Hip sonography according to Graf: practical notes for the student, the examiner and the reviewer.

Since the publication of Professor Reinhard Graf's work in 1980, Graf's technique has become the gold standard for screening Developmental Dysplasia of the Hip (DDH) in many European and non-European countries. Despite the fact that it is supported by robust literature evidence, there is criticism about its reliability and reproducibility, questioning severalaspects of the diagnostic procedure. There is, however, concern, based on recent literature, about the quality and reliability of the published data, which may, in many cases, be based on inadequate scans, and therefore any conclusions drawn have to be questioned. The aim of this review is to demonstrate the most important aspects of Graf's technique, to clarify the potential sources of confusion and to flag up the most common errors and mistakes made, either during the ultrasound examination, or during the reporting procedure. Furthermore, this review can be used as a guide for reviewers and editors and should help to enhance the quality control of publications on this subject.

Hemiepiphysiodesis: when should it be considered a day-case procedure?

Hemiepiphysiodesis is usually planned as a day-case but patients may stay overnight for pain control. In this study, we assessed the required level of analgesia (LOA) and length of stay (LOS) in patients undergoing hemiepiphysiodesis about the knee joint. We conducted a retrospective cohort study of patients that underwent temporary hemiepiphysiodesis of the distal femur or proximal tibia using hemiepiphysiodesis plates (eight-plates) for coronal plane deformities between January 2012 and October 2019. Demographics, type of procedure, anatomical site, anaesthetic time, preoperative, intraoperative and postoperative analgesia, and time of surgery were collected. Anterior hemiepiphysiodesis and permanent drill epiphysiodesis procedures were excluded. In this series of 79 patients, those with increased American Society of Anesthesiologists Score >1 and patients that were operated on >2 sites required increased LOA, (P < 0.05) and prolonged LOS (P < 0.05). The timing of surgery (morning vs. afternoon list) did not influence LOS or LOA. Patient-controlled analgesia (PCA) was required in 8 of 14 (57%) patients with four growth plates operated on. All (n = 12) patients that received PCA remained in hospital for at least one night. The use of local infiltration intraoperatively played a significant role in early discharge of the patients and t lower the LOA postoperatively (P < 0.05). Parameters including the number of growth plates operated on, use of tourniquet and intraoperative local infiltration can independently influence LOS and LOA postoperatively and at discharge. These parameters should be taken into consideration when consulting with the patient and family and when planning the postoperative course.

'Does compliance with BOAST guidelines matter for displaced supracondylar fractures in children?': the experience of a tertiary referral major trauma centre over a 3.5-year period.

Supracondylar fractures are the most frequently occurring paediatric fractures about the elbow and can be associated with neurovascular injury. For that reason, the British Orthopaedic Association has published the British Orthopaedic Association Standards for Trauma (BOAST) 11 guidelines, aiming to the best management of supracondylar fractures. The aim of this study was to assess adherence to the BOAST 11 guidelines for displaced supracondylar fractures at a Major Trauma Centre in London, UK between 2015 and 2018 and to see whether adherence to guidelines affected the outcomes. A retrospective review was carried out between January 2015 and August 2018 of all paediatric patients who underwent either closed reduction and percutaneous pinning or open reduction and fixation for a displaced supracondylar fracture of the humerus. One hundred nine patients between 1 and 16 years of age with isolated displaced extension type supracondylar fractures (Gartland II, III and IV) were included in the study. The current study did not manage to achieve complete compliance with the BOAST 11 guidelines. K-wire size, fixation technique and pre-, intra-, postoperative documentation were the most important points of lack of compliance. However, deviating from specific guidelines did not cause any adverse clinical outcomes. Lack of correct documentation either preoperatively or postoperatively could be detrimental to patient outcome, especially with respect to neurovascular status. Implementation of a clerking template for use in the electronic medical records for all children with displaced supracondylar fractures is of value in order to improve our documentation.

Perioperative Blood Management Strategies for Patients Undergoing Total Hip Arthroplasty: Where Do We Currently Stand on This Matter?

Total hip replacement (THR) has proved to be a reliable treatment for the end stage of hip osteoarthritis. It is a common orthopaedic procedure with excellent results, but is associated with significant blood loss and high rates of allogeneic blood transfusion (ABT). The potential complications and adverse events after ABT, combined with the ongoing research, have resulted in multimodel, multidisciplinary blood management strategies adoption, aiming to reduce the blood loss and transfusion rates. Many reviews and meta-analyses have tried to demonstrate the best blood management strategies. The purpose of this study is to review any evidence-based blood conserving technique, dividing them in three stages: preoperative, intraoperative and postoperative.

Multiple intravenous tranexamic acid doses in total knee arthroplasty without tourniquet: a randomized controlled study.

BACKGROUND: Tranexamic acid (TXA) is widely used in the orthopedic field and particularly in total knee arthroplasty (TKA). Its efficacy and safety in reducing the blood loss in TKA have been well-documented in the current literature. Little data regarding TKA without tourniquet and TXA exist. Our aim is to compare three different dosages of intravenous (IV) TXA in TKA without tourniquet. MATERIALS AND METHODS: A total of 180 patients undergoing TKA for knee osteoarthritis were stratified in three equal groups. All surgeries were performed under spinal anesthesia, without tourniquet. Group A (60 patients) received 15 mg/kg of IV TXA given on induction, Group B (60 patients) received an additional dose of IV TXA (15 mg/kg) 3 h after incision and Group C (60 patients) received an additional (third) dose 3 h later (15 mg/kg). The measured outcomes were the change in hemoglobin (Hb) from pre-operatively to post-operatively, the amount of blood transfusion given (units), the functional and quality of life (QoL) and pain assessment based on their corresponding scoring system. RESULTS: Calculated blood loss, Hb decrease and transfusion rate were significantly lower in Group C (p value < 0.05). Additionally, patients that had been included in the three-dosage group benefited much more in terms of faster rehabilitation, better QoL, decreased post-operative pain, with no increase in complications. CONCLUSION: According to our results, three doses of IV TXA have effectively and safely reduced blood loss and the need of allogeneic blood transfusion in patients undergoing TKA without tourniquet, with additional patients-related benefits. LEVEL OF EVIDENCE: II.

Adolescent Lisfranc injury treated with TightRopeTM: A case report and review of literature.

BACKGROUND: Lisfranc injuries are rare and can be easily missed. This injury is extremely rare in children, with limited published data. Different treatment options have been described; one of the options in adults is the "mini" TightRope™ Syndesmosis Device that provides non-rigid fixation with impressive results. However, there is no reference regarding the use of this device in children. CASE SUMMARY: We describe the case of an 11-year-old girl who sustained a Lisfranc injury of her right foot that was initially missed in the Accident and Emergency department of her local hospital. This case was a ligamentous/periosteal sleeve avulsion type of Lisfranc injury and a percutaneous technique using the "mini" TightRope™ syndesmosis device was used. Clinical and radiological results were excellent at final follow up. CONCLUSION: The "mini" TightRope™ syndesmosis device is a promising method of fixation for children with certain Lisfranc injuries. This method has many advantages, including the non-rigid type of the fixation and no need for subsequent metalwork removal.

Minimally invasive versus conventional approaches in total knee replacement/arthroplasty: A review of the literature.

BACKGROUND: Life expectancy lengthening and aging of population resulted in dramatically increase of patients with osteoarthritis. Total knee arthroplasty is widely used as the gold standard in order to relieve pain, correct deformity and restore function. A contemporary and controversial topic, is that of minimally invasive surgery for TKA. The minimally invasive approaches are based on the concept that they don't violate the extensor mechanism, resulting in earlier functional recovery, shorter hospital stay and enhanced patients' overall satisfaction. The most commonly used MIS approaches in TKA are the subvastus, midvastus and the quadriceps sparing. There is a debate regarding the efficacy and safety of these methods. OBJECTIVE: In this article we will review the current literature (randomized controlled trials and systematic reviews/meta-analyses) on MIS compared to traditional approach and analyse their clinical safety, efficacy and long-term results. DESIGN: Comparison of well-designed studies have tried to demonstrate the advantages/disadvantages, the clinical results and the complications of the MIS approaches compared to the MPP approach. RESULTS: MIS approaches seem to provide advantages in the immediate post-operative period accompanied by increased reports of complications. Consequently, further investigation based on large well-designed studies with long-term results are warranted to further clarify MIS effectiveness/safety.

Oblong Sesamoid Bone Appearance into the Nuchal Ligament. A Case Report.

Radio-opaque formations behind the spinous processes of the cervical spine are really rare. They were described in 1929 for the first time. Sesamoid ossicles are found close to a bone or a joint and are usually small. Some sesamoids form part of normal human anatomy, while others are normal anatomical variants. We report a case of a 73-year-old Caucasian male who visited the outpatient clinic complaining about chronic cervical pain. An oblong sesamoid accidentally discovered during routine anteroposterior (AP) and lateral x-ray, within the nuchal ligament (NL) at the C3-C6 spinous processes level. A cervical MRI scan was performed and the result showed 'fabella nuchae'. This type of sesamoids are rarely symptomatic, but it should be differentially diagnosed anyway. We review its morphology, the mechanical factors of the region acting throughout life and last, but not least, the differential diagnosis.

Intravenous vs Topical Tranexamic Acid in Total Knee Arthroplasty Without Tourniquet Application: A Randomized Controlled Study.

BACKGROUND: Use of tranexamic acid (TXA) is effective and safe in reducing the blood loss in total knee arthroplasty (TKR) performed using a tourniquet, but, data in TKR performed without tourniquet are limited, and there is no study comparing the topical (T) with intravenous (IV) TXA administration. Our aim was to compare the topical (T) with intravenous (IV) TXA administration in TKR performed without tourniquet. MATERIAL AND METHODS: A total of 120 patients undergoing unilateral TKR for knee osteoarthritis were included in a prospective randomized study. Operations were performed under spinal anesthesia, no tourniquet was used, and the postoperative regime was the same for all patients. Patients were divided into 3 groups; in group C (control), 40 patients received no TXA, in group IV, 40 patients received 1 g of TXA intravenously, and in group L, 1 g of TXA was applied locally to 40 patients. The primary outcome measures included the calculated blood loss, the transfusion rate, and quantity of allogeneic blood units, whereas secondary outcome measures were complications. RESULTS: There was no statistically significant difference in patient's demographics and perioperative results. Calculated blood loss, allogeneic blood transfusion rate, and quantity in group C were significantly higher compared with those of TXA groups (P < .001). There was no significant difference in complications rate between the 3 groups. CONCLUSIONS: According to the results of this study, IV or T administration of 1-g TXA significantly reduced the blood loss and the need for allogeneic blood transfusion in patients undergoing TKR without a tourniquet (with no significant difference between the 2 routes of administration).

Fine needle aspiration cytology diagnosis of gastrointestinal stromal tumors utilizing scanning electron microscopy.

BACKGROUND: Digestive stromal neoplasms are the most frequent undifferentiated mesenchymal tumors. The outcome of these malignancies is difficult to predict and the histogenesis is still controversial. However, the frequent and specific expression of CD117 (c-kit) by these tumors could imply an origin from interstitial cells of Cajal. Our objective was to analyze the role of fine needle aspiration cytology, cell block preparation, and immunocytochemistry in the interpretation of gastrointestinal stromal tumors, and to establish scanning electron microscopy as a useful research aid for pathologic changes of the surface cells of gastrointestinal stromal tumors, not totally appreciated by light microscopy. MATERIAL AND METHODS: Twelve cases of gastrointestinal stromal tumors were included in this study, in which fine needle aspiration cytology was performed. RESULTS: On aspirated material, the tumor cells formed closely packed cohesive tissue fragments with high cellular density often in bloody background, or fascicles with parallel side-by-side arrangements of the nuclei. On cell block biopsy material, gastrointestinal stromal tumors were highly cellular spindle or epithelioid tumors with basophilic appearance. Immunocytochemically, they were CD117 positive in all twelve cases, CD34 positive in nine, weakly smooth muscle actin-positive in five, and S-100 and GFAP-negative in all cases. The scanning electron microscopy study showed a strong correlation with the cytomorphological profile. CONCLUSIONS: Gastrointestinal stromal tumors show a broad morphologic variety, but nuclear pleomorphism by cytology alone, rarely correlates with malignant potential. In the appropriate clinical and radiological setting, a confident diagnosis of gastrointestinal stromal tumors can be documented by fine needle aspiration cytology, cell block, immunocytochemical, and scanning electron microscopy results.