity prevalence for ages 2-5 children provided by the National Health and Nutritional Examination Survey (NHANES) surveys. Changes in obesity prevalence may visually reflect RHS incidence trends, but no causality between obesity prevalence and RHS incidence could be confirmed. CONCLUSION: This study corroborated previous findings that falls and arm pulling contribute to the vast majority of RHS cases. The nonsignificant rise in RHS cases may reflect a possible plateau in obesity prevalence of children aged 2-5 years in recent years. LEVEL OF EVIDENCE: III.

Septic arthritis of the hip and knee treated surgically in pediatric patients: Analysis of the Kids' Inpatient Database.

OBJECTIVE: This study evaluated incidence over time, any association between race and demographics, and hospital-related parameters in pediatric patients with septic hip or knee arthritis. METHODS: The Kids' Inpatient Database was used to identify all children with a diagnosis of septic hip or knee arthritis who underwent incision and drainage (1997-2012). RESULTS: Between 1997 and 2012, overall incidence of septic arthritis of the knee (0.20-0.33 per 100,000) and hip (0.12-0.18 per 100,000) increased. CONCLUSION: Incidence of pediatric septic joint arthritis, an emergent orthopaedic condition, has increased over time. Patient demographics may vary with respect to both age and race.

Intrasubstance Anterior Cruciate Ligament Injuries in the Pediatric Population.

Pediatric intrasubstance anterior cruciate ligament (ACL) tears have a significant epidemiologic impact as their numbers continue to grow globally. This review focuses on true pediatric intrasubstance ACL tears, which occur >400,000 times annually. Modifiable and non-modifiable risk factors include intercondylar notch width, ACL size, gender, landing mechanisms, and hormonal variations. The proposed mechanisms of injury include anterior tibial shear and dynamic valgus collapse. ACL tears can be associated with soft tissue and chondral defects. History and physical examination are the most important parts of evaluation, including the Lachman test, which is considered the most accurate physical examination maneuver. Imaging studies should begin with AP and lateral radiographs, but magnetic resonance imaging is very useful in confirming the diagnosis and preoperative planning. ACL injury prevention programs targeting high risk populations have been proven to reduce the risk of injury, but lack uniformity across programs. Pediatric ACL injuries were conventionally treated nonoperatively, but recent data suggest that early operative intervention produces best long term outcomes pertaining to knee stability, meniscal tear risk, and return to previous level of play. Current techniques in ACL reconstruction, including more vertically oriented tunnels and physeal sparing techniques, have been described to reduce the risk of physeal arrest and limb angulation or deformity. Data consistently show that autograft is superior to allograft regarding failure rate. Mean durations of postoperative therapy and return to sport were 7 ± 3 and 10 ± 3 months, respectively. These patients have good functional outcomes compared to the general population yet are at increased risk of additional ACL injury. Attempts at primary ACL repair using biological scaffolds are under investigation.

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.

The Influence of the Unaffected Hip on Gait Kinematics in Patients With Hemiplegic Cerebral Palsy.

BACKGROUND: Hemiplegic cerebral palsy (HCP) patients have transverse-plane gait deviations that may include the "uninvolved" side. The aim of this study is to quantify the static rotational profile, the dynamic position during gait and determine whether any correlations between the involved and uninvolved side exist. METHODS: A total of 171 subjects that met the inclusion criteria of HCP and no prior history of bony surgery were reviewed. Clinical and gait measurements were analyzed and compared between subjects and a population of typically developing (TD) children. RESULTS: Among children with HCP, static internal hip rotation of the affected limb was strongly correlated to static internal hip rotation on the unaffected limb (r=0.543, P<0.0001).There were 100 patients with maximum static internal rotation ≥66% of the total arc of motion in the affected hip. These subjects showed significant differences of static range of motion measures of the affected hip compared with TD. They also showed statistical significant differences between the dynamic measures of the affected limb of HCP and TD for mean pelvic rotation, mean hip rotation, and mean knee progression.In these 100 subjects, 23 patients had a maximum static internal rotation ≥66% of the total arc of motion on the unaffected hip and there were 77 subjects with <66% static internal rotation. Pelvic rotation and hip rotation were statistically different between these 2 groups, but knee progression angle was not significant. CONCLUSIONS: The "unaffected" side in patients with HCP influence gait kinematics. If static internal hip rotation exceeds 66% of the total arc of motion, almost all studied static and gait parameters were abnormal in HCP children, regardless if it was the affected side. Compensations on the "unaffected" side seem to be somewhat limited if the anatomic alignment is significantly asymmetric. This may be 1 reason pelvic transverse-plane changes after femoral rotation osteotomy are unpredictable. LEVEL OF EVIDENCE: Level II.

Demographics of Tennis-Related Injuries that Presented to Emergency Departments in the United States.

INTRODUCTION: Tennis injuries are not uncommon, and efforts have been made to reduce the risk of these injuries. There are a number of different factors that have been shown to influence injury rates of tennis players, in particular patient-related risks. Therefore, the purpose of this study was to investigate the epidemiology of tennis-related injuries. Specifically, we evaluated: 1) demographics; 2) incidence and trends of injuries; and 3) incidence and trends of body parts that were injured. MATERIALS AND METHODS: This study utilized the National Electronic Injury Surveillance System (NEISS) database to collect all tennis-related sprains/strains that occurred between January 1, 2010 and December 31, 2016. Patients were stratified into four groups based on their age: 13 years and younger, 14 to 29 years, 30 to 54 years, and 55 years and older. Race was reported as white, black, Hispanic, Asian, Native Hawaiian, American Indian, Multiracial, and not stated. The various types of tennis-related injuries that occurred, and the different body parts that were affected were identified. RESULTS: There were a total of 150,747 tennis-related injuries that occurred during the study period. Thirty-nine percent of all injuries occurred in patients aged 55 years and older, 25% in patients between the ages of 14 and 29 years, 24% occurred between the ages of 30 and 54 years, and 12% occurred in patients aged 13 years and younger. In terms of gender, 56% were men and 44% were women. In terms of race, injuries most commonly occurred in patients who were white (48%). The most common overall injury pattern was sprains/strains, which represented 32% of all reported injuries, followed by fractures (15%) and contusions (11%). The most commonly injured body parts were the ankle (13%), wrist (9.4%), upper-trunk (8.5%), knee (7.8%), and lower-trunk (6.7%). Over the study period, there was a significant decrease in ankle injuries (R2=0.691, p=0.021) and a significant increase in upper-trunk injuries (R2=0.695, p=0.020). CONCLUSION: The present study provided important insight regarding tennis-related injuries in terms of demographics, injury types, and injury patterns. This information is paramount for the future treatment of all tennis-related injuries and for the implementation of prevention strategies for those injuries which are most prevalent.

Transgenic Anopheles stephensi coexpressing single-chain antibodies resist Plasmodium falciparum development.

Anopheles stephensi mosquitoes expressing m1C3, m4B7, or m2A10 single-chain antibodies (scFvs) have significantly lower levels of infection compared to controls when challenged with Plasmodium falciparum, a human malaria pathogen. These scFvs are derived from antibodies specific to a parasite chitinase, the 25 kDa protein and the circumsporozoite protein, respectively. Transgenes comprising m2A10 in combination with either m1C3 or m4B7 were inserted into previously-characterized mosquito chromosomal "docking" sites using site-specific recombination. Transgene expression was evaluated at four different genomic locations and a docking site that permitted tissue- and sex-specific expression was researched further. Fitness studies of docking site and dual scFv transgene strains detected only one significant fitness cost: adult docking-site males displayed a late-onset reduction in survival. The m4B7/m2A10 mosquitoes challenged with P. falciparum had few or no sporozoites, the parasite stage infective to humans, in three of four experiments. No sporozoites were detected in m1C3/m2A10 mosquitoes in challenge experiments when both genes were induced at developmentally relevant times. These studies support the conclusion that expression of a single copy of a dual scFv transgene can completely inhibit parasite development without imposing a fitness cost on the mosquito.