Postoperative Immobilization Research Articles

Microsurgical reconstruction affects the outcome in a translational mouse model for Achilles tendon healing.

SummaryBackgroundAnimal models are one of the first steps in translation of basic science findings to clinical practice. For tendon healing research, transgenic mouse models are important to advance therapeutic strategies. However, the small size of the structures complicates surgical approaches, histological assessment, and biomechanical testing. In addition, available models are not standardized and difficult to compare. How surgery itself affects the healing outcome has not been investigated yet. The focus of the study was to develop a procedure that includes a transection and microsurgical reconstruction of the Achilles tendon but, unlike other models, preserves the sciatic nerve. We wanted to examine how distinct parts of the technique influenced healing.MethodsFor this animal model study, we used 96 wild-type male C57BL/6 mice aged 8–12 weeks. We evaluated different suture techniques and macroscopically confirmed the optimal combination of suture material and technique to minimize tendon gap formation. A key element is the detailed, step-by-step illustration of the surgery. In addition, we assessed histological (Herovici and Alcian blue staining) outcome parameters at 1–16 weeks postoperatively. Microcomputed tomography (micro-CT) was performed to measure the bone volume of heterotopic ossifications (HOs). Biomechanical analyses were carried out using a viscoelastic protocol on the biomechanical testing machine LM1.ResultsA modified 4-strand suture combined with a cerclage for immobilization without transection of the sciatic nerve reliably eliminated gap formation. The maximal dorsal extension of the hindlimb at the upper ankle joint from the equinus position (limited by the immobilization cerclage) increased over time postoperatively (operation: 28.8 ± 2.2°; 1 week: 54 ± 36°; 6 weeks: 80 ± 11.7°; 16 weeks: 96 ± 15.8°, p > 0.05). Histological staining revealed a maturation of collagen fibres within 6 weeks, whereas masses of cartilage were visible throughout the healing period. Micro-CT scans detected the development of HOs starting at 4 weeks and further progression at 6 and 16 weeks (bone volume, 4 weeks: 0.07604 ± 0.05286 mm3; 6 weeks: 0.50682 ± 0.68841 mm3; 16 weeks: 2.36027 ± 0.85202 mm3, p > 0.001). In-depth micro-CT analysis of the different surgical elements revealed that an injury of the tendon is a key factor for the development of HOs. Immobilization alone does not trigger HOs. Biomechanical properties of repaired tendons were greatly altered and remained inferior 6 weeks after surgery.ConclusionWith this study, we demonstrated that the microsurgical technique greatly influences the short- and longer-term healing outcome. When the sciatic nerve is preserved, the best surgical reconstruction of the tendon defect is achieved by a 4-strand core suture in combination with a tibiofibular cerclage for postoperative immobilization. The cerclage promotes a gradual increase in the range of motion of the upper ankle joint, comparable with an early mobilization rehabilitation protocol. HO, as a key mechanism for poor tendon healing, is progressive and can be monitored early in the model.The translational potential of this articleThe study enhances the understanding of model dependent factors of healing. The described reconstruction technique provides a reproducible and translational rodent model for future Achilles tendon healing research. In combination with transgenic strains, it can be facilitated to advance therapeutic strategies to improve the clinical results of tendon injuries.

Safety of Early Postoperative Range of Motion in Burn Patients With Newly Placed Hand Autografts: A Pilot Study.

Patients who suffer hand burns are at a high contracture risk, partly due to numerous cutaneous functional units, or contracture risk areas, located within the hand. Patients who undergo split-thickness skin grafting are often immobilized postoperatively for graft protection. Recent practice at our burn center includes an early range of motion (EROM) following hand grafting to limit unnecessary immobilization. The purpose of this study was to determine whether EROM is safe to perform after hand grafting and if there is any clinical benefit. This retrospective, matched case-control study of adults compared patients who received EROM to subjects who received the standard 3 to 5 days of postoperative immobilization. Patients were evaluated for graft loss and range of motion. Seventy-one patients were included in this study: 37 EROM patients and 34 matched controls. Six patients experienced minor graft loss, three of these were not attributable to EROM. All graft loss was less than 1 cm and none required additional surgery. Significantly more patients who received EROM achieved full-digital flexion by the first outpatient visit (25/27 = 92.6% vs 15/22 = 68.2%; P = .028). Performing EROM does not cause an increase in graft loss. All areas of graft loss from the EROM group healed without intervention. There appears to be a benefit to EROM since there was a significant improvement in the patients' ability to make a full fist at initial outpatient follow-up. Additional prospective analysis is needed to examine the true clinical utility of EROM in the hand and other contracture-prone areas.

A Comparison of Hip Spica Casting to Short Leg Casts and Bar after Hip Reconstruction in Cerebral Palsy.

BackgroundImmobilization after hip reconstruction in children with cerebral palsy varies according to surgeon preference. The effect of postoperative immobilization on postoperative pain is unknown. Success in achieving hip stability and complications may also differ depending on the immobilization technique utilized.Questions/purposesUsing retrospective data, we aimed to evaluate: (a) what effect does postoperative immobilization with hip spica casting versus short leg casts and bar (SLCaB); have on pain and pain management in children with quadriplegic cerebral palsy undergoing femoral and/or pelvic osteotomy? and (b) Do complications and radiographic outcomes differ between those treated postoperatively with hip spica casting and those in short leg casts?Materials and MethodsChildren with quadriplegic cerebral palsy (GMFCS IV-V, mean age 7.8 years [range: 3-15 years]) undergoing femoral or pelvic osteotomy between 2012 and 2014 in the treatment of spastic hip subluxation were reviewed. Modes of immobilization were compared, between spica casting (n=15) and SLCaB (n=12). Preoperative, perioperative, and postoperative pain was quantified between groups. In-hospital epidural dosage, morphine equivalent dosages (MED), adjunctive medications, early maintenance of radiographic hip stability, and all complications were noted and analyzed.ResultsChildren were more likely to have spica cast immobilization if they were younger. Postoperative pain scores were similar between groups, with comparable patterns of epidural and MED administered during hospitalization. Spica casts were often flared up during hospitalization, but skin ulcers were uncommon and comparable between the two groups. Within 12 months of surgery, more ipsilateral femur fractures were observed distant to implants in the hip spica group, although the incidence of fractures did not meet statistical thresholds.ConclusionSpica casting and SLCaB after neuromuscular hip reconstruction did not show a difference in hip stability, narcotic pain medication usage or complication profile.

Rehabilitation following shoulder arthroplasty in the United Kingdom National Health Service: A survey of publicly facing information.

The prevalence of shoulder arthroplasty (SA) is rising, but there is limited research evaluating rehabilitation following SA and whether there is an optimal approach remains unknown. The aim of this study was to understand current National Health Service (NHS) practice for rehabilitation following SA as a platform for conducting much needed further research. Two reviewers independently undertook electronic searches for publicly available information sheets (PIS) from websites of NHS Trusts that included detail about rehabilitation following SA, for example, duration of immobilisation. One reviewer extracted data, and a second reviewer verified this. Not required. Forty-three PIS from 40 Trusts were identified. Twenty-four referred to more than one type of arthroplasty (anatomic, reverse and hemiarthroplasty) but did not describe different approaches to rehabilitation based on prosthesis type. Twenty-five PIS provided some instruction regarding movement restrictions, which varied considerably. All PIS referred to postoperative immobilisation, typically with a sling, with median duration of 4 weeks (range 0 to 8). Thirty-four PIS reported commencing passive exercise immediately. Median time to commencing active exercise was 4 weeks (range 1 to 6) and 5 weeks (range 1 to 16) for resisted exercise. Median time expected to return to driving was 6 weeks (range 3 to 12) and general work 12 weeks (range 3 to 26). This study has highlighted significant heterogeneity between rehabilitation approaches following SA, not previously reported in the United Kingdom, with a lack of specific rehabilitation PIS for different prosthesis types. Our results will facilitate evaluation of rehabilitation strategies in future research.

RISK FACTORS FOR ARTHROFIBROSIS IN TIBIAL SPINE FRACTURES: A NATIONAL 10-SITE MULTICENTER STUDY

Background:Tibial spine fractures are common pediatric injuries with similar mechanism of injury to anterior cruciate ligament tears. Post-operative arthrofibrosis remains the most common complication following treatment of this injury, and many patients require subsequent manipulation under anesthesia. Several prior studies have examined risk factors for the development of arthrofibrosis, but with small patient populations and varying reported predictors. Therefore, our objective was to identify risk factors for arthrofibrosis in the largest known cohort of pediatric tibial spine patients.Hypothesis/Purpose:Identify risk factors for developing arthrofibrosis after TSF treatment.Methods:This was a retrospective, multi-center study across ten institutions of 448 patients <25 years old who presented to care with a tibial spine fracture between 1/2000 and 2/2019. Patient records were reviewed for a multitude of pre-operative, intra-operative, and post-operative characteristics. Patients were then separated into two cohorts based on if they suffered from post-treatment arthrofibrosis.Results:Chart review demonstrated that 43 (9.6%) of the patients suffered from post-treatment arthrofibrosis. There were no demographic differences observed between the two groups. However, based on MRIs at the time of injury, distal femoral and proximal tibial growth plates were more frequently closed in the arthrofibrosis group (17.6% vs 4.4%, p=0.023 for both comparisons). Additionally, there was no difference in Meyers & McKeever (MM) classification (p=0.597). All arthrofibrosis patients received operative treatment (p=0.003), though there was no difference in fixation technique (p=0.734). Intraoperatively, a higher number of screws were used in the arthrofibrosis group (p=0.002) with the placement of hardware more likely to be epiphyseal (p=0.007). Other operative parameters including number of sutures were not different. Post-operatively, arthrofibrosis patients were more likely to have been immobilized in a cast (p<0.001) with no difference observed for weight-bearing status. After multivariate regression, screw number (OR 8.9, CI 1.9-41.7, p=0.005) and immobilization in a cast (OR 7.8, CI 1.0-60.4, p=0.049) remained significant predictors of post-treatment arthrofibrosis.Conclusion:This serves as the largest study of tibial spine fractures to analyze risk factors for the development of post-treatment arthrofibrosis. Our study demonstrates that pre-operative factors were largely similar between groups, but that intra-operative decisions, including the number of screws used for fixation and placement of hardware in relation to the physis, were significant predictors of post-treatment arthrofibrosis. These findings may influence operative decision-making in tibial spine fracture patients. Additionally, post-operative immobilization in a cast should be avoided given the high risk of arthrofibrosis.Table 1.Characteristics of patients with post-operative arthrofibrosis Arthrofibrosis (N=43)No Arthrofibrosis (N=405)P-valueDemographicAge (years)Male: Female ratioBMI11.124:1920.212.0282:12320.40.0650.0640.824InjurySports-related (%)MM classification III/IVConcomitant ACL injury (%)Delay to surgery (days)13 (30.2)20 (64.5)5 (22.7)24.2205 (50.4)134 (59.6)46 (21.6)24.3 0.0120.5970.9020.989OperativeReceived surgery (%)Operative time (min)Treatment type (%)ARIFORIFScrews (%)Number of ScrewsScrew/Suture Placement (%)TransphysealEpiphyseal43 (100.0)142.0 36 (83.7)7 (16.3)22 (51.2)1.8 5 (17.9)23 (82.1)325 (78.5)123.9 269 (82.8)45 (13.8)114 (35.5)1.4 94 (44.5)117 (55.5) 0.0030.209 0.734 0.0460.0020.0050.007Post-operativeImmobilizedCast immobilizationNon-weightbearing41 (97.6)21 (51.2)16 (39.0)11 (34.4)305 (97.8)72 (23.7)208 (68.2)72 (25.4) 0.955<0.0010.277

Functional and radiological outcome of distal radius fractures stabilized by volar-locking plate with a minimum follow-up of 1year.

Distal radius fractures (DRF) are the most common fractures of the upper extremities and incidence is expected to continue rising as life expectancy increases. Palmar locking plate stabilizing has since become the standard treatment for dorsally displaced DRF. Main aim of this study was to investigate correlation between radiological and clinical outcome in patients stabilized by palmar locking plate with a minimum follow-up of one year. A total of 524 patients with DRF, stabilized using palmar angular stable locking plate fixation were included in the study. Of these, 117 patients had to be excluded and another 177 were not accessible. The study group thus compromised 230 patients who returned for the follow-up investigation and were followed-up clinically and radiologically with a mean follow-up interval of 20months. Outcome was evaluated using pain, range of motion (ROM) and grip strength parameters. In addition, self-assessment by patients was registered on the QuickDASH, PRWE and Mayo Score. The immediate postoperative and final checkup radiographs were scrutinized for alignment and intra-articular step-off. Bivariant correlation analysis showed a significant correlation between ulnar variance and QuickDASH (r = 0.18, p = 0.01), grip strength (r = -0.18, p = 0.04) and Mayo Score (r = -0.23, p = 0.001). No significant differences could be found between an unacceptable (> 2mm) and acceptable (< 2mm) ulnar variance in respect of pain, ROM, grip strength and patient-reported outcome measurements. Age, gender, additional fracture to the ulnar styloid, or type of postoperative immobilization showed no significant or clinical important impact on the final patient-reported outcome. No significant differences in incidence of complications, ROM or loss of reduction could be found in any patients over or under 65years of age. Stabilization of DRF by palmar angular stable locking plate is a safe form of treatment and results in a good clinical and radiological outcome with low complication rate. Ulnar variance showed a significant correlation to grip strength, QuickDASH and Mayo Score, but an unacceptable ulnar variance (> 2mm) was not associated with a worse clinical important outcome. Age (< 65/> 65years), gender and type of immobilization had no impact on the complication rate or in the final functional or radiological outcome.

Fusion rates support wired allograft combined with instrumented craniocervical fixation in the paediatric population

BackgroundOccipitocervical and atlantoaxial instability in the pediatric population is a rare and challenging condition to treat. Variable surgical techniques have been employed to achieve fusion. The study aimed to assess bony fusion with rigid craniocervical fixation using an allograft bone block to serve as scaffold for bony fusion.MethodsThis is a single center case series from a tertiary referral neurosurgical center. The series includes 12 consecutive pediatric patients with rigid craniocervical fusion between 2006 and 2014. The primary outcome was bony fusion as assessed by computed tomography and flexion-extension radiographs. The authors did not receive external funding for this study.ResultsTwelve patients (age 1–15 years) were operated with a median imaging follow-up time of 22 months (range 6–69 m). A modified Gallie fusion technique with a tightly wired allograft bone block was used in 10 of 13 procedures. One patient underwent re-fixation due to screw breakage. Eleven out of 13 procedures resulted in a stable construct with bony fusion. All 10 patients operated with the modified Gallie fusion technique with sublaminar wiring of allograft bone block had bony fusion. No post-operative complications of the posterior fixation procedure were noted.ConclusionsThe modified Gallie fusion technique with allograft bone block without post-operative immobilization achieved excellent fusion. We conclude there is no need to use autograft or BMPs in craniocervical fusion in the pediatric population, which avoids related donor-site morbidity.Level of evidenceLevel IV—case series; therapeutic.

Pediatric tracheostomy practice patterns

ObjectiveDespite recent guidelines and the frequency of pediatric tracheostomy, surgical techniques and perioperative management are variable. We aim to describe the post-operative practice patterns following tracheostomy in children. MethodsAn electronic cross-sectional survey was distributed to American Society of Pediatric Otolaryngologists (ASPO) members in academic and private practice settings. Responses were collected anonymously and analyzed by percentages of respondents who employ specific management strategies. Statistical analysis of response distributions performed using the Z test of proportions for binary questions and the Mantel-Haenszel chi-square test for questions with more than two options. For questions with ordered categorical responses, Cuzick's nonparametric test of trend was used. ResultsOne-hundred twenty-four responses were received (22.3%). Most respondents were fellowship trained and practiced in academic medical centers. A greater number of tracheostomies were performed by respondents practicing in the Midwest region (p = 0.042). There was no variability in the number of tracheostomies performed based on practitioner age, hospital setting, or fellowship training. The majority perform stoma maturation and/or stay suture techniques intraoperatively and send patients to the intensive care unit postoperatively. The routine use of postoperative paralysis was reported by a minority of respondents and 50% reported the use of sedation. There was a roughly-even distribution of respondents who reported postoperative immobilization, mobilization to a chair, and ambulation respectively. Routine; postoperative airway evaluations were reported by 35% of respondents. Clinic follow-up was; variable. ConclusionThese results demonstrate ongoing variability in the postoperative management strategies following tracheostomy in children and highlight areas for further study.

T2 Safety of Early Post-operative Range of Motion in Burn Patients with Newly Placed Hand Autografts

Abstract Introduction Patients who suffer hand burns are at a high risk for developing contractures, partly due to the presence of numerous cutaneous functional units, or contracture risk areas, located within the hand. Patients who undergo split-thickness skin grafting (STSG) are often immobilized post-operatively for graft protection. Restricting mobility following a STSG is thought to protect against subdermal edema and shear forces, despite limited evidence. Early range of motion (EROM) has been described previously. Recent practice at our burn center includes EROM following hand STSG to limit unnecessary immobilization. The purpose of this retrospective study was to determine if EROM is safe to perform after hand STSG and if there is any clinical benefit. Methods In an approved, retrospective, matched case-control study of adult patients who sustained hand burns, patients who received EROM were defined as cases; patients who did not receive EROM were considered controls and received the standard 3–5 days of post-operative immobilization in a resting hand splint. Adult patients admitted over a 3-year period were eligible for inclusion. Patients were evaluated for graft loss and range of motion. Results Seventy-two patients were included in this study; 37 EROM patients and 35 matched controls. EROM patients tended to have a larger area excised (170.4 ± 69.8cm2 vs. 132.9 ± 76.2cm2; p=0.034) and grafted (171 ± 70.8 cm2 vs. 132.9 ± 76.2 cm2; p=0.033). Most patients were male, with an average age of 39 years. Patients had an average of approximately 5% TBSA burns with 1.5% to the hands. On post-op day (POD) 1 and 2, patients received EROM for an average of 30 minutes (29.25 ± 14.9 vs. 31 ± 16.4 minutes). Six patients experienced minor graft loss. Three patients (8%) experienced graft loss not attributable to EROM. One patient (2.7%) experienced graft loss pre-EROM on POD2 and 3 patients (8%) experienced graft loss post-EROM on either POD1 or POD2. All graft loss was less than 1 cm in greatest dimension and no patient who experienced graft loss required additional surgery as they all closed by their first outpatient follow-up. Significantly more patients who received EROM achieved full digital flexion by the first outpatient visit (25/27=92.6% vs. 15/22=68.2%; p=0.028). Conclusions Performing EROM does not cause an increase in graft loss. All areas of graft loss from the EROM group healed without intervention. There appears to be a benefit to EROM since there was a significant improvement in the patients’ ability to make a full fist at initial outpatient follow up. Further prospective analysis is needed to examine the true clinical utility of EROM in the hand and other contracture-prone areas. Applicability of Research to Practice Clinical change in post-operative management after hand grafting.

Distal femural fractures. Surgical options

Distal femur fractures are complex and relatively rare. Conservative treatment has now been abandoned. The purpose of surgical treatment is to obtain an anatomical reduction of the articular surface, restoring the coronal and sagittal axis of the skeletal segment with a stable osteosynthesis, thus avoiding post-operative immobilization and allowing for early physical therapy. The literature reports similar results with different kinds of osteosynthesis: anterograde or retrograde nailing, dynamic compression screw plate, locking compression plates, and blade plates. Not only the type of fracture, but also the experience of the single surgeon should be taken into account when choosing the type of osteosynthesis.

Percutaneous pinning for treating distal radial fractures in adults.

Background Fracture of the distal radius is a common clinical problem. A key method of surgical fixation is percutaneous pinning, involving the insertion of wires through the skin to stabilise the fracture. Objectives To evaluate the evidence from randomised controlled trials for the use of percutaneous pinning for fractures of the distal radius in adults. Search methods We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (September 2006), the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and other databases, conference proceedings and reference lists of articles. No language restrictions were applied. Selection criteria Randomised or quasi-randomised controlled clinical trials involving adults with a fracture of the distal radius, which compared percutaneous pinning with conservative treatment, or different aspects of percutaneous pinning. Data collection and analysis Two authors independently assessed and extracted data from the included trials. Some pooling of data was undertaken for one comparison. Main results Thirteen trials, involving 940 generally older adults with dorsally displaced and potentially or evidently unstable distal radial fractures, were included. Methodological weaknesses among these trials included lack of allocation concealment and inadequate outcome assessment. Factors affecting the applicability of trial evidence included inconsistent fracture classification, variations in outcome assessment and incomplete reporting. Six heterogeneous trials compared percutaneous pinning with plaster cast immobilisation. Across-fracture pinning, used in five trials, was associated with improved anatomical outcome and generally minor complications. There was some indication of similar or improved function in the pinning group. One quasi-randomised trial found an excess of complications after Kapandji pinning. Three trials compared different methods of pinning. Two trials found a higher incidence of complications after Kapandji fixation compared with two methods of across-fracture fixation. The third trial provided inadequate evidence for modified Kapandji fixation versus Willenegger fixation. Two small trials comparing biodegradable pins versus metal pins found a significant excess of complications associated with biodegradable material. Two small trials compared plaster cast immobilisation for one week versus for six weeks after surgery. One trial found duration of immobilisation after trans-styloid fixation did not have a significant effect on outcome. More complications occurred in the early mobilisation group after Kapandji pinning in the second trial. Authors' conclusions Though there is some evidence to support its use, the precise role and methods of percutaneous pinning are not established. The higher rates of complications with Kapandji pinning and biodegradable materials casts some doubt on their general use.

Predictors of reoperation after internal fixation of intra-articular distal humerus fractures.

Despite good reported outcomes with open reduction and internal fixation of intra-articular distal humerus fractures, complication rates remain high. The objective of this work is to identify factors associated with reoperation. Sixty-three patients treated with open reduction and internal fixation for intra-articular (Arbeitsgemeinschaft für Osteosynthesefragen type C) distal humerus fractures between 2004 and 2010 were identified using an institutional trauma registry, 62 of which were followed for a minimum of six months. Age, gender, fracture subclassification, open fracture presence, Injury Severity Score, time to definitive surgery, length of postoperative immobilization, and type of approach were recorded. Multivariate analysis was utilized to identify factors independently associated with reoperation. Complications requiring reoperation developed in 25 (40.3%) elbows. The most common reasons were wound dehiscence or infection in nine elbows (14.5%) and symptomatic hardware in six (9.6%). During multivariate analysis, only olecranon osteotomy remained an independent predictor for reoperation (P = 0.043). Despite improved internal fixation techniques, a high proportion of elbows require reoperation after open reduction and internal fixation for distal humerus fractures. Higher complication rates in fractures fixed through an olecranon osteotomy may reflect additional reoperations due to nonunion of the osteotomy or need to remove hardware from the ulna. Prognostic Level III.

Elastic Stable Intramedullary Nailing of Pediatric Tibial Fractures.

Most pediatric tibial shaft fractures (75%)1 can be treated nonoperatively; however, unstable and open fractures require surgical intervention. Titanium elastic nails have become a popular technique for fixation of pediatric tibial shaft fractures. They act as internal splints that impart relative stability to the fracture, promoting callus formation at the fracture site2. After the patient is placed in the supine position, the proximal tibial physis is marked using fluoroscopy. An anteromedial and anterolateral incision are made distal to the physis. Entry holes are created in the proximal part of the tibia, and appropriately sized titanium nails are introduced into the bone. Nail size should be 40% of the width of the canal, yielding 80% canal fill when 2 nails are used. The nails are prebent into a gentle C-shape to increase cortical contact at the apex so that 3-point fixation is achieved. The nails are passed to the fracture site, and the fracture is then reduced. The nails are then passed across the fracture site and stopped proximal to the distal tibial physis. The nails are then cut and tamped distally until there is just a short portion of nail left out of the proximal part of the tibia so that the nails can be removed once the fracture is healed. The wounds are then closed, and postoperative immobilization is applied. Many pediatric tibial shaft fractures can be treated with closed reduction and cast immobilization. Open fractures, or fractures that fail nonoperative management, can be treated with external fixation, open reduction and internal fixation (ORIF), or intramedullary stabilization3. Anatomic reduction and fracture compression can be achieved with ORIF; however, a drawback to this technique is the lack of soft-tissue coverage in the diaphyseal area of the tibia, which can lead to infection and wound-healing problems4. External fixation has traditionally been the technique of choice for open tibial fractures; however, with the ability to use flexible tibial nails in both open and closed tibial fractures, external fixation is now reserved for open fractures with large soft-tissue defects or in fractures with segmental bone loss. Intramedullary flexible nailing can be used in both open and closed tibial fractures, provides excellent fracture fixation, and utilizes incisions that are more cosmetically appealing to patients5,6. Outcomes following flexible nailing for pediatric tibial fractures are excellent. In a study of 19 patients undergoing flexible nailing for tibial shaft fractures, 18 had excellent or satisfactory results7. Compared with patients who had external fixation, those treated with flexible nails had less pain, shorter time to union, and better functional outcomes2. Compared with patients treated with ORIF, those who underwent flexible intramedullary nailing spent less time in the operating room and had lower rates of wound complications4. In the immediate postoperative period, clinicians should be aware of the risk of compartment syndrome, particularly in patients with high-energy injuries, older patients (>14 years old), and heavier patients (>50 kg)8. There is also an increased risk of soft-tissue irritation and fracture malunion in heavier patients treated with flexible nails9,10. Nail size should be 80% of the canal diameter (e.g., two 4.0-mm nails should be chosen for a canal that measures 10 mm).Nails should be properly contoured to avoid corticotomy of the far cortex during insertion; apex of the bend should be positioned at the level of the fracture.During insertion, leave room to advance nails further after they are cut proximally.Do not bury the proximal nail tips beneath the cortex as extraction will be difficult.Ensure that the ends of the nails are not lying up against the proximal tibial physis as this may cause premature growth arrest.

Alternatives to Traditional Cast Immobilization in Pediatric Patients.

Casts are commonly used for fracture management and postoperative immobilization in pediatric patients. However, cast immobilization is not without complications (eg, thermal injuries, pressure sores, infection, and neurovascular injury) and may be associated with additional costs and increased loss of school/work days for cast removal or other complications. The disadvantages of traditional casting can be minimized by alternative management strategies: waterproof casts to facilitate bathing and swimming; a Pavlik harness in infants, a single-leg spica cast, or flexible intramedullary nails to avoid complications with double-leg spica casts for femur fractures; and braces or splints to manage buckle and minimally displaced distal radius fractures, toddler's fractures, and stable foot/ankle fractures.

Prevention of Pulmonary and Venous Thromboembolism Post Coronary Artery Bypass Graft Surgery - Literature Review.

ObjectiveThe current review evaluates recent literature on the different aspects of prophylaxis in postoperative pulmonary and venous thromboembolism and their main risk factors.MethodsThe literature survey was carried out based on the PubMed data using the keywords “coronary artery bypass graft” and “venous thromboembolism” as components of the search field title.ResultsStudies reported several risk factors for postoperative thromboembolism including advanced age, postoperative immobilization, type of thromboprophylaxis, obesity, and location of the surgery.ConclusionAccording to the studies, tailored prophylaxis could be easily adapted to decrease the intensity and duration of postoperative thromboembolism in a patient with several disorders and comorbidities, especially in cardiovascular disease.

Primary bipolar hemiarthroplasty as a treatment option for unstable intertrochanteric fractures.

Management of unstable intertrochanteric fractures is challenging, especially in patients with osteoporosis. Comminuted unstable intertrochanteric fractures require postoperative immobilization. Several recent reports have recommended hemiarthroplasty for treatment of unstable intertrochanteric fractures to avoid various immobilization-associated complications. The purpose of this study was to evaluate the functional and clinical outcomes of bipolar hemiarthroplasty for unstable intertrochanteric fractures in older persons. Sixty patients aged over 75 years underwent hemiarthroplasty to treat unstable intertrochanteric fractures and were followed up over 12 months. All surgeries were performed by the same surgical team using the standard posterolateral approach. Wires, cables, and plates were used as required. Use of cemented protheses was considered when the lesser trochanter had been displaced. All patients were allowed full weight-bearing as tolerated. Clinical evaluation was based on Harris Hip Scores. The cohort comprised 16 men and 44 women (aged 75-96 years). According to the Jensen classification, 24 fractures were type III, 14 type IV, and 22 type V. Cement was used in 24 patients. At 12 months follow-up, Harris Hip Scores were excellent in 18%, good in 42%, fair in 25%, and poor in 15%. No radiological abnormalities were detected. Primary bipolar hemiarthroplasty for treating unstable intertrochanteric fractures eliminates the need for prolonged immobilization and permits early ambulation. As reported by others, hip hemiarthroplasty is an effective treatment choice for unstable intertrochanteric femoral fracture in older patients.

Past, present, and future in pediatric spinal surgery.

According the almost 55 years of experience in Pediatric Spinal surgery it was easy for me to describe the evolution during the past of the surgical techniques as well as the indications for spinal deformities done first without any instrumentation (still useful from time to time nowadays), as from the back as on the front, post-operative immobilization achieved thanks to casting. The real instrumentation appeared successively with Harrington, Luque, and simultaneously the introduction of pedicle screw thanks Raymond Roy Camille. It was necessary to wait another 20 years to get the segmental 3D strategy of the CD instrumentation still the basis of modern spinal surgeries techniques whatever using Hooks Screws, Universal clamps or Hybrid constructs. For present & future, Early surgery is still indicated for localized lesion generally secondary to congenital malformations with or without spinal cord decompression. But for extended lesions especially involving the thoracic area cast and brace is still the good choice whatever the etiology with or without pelvic obliquity. When this treatment fails many attempts with various techniques were used with some success for spinal growth without disturbances about the respiratory function. But it was also demonstrated that the number of complications were still high, with in many cases the necessity to perform a final surgical fusion. It is why the development of the bipolar minimal invasive technique appeared, with very promising results, including the fact that a substantial number of patients get a spontaneous fusion, excluding final surgery. For the older or adolescent patients, the evolution toward a race to obtain the maximum correction of the Cobb angle become more and more disputable as is was demonstrated that the most important for the future regarding the spinal function is the 3D dynamic balance of the discs spaces left free below and above the fused area.

Laparoscopic Repair of Ventral and other hernias of the abdominal wall with Composite meshes (Ventralight ST with Echo PS System and Physiomesh): Our case series of 101 patients and the literature

IntroductionA meta-analysis of studies has shown that the incidence of ventral hernias varies from 4 to 10%. During the last twenty years, the use of laparoscopic repair of ventral and other hernias of the abdominal wall has rapidly increased. Presentation of casesFrom January 2011 to March 2020 101 patients underwent laparoscopic ventral hernia repair (LVHR).The diameter of the hernial defect intraoperatively was in average 6.22 ± 5.17 cm (SD) (range 2–30 cm). The difference with the defect diameter measured in CT is small (average 0.77 ± 2.21 cm). The mean operative time was 96.20 min. We used Physiomesh and Secure strap in 37 cases and Ventralight ST plus Sorbafix in 58 cases. The conversion rate was 6.93%. The mean hospital stay was 6.03 days. The 30-day mortality was 0%. The overall morbidity was 11.88%. DiscussionLVHR indications are debated. The IEHS guidelines and the EAES/EHS Consensus conference of 2015 discussed the main indications, contraindications, and features of laparoscopic techniques. Laparoscopic approach seemed to have some benefits: absence of intraparietal dissection, of postoperative immobilization, lower risk of bronchopulmonary complications and lesser abdominal pain. We compared our case series with other similar studies, and we revealed our short-term outcomes are in line with literature. ConclusionOur case series revealed that the LVHR with Ventralight ST/Sorbafix is a safe and effective technique with low postoperative morbidity and low reoperation rate. Careful patient selection is one of the main methods of choice. Studies with higher level of evidence are needed.

Management of septic arthritis of the pediatric hip

Abstract: Purpose The purpose of this study was to compare outcomes and reoperation rate between open and arthroscopic treatment of a suspected isolated septic hip in the pediatric population. Methods Retrospective review was performed on two cohorts of pediatric patients who underwent surgical intervention for suspected isolated septic hip arthritis at a single institution. Patients were subdivided into two cohorts based on whether they underwent an open versus arthroscopic approach. Patients were excluded if they received an initial surgery from an outside institution, did not have an acute, active infection at presentation, defined as a hip aspiration leukocyte count <50,000 cells with <75% neutrophils, had extracaspular pathology or osteomyelitis, or had septic arthritis of a joint other than the hip. Results Fifty-six hips were included [Open group (n = 36); Arthroscopic group (n = 20)]. Six percent (2/36) of hips in the open group and 26% (5/19) of hips in the arthroscopy group had a positive tissue culture (p = 0.041). Eleven hips (31%) underwent postoperative immobilization in the open group compared to one hip (5%) in the arthroscopic group (p = 0.039). Conclusions In the setting of isolated arthritis, arthroscopy is a reasonable treatment modality with no observed additional risk compared to open arthrotomy. However, with concomitant osteomyelitis or soft tissue abscess, open arthrotomy should remain the mainstay approach to address all elements of the infection.Level of Evidence: Level III

Suture Button Suspensionplasty in the Treatment of Carpometacarpal Arthritis: A Retrospective Analysis of One Surgeon’s Experience Over 9 Years

PurposeTrapeziectomy with suture button suspensionplasty (SBS) to treat thumb carpometacarpal (CMC) arthritis has been proposed as an alternative to ligament reconstruction tendon interposition. There have been limited large-scale or long-term reports regarding SBS outcomes. Single-surgeon intermediate follow-up is reported.MethodsWe conducted a retrospective review of patients undergoing SBS procedures by a single surgeon. Implant manufacturer and postoperative immobilization protocol were recorded. Surgical outcomes, complications, and revision procedures were identified. Postoperative Disabilities of the Arm, Shoulder, and Hand scores were collected.ResultsA total of 242 SBS surgeries were included, involving 215 patients, average age 64.82 years (range, 42–86 years). Average follow-up was 35 ± 25 months. In all, 183 Arthrex and 59 Stryker systems were used, 42 of which were immobilized for 6 weeks after surgery and 200 of which were mobilized at 2 weeks afterward. Postoperative Disabilities of the Arm, Shoulder, and Hand surveys were completed by 122 patients (57%), with an average score of 12. No scaphometacarpal abutment was reported. Thirteen complications were reported (5%), 7 of which were implant-associated (3%) and 6 of which were not (2%). Implant-associated complications consisted of 3 suture button pull-outs, 2 thumb–index metacarpal abutments, one suture tail irritation, and one index metacarpal fracture. Operative revision was required in 4 of 7 implant-associated cases and 5 of 6 non–implant associated cases. No suture button pull-outs required revision surgery.ConclusionsResults for a large series of SBS for CMC arthroplasty with intermediate follow-up revealed excellent clinical outcomes and low complication rates.Clinical relevanceSuture button suspensionplasty as an alternative to ligament reconstruction tendon interposition may be a viable option for treating thumb CMC arthritis. In addition, a technique to manage thumb–index metacarpal abutment is described.