Faculty Bibliography

INTRODUCTION: Growth modulation has been recognized as early as 1905 in the orthopaedic literature. It uses growth potential to correct deformities with an easy procedure; thus avoiding osteotomies and their associated risks if the problem is to be addressed later in adulthood. The tension band plate (TBP) has replaced the Blount staple for growth modulation due to its ease of application and better complication profile, namely implant breakage and extrusion. However, the unpredictable time to effect of the TBP is still an issue. We are not aware of any study that has looked into the use of a locking plate compared to a non-locked plate in growth modulation. We hypothesize that the locking plate will be superior to the nonlocking plate in predicting the time to effect in growth modulation. METHODS: A Sawbones model was created to simulate pediatric metaphyseal bone. One-millimeter thick medium-low density closed-cell urethane foam was fixed to medium density, open-cell urethane foam using Gorilla glue (Figure 1b). Blocks were then made measuring 3x2x2.5 cm in dimensions. A two-hole foot plate (THLP) that allowed for locking and non-locking configurations was selected to test the hypothesis. The test specimen consisted of two blocks held together using the implant being studied (Figure 1a). Metal clips were applied on the contralateral side of the block for loading purposes. There were four test groups in this study. Groups 1 and 2 had the conventional TBP with parallel and divergent screw configurations, respectively. Groups 3 and 4 had the THLP in non-locked and locked configurations, respectively. The four groups were tested using a pulley loading apparatus (Figure 1c) with weight increments of 500 grams to a maximum of 2500 grams. Distraction across the blocks was measured using a caliper. The data obtained was then analyzed using the Kruskall-Wallis one-way analysis of variance on Stata to look for differences in distraction among the groups. RESULTS: There was a significant difference between the groups at loads of 1500 grams and higher (Figure 2). A Post Hoc Dunn's test was then performed to look into the source of difference. There was a significant difference showing a superiority of the THLP in the locking configuration over the conventional TBP in both parallel and divergent screw configurations. There was also a significant superiority, though to a lesser extent, of the THLP in the locking over the non-locking configuration (Figure 3). DISCUSSION: The aim of guided growth is to achieve a point fixation on one side of the physis that will result in a pressure gradient, leading to an incremental increase in growth away from that point fixation. Traditionally the Blount staple achieved this desired effect. The complications of the staple, namely extrusion and breakage, made this implant less appealing. The TBP replaced the Blount staple for its ease of application and better complication profile. Biomechanical studies looked into the best screw configuration to achieve the desired effect and parallel screws were reported to be superior to others. However, the time to effect is still an issue, which may be critical in children with little growth potential remaining. By locking the plate, we achieved a point fixation superior to the non-locked plate and conventional TBP. This is a Sawbone study. Further studies on animal models are needed to confirm these findings and to elucidate whether the locked plate maintains the same safety profile as the TBP

Ankle fractures requiring open reduction and internal fixation vary in severity from unimalleolar fractures to bimalleolar/trimalleolar (BT) fractures to pilon fractures. Consequently, the postoperative outcomes with these surgeries can vary. Most previous studies of these injuries had small sample sizes, studied a single risk factor or adverse event, or did not compare different injuries by severity. The purpose of the present study was to describe and compare the patient characteristics and postoperative outcomes of 2 high-energy ankle fractures: BT and pilon fractures. The relevant patients were identified from the American College of Surgeons National Surgical Quality Improvement Program database using the Current Procedural Terminology codes for BT and pilon fractures. Patient demographics, characteristics, comorbidities, and 30-day mortality and adverse events were recorded and compared between the 2 types of ankle fractures. More than 45% of patients with these fracture types were aged 40 to 65 years. Pilon fractures occurred more frequently in younger patients, were more likely to occur in men, required a longer hospital stay and operative time, were less likely to occur in patients with a body mass index of >30 kg/m², and conferred a greater risk of wound complications (odds ratio 1.76; p = .048) compared with BT fractures. The findings from the present study help us understand the differences in patient characteristics and potential early adverse events after open reduction and internal fixation of BT fractures versus pilon fractures.

Intramuscular myxoma is a rare entity in itself, and while it has been described in several locations in the body, its presence in the tibialis anterior muscle has only been reported once in the literature. In this case report, we present, to our knowledge, the first case of an intramuscular myxoma in the tibialis anterior muscle in the English literature, which was successfully managed with wide surgical resection.

OBJECTIVE OF THE STUDY/OBJECTIVE:To assess the prevalence of cortical bone invasion (CBI) with secondary extramedullary hematopoiesis (EMH) in patients with non-transfusion-dependent thalassemia (NTDT), to determine its predilection sites on thoracic and abdominal imaging, to determine whether there is an association between various clinical and hematological parameters, and to evaluate its various findings mainly on magnetic resonance imaging (MRI), in addition to computed tomography (CT) scans. MATERIALS AND METHODS/METHODS:This is a retrospective cohort study of 57 patients with NTDT imaged by CT or MRI. Both clinical and laboratory data were gathered. An imaging scoring system was used to describe the appearance of CBI by MRI. RESULTS:Twenty-seven patients (47.4 %) were found to have CBI and EMH with the most common location being the thoracic spine. Splenectomy and lower hemoglobin level were found to be independent risk factors for its development. Most lesions were homogenous (70 %), had predominant red marrow signal (67 %), and well-defined margins (89 %). CONCLUSION/CONCLUSIONS:CBI and secondary tumefactive EMH are common findings in patients with NTDT, with distinct imaging and clinical characteristics. An increased risk was seen in patients with splenectomy and lower hemoglobin. The imaging scoring system described is helpful in diagnosing and describing this entity, hence precluding unnecessary biopsies.

Back pain in children is underdiagnosed and increases incidence in adolescence. A systematic approach can diagnose the most common causes: trauma, structural deformities, inflammatory diseases, infection and malignancy.

BACKGROUND: The literature is sparse regarding the association between pneumonia and venous thrombosis in surgical patients. The aim of this study was to investigate the risk of postoperative venous thrombosis in patients who fit the criteria for preoperative pneumonia using data from the ongoing American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database while adjusting for potential confounders. METHODS: This is a cohort study using data from the ACS NSQIP database participating sites from 2008 (211 sites) and 2009 (237 sites). 427,656 patients undergoing major general surgery were included. The 30-day risk of postoperative venous thrombosis including deep vein thrombosis (DVT) and pulmonary embolism (PE) was evaluated in patients with preoperative pneumonia diagnosed before undergoing major general surgery. RESULTS: Patients with preoperative pneumonia had a higher incidence of both 30-day DVT and PE than patients without preoperative pneumonia. After adjusting for all potential confounders, the effect estimates for the association between preoperative pneumonia and venous thrombosis were DVT, OR: 1.67 (95% CI 1.32-2.11) and PE, OR: 2.18 (95% CI 1.48-3.22). CONCLUSIONS: A large, multicenter database of surgical patients showed that preoperative pneumonia may increase risk for developing venous thrombosis. This adds to our understanding of risk factors for venous thrombosis and suggests a potential benefit of diagnosing preoperative pneumonia in patients undergoing major general surgery.

The management of soft tissue defects in tibial fractures is essential for limb preservation. Current techniques are not without complications and may lead to poor functional outcomes. A salvage method is described using three illustrative cases whereby a combination of flaps and antibiotic-impregnated polymethylmethacrylate beads are employed to fill the bony defect, fight the infection, and provide a surface for epithelial regeneration and secondary wound closure. This was performed after the partial failure of all other options. All patients were fully ambulatory with no clinical, radiographic or laboratory sign of infection at their most recent follow-up. Although our findings are encouraging, this is the first report of epithelialization of the skin on a polymethylmethacrylate scaffold. Further studies investigating the use of this technique are warranted.

BACKGROUND:The purpose of this study is to assess whether an association exists between preoperative anemia and postoperative cardiac events or death in patients undergoing unilateral primary total knee arthroplasty (TKA) with no prior cardiac history. METHODS:Data from the 2008-2012 American College of Surgeons National Surgical Quality Improvement Program database were analyzed. Patients aged ≥18 years undergoing unilateral primary TKA were included. We divided the patients into 4 groups: no anemia, any anemia, mild anemia, and moderate-severe anemia. Associations between anemia and different characteristics as well as cardiac outcomes and death were studied, after adjusting for all potential confounders. RESULTS:In the nonanemic group, the occurrence of myocardial infarction, cardiac arrest, and death were 61 of 34,661 (0.18%), 23 of 34,661 (0.07%), and 30 of 34,661 (0.09%), respectively. The numbers in the anemia group were 23 of 6673 (0.34%), 9 of 6673 (0.13%), and 14 of 6673 (0.21%). These were not statistically different. The anemic group had higher odds for respiratory and renal morbidities and for receiving transfusions. CONCLUSION/CONCLUSIONS:We found no association between preoperative anemia or its severity and myocardial infarction, cardiac arrest, or death up to 30 days postoperatively. This could potentially lower the bar for safe preoperative hematocrit levels for elective TKA, theoretically increasing the percentage of anemic patients undergoing the procedure. This, however, is at the expense of potential respiratory and renal insults.

Osteochondral lesions of the talus might be a more common cause of pain than previously recognized, especially among those involved in athletic activities. However, the location of an osteochondral lesion on the talar head is much less common than such lesions localized to the dome of the talus and can pose diagnostic difficulties. We present the case of a 14-year-old soccer player who complained of longstanding pain in his left foot. After unsuccessful conservative treatment consisting of rest and bracing, he was ultimately treated with retrograde percutaneous drilling of the talar head performed by a medial approach. This was followed by casting and non-weightbearing for 6 weeks, after which physical therapy was undertaken. He was able to return to full activity and remained asymptomatic during a 5-year observation period. Although rare, osteochondritis dissecans of the talar head should be considered in young athletes with persistent foot pain that is unresponsive to reasonable therapy.

Fluoroquinolones are widely used antibiotics; however, numerous side effects have been reported in published studies, including a spectrum of tendinopathies, affecting numerous anatomic sites. Several risk factors have been identified, including advanced age (>60 years), corticosteroid use, renal failure or dialysis, female sex, and nonobesity. We present the case of an elderly male with minimal change disease treated with glucocorticoids and acute kidney injury, who sustained spontaneous nontraumatic bilateral Achilles tendon tears 4 days after initiating ciprofloxacin.