Medial versus anterior open reduction for developmental hip dislocation in age-matched patients.

BACKGROUND: The difference between medial (MAOR) and anterior (AAOR) approaches for open reduction of developmental hip dysplasia in terms of risk for avascular necrosis (AVN) and need for further corrective surgery (FCS, femoral and/or acetabular osteotomy) is unclear. This study compared age-matched cohorts undergoing either MAOR or AAOR in terms of these 2 primary outcomes. Prognostic impact of presence of ossific nucleus at time of open reduction was also investigated. METHODS: Institutional review board approval was obtained. Nineteen hips (14 patients) managed by MAOR were matched with 19 hips (18 patients) managed by AAOR based on age at operation (mean 6.0; range, 1.4 to 14.9 mo). Patients with neuromuscular conditions and known connective tissue disorders were excluded. Primary outcomes assessed at minimum 2 years' follow-up included radiographic evidence of AVN (Kalamchi and MacEwen) or requiring FCS. RESULTS: MAOR and AAOR cohorts were similar regarding age at open reduction, sex, laterality, and follow-up duration. One hip in each group had AVN before open reduction thus were excluded from AVN analysis. At minimum 2 years postoperatively (mean 6.2; range, 1.8 to 11.7 y), 4/18 (22%) MAOR and 5/18 (28%) AAOR met the same criteria for AVN (P=1.0). No predictors of AVN could be identified by regression analysis. Presence of an ossific nucleus preoperatively was not a protective factor from AVN (P=0.27). FCS was required in 4/19 (21%) MAOR and 7/19 (37%) AAOR hips (P=0.48). However, 7/12 (54%) hips failing closed reduction required FCS compared with 4/26 (16%) hips without prior failed closed reduction (P=0.024). Cox regression analysis showed that patients who failed closed reduction had an annual risk of requiring FCS approximately 6 times that of patients without a history of failed closed reduction (hazard ratio=6.1; 95% CI, 1.5-24.4; P=0.009), independent of surgical approach (P=0.55) or length of follow-up (P=0.78). CONCLUSIONS: In this study of age-matched patients undergoing either MAOR or AAOR, we found no association between surgical approach and risk of AVN or FCS. In addition, we identified no protective benefit of a preoperative ossific nucleus in terms of development of AVN. However, failing closed reduction was associated with a 6-fold increased annual risk of requiring FCS. SIGNIFICANCE: To the best of our knowledge, this is the first study comparing these 2 surgical techniques in an age-matched manner. It further corroborates previous studies stating that there may be no difference in risk of AVN based on surgical approach or presence of ossific nucleus preoperatively. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Likelihood of surgery in isolated pediatric fifth metatarsal fractures.

BACKGROUND: Fractures of the fifth metatarsal bone are common and surgery is uncommon. The "Jones" fracture is known to be in a watershed region that often leads to compromised healing, however, a "true Jones" fracture can be difficult to determine, and its impact on healing in pediatric patients is not well described. The purpose of this study was to retrospectively assess patterns of fifth metatarsal fracture that led to surgical fixation in an attempt to predict the likelihood for surgery in these injuries. METHODS: A retrospective review was performed on patients aged 18 and under who were treated for an isolated fifth metatarsal fracture from 2003 through 2010 at our pediatric hospital. Patient demographics, treatment, and complications were noted. Radiographs were reviewed for location of fracture and fracture displacement. Patients and fracture characteristics were then compared. RESULTS: A total of 238 fractures were included and 15 were treated surgically. Most surgical indications were failure to heal in a timely manner or refracture and all patients underwent a trial of nonoperative treatment. Jones criteria for fracture location were predictive of needing surgery (P<0.01) but confusing in the clinic setting. Fractures that occurred between 20 and 40 mm (or 25% to 50% of overall metatarsal length) from the proximal tip went on to surgery in 18.8% (6/32) of the time, whereas those that occurred between <20 mm had surgery in 4.9% (9/184). This was a statistically significant correlation (P=0.0157). CONCLUSIONS: Although fractures of the fifth metatarsal are common, need for surgery in these fractures is not. However, a region of this bone is known to have trouble healing, and it can be difficult to identify these "at-risk" fractures in the clinical setting. We found simple ruler measurement from the proximal tip of the fifth metatarsal to the fracture to help determine this "at-risk" group and found a significant difference in those patients with a fracture of <20 mm compared with those 20 to 40 mm from the tip; this can help guide treatment and counsel patients. LEVEL OF EVIDENCE: Level 3.

Constructing an Osseointegrated Prosthetic Leg.

Background: Constructing an osseointegrated prosthetic leg is the necessary subsequent phase of care for patients following the surgical implantation of an osseointegrated prosthetic limb anchor. The surgeon implants the bone-anchored transcutaneous implant1,2 and the prosthetist constructs the prosthetic leg, which then attaches to the surgically implanted anchor. An osseointegration surgical procedure is usually considered in patients who are unable to use or are dissatisfied with the use of a socket prosthesis. Description: This present video article describes the techniques and principles involved in constructing a prosthetic leg for transfemoral and transtibial amputees, as well as postoperative patient care. Preoperatively, as part of a multidisciplinary team approach, the prosthetist should assist in patient evaluation to determine suitability for osseointegration surgery. Postoperatively, when approved by the surgeon, the first step is to perform an implant inspection and to take patient measurements. A temporary loading implant is provided to allow the patient to start loading the limb. When the patient is approved for full-length leg to begin full weight-bearing, the implant and prosthetic quality are evaluated, including torque, implant position, bench alignment, static alignment in the standing position, and initial dynamic alignment. This surgical procedure also requires long-term, continued patient care and prosthetic maintenance. Alternatives: For patients who are dissatisfied with the use of a socket prosthesis, adjustments can often be made to improve the comfort, fit, and performance of the prosthesis. Non-osseointegration surgical options include bone lengthening and/or soft-tissue contouring. Rationale: Osseointegration can be provided for amputees who are expressing dissatisfaction with their socket prosthesis, and typically provides superior mobility and quality of life compared with nonoperative and other operative options3,4. Specific differences between the appropriate design and construction of osseointegrated prostheses versus socket prostheses include component selection, component fit, patient-prosthesis static and dynamic alignment, tolerances and accommodations, and also the expected long-term changes in patient joint mobility and behavior. Providing an osseointegrated prosthesis according to the principles appropriate for socket prostheses may often leave an osseointegrated patient improperly aligned and provoke maladaptive accommodations, hindering performance and potentially putting patients at unnecessary risk for injury. Expected Outcomes: Review articles describing the clinical outcomes of osseointegration consistently suggest that patients with osseointegrated prostheses have improved prosthesis wear time, mobility, and quality of life compared with patients with socket prostheses. Importantly, studies have shown that osseointegrated prostheses can be utilized in patients with short residual limbs that preclude the use of a socket prosthesis, allowing them to regain or retain function of the joint proximal to the short residuum5,6. Osseoperception improves patient confidence during mobility7. Because there is an open skin portal, low-grade soft-tissue infection can occur, which is usually treated with a short course of oral antibiotics. Much less often, soft-tissue debridement or implant removal may be needed to treat infection8. Periprosthetic fractures can nearly always be treated with familiar fracture fixation techniques and implant retention9,10. Important Tips: Falls can lead to periprosthetic fractures.Malalignment can lead to unnecessary pathologic joint forces, soft-tissue contractures, and an accommodative gait.Inadequately sophisticated components can leave patients at a performance deficit.Wearing the prosthetic leg while sleeping may lead to rotational forces exerted on the limb, which may cause prolonged tension on the soft tissue. Acronyms and Abbreviations: QTFA = Questionnaire for Persons with a Transfemoral AmputationLD-SRS = Limb Deformity Modified Scoliosis Research SocietyPROMIS = Patient-Reported Outcomes Measurement Information SystemEQ-5D = EuroQol 5 Dimensions.

Development of an evidence-based diagnostic algorithm for infection in patients with transcutaneous osseointegration following amputation.

Introduction: Transcutaneous osseointegration following amputation (TOFA) confers better mobility and quality of life for most patients versus socket prosthesis rehabilitation. Peri-TOFA infection remains the most frequent complication and lacks an evidence-based diagnostic algorithm. This study's objective was to investigate preoperative factors associated with positive intraoperative cultures among patients suspected of having peri-TOFA infection in order to create an evidence-based diagnostic algorithm. Methods: We conducted a retrospective study of 83 surgeries (70 patients) performed to manage suspected lower-extremity peri-TOFA infection at a specialty orthopedic practice and tertiary referral hospital in a major urban center. The diagnosis of infection was defined as positive intraoperative cultures. Preoperative patient history (fevers, subjective pain, increased drainage), physician examination findings (local cellulitis, purulent discharge, implant looseness), and laboratory data (white blood cell count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and external swab culture) were evaluated for association with subsequent positive intraoperative cultures using regression and area under receiver-operator curve (AUC) modeling. Results: Peri-implant limb pain (highly correlated with infection), ESR >30 (highly correlated against infection), positive preoperative swab (moderately correlated with infection), gross implant motion (moderately correlated against infection), and erythema or cellulitis of the transcutaneous region (mildly correlated with infection) were variables included in the best AUC model, which achieved an 85 % positive predictive value. Other clinical findings and laboratory values (notably CRP and WBC) were non-predictive of infection. Conclusions: This seminal investigation to develop a preoperative diagnostic algorithm for peri-TOFA infection suggests that the clinical examination remains paramount. Further evaluation of a wider spectrum of clinical, laboratory, and imaging data, consistently and routinely collected with prospective data techniques in larger cohorts of patients, is necessary to create a robust predictive algorithm.

Horrifying Basal Cell Carcinoma Presenting as Progressive Pyoderma Gangrenosum: Case Report.

Introduction: Skin ulcers can be challenging to diagnose and manage, particularly with comorbid autoimmune and gastrointestinal diseases. Occam's razor encourages the simplest explanation to guide care, but reconsideration must occur when intervention proves futile. Case Presentation: We report the case of a 70-year-old male, with a 17-year history of expanding pretibial skin ulcer, presumed by prior care providers to be pyoderma gangrenosum related to Crohn's disease. A surgical biopsy performed upon presentation to our institution revealed basal cell carcinoma of the skin, invasive to the proximal tibia with associated deep infection, prompting transfemoral amputation. Conclusion: This report is written as a reminder to reconsider a diagnosis and consider seeking additional expertise when a patient's condition progressively worsens despite intervention. Earlier diagnosis likely would have facilitated therapeutic limb salvage care.

Transcutaneous osseointegration for amputees with burn trauma.

OBJECTIVE: Transcutaneous osseointegration for amputees (TOFA) surgically implants a prosthetic anchor into the residual limb's bone, enabling direct skeletal connection to a prosthetic limb and eliminating the socket. TOFA has demonstrated significant mobility and quality of life benefits for most amputees, but concerns regarding its safety for patients with burned skin have limited its use. This is the first report of the use of TOFA for burned amputees. METHODS: Retrospective chart review was performed of five patients (eight limbs) with a history of burn trauma and subsequent osseointegration. The primary outcome was adverse events such as infection and additional surgery. Secondary outcomes included mobility and quality of life changes. RESULTS: The five patients (eight limbs) had an average follow-up time of 3.8 ± 1.7 (range 2.1-6.6) years. We found no issues of skin compatibility or pain associated with the TOFA implant. Three patients underwent subsequent surgical debridement, one of whom had both implants removed and eventually reimplanted. K-level mobility improved (K2 +, 0/5 vs 4/5). Other mobility and quality of life outcomes comparisons are limited by available data. CONCLUSION: TOFA is safe and compatible for amputees with a history of burn trauma. Rehabilitation capacity is influenced more by the patient's overall medical and physical capacity than their specific burn injury. Judicious use of TOFA for appropriately selected burn amputees seems safe and merited.

Precice Stryde® Magnetic Internal Lengthening Nail does not Impair Bone Healing Despite Radiographic and Clinical Symptoms.

Aims: The Precice Stryde® internal magnetic lengthening nail allowed many patients a full weight-bearing experience during femur and tibia lengthening, but concerns over corrosion, pain and radiographic changes led to the implant's recall. Despite the recall, it is important to understand the rate of these occurrences and their influence on the overall success of the lengthening procedure. We aimed to investigate radiographic changes, patient-reported symptoms and bone healing indices for our cohort of Stryde lengthening. Materials and methods: Our surgical database and electronic medical record system were used to review and document patient demographics, indications for lengthening, length achieved, bone healing index (BHI), location and type of radiographic changes, time until radiographic changes were first visible, presence of pain symptoms (not attributable to surgery or distraction), time to implant removal and if the pain symptoms resolved following implant extraction. Results: From January 2019 to February 2021, 90 Stryde nails (78 femur and 12 tibia) were implanted in 63 patients. The cohort included 48 males and 15 females. The average length [± standard deviation (SD)] achieved was 58.4 ± 22.7 mm. The 66 bones (73%) developed radiographic changes and were found to be 58/78 (74%) femurs and 8/12 (67%) tibias. The average time to initial radiographic changes was 168 ± 108.1 days (femur) and 276 ± 126.8 days (tibia). Late-onset pain developed in 10 femur lengthening (11.1% of all nails) surgeries across eight patients (12.7% of all patients). All patients' pain resolved; three instances prior to nail removal and the remaining seven after nail removal. No patients were re-presented with worsening pain or radiographic changes following implant removal. Radiographic or symptomatic abnormalities did not impair bone formation. The BHI for femurs with (29.6 ± 16.6 days/cm, n = 58) vs without (29.4 ± 17.9 days/cm, n = 20) radiographic or symptomatic irregularity were nearly identical (p = 0.961). The difference between BHI for tibias with (39.3 ± 7.8 days/cm, n = 8) vs without (86.1 ± 38.2 days/cm, n = 4) radiographic changes was influenced by outliers and underpowered to draw a conclusion. Conclusion: Bone lengthening with the Stryde nail was associated with high rates of radiographic abnormalities, but symptoms were uncommon and resolved with explantation. The radiographic changes did not affect bone healing in the femur. Clinical significance: Radiographic changes including bone hypertrophy and osteolysis were common after bone lengthening with the Stryde nail, but the development of pain following consolidation was rare and resolved with implant removal.The BHI in femurs was not affected by radiographic changes. How to cite this article: Reif TJ, Geffner A, Hoellwarth JS, et al. Precice Stryde® Magnetic Internal Lengthening Nail does not Impair Bone Healing Despite Radiographic and Clinical Symptoms. Strategies Trauma Limb Reconstr 2023;18(2):94-99.

Comparative fixation devices for preventing migration of the proximal tibiofibular joint during tibial lengthening: a tether versus screw fixation.

BACKGROUND: When lengthening the tibia segment using motorized internal lengthening nails (MILN), undesired distal migration of the proximal fibula segment is prevented by tibiofibular stabilization, traditionally using a screw. A tightened cortical suspensory fixation rope (tether) is an alternative option, but its appropriateness has never been studied. The primary outcome was comparing the amount of proximal fibular migration between patients who were stabilized with either a tether or a screw. The secondary outcome was to evaluate the effect of fibular migration on the clinical outcome between both groups. METHODS: A retrospective study was conducted on patients who underwent tibial lengthening with MILN between April 2016 and June 2022. Two cohorts were compared: 18 limbs with tether fixation versus 29 limbs with screw fixation. Data on the patient's age, sex, etiologies, and clinical outcomes were collected. Radiographic measurements included the lengthening distance and the amount of proximal fibular migration. RESULTS: In total, 47 limbs from 41 patients, with average age 35.01 ± 13.72 years old. There were 28 males (68.29%) and 13 females (31.71%). The tether group demonstrated a statistically significant greater distance of migration than the screw group (p < 0.001), with an average migration distance of 8.39 ± 5.09 mm and 2.59 ± 3.06 mm, respectively. No correlation was found between the amount of tibial lengthening and the distance of proximal fibular migration in both the tether group (p = 0.96) and the screw group (p = 0.32). There was no significant difference in the change of knee extension between both groups (p = 0.3), and no patients reported knee pain or tightness. CONCLUSION: A screw provides better resistance to proximal tibiofibular joint migration during MILN lengthening, but the difference appears clinically inconsequential. Either option appears suitable.

Modern Internet Search Analytics and Osseointegration: What are Patients Asking and Reading Online?

Background: Osseointegration (OI) limb has been performed for over 30 years and is an example of an advance in technology and surgical technique which has led to improvements in patient mobility and quality of life. An increasing number of patients seek information about osseointegration. The aim of this study was to categorise the most frequently asked questions by patients using the Google search engine and the most frequently accessed websites with the highest return on answers. The secondary aims of this study were to assess the quality of the information provided on those websites and to stratify, by category, which websites provide the best quality information. Materials and methods: Ten permutations and conjugations of the word 'osseointegration' were entered into Google. The first fifty 'People also ask' and associated websites by Google's machine learning and natural language processing engine were collected for each search term. The Rothwell classification system of questions by topic (Fact, Value, Policy) and websites by category was used (Commercial, Academic, Medical Practice, Single Surgeon Personal, Government, Social Media). Website quality was assessed using the Journal of the American Medical Association (JAMA) benchmark criteria (Likert-style rating 0-4). Pearson's Chi-squared and Student's t-tests were performed for statistical analysis as appropriate (significance, p < 0.05). Results: The 10 search terms generated 454 questions and referenced 408 websites. Of the 454 questions generated, the most common question categories were fact (70.8%), value (19.2%), and policy (10%). The most common website type was social media (37.4%). The most common question types were technical details (30.4%), specific activity (20.6%), and cost (14.1%). Only 1.6% of questions related to risks and complications. Generally, website quality was poor with 64.1% having a JAMA score of 0 or 1. Websites that were categorised as 'Government' had the highest overall JAMA scores: 71.4% had a score of 4. Conclusion: Based on Google search engine's results, the most commonly asked questions about osteointegration related to technical details, specific activities and cost; only 1.6% related to risks and complications. Interestingly, social media websites represented the highest volume of search result referrals. Overall, the quality of websites was poor with the most factual information coming from governmental websites. How to cite this article: Murphy EP, Sheridan GA, Page BJ, et al. Modern Internet Search Analytics and Osseointegration: What Are Patients Asking and Reading Online? Strategies Trauma Limb Reconstr 2023;18(3):163-168.

Percutaneous Femoral Derotational Osteotomy in the Skeletally Immature Patient.

Percutaneous femoral derotational osteotomies are performed in both adult and pediatric patients for excessive symptomatic femoral anteversion or retroversion1,2. The aim of the procedure is to correct version abnormalities with use of a minimally invasive technique3. Description: This is a percutaneous procedure that involves creation of femoral drill holes at the osteotomy site prior to reaming the canal4. External fixator pins are placed proximal and distal to the osteotomy site prior to completing the osteotomy. These pins are derotational markers for the surgeon and act to hold the correction with use of an external fixator while the interlocking screws are being placed. The pins are placed at a degree of divergence that is equal to the degree of intended derotation so that the pins will become parallel in the axial plane following derotation of the femur. The percutaneous osteotomy is then completed with use of an osteotome, and the trochanteric entry nail is passed across the osteotomy site while correcting rotation. Once rotation is fully corrected and the pins are parallel, the external fixator is placed to hold the rotation and interlocking screws are placed. Alternatives: Nonoperative alternatives to this procedure include physical therapy for gait training and strengthening as well as modalities to address hip and knee pain that may be associated with version abnormalities. Although physical therapy is often prescribed, it must be noted that excess version is a fixed osseous structural pathology that therapy cannot address. Additionally, compensatory mechanisms that may be taught to improve gait and walk with a neutral foot progression angle may exacerbate hip or knee pathology as a result of the underlying version abnormality. Surgical alternatives include derotational osteotomies of the proximal or distal aspects of the femur with use of an open technique with plate fixation, as opposed to an intramedullary nail following percutaneous diaphyseal osteotomy as presented here1. Additionally, an open technique with intramedullary nail fixation may be performed5. Rationale: Excessive anteversion can cause both hip and knee symptoms, including hip pain, instability, labral and psoas pathology, and patellofemoral instability6. Excessive retroversion can cause impingement between the femoral neck and acetabulum, which results in pathology of the labrum and articular cartilage7. Additionally, abnormalities of version often lead to gait disturbances with frequent tripping and difficulty running8. Children with femoral version abnormalities have limited remodeling potential after age 83. A derotational osteotomy may be performed to correct symptomatic excess femoral version in an older child or adolescent. Expected Outcomes: The patient may be weight-bearing as tolerated with upper-extremity assistance immediately following the procedure. The osteotomy typically heals between 6 and 12 weeks, and the patient may return to activities as tolerated once the osteotomy is healed. Gordon et al. described the outcomes of a similar technique for femoral derotational osteotomy in skeletally immature patients with excessive femoral anteversion3. The study retrospectively reviewed the results of the technique in 13 patients and 21 limbs at a minimum follow-up of 1 year. All patients complained of tripping and gait abnormalities preoperatively. All patients noted gait improvement, and no intraoperative or postoperative complications were reported. Healing of the osteotomy occurred at a mean of 6 weeks postoperatively. No patient developed osteonecrosis. We routinely remove hardware in skeletally immature patients approximately 1 year postoperatively. Complications are rare and include hardware irritation, infection, nonunion, and neurovascular injury. Important Tips: Preoperative planning is critical for this procedure, and the surgeon should know the intended degree of derotation, the location of the osteotomy relative to the greater trochanter, the length of the nail, and the approximate diameter of the nail prior to entering the operating room.Percutaneous bicortical femoral drill holes are created at the site of the osteotomy prior to reaming to allow for egress of reamings and bone marrow elements at the osteotomy site, which serve as autograft and stimulate bone healing. Additionally, the drill holes provide ventilation to prevent excessive intramedullary pressure during reaming9-11.External fixator pins are placed proximal and distal to the osteotomy prior to completion of the osteotomy to allow for rotational assessment after completion of the osteotomy. Placing these pins bicortically so that they are secure in the bone and ensuring that the divergence is correct for the intended amount of derotation is critical in this procedure because once the osteotomy is complete, the pins are the only markers of rotation the surgeon has to guide the correction.An external fixator is helpful in holding the femur at the intended degree of derotation during placement of the interlocking screws. Acronyms & Abbreviations: ROM = range of motionCT = computed tomographyMRI = magnetic resonance imagingAP = anteroposteriorGT = greater trochanterAV = anteversionER = external rotationIR = internal rotationA = anteriorP = posteriorM = medialL = lateralXR = X-rayProx = proximalEx fix = external fixatorWBAT = weight-bearing as toleratedBLE = bilateral lower extremitiesDVT = deep venous thrombosisPT = physical therapyppx = prophylaxisAVN = avascular necrosis (osteonecrosis).

Revision Amputation with Press-Fit Osseointegration for Transfemoral Amputees.

Press-fit transfemoral osseointegration is the technique of inserting an intramedullary metal implant into the residual femur of an amputee; the implant is passed transcutaneously to attach to a standard prosthesis that includes a knee, tibia, ankle, and foot. This allows the prosthesis to be skeletally anchored, eliminating socket-related problems such as tissue compression that can provoke neurogenic pain, skin abrasion, and fitting problems resulting from residual limb size fluctuation1. Amputees with osseointegrated prostheses typically wear their prosthesis more and experience better mobility, quality of life, and extremity proprioception compared to those with socket prostheses2-4. Description: We demonstrate the fundamentals of a single-stage procedure involving an impacted press-fit porous-coated titanium osseointegration implant. The preoperative evaluation is summarized and the specific surgical steps are described: exposure, osteotomy, canal preparation, implant insertion, (optional) targeted muscle reinnervation, muscle closure, soft-tissue contouring and stoma creation, and abutment insertion. Alternatives: Amputees who are dissatisfied with their quality of life or mobility when using a socket prosthesis can attempt to modify their socket or activity level or accept their situation. Non-osseointegration surgical options to try to improve socket fit include bone lengthening and/or soft-tissue contouring. An alternative design is a screw-type osseointegration implant1. Rationale: Press-fit osseointegration can be provided for amputees having difficulty with socket wear5. Press-fit osseointegration usually provides superior mobility and quality of life compared with nonoperative and other operative options for patients expressing dissatisfaction for reasons such as those mentioned above, including poor fit, compromised energy transfer, skin pinching, compression, and abrasions. Expected Outcomes: Review articles describing the clinical outcomes of osseointegration consistently suggest that patients have improved prosthesis wear time, mobility, and quality of life compared with patients with a socket prosthesis3,4. In a recent study2 of 18 femoral and 13 tibial amputees who had osseointegration, Reif et al. showed significant improvements in prosthesis wear time, mobility, and multiple quality-of-life surveys at a mean follow-up of nearly 2 years. The most common postoperative complication for this procedure is low-grade soft-tissue infection, which is usually managed by a short course of oral antibiotics. Much less often, soft-tissue debridement or implant removal may be needed to manage infection. Periprosthetic fractures can nearly always be managed with familiar fracture fixation techniques and implant retention6. Important Tips: Template and choose an implant with an optimal diameter that encroaches the inner cortex at the narrowest bone diameter; an implant that is too wide may not fit without causing a large fracture, and an implant that is too narrow may fall out. Do not cement the implant7.Ideally, the abutment of the implant should rest against a flat transverse bone end with cortical contact and leave the correct amount of room for the prosthetic knee so that it matches the height of the contralateral knee; avoid inserting an implant too distally or in too wide a metaphyseal flare.Gentle impaction pressure is necessary and small contained distal fractures are acceptable, but avoid causing a propagating fracture. Do not place cerclage cables or loose bone graft at these small fracture sites.Avoid the use of a tourniquet during intramedullary reaming to prevent potential heat-induced osteonecrosis.Nerve surgery such as targeted muscle reinnervation, if indicated, can be performed in the same surgical episode as the osseointegration.The muscles should be closed at the bone-implant interface with use of a tight purse string in order to provide a vascularized tissue barrier against bacterial ingress8.The skin surrounding the stoma should have unnecessary fat removed, but not excess removal leading to skin necrosis. The skin fascia should be sutured to the muscle surrounding the stoma to stabilize the peri-stomal skin.Soft-tissue contouring is needed to achieve the optimal soft-tissue tension around the stoma and abutment. Single-stage surgery has a distinct advantage in this regard. Acronyms and Abbreviations: MVA = motor vehicle accidentAP = anteroposteriorCT = computed tomographyTMR = targeted muscle reinnervationQTFA = Questionnaire for Persons with a Transfemoral AmputationEQ-5D = EuroQol 5 DimensionsLD-SRS = Limb Deformity-Scoliosis Research Society (questionnaire)PROMIS = Patient-Reported Outcomes Measurement Information System.

Unexpected positive intraoperative cultures (UPIC) at index osseointegration do not lead to increased postoperative infectious events.

Introduction: The most common complication following transcutaneous osseointegration for amputees is infection. Although an obvious source of contamination is the permanent stoma, operative site contamination at the time of implantation may be an additional source. This study investigates the impact of unexpected positive intraoperative cultures (UPIC) on postoperative infection. Methods: Charts were reviewed for 8 patients with UPIC and 22 patients with negative intraoperative cultures (NIC) who had at least 1 year of post-osseointegration follow-up. All patients had 24 h of routine postoperative antibiotic prophylaxis, with UPIC receiving additional antibiotics guided by culture results. The main outcome measure was postoperative infection intervention, which was graded as (0) none, (1) antibiotics unrelated to the initial surgery, (2) operative debridement with implant retention, or (3) implant removal. Results: The UPIC vs. NIC rate of infection management was as follows: Grade 0, 6/8 = 75 % vs. 14/22 = 64 %, p = 0.682; Grade 1, 2/8 = 25 % vs. 8/22 = 36.4 % (Fisher's p = 0.682); Grade 2, 1/8 = 12.5 % vs. 0/22 = 0 % (Fisher's p = 0.267); Grade 3, 0/8 = 0 % vs. 1/22 = 4.5 % (Fisher's p = 1.000). No differences were statistically significant. Conclusions: UPIC at index osseointegration, managed with directed postoperative antibiotics, does not appear to increase the risk of additional infection management. The therapeutic benefit of providing additional directed antibiotics versus no additional antibiotics following UPIC is unknown and did not appear to increase the risk of other adverse outcomes in our cohort.

Pelvic Osseointegration for Unilateral Hip Disarticulation: A Case Report.

CASE: A 24-year-old man with right unilateral hip disarticulation, intolerant of a traditional socket-mounted prosthesis (TSP), underwent pelvic transcutaneous osseointegration and was fit with a prosthetic lower extremity 7 months later. Twenty-four months after osseointegration, he remains pain-free and complication-free, wears his prosthesis all waking hours, walks without assistive devices and can carry 2-handed objects, and works as a livestock farmer. CONCLUSION: Through 24 months, the world's first patient with pelvic osseointegration has no complications and better mobility than most patients with unilateral hip disarticulation using TSPs. Pelvic osseointegration seems reasonable to further consider in carefully selected patients.

Cementing Osseointegration Implants Results in Loosening: Case Report and Review of Literature.

Skeletal transcutaneous osseointegration was performed on a 54-year-old female transfemoral amputee. None of the available osseointegration implants achieved press-fit stability, so an implant was cemented in position. Although initially stable, by six months the patient reported painful loading and radiographs revealed cement mantle lucency. The osseointegration implant was removed, antibiotics were delivered via implanted spacer and intravenously, and revision osseointegration three months later achieved appropriate immediate press-fit stability. Cemented transcutaneous osseointegration implants loosen within one year. Osseointegration is only successful when bone grows directly onto the implant.

Evaluating the reoperation rate and hardware durability of three stabilizing implants for 105 malignant pathologic humerus fractures.

INTRODUCTION: Many patients sustaining a malignant pathologic humerus fracture (MPHF) elect for surgical stabilization. Complications prompting reoperation can occur, leading to additional quality of life and financial cost. One common event preceding reoperation is a broken implant (BI). The purpose of this study was to identify the rate of reoperation following surgical stabilization of MPHF with three techniques - photodynamic bone stabilization (PBS), intramedullary nail (IMN), and cemented plate fixation (CPF) - and estimate to what extent improved implant durability might prevent reoperation. MATERIALS AND METHODS: Retrospective data collection was performed, identifying 105 procedures (100 patients) who underwent non-articular MPHF surgery from 2010-2016: 19 PBS, 65 IMN, 21 CPF. All patients were followed for at least two years or until death. RESULTS: Reoperation rates were similar at one year (10.5%,6.2%,4.8%, p = 737), two years (15.8%,6.2%,9.5%, p = 375), and final evaluation (15.8%,7.7%,14.3%, p = 248). The rate of BI for PBS, IMN, and CPF was 10.5%,0%, and 4.8% (p = 049 PBS/IMN) at one year, 15.8%,0%, and 9.5% (p = 010 PBS/IMN) at two years, and 15.8%,0%, and 14.3% (p = 010 IMN/PBS, p = 013 IMN/CPF) at final evaluation. CONCLUSIONS: Reoperation rate was not significantly different at any time point. However, IMN surgery resulted in the lowest rate of broken implants (zero), statistically significant versus PBS at all time periods and versus CPF at final follow-up. PBS may eventually offer selected advantages for MPHF management, but current data suggests fragility must be thoughtfully considered.

Periprosthetic osseointegration fractures are infrequent and management is familiar.

AIMS: Osseointegrated prosthetic limbs allow better mobility than socket-mounted prosthetics for lower limb amputees. Fractures, however, can occur in the residual limb, but they have rarely been reported. Approximately 2% to 3% of amputees with socket-mounted prostheses may fracture within five years. This is the first study which directly addresses the risks and management of periprosthetic osseointegration fractures in amputees. METHODS: A retrospective review identified 518 osseointegration procedures which were undertaken in 458 patients between 2010 and 2018 for whom complete medical records were available. Potential risk factors including time since amputation, age at osseointegration, bone density, weight, uni/bilateral implantation and sex were evaluated with multiple logistic regression. The mechanism of injury, technique and implant that was used for fixation of the fracture, pre-osseointegration and post fracture mobility (assessed using the K-level) and the time that the prosthesis was worn for in hours/day were also assessed. RESULTS: There were 22 periprosthetic fractures; they occurred exclusively in the femur: two in the femoral neck, 14 intertrochanteric and six subtrochanteric, representing 4.2% of 518 osseointegration operations and 6.3% of 347 femoral implants. The vast majority (19/22, 86.4%) occurred within 2 cm of the proximal tip of the implant and after a fall. No fractures occurred spontaneously. Fixation most commonly involved dynamic hip screws (10) and reconstruction plates (9). No osseointegration implants required removal, the K-level was not reduced after fixation of the fracture in any patient, and all retained a K-level of ≥ 2. All fractures united, 21 out of 22 patients (95.5%) wear their osseointegration-mounted prosthetic limb longer daily than when using a socket, with 18 out of 22 (81.8%) reporting using it for ≥ 16 hours daily. Regression analysis identified a 3.89-fold increased risk of fracture for females (p = 0.007) and a 1.02-fold increased risk of fracture per kg above a mean of 80.4 kg (p = 0.046). No increased risk was identified for bilateral implants (p = 0.083), time from amputation to osseointegration (p = 0.974), age at osseointegration (p = 0.331), or bone density (g/cm2, p = 0.560; T-score, p = 0.247; Z-score, p = 0.312). CONCLUSION: The risks and sequelae of periprosthetic fracture after press-fit osseointegration for amputation should not deter patients or clinicians from considering this procedure. Females and heavier patients are likely to have an increased risk of fracture. Age, years since amputation, and bone density do not appear influential. Cite this article: Bone Joint J 2020;102-B(2):162-169.

Lipofibromatous Hamartoma of the Palmar Cutaneous Branch of the Median Nerve.

Background Lipofibromatous hamartoma (LFH) is a benign tumor of peripheral nerves, most commonly reported in the median nerve, and often associated with carpal tunnel symptoms. There have been nearly 200 reported cases of LFH in the median nerve, but to the authors' knowledge, this 10-year-old girl represents the first case report involving the palmar cutaneous branch. Methods An excisional biopsy of the mass was performed via a standard midline palmar incision. The tumor was found encapsulating the palmar cutaneous branch, and thus it was sacrificed. Results The incision healed without issue, but the patient reported numbness in the palm of her hand as was expected. Conclusion LFH is a benign tumor, although it can cause symptoms due to mass effect. If the diagnosis is uncertain or a patient is symptomatic, excisional biopsy can be performed even if involving a cutaneous nerve.

Equivalent mortality and complication rates following periprosthetic distal femur fractures managed with either lateral locked plating or a distal femoral replacement.

INTRODUCTION: Management of distal femur fractures above total knee arthroplasty (TKA) remains challenging. Two common surgical options are locked lateral plating (LLP) and distal femoral arthroplasty (DFR). Unfortunately, approximately 30-50% of patients may die within one year of injury, require further surgery, or not regain prior mobility performance. We compared 87 LLP to 53 DFR patients - to our knowledge the largest comparative study - focusing on 90- and 365-day mortality, mobility maintenance, and further surgery. METHODS: We performed a retrospective review of patients at least 55 years old who sustained femur fractures near a primary TKA (essentially OTA-33 or Su types 1, 2, or 3) from 2000 to 2015 assigning cohort based on treatment: LLP or DFR. We excluded patients having prior care for the injury, whose surgery was not for fracture (e.g. loosening), or having other surgical intervention (e.g. intramedullary nail). RESULTS: Results Cohorts were similar based on body mass index and age adjusted Charlson Comorbidity Index (aaCCI). LLP was more common than DFR for fractures above and at the level of the implant, but similar for fractures within the implant for patients with aaCCI ≥ 5. LLP and DFR had similar mortality at 90 days (9% vs 4%) and 365 days (22% vs 10%), need for additional surgery (9% vs 3%), and survivors maintaining ambulation (77% vs 81%). Patients whose surgery occurred 3 or more days after presentation had similar mortality risk to those whose surgery was before 3days. The mean age of one year survivors was 77 whereas for patients who died it was 85. Neither surgical choice nor aaCCI was associated with increased risk in time to surgery. CONCLUSIONS: Fracture location, remaining bone stock, and patient's prior mobility and current comorbidities must guide treatment. Our study suggests that 90- and 365-day mortality, final mobility, and re-operation rate are not statistically different with LLP vs DFR management.

Recurrent Cubital Tunnel Syndrome: A Critical Analysis Review.

Most patients (>90%) will have continued or recurrent symptoms after primary cubital tunnel release. Those patients with severe preoperative findings are at a higher risk of failure. Failed primary surgery may be due to diagnostic, technical, or biologic factors. Revision surgical interventions can provide relief, but there is no consensus on what is the optimal technique. The options for revision surgery include simple neurolysis, neurolysis with subcutaneous transposition, and neurolysis with submuscular transposition. Autogenous (vein) and non-autogenous nerve wraps may be placed around the nerve to prevent cicatrix reformation.

Painful pes planovalgus: an uncommon pediatric orthopedic presentation of Charcot-Marie-Tooth disease.

Charcot-Marie-Tooth (CMT) disease is an inherited progressive neurologic disorder often diagnosed by the characteristic cavovarus feet. In the pediatric population, the presentation is often more variable and age dependent. Pediatric orthopedic surgeons may be referred patients for the evaluation of musculoskeletal symptoms that may be consistent with early CMT, but because of the lack of the surgeon's familiarity, the diagnosis may be delayed or missed. We present three patients with pes planovalgus who were found to have CMT and review the recent literature relevant to the pediatric orthopedic surgeon. The clinical summary is given for three patients who presented to the orthopedic surgery department for lower extremity symptoms and were eventually diagnosed with CMT. A literature search was performed and information valuable for a pediatric orthopedic surgeon to consider is summarized. Foot morphology in most young children with CMT initially is pes planovalgus, with the minority being pes cavovarus. As the child grows, the proportion changes to become nearly entirely cavus or cavovarus, with very few remaining planovalgus or planus. Unexplained regional pain may also be suggestive of CMT. Whereas CMT often presents initially in adolescent or adult patients with cavovarus feet, thin calves, or a high-stepping gait, pediatric presentation is not so consistent. Young children with CMT often have pes planovalgus. There are even some variants of CMT where patients still may present with severe pes planovalgus into late adolescence. We recommend that pediatric orthopedic surgeons consider CMT even in patients who do not have cavus or cavovarus feet, especially in the context of unexplained regional pain of the lower extremities. Patients should be referred to a pediatric neurologist for definitive diagnosis and management, with the orthopedic surgeon remaining involved for specific procedures.