Postoperative Immobilization Period for Pediatric Supracondylar Fractures: The Shorter the Better?

BACKGROUND: There are now recognized standards of care published by the British and American Orthopaedic Associations which detail key areas of evidence-based recommendations for the treatment of children with displaced supracondylar humerus fractures. Although many aspects of treatment are covered in these recommendations, both the American and British Orthopaedic Associations do not recommend the exact duration of immobilization postoperatively. METHODS: This study retrospectively compared outcomes of operatively managed supracondylar fractures immobilized postoperatively for short immobilization (SI) defined as 28 days or less, with long immobilization (LI) defined as more than 28 days. The outcomes measured were clinical (deformity, range of motion, and pin site infection) and radiologic (loss of position after the removal of K-wires, Baumann's angle, anterior humeral line, refracture, and signs of osteomyelitis). Demographic data were recorded to evaluate and ensure satisfactory matching of the 2 groups for analysis. RESULTS: The study included 193 pediatric supracondylar fractures over a 4-year period which were treated with manipulation under anesthetic and K-wire fixation. The difference in average time in plaster between the 2 groups was statistically significant (SI: n=27.5 d, SD 1.23; LI: n=43.9 d, SD 15.29, P =0.0001). Data for operative techniques-closed or open reduction (SI: n=66, LI: n=78, P =0.59), and crossed wires (SI: n=37, LI: n=50, P =0.57) between the two groups showed no statistical significance. There was no statistical difference between the groups for the average number of days postoperatively at which wires were taken out (SI: n=28.9 d, SD 5.95, LI: n=30.1 d, SD 5.57, P =0.15), number of pin site infections requiring antibiotic treatment (SI: n=3, LI: n=5, P =0.70), or children from each group who were recorded to have regained full range of motion symmetrical to their contralateral arm (SI: n=79, LI: n=99, P =0.74). CONCLUSIONS: Our study therefore suggests that shorter immobilization of these patients (SI group) does not yield a higher rate of complications including refracture and malunion.

Outcomes following surgery for fractured neck of femur in dialysis patients: a 5-year review from a district general hospital in the United Kingdom.

BACKGROUND: Neck of femur fractures are associated with high mortality and have increased prevalence in dialysis patients. Delays in operating on dialysis patients can occur as a result of logistical or medical issues; it has previously been shown that delays on operating on neck of femur fractures in the general population results in increased mortality. METHODS: Medical records of 27 dialysis patients admitted to a large district general hospital in the UK with a fractured neck of femur between January 2009 and January 2014 were analysed alongside records of 27 age and sex-matched non-dialysis patients. Fisher's exact test and the unpaired t test were applied to data to explore outcomes. Odds ratio was also used to compare mortality between the dialysis and non-dialysis groups. RESULTS: Thirty-day mortality amongst dialysis patients was 22 %, compared to 7 % in the non-dialysis cohort. One-year mortality amongst dialysis patients was 70 %, compared to 15 % in the non-dialysis cohort (odds ratio 13.7 (3.56-52.4, 95 % confidence interval; p = 0.0001)). Average length of survival in dialysis patients overall was 311 days; average length of survival if the patient was operated on within 48 h of admission was 450 days (192-708 days, 95 % confidence interval) and was 224 days (45-402, 95 % confidence interval) if operated on after more than 48 h of admission (p = 0.16). CONCLUSIONS: Dialysis patients had higher post-operative mortality than the non-dialysis cohort. Odds ratio for death was significantly greater at one-year in the cohort of dialysis patients compared to the non-dialysis patients. Delay to operation amongst the dialysis patient cohort did not contribute significantly to mortality in this study. The higher rates of coronary artery disease, diabetes mellitus and malignancy may confound mortality amongst patients on dialysis who sustain a fractured neck of femur. Limitations of this study included small patient numbers, data from only one centre being used, and some missing data for certain patients.

Pediatric meniscal injuries: Current concepts.

Meniscal pathology is widely prevalent in the adult population, secondary to acute trauma and chronic degeneration. It is less commonly seen in children, although its incidence is rising. The true prevalence in children remains unknown, as pathologies such as discoid menisci often go undiagnosed, or are found only incidentally. The rising incidence can be attributed to increased participation in sports at younger ages, both in intensity and frequency, with potentially year-round competition. Meniscal tears lead to pain and mechanical symptoms in the short to medium term, but more significantly, have been shown to lead to compartmental chondral degeneration and early arthritis in the long term. With advancing arthroscopic techniques, and children's propensity for better healing, osteoarthritis secondary to meniscal pathology is a potentially preventable problem. This article discusses meniscal injuries in children and adolescents and their management.

Tibialis anterior tendon transfer using bone anchor for dynamic supination in congenital talipes equinovarus.

Tibialis anterior tendon transfer (TATT) is a recognised procedure for the treatment of recurrent congenital talipes equinovarus. The most common technique in use requires three skin incisions and breaching of the plantar tissues, risking pressure areas and damage to neurovascular structures. There have been no studies showing the clinical results of the use of a bone anchor to secure the tendon without drilling through the lateral cuneiform. This study presents the largest series of outcomes for such a procedure. Retrospective case series. Electronic records for all children under 18 undergoing TATT with anchor fixation included. Outcomes recorded were a failure of the tendon transfer and complications. Seventy-seven feet were identified in 61 children with a male-to-female ratio of 2.5:1, the average age at surgery of 5.6 years, and an average follow-up of 4.4 years. There were no cases of pullout of the anchor. Seventy-six cases (98.7%) had no recurrence of dynamic supination on follow-up. No revision surgery was required. Consistently reliable, reproducible and safe fixation of the tibialis anterior tendon in TATT can be achieved using a bone anchor for the treatment of dynamic supination in children with clubfeet following correction using the Ponseti method and is a quick and straightforward alternative method to traditional techniques.

Stabilization of Recurrent Elbow Instability in the Presence of Hyperlaxity in Children Using a Nonanatomic Soft Tissue Reconstruction.

Despite growing concordance of opinion in the adult setting, pediatric elbow instability and its management are poorly represented in the literature due to its low prevalence and often unique circumstances. The authors present a case of posttraumatic recurrent posterior pediatric elbow instability in a patient with joint hypermobility. Our patient, a 9-year-old girl, sustained a right-sided supracondylar fracture of the humerus in April 2019. Having been managed operatively, the elbow remained unstable and dislocated posteriorly in extension. Definitive surgical management was designed to provide a stable functional elbow. The principle of the surgery was to create a checkrein of tissue, not changing in length in extension and flexion, and to prevent further posterior elbow instability. A 3 mm slip of the central triceps tendon was dissected, leaving its attachment to the olecranon tip. Gracilis allograft was sutured to the strip of the triceps tendon to increase the tensile properties of the native tendon graft using a braided nonabsorbable suture. The tendon construct was then passed through a window made in the olecranon fossa and a transosseous tunnel in the ulna from the coronoid tip to the dorsal cortex. The tendon was tensioned and secured to the radial-dorsal aspect of the ulna with a nonabsorbable suture anchor in 90 degrees of flexion. At one year follow-up, the patient has a stable and pain-free elbow joint with no functional limitations.

The Importance of Monitoring and Factors That May Influence Leg Length Difference in Developmental Dysplasia of the Hip.

In unilateral Developmental Dysplasia of the Hip (DDH), avascular necrosis (AVN), femoral or pelvic osteotomy, and residual dysplasia causing subluxation of the proximal femur may influence Leg Length Discrepancy (LLD). This can lead to gait compensation, pelvic obliquity, and spinal curvature. The aim of this study is to determine the prevalence of LLD, establish which limb segment contributes to the discrepancy, describe how AVN influences LLD, and ascertain variables that may influence the need for LLD corrective procedures. METHODOLOGY: This study assessed long-leg radiographs at skeletal maturity. Radiographs were assessed for the articulo-trochanteric distance (ATD) and femoral and tibial length. AVN was classified according to Kalamchi-MacEwen. RESULTS: 109 patients were included. The affected/DDH leg was longer in 72/109 (66%) patients. The length difference was mainly in the subtrochanteric segment of the femur. AVN negatively influenced leg length. Older (≥three years) patients with multiple procedures were more likely to have AVN. LLD interventions were performed in 30 (27.5%) patients. AVN grade or type of DDH surgery did not influence the odds of needing a procedure to correct LLD. CONCLUSIONS: Procedures to correct LLD were performed irrespective of previous DDH surgery or AVN grades. In most patients, the affected/DDH leg was longer, mainly in the subtrochanteric segment of the femur, largely influenced by femoral osteotomy in patients with multiple operative procedures for DDH. We recommend careful monitoring of LLD in DDH.

Fixation and Implant Retention of Extracapsular Femoral Neck Periprosthetic Fractures Around Hip Resurfacing Arthroplasty - A Case Series.

BACKGROUND: Extracapsular femoral neck fractures in the presence of a resurfacing hip arthroplasty (RHA) appear to be independent of suboptimal technique during the initial implantation of the RHA and present with a similar etiology as native hip fractures - that is, a fragility fracture related to pathological or age-related osteoporosis, as a consequence of trauma. In the presence of a well-fixed and previously well-functioning RHA, the options for management include revision arthroplasty or open reduction and internal fixation (ORIF). In the absence of loosening through mechanisms of wear, infection, metallosis, or suboptimal prosthesis positioning, many authors have advocated ORIF with implant retention. However, there is often debate regarding the use of total hip arthroplasty in these cases. CASE SERIES: The authors conducted a thorough assessment of the literature followed by a retrospective review of outcomes for three patients treated by ORIF with implant retention for extracapsular femoral neck fractures around a RHA, using a standardized technique. All patients were independently mobile and active with well-fixed and well-functioning RHAs before the date of injury. All patients suffered low-energy trauma resulting in the fracture. There were no intraoperative or perioperative complications. All patients achieved full weight-bearing status and independent mobility. Two patients achieved radiographic union and returned to full range of movement and independent mobilization comparable to their preoperative state. One patient was lost to follow-up. CONCLUSION: The authors believe that fixation of extracapsular proximal femoral fractures distal to a well-fixed, well-functioning RHA is a good management option in an independent and active patient. A higher level of evidence is needed to investigate the surgical management options of these injuries comparing osteosynthesis with revision arthroplasty.