Faculty Bibliography

The Ponseti method for the correction of idiopathic talipes equinovarus (ITEV) produces excellent results, however recurrence is common, ranging from 11-37%. Recurrences require repeat manipulation and casting, frequently followed by surgical procedures. We hypothesized that at a minimum 4-year follow-up, the rate of invasive surgical interventions such as posteromedial release (PMR) or osteotomy, is low. A retrospective chart review of patients with ITEV treated by the Ponseti method from January 1999 to June 2017 was conducted. An invasive procedure was defined as a PMR or osteotomy, whereas minimally invasive procedures involved tendon lengthening and transfers. Inclusion criteria were patients with ITEV, less than 90 days old at initial visit, no previous series of casts, and potential of being 4 years old at last visit. A total of 150 feet (102 patients) were studied. Mean age at initial visit and last follow-up were 19.5 days and 7.6 years, respectively. For the initial series of casts, mean number of casts was 5.4 and 67.3% of feet had percutaneous Achilles tenotomies. Fifty-eight percent did not undergo any form of surgical procedure, while 33% underwent a tibialis anterior tendon transfer alone or in combination with a gastrocnemius recession, tendo-Achilles lengthening, or plantar fascia release. Early in the series, three feet in two patients underwent a PMR. The mean age at time of surgery was 55.3 months. In contrast to those treated for recurrence after PMR, the vast majority (98%) of feet with recurrence after Ponseti-treated ITEV had either no surgery or minimally invasive surgery

BACKGROUND:Simultaneous bilateral total knee arthroplasty (SBTKA) may offer certain benefits; however, its overall safety is still disputed. This study aimed at comparing the risk of thromboembolism and bleeding in patients who underwent SBTKA vs unilateral total knee arthroplasty (TKA). METHODS:The American College of Surgeons National Surgical Quality Improvement Program database from 2008 to 2015 was used to investigate the short-term postoperative complications and their risk factors following SBTKA as compared to unilateral TKA. Demographics, comorbidities, and 30-day outcomes were analyzed. Complications with an increased incidence following SBTKA were stratified to identify subgroups of patients at high risk. RESULTS:A total of 155,022 patients were identified, of which 150,581 underwent unilateral TKA and 4441 underwent SBTKA. The SBTKA group was found to be at a higher risk of venous thromboembolism (VTE), bleeding, and composite morbidity. Stratification analysis revealed that SBTKA subgroups at higher risk of VTE include patients of black or Asian origin, obese patients, and those who underwent anesthesia other than general or spinal/epidural. SBTKA subgroups at higher risk of bleeding include patients older than 85 years, those with race other than white, underweight and obese patients, and patients who underwent anesthesia other than spinal/epidural. Although none of the subgroups were protected from bleeding, patients who underwent spinal/epidural anesthesia had a lower risk of bleeding compared to other types of anesthesia. CONCLUSION/CONCLUSIONS:SBTKA confers an increased risk of postoperative VTE, bleeding, and composite morbidity at 30 days, with no increase in mortality.

Purpose/UNASSIGNED:Patients with late-presenting developmental dysplasia of the hip (DDH) are more likely to require an open reduction. Since many developing countries do not have mandated screening, there continues to be a relatively high incidence of late-presenting DDH. We report the clinical and radiographic outcomes of open reduction in a series of patients who presented late. Patients and methods/UNASSIGNED:This was a retrospective review of 712 hips in 645 patients that underwent open reduction, alone or in combination with a pelvic osteotomy. In all, 91 hips had open reduction alone and 621 had open reduction and pelvic osteotomy. Femoral shortening was performed in 221 hips. The mean age at the time of surgery was 2.1 years (1 to 6.5) and the mean follow-up time was 9.3 years (6 to 14). We used the Children's Hospital Oakland Hip Evaluation Score (CHOHES) to determine functional outcomes and the Severin classification was used to evaluate radiographic outcomes. The rate of avascular necrosis (AVN) and the need for a reoperation were also recorded and analyzed. Results/UNASSIGNED:In all 80% (570 hips) had good radiographic outcomes (Severin type I or II) and 87% had a CHOHES score of > 90 at final follow up. There was a 14% rate of AVN and only a 2% rate of redislocation. Better radiographic outcomes and lower reoperation rates were seen with patients who underwent both an open reduction and pelvic osteotomy. A trend was observed towards worse outcomes in older patients. Conclusions/UNASSIGNED:There was a high rate of good clinical and radiographic outcomes at a minimum six-year follow-up in patients with late-presenting DDH who underwent open reduction. Those who underwent open reduction in combination with a pelvic osteotomy had a higher rate of good radiographic outcomes and a lower rate of complications, particularly reoperation.

Infected nonunion of long bones may require intravenous antibiotics over a lengthy period which may result in a high rate of complications. This study aims to assess the efficacy of local antibiotics used as a replacement to prolonged intravenous therapy. Thirteen patients with infected nonunion of long bones who failed at least one previous surgery were included. The infection was treated through extensive debridement, application of antibiotic-impregnated calcium sulphate pellets and the bone stabilized with external fixation. These patients were monitored for union and infection by clinical signs, laboratory values, and radiographs over a period of 24 months. The results support an eradication of infection and union in all patients with no antibiotic-associated complications. Local antibiotic delivery using calcium sulphate pellets provides an effective method for treatment of nonunion in long bones and is free of the complications from the intravenous route.

Full extent of gender differences on postoperative outcomes has never been studied on large scale, specifically postoperative complications. This study aims to assess the effect of gender on 30-day morbidity and mortality after major surgery. A retrospective cohort study was carried out using data of patients undergoing major surgeries from the American College of Surgeons' National Surgical Quality Improvement Program database between 2008 and 2011. Demographics, pre- and perioperative risk factors, as well as 30-day morbidities, both overall and specific, were reviewed. The 30-day mortality data were also assessed. Multivariate logistic regression analyses, basic (Adj1) and extended (Adj2), were used to assess the association between gender and outcomes. Out of 1,409,131 patients, 57.2 per cent were females. Females had lower prevalence of most system-specific risk variables. Overall morbidities were also lower in females versus males, even after adjustment for variables [total overall morbidity: ORadj2 = 0.9 (0.89-0.92), P < 0.0001] except in some cases such as after cardiac surgeries [ORadj2 = 1.29 (1.14-1.44), P < 0.0001] and vascular surgeries [ORadj2 = 1.14 (1.10-1.18), P < 0.0001], where overall morbidities of females were higher. Specific morbidities were also lower in females than in males in all types of complications except central nervous system-related postoperative complications [ORadj2 = 1.15 (1.08-1.22), P < 0.0001] and return to the operating room [ORadj2 = 1.06 (1.04-1.08), P < 0.0001]. The 30-day mortality rate for females was lower than males [ORadj2 = 0.99 (0.96-1.03), P = 0.94]. Female gender was associated with less perioperative morbidity and mortality versus males, but they did worse after cardiovascular procedures and had more central nervous system-related complications. These outcomes should be taken into consideration by surgeons and should be evaluated further in future studies.

Background:Patients with Legg-Calvé-Perthes Syndrome (LCPS) are at an increased risk for developing osteoarthritis of the hip and undergoing total hip arthroplasty (THA) at an early age. Importantly, this younger age may put them at a higher risk for failure and revision surgery. The purpose of the study was to assess the clinical and radiographic outcomes as well as implant failure rate and risk for revision surgery at an average 20 years follow up. Methods:Data from LCPS patients treated with THA were collected including age, gender, operative date, revision date, as well as reason for and type of revision. Living patients filled the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaires at the time of last follow-up. Radiographs were evaluated for lucencies, debonding, loosening, osteolysis, wear, heterotopic ossification and sclerosis. Results:Nineteen patients (20 hips) treated with THA were followed-up for a mean of 18.3 years (range, 10.1 - 36.2 years). Radiographic evidence of lucency of the acetabular component was seen in 70% of the patients and femoral cortical hypertrophy in 85% at last follow-up. The rate of revision for any reason was 35%, mostly due to aseptic acetabular loosening. Conclusions:Our findings support the use of THA for the treatment of OA in patients with LCPS, bearing in mind the potentially lower survival rate at 20 years as compared those treated with THA for primary OA. Further studies are needed to identify the possible causes of the high rate of cortical hypertrophy seen in this patient population.Level of Evidence: IV Therapeutic.

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.