Removal of Metaphyseal Screw Only After Hemiepiphysiodesis Correction of Coronal Plane Deformities Around the Knee Joint: Is This a Safe and Advisable Strategy?

PURPOSE: Correcting lower limb angular deformities in the skeletally immature patient with guided growth is a very common procedure. Using an 8-plate construct to produce reversible hemiepiphysiodesis allows correction of the mechanical axis of the limb. It has become routine strategy to remove only the metaphyseal screw from the 8-plate construct after desired correction is achieved, in order to ease its reinsertion in case of deformity recurrence. In this study, we evaluated the efficacy and safety of this technique. METHODS: We reviewed the results of 80 patients (133 limbs) who were treated by guided growth using 8-plate hemiephisiodesis around the knee. After achievement of the correction goal, both screws and plate were removed in 78 limbs while only the metaphyseal screw was removed in 55 limbs. RESULTS: The mean age of patient was 8.9 years at the time of surgery. Within the group whose metaphyseal screw was removed, 12 limbs showed radiographic signs of deformity recurrence and underwent reinsertion of the metaphyseal screw. In 9 of the cases of metaphyseal screw reinsertion, the plate or its location had to be changed (mean follow-up after screw removal was 14 mo). There were 2 cases where leaving the plate with an epiphyseal screw caused a radiographic bone bar and undesired clinical growth arrest. CONCLUSIONS: On the basis of our experience, leaving the 8-plate construct with an epiphyseal screw in place exposes the patient to risks of bony bar, growth arrest, and an additional surgery for hardware removal. The majority of 8-plate constructs are not suitable for reinsertion of the metaphyseal screw.

Intermediate to Long-term Results of Femoral Neck Lengthening (Morscher Osteotomy).

BACKGROUND: Femoral neck lengthening and transfer of the greater trochanter were introduced by Morscher as treatment for patients with coxa breva and overgrowth of the greater trochanter. In this study we evaluated intermediate and long-term results of this operation. METHODS: We reviewed clinical and radiographic results of 18 patients (20 hips) who were treated by Morscher osteotomy. Ten patients had Perthes disease, 4 had developmental dysplasia of the hip, and 4 had avascular necrosis of the hip. The median age at surgery was 16 years [interquartile range (IQR): 14 to 17.5]. The median follow-up period was 7 years (IQR: 4.5 to 10). All patients were evaluated clinically by means of Harris Hip Score (HHS) before and after surgery. RESULTS: Preoperative clinical examination revealed that all patients had a limp and a positive Trendelenburg test. Median HHS was 72.5 (IQR: 69 to 83). Postoperatively, the Trendelenburg test was negative in 14 hips and positive in 6 hips. Postoperative median HHS was 94.5 (IQR: 89 to 96). Radiographic examination showed progression of osteoarthritis in 3 patients. One operation failed and was converted to total arthroplasty (total hip replacement) after 4 years. Two hips required total hip replacement 10 years after the operation. Leg length discrepancy was reduced in 17/20 hips. Overall patient satisfaction level was good-excellent in 12 patients, fair in 4, and bad in 2 patients. Postoperative complications included blade migration (1 patient (and wire breakage (2 patients). CONCLUSIONS: Morscher osteotomy can be effective for the treatment of patients with short femoral neck and overgrowth of the greater trochanter with a positive Trendelenburg test and mild leg length discrepancy. A congruent nonarthritic hip joint is a prerequisite for the success of the operation. LEVEL OF EVIDENCE: Level IV.

Reliability of Smartphone-Based Instant Messaging Application for Diagnosis, Classification, and Decision-making in Pediatric Orthopedic Trauma.

OBJECTIVE: Smartphones have the ability to capture and send images, and their use has become common in the emergency setting for transmitting radiographic images with the intent to consult an off-site specialist. Our objective was to evaluate the reliability of smartphone-based instant messaging applications for the evaluation of various pediatric limb traumas, as compared with the standard method of viewing images of a workstation-based picture archiving and communication system (PACS). METHODS: X-ray images of 73 representative cases of pediatric limb trauma were captured and transmitted to 5 pediatric orthopedic surgeons by the Whatsapp instant messaging application on an iPhone 6 smartphone. Evaluators were asked to diagnose, classify, and determine the course of treatment for each case over their personal smartphones. Following a 4-week interval, revaluation was conducted using the PACS. Intraobserver agreement was calculated for overall agreement and per fracture site. RESULTS: The overall results indicate "near perfect agreement" between interpretations of the radiographs on smartphones compared with computer-based PACS, with κ of 0.84, 0.82, and 0.89 for diagnosis, classification, and treatment planning, respectively. Looking at the results per fracture site, we also found substantial to near perfect agreement. CONCLUSIONS: Smartphone-based instant messaging applications are reliable for evaluation of a wide range of pediatric limb fractures. This method of obtaining an expert opinion from the off-site specialist is immediately accessible and inexpensive, making smartphones a powerful tool for doctors in the emergency department, primary care clinics, or remote medical centers, enabling timely and appropriate treatment for the injured child. This method is not a substitution for evaluation of the images in the standard method over computer-based PACS, which should be performed before final decision-making.

Is Leclercia adecarboxylata a new and unfamiliar marine pathogen?

Leclercia adecarboxylata infection is rarely reported in the context of human infections. In the scant cases reported in the literature, it usually involves individuals who are immunocompromised with infections of a polymicrobial nature. Recently, data have begun to accumulate suggesting that L. adecarboxylata is a pathogen associated with water environments. We review the literature regarding L. adecarboxylata infections and present a case of cellulitis and soft-tissue infection in the foot of a healthy surfer.

Interobserver and intraobserver agreement for Letournel acetabular fracture classification system using 3-dimensional printed solid models.

BACKGROUND: Acetabular fractures pose diagnostic and surgical challenges. They are classified using the Judet-Letournel system, which is based solely on X-ray. However, computed tomography (CT) imaging is now more widely utilized in diagnosing these injuries. The emergence of 3-dimensional (3-D) printing technology in varying orthopedic fields has provided surgeons a solid model that improves their spatial understanding of complex fractures and ability to plan pre-operatively. AIM: To evaluate the reliability of the Judet-Letournel classification system of acetabular fractures, when using either CT imaging or 3-D printed models. METHODS: Seven patients with acetabular fractures underwent pelvic CT imaging, which was then used to create solid, 3-D printed models. Eighteen orthopaedic trauma surgeons responded to questionnaires regarding fracture classification and preferred surgical approach. The same questionnaire was completed using only CT imaging, and two weeks later, using only 3-D printed models. The inter- and intra-observer agreement rates were then analyzed. RESULTS: Inter-observer agreement rates based on CT imaging or 3-D printed models were moderate for fracture classification: κ = 0.44, κ = 0.55, respectively (P < 0.001) and fair for preferred surgical approach: κ = 0.34, κ = 0.29, respectively (P < 0.005). Intra-observer agreement rates for fracture classification and preferred surgical approach comparing CT imaging or 3-D printed models were moderate: κ = 0.48, κ = 0.41, respectively. No significant difference in intra-observer agreement was detected when comparing orthopedic pelvic specialists to general orthopedic traumatologists. CONCLUSION: The Judet-Letournel classification demonstrated only moderate rates of agreement. The use of 3-D printed models increased the inter-observer agreement rates with respect to fracture classification, but decreased it with respect to the preferred surgical approach. This study highlights the role of 3-D printed models in acetabular fractures by improving spatial understanding of these complex injuries, thus providing more reliable fracture diagnoses and alternative viewpoints for pre-operative planning.

Open Reduction Internal Fixation of Femoral Neck Fracture-Anterior Approach.

Femoral neck fractures are frequently treated with open reduction and internal fixation to achieve anatomical reduction. This video demonstrates open reduction internal fixation of a femoral neck fracture in a 59-year-old man, performed through an anterior approach. This approach provides safe and effective access to the femoral neck, including the subcapital and basicervical regions, with excellent direct visualization of the fracture site.

Management of common elective paediatric orthopaedic conditions during the COVID-19 pandemic: the Montreal experience.

PURPOSE: To explore safe delays for the treatment of common paediatric orthopaedic conditions when faced with a life-threatening pandemic, COVID-19, and to propose a categorization system to address this question. METHODS: Review of the literature related to acceptable delays for treatment of common orthopaedic conditions, experience of healthcare professionals from low resource communities and expertise of experienced surgeons. RESULTS: Guidelines for the management of cancellations of elective surgeries during a period of resource reallocation are proposed. Elective cases must not be postponed indefinitely as adverse outcomes may result. Triage of waiting lists should include continuous monitoring of the patient and close communication with families despite social distancing and travel restrictions. Telehealth becomes a necessity. Common orthopaedic conditions are triaged into four groups according to urgency and safe and acceptable delay. Categories proposed are Emergent (life and limb threatening conditions), Urgent (within seven days), Semi-elective (postponed for three months) and Elective (postponed for three to 12 months). In total, 25 common orthopaedic conditions are reviewed and categorized. CONCLUSION: Given the uncertainty within healthcare during a pandemic, it is necessary to determine acceptable delays for elective conditions. We report our experience in developing guidelines and propose categorizing elective cases into four categories, based on the length of delay. Telemedicine plays a key role in determining the gravity of each situation and hence the amount of delay. These guidelines will assist others dealing with elective cases in the midst of a crisis. This paper initiates a coordinated effort to develop a consensus statement on safe delays.Published without peer review.

Clinical utility of the Taylor spatial frame for limb deformities.

The Taylor spatial frame (TSF) is a hexapod external fixator that can correct six-axis deformities. The mathematical base of all hexapod systems is projective geometry, which describes complex repositioning of an object in space. The Taylor brothers developed one of the first six-axis correction systems, which is known today as TSF. Over the years, this system has become the most used six-axis deformity correction device. In this review, we describe the history behind TSF development, and describe the principles and clinical utility for application of the TSF in different settings, such as acute trauma, malunions, and various deformities of the lower and upper limb.

The effect of 'Out of hours surgery Service' in Israel on hip fracture fixation outcomes: a retrospective analysis.

BACKGROUND: 'Out of Hours Surgery Service' (OHSS) was implemented in Israel, amongst other reasons, in order to reduce the time interval between hospital admission and surgery and consequently improve outcomes. The OHSS is currently operated in the public hospitals in Israel. In this study we compared the data of patients before and after OHSS implementation to determine its efficacy in improving patient care. METHODS: This is a retrospective observational study of 792 adult patients who underwent hip fracture surgery between 2002 and 2007 in a single hospital. The study population included two groups: patients that were operated before the implementation of the OHSS (2002-2004) and after the implementation of the OHSS (2005-2007). Data regarding all patients was collected using the institution's computer program. The following variables were analyzed: patients' demographics, time interval from hospitalization to surgery, causes for delaying surgery, post-operative length of hospitalization and mortality. RESULTS: Patients in the post-OHSS group had more illnesses and higher ASA classification than those in the pre-OHSS group. The post-OHSS group had a significantly decreased length of stay in the hospital before and after the surgery. After adjusting for ASA score and age, the post-OHSS group was found to have decreased post-operative hospitalization and lower post-operative mortality. Surgery was delayed in pre-OHSS period mainly due to operating rooms unavailability. CONCLUSION: Implementation of OHSS facilitated operating room availability, thus early operation and reduced post-operative mortality. In accordance with other studies, patient's outcome is greatly influenced by the time from admission to hip fracture surgery.

Treatment of avulsion fractures of the intercondylar eminence by medial parapatellar approach, open reduction and cross wire fixation.

Avulsion fractures of the intercondylar eminence in children and adolescents are relatively uncommon and can lead to significant disability with improper union. Many operative techniques have been developed to fixate these fractures, most of them utilizing sophisticated fixation modes. In this study, a small medial parapatellar approach was used with open reduction and percutaneous cross Kirschner wire fixation. The aim of this study was to evaluate the effectiveness of this method. From 2007 to 2012, eight children were treated, mean age 11.8 years (range 10-14 years). All underwent open reduction by a medial parapatellar incision and fixation by two cross Kirschner wires introduced in an oblique crossed manner from the medial and lateral aspects of the proximal tibia. Fractures were classified as Meyers and McKeever type III and were not candidates for conservative treatment. All operated limbs were immobilized postoperatively in a circular cast in extension for 6 weeks and allowed partial weight bearing from day 1 after the procedure. Outcomes were evaluated clinically and through radiographs taken during follow-up. All fractures were successfully reduced and healed, with no occurrences of malunion or nonunion. At follow-up, all patients had full knee range of motion, there was no gross laxity of the knee compared with the contralateral knee, and good functional outcome was achieved. On the basis of our experience, we believe that the procedure that we used is a simple, low-tech, and minimally invasive technique for the treatment of these fractures, with good functional outcome.