Webril-only Soft Spica Cast for Pediatric Femoral Fractures: A Preliminary Study.

We report using a spica cast created with cotton padding and Ace wrap without a rigid component for femur fracture in infants. Outcomes and complications of this soft spica cast were retrospectively compared with other treatments. There were 43 children younger than 6 months (43 diaphyseal fractures) included in the study. Treatment was a Pavlik harness (26 patients), a hard spica cast (8), or a soft spica cast (9) for an average of 3 weeks. All fractures demonstrated healing with similar final angulation and shortening. Hard spica casts caused the most complications. As for material costs, the soft spica is the least costly method ($2 per cast versus $87-$107 for Pavlik harness and $150 for hard spica). In conclusion, soft spica casts are as effective as other treatment options for femoral shaft fractures in young children. These casts are advantageous since they are easier to apply, easier to manage, and have a lower cost. (Journal of Surgical Orthopaedic Advances 30(1):040-043, 2021).

Applications of the transfibular approach to the hindfoot: A systematic review and description of a preferred technique.

BACKGROUND: The indications and technique for the transfibular approach to the tibiotalar joint have evolved since its initial popularization in 1942. The purpose of this systematic review is to assess the indications, techniques, and postoperative outcomes among procedures performed with the transfibular approach. METHODS: A comprehensive search of PubMed, Medline, and Embase databases from 1942 to 2018 was performed in accordance with PRISMA guidelines. After an initial broad search of transfibular approach indications, articles were stratified into 4 major surgical categories for assessment: (1) tibiotalar arthrodesis (2) tibiotalocalcaneal arthrodesis (3) total ankle replacement and (4) distal tibial tumor excision. Data was analyzed according to these 4 categories. RESULTS: A total of 32 studies (874 ankles) were included. Fibular non-union rates were 0.7 % (5 of 672) across all studies, 0.6% (2 of 329) for tibiotalar arthrodesis, 0.0% (0 of 12) for tibiotalocalcaneal arthrodesis, 1.0 % (3 of 296) for total ankle arthroplasty and 0.0% (0 of 15) for other procedures. Rates of deep infection were 2.5% (23 of 903) across all studies, 3.2% (15 of 466) for tibiotalar arthrodesis, 3.7% (4 of 106) for tibiotalocalcaneal arthrodesis, 1.3% (4 of 296) for total ankle arthroplasty, and 0.0% (0 of 15) for other procedures. CONCLUSIONS: The transfibular approach is useful for cases requiring extensile exposure of the tibiotalar joint. This study provides evidence that the transfibular approach yields satisfactory results, with low complication and infection rates. LEVEL OF EVIDENCE: IV.

Predictive Accuracy of the ACS-NSQIP Surgical Risk Calculator for Pathologic Humerus Fracture Fixation.

Pathologic fractures are associated with poor outcomes. This article investigated the prevalence of underestimation of risk by the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Surgical Risk Calculator (SRC) in patients with pathologic humerus fractures. Two hundred seven (207) patients were identified and analyzed using the ACS-NSQIP SRC. Predicted and actual outcomes were then compared. Average hospitalization was 6 ± 10 days. Ten patients (5%) had a mild adverse event (AE), and 15 (7%) had a serious AE. The ACS-NSQIP SRC underestimated hospitalizations (p < 0.001), but not serious AE (p = 0.601), mild AE (p = 0.948), cardiac complications (p = 0.817), pneumonia (p = 0.713), surgical site infection (p = 0.692), urinary tract infection (p = 0.286), venous thromboembolism (p = 0.554), acute renal failure (p = 0.191), discharge to acute care facility (p = 0.865), readmission (p = 1.0), reoperation (0.956) or mortality (p = 0.872). Negative outcomes were limited in this cohort, and the SRC demonstrated acceptable accuracy. Future investigation of the calculator in other orthopaedic populations is warranted. (Journal of Surgical Orthopaedic Advances 28(4):250-256, 2019).

Myositis Ossificans in Sport: A Review.

Myositis ossificans is a benign, solitary, frequently self-limiting, ossifying soft-tissue mass encountered often in the active sporting population. Typically occurring within skeletal muscle - most often the brachialis, quadriceps and adductor muscle groups - lesions may arise with or without a traumatic history. The exact pathophysiology of these ossifying lesions is still poorly understood. Patients present with localized pain and swelling with loss of range of motion. Plain radiographs may not be able to detect early lesions, which allows for an expanded role of ultrasonography as an early screening modality, despite magnetic resonance imaging remaining the gold standard for imaging of soft tissue masses. Conservative treatment is implemented for most patients with excellent outcomes, with surgical excision being an option for persistent symptoms or progressive disease. Typically, athletes are able to progress to light activity at 2 to 3 months, full activity by 6 months, and back to their preinjury level by 1 year.

A retained secretory signal peptide mediates high density lipoprotein (HDL) assembly and function of haptoglobin-related protein.

Haptoglobin-related protein (Hpr) is a component of a minor subspecies of high density lipoproteins (HDL) that function in innate immunity. Here we show that assembly of Hpr into HDL is mediated by its retained N-terminal signal peptide, an unusual feature for a secreted protein and the major difference between Hpr and the soluble acute phase protein haptoglobin (Hp). The 18-amino acid signal peptide is necessary for binding to HDL and interacts directly with the hydrocarbon region of lipids. Utilizing model liposomes, we show that the rate of assembly and steady-state distribution of Hpr in lipid particles is mediated by the physical property of lipid fluidity. Dye release assays reveal that Hpr interacts more rapidly with fluid liposomes. Conversely, steady-state binding assays indicate that more rigid lipid compositions stabilize Hpr association. Lipid association also plays a role in facilitating hemoglobin binding by Hpr. Our data may offer an explanation for the distinct distribution of Hpr among HDL subspecies. Rather than protein-protein interactions mediating localization, direct interaction with phospholipids and sensitivity to lipid fluidity may be sufficient for localization of Hpr and may represent a mechanism of HDL subspeciation.

Bis-aryloxadiazoles as effective activators of the aryl hydrocarbon receptor.

Bis-aryloxadiazoles are common scaffolds in medicinal chemistry due to their wide range of biological activities. Previously, we identified a 1,2,4-bis-aryloxadiazole that blocks mammary branching morphogenesis through activation of the aryl hydrocarbon receptor (AHR). In addition to defects in mammary differentiation, AHR stimulation induces toxicity in many other tissues. We performed a structure activity relationship (SAR) study of 1,2,4-bis-aryloxadiazole to determine which moieties of the molecule are critical for AHR activation. We validated our results with a functional biological assay, using desmosome formation during mammary morphogenesis to indicate AHR activity. These findings will aid the design of oxadiazole derivative therapeutics with reduced off-target toxicity profiles.

Giant Cell Tumor of the Distal Radius: A Review.

Giant cell tumor of the distal radius presents a significant challenge in management due to high risk of recurrence and potential loss of function. Shared decision-making guides management, particularly for more advanced lesions. Intralesional curettage can optimize wrist function but at the cost of a higher recurrence risk. Wide resection decreases local recurrence but has higher complication rates regardless of reconstruction method. No functional difference exists between motion-preserving procedures and arthrodesis; therefore, patients should be clearly informed of the risks and benefits of each treatment option.

Intravenous tranexamic acid decreases intraoperative transfusion requirements and does not increase incidence of symptomatic venous thromboembolic events in musculoskeletal sarcoma surgery.

BACKGROUND AND OBJECTIVES: Tranexamic acid (TXA) is poorly studied in patients with bone and musculoskeletal sarcoma due to perceived increased risk of venous thromboembolism (VTE). This study aims to assess the safety and efficacy of intravenous (IV) TXA for patients undergoing surgical resection of primary bone or soft-tissue sarcoma. METHODS: A retrospective, single center review of adult patients with pelvic or extremity sarcoma who underwent surgical resections between January 2005 and March 2020 was performed. Patients between 2005 and 2012 were included as a historical comparison prior to the routine use of IV TXA for all sarcoma resections at our institution. RESULTS: Thirty-nine non-TXA and 59 TXA resections were identified. Two non-TXA patients experienced symptomatic pulmonary embolism compared to zero VTEs amongst TXA patients. IV TXA administered at any dose significantly reduced the probability of intraoperative transfusion (p = 0.003) and the median units of blood transfused at the time of any perioperative transfusion (p = 0.007). Intraoperative times were significantly shorter for TXA patients (128 vs 190 min; p = 0.004). A subset of patients who underwent wide resection with endoprosthetic reconstruction and received TXA similarly showed decreased requirement for intraoperative transfusion (p = 0.014) and decreased procedure times (p = 0.009). CONCLUSIONS: During sarcoma resection, at least 1 g of IV TXA can safely decrease the need for any intraoperative transfusion and the median number of PRBCs transfused by 2 units when any perioperative transfusion is given.

Outcomes of SARS-CoV-2 infection among patients with orthopaedic fracture surgery in the National COVID Cohort Collaborative (N3C).

BACKGROUND: The objective of this study was to investigate the outcomes of COVID-19-positive patients undergoing orthopaedic fracture surgery using data from a national database of U.S. adults with a COVID-19 test for SARS-CoV-2. METHODS: This is a retrospective cohort study using data from a national database to compare orthopaedic fracture surgery outcomes between COVID-19-positive and COVID-19-negative patients in the United States. Participants aged 18-99 with orthopaedic fracture surgery between March and December 2020 were included. The main exposure was COVID-19 status. Outcomes included perioperative complications, 30-day all-cause mortality, and overall all-cause mortality. Multivariable adjusted models were fitted to determine the association of COVID-positivity with all-cause mortality. RESULTS: The total population of 6.5 million patient records was queried, identifying 76,697 participants with a fracture. There were 7,628 participants in the National COVID Cohort who had a fracture and operative management. The Charlson Comorbidity Index was higher in the COVID-19-positive group (n = 476, 6.2 %) than the COVID-19-negative group (n = 7,152, 93.8 %) (2.2 vs 1.4, p<0.001). The COVID-19-positive group had higher mortality (13.2 % vs 5.2 %, p<0.001) than the COVID-19-negative group with higher odds of death in the fully adjusted model (Odds Ratio=1.59; 95 % Confidence Interval: 1.16-2.18). CONCLUSION: COVID-19-positive participants with a fracture requiring surgery had higher mortality and perioperative complications than COVID-19-negative patients in this national cohort of U.S. adults tested for COVID-19. The risks associated with COVID-19 can guide potential treatment options and counseling of patients and their families. Future studies can be conducted as data accumulates. LEVEL OF EVIDENCE: Level III.

Is it necessary to fuse to the pelvis when correcting scoliosis in cerebral palsy?

BACKGROUND: Neuromuscular scoliosis is commonly associated with a large pelvic obliquity. Scoliosis in children with cerebral palsy is most commonly managed with posterior spinal instrumentation and fusion. While consensus is reached regarding the proximal starting point of fusion, controversy exists as to whether the distal level of spinal fusion should include the pelvis to correct the pelvic obliquity. AIM: To assess the role of pelvic fusion in posterior spinal instrumentation and fusion, particularly it impact on pelvic obliquity correction, and to assess if the rate of complications differed as a function of pelvic fusion. METHODS: This was a retrospective, cohort study in which we reviewed the medical records of children with cerebral palsy scoliosis treated with posterior instrumentation and fusion at a single institution. Minimum follow-up was six months. Patients were stratified into two groups: Those who were fused to the pelvis and those fused to L4/L5. The major outcomes were complications and radiographic parameters. The former were stratified into major and minor complications, and the latter consisted of preoperative and final Cobb angles, L5-S1 tilt and pelvic obliquity. RESULTS: The study included 47 patients. The correction of the L5 tilt was 60% in patients fused to the pelvis and 67% in patients fused to L4/L5 (P = 0.22). The pelvic obliquity was corrected by 43% and 36% in each group, respectively (P = 0.12). Regarding complications, patients fused to the pelvis had more total complications as compared to the other group (63.0% vs 30%, respectively, P = 0.025). After adjusting for differences in radiographic parameters (lumbar curve, L5 tilt, and pelvic obliquity), these patients had a 79% increased chance of developing complications (Relative risk = 1.79; 95%CI: 1.011-3.41). CONCLUSION: Including the pelvis in the distal level of fusion for cerebral palsy scoliosis places patients at an increased risk of postoperative complications. The added value that pelvic fusion offers in terms of correcting pelvic obliquity is not clear, as these patients had similar percent correction of their pelvic obliquity and L5 tilt compared to children whose fusion was stopped at L4/L5. Therefore, in a select patient population, spinal fusion can be stopped at the distal lumbar levels without adversely affecting the surgical outcomes.

Diagnosis and Management of Traumatic Hemipelvectomy.

Traumatic hemipelvectomy (THP) is a catastrophic injury associated with high-energy trauma and high mortality. THP has been defined as a complete dislocation of the hemipelvis, often with disruption through the symphysis pubis and sacroiliac joint with concurrent traumatic rupture of the iliac vessels. Despite recent advances in prehospital resuscitative techniques, the true incidence of THP is difficult to ascertain because many patients die before hospital arrival. The leading causes of death associated with THP include blood loss, infection, and multiple system organ failure. Recognition and immediate intervention for these injuries is imperative for survival. The initial assessment includes a thorough physical examination assessing for signs of arterial damage and other associated injuries. Hemorrhage control and vigorous resuscitation should be prioritized to combat impending exsanguination. Emergent amputation has been found to be a lifesaving operation in these patients. The basis of this approach is rooted in achieving complete hemostasis while reducing complication rates. Understanding the nature of these massive pelvic injuries, the role of early amputation, and the importance of subspecialty communication can improve survivability and optimize patient outcomes.

Prevalence and Risk Factors of Postoperative Falls Following Foot and Ankle Surgery.

BACKGROUND: No study has examined the incidence of risk factors for postoperative falls following foot and ankle surgery. We investigated the incidence and risk factors for postoperative falls in foot and ankle surgery using inpatient and outpatient population. METHODS: A single fellowship-trained foot and ankle surgeon instituted collection of a postoperative fall questionnaire at 2 and 6 weeks postoperatively. A retrospective review of 135 patients with complete prospectively collected fall questionnaire data was performed. Patient demographic information, injury characteristics, comorbidities, baseline medications, length of hospital stay, visual analog scale (VAS) pain scores were collected. After univariable analysis, a multivariable binary logistic regression was conducted to assess independent risk factors for postoperative falls. RESULTS: The median (interquartile range) age was 52 (21) and body mass index was 32.7 (11.1). A total of 108 patients (80%) underwent outpatient procedures. Thirty-nine of the 135 patients (28.9%) reported experiencing a fall in the first 6 weeks after surgery. In multivariable analysis, antidepressant use (adjusted odds ratio 3.41, 95% CI 1.19-9.81) and higher VAS pain scores at 2 weeks postoperatively (adjusted odds ratio 1.27, 95% CI 1.08-1.50) were found to be independent risk factors for postoperative falls. CONCLUSION: This study found a high incidence of postoperative falls in the first 6 weeks after foot and ankle surgery. Baseline antidepressant use and higher 2-week VAS pain scores were associated with postoperative falls. Foot and ankle surgeons should discuss the risk of falling with patients especially those with risk factors. LEVEL OF EVIDENCE: Level III, retrospective cohort study at a single institution.

Non-Necrotizing Bullous Cellulitis and Bacteremia: A Rare Presentation of the Shewanella Algae Infection.

A 58-year-old male with severe psoriasis on Risankizumab presented with painful, left leg swelling with erythema and blisters concerning for necrotizing fasciitis. Intraoperative findings showed non-necrotizing bullous cellulitis. The blood and tissue cultures grew Shewanella algae. A handful case of non-necrotizing bullous cellulitis has been reported but this is the first documented case of non-necrotizing bullous cellulitis and bacteremia in PubMed.

COVID-19 and Acute Cervical Spinal Cord Injury-Case Report of 2 Patients: Do We Need to Rethink Our Standard Treatment Strategy?

STUDY DESIGN: This was a case series. OBJECTIVE: The authors sought to examine the high-risk population of COVID-positive patients with acute cervical spinal cord injury (SCI) in a large level 1 trauma and tertiary referral center. SUMMARY OF BACKGROUND DATA: There are limited studies regarding the surgical management of patients with acute SCI in the setting of the recent coronavirus pandemic. METHODS: The authors describe the cases of 2 patients who died from COVID-related complications after acute cervical SCI. RESULTS: Patients with SCI are at increased risk of pulmonary complications. COVID-19 infection represents a double hit in this patient population, increasing potential morbidity and mortality in the perioperative time frame. Careful consideration must be made regarding the timing of potential surgical intervention in the treatment of acute SCI. CONCLUSIONS: Nationwide database of COVID-positive patients with acute spinal cord injury should be collected and analyzed to better understand how to manage acute SCI in the COVID-19 era. The authors recommend preoperative discussion in patients with acute cervical SCI with COVID-19, specifically emphasizing the increased risk of respiratory complications and mortality.

Reamed Versus Unreamed Intertrochanteric Femur Fractures, Is It Time?

OBJECTIVES: This study compares the intraoperative and postoperative outcomes of the traditional technique of femoral canal reaming to placement of an unreamed 10-mm nail. DESIGN: Retrospective cohort study. SETTING: Academic Level I Trauma Center, Southeastern US. PATIENTS/PARTICIPANTS: Intertrochanteric femur fractures treated with a CMN (January 2016-December 2018) were retrospectively identified. Inclusion criteria were as follows: low-energy mechanism, at least 60 years of age, and long CMN. Exclusion criteria were as follows: short CMN, polytrauma, and subtrochanteric fractures. OUTCOME MEASUREMENTS: Records were reviewed for demographics, hematologic markers, transfusion rates, operative times, and postoperative complications. Variables were assessed with a χ or Student T-test. Significance was set at 0.05. RESULTS: Sixty-five patients were included (37 reamed and 28 unreamed), with a mean age of 76.2 years and mean body mass index of 25.1. Between the reamed and unreamed groups, respectively, mean nail size was 11.0 (SD 1.1) and 10.0 (SD 0.0), P < 0.001; mean blood loss was 209.1 mL (SD 177.5) and 195.7 mL (SD 151.5), P = 0.220; 55% (21/38), and 43% (12/28) were transfused, P = 0.319; operative time was 98.2 (SD 47.3) and 81.5 minutes (SD 40.7); P = 0.035. Changes in hemoglobin/hematocrit were not significant between the study groups. Two patients from the reamed group experienced implant failure due to femoral head screw cut out and returned to the operating room. Two patients from the unreamed group returned to operating room for proximal incision infection, without implant removal. One reamed patient and 2 unreamed patients died before 6-month follow-up. CONCLUSIONS: Unreamed CMNs for geriatric intertrochanteric femur fractures provide shorter operative times with no difference in perioperative complications. Both reamed and unreamed techniques are safe and effective measures for fixation of these fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Descriptive Epidemiology of Injuries in Professional Ultimate Frisbee Athletes.

CONTEXT: Injuries in professional ultimate Frisbee (ultimate) athletes have never been described. OBJECTIVE: To determine injury rates, profiles, and associated factors using the first injury-surveillance program for professional ultimate. DESIGN: Descriptive epidemiology study. SETTING: American Ultimate Disc League professional ultimate teams during the 2017 season. PATIENTS OR OTHER PARTICIPANTS: Sixteen all-male teams. MAIN OUTCOME MEASURE(S): Injury incidence rates (IRs) were calculated as injuries per 1000 athlete-exposures (AEs). Incidence rate ratios were determined to compare IRs with 95% confidence intervals, which were used to calculate differences. RESULTS: We observed 299 injuries over 8963 AEs for a total IR of 33.36 per 1000 AEs. Most injuries affected the lower extremity (72%). The most common injuries were thigh-muscle strains (12.7%) and ankle-ligament sprains (11.4%). Running was the most frequent injury mechanism (32%). Twenty-nine percent of injuries involved collisions; however, the concussion rate was low (IR = 0.22 per 1000 AEs). Injuries were more likely to occur during competition and in the second half of games. An artificial turf playing surface did not affect overall injury rates (Mantel-Haenszel incidence rate ratio = 1.28; 95% confidence interval = 0.99, 1.67). CONCLUSIONS: To our knowledge, this is the first epidemiologic study of professional ultimate injuries. Injury rates were comparable with those of similar collegiate- and professional-level sports.

Distal clavicle autograft for anterior-inferior glenoid augmentation: A comparative cadaveric anatomic study.

INTRODUCTION: The aim of this study was to anatomically compare distal clavicle and coracoid autografts and their potential to augment anterior-inferior glenoid bone loss. METHODS: Ten millimeters of distal clavicle and 20 mm of coracoid were harvested bilaterally from 32 cadavers. Length, weight, and height were measured and surface area and density were calculated. For each graft, ipsilateral measurements were compared and the ability to restore corresponding glenoid bone loss was calculated. RESULTS: Distal clavicle grafts were larger than coracoid grafts with respect to length (22.3 mm versus 17.7 mm; p < 0.001), height (12.49 mm versus 9.65 mm; p < 0.001), mass (2.72 g versus 2.45 g; p = 0.0437), and volume (2.36 cm3 versus 1.96 cm3; p = 0.002). Coracoid grafts had larger widths (14.56 mm versus 10.52 mm; p < 0.001) and greater density (1.24 g/cm3 versus 1.18 g/cm3; p < 0.001). Distal clavicle surface area was greater on both the articular (2.93 cm2 versus 1.5 cm2; p < 0.001) and superior surfaces (2.76 cm2 versus 1.5 cm2; p < 0.001) when compared to lateral coracoid surface area. DISCUSSION: Distal clavicle grafts were larger and restored larger bony defects but had greater variability and lower density than coracoid grafts. Clinical studies are needed to compare these graft options.

Accurate Prediction of Antegrade and Retrograde Femoral Intramedullary Implant Length From Patient-Reported Height.

OBJECTIVE: To determine whether patient height correlates with implant length selection of antegrade or retrograde femoral intramedullary implants. DESIGN: Case-control Study. SETTING: A single level 1 trauma center. PATIENTS/PARTICIPANTS: All patients with operatively treated femoral shaft fractures from 2011 to 2017. INTERVENTION: All fractures were treated with an intramedullary nail. Retrograde or antegrade insertion was decided at the discretion of the surgeon and fracture location. MAIN OUTCOME MEASUREMENTS: Length of femoral implant and patient height. RESULTS: Five hundred sixty-seven operatively treated fractures were reviewed, 322 antegrade and 245 retrograde. The correlation between patient height and actual nail length was 0.55 for antegrade implants (P < 0.01) and 0.59 for retrograde implants (P < 0.01). Separate prediction equations for nail length based on patient height were estimated for antegrade and retrograde implants and found accurate prediction of length 86% and 88% of the time, respectively. CONCLUSIONS: Intramedullary nail length can be accurately predicted based on patient height and the technique using the equations below. This is the first study to establish a simple equation to serve as an adjunct for selecting the most appropriate length implant. This equation can be used in cases of bilateral femur fractures, templating to have appropriate sized implants in close proximity to the odds ratio, and in remote environments where surgical planning is critical for determining implant needs.