Superficial Pin Site Infection Research Articles

Complications and Learning Curve Associated with an Imageless Burr-Based (CORI) Robotic-Assisted Total Knee Arthroplasty System: Results from First 500 Cases.

The use of robotic-assisted total knee arthroplasty (RA-TKA) is gaining traction. There is evidence to suggest that RA-TKA can help to optimize the precision and accuracy of implant positioning and that there may be protective effects on surrounding bony and soft tissues. Yet, there are important differences between the various RA-TKA systems currently on the market. One such newly introduced RA-TKA system uses imageless technology and performs bony cuts with the use of a burr-based device. The learning curve and complications unique to this system have yet to be assessed. We evaluated 500 consecutive RA-TKA cases using a newly developed burr-based and imageless system which were done by a single surgeon between the months of October 2021 and February 2023. Operative times were recorded and compared to the previous 150 conventional TKA cases allowing for the learning curve to be calculated using the CUSUM method. Intraoperative and postoperative complications were categorically profiled. The learning curve of this RA-TKA system was found to be 6 cases. Intraoperative complications included unintended bony over resection (n = 3), soft tissue injury (n = 2), and robotic system hardware (n = 2) or software (n = 2) malfunction. Postoperative complications consisted of superficial pin site infection (n = 1) and periprosthetic fracture near the pin sites (n = 1). There were no identified cases of prosthetic joint infection, instability events, or wound complications. The learning curve and the complication profile of a newly introduced imageless and burr-based RA-TKA system were described. This information serves to guide surgeons in adopting this technology and can counsel them regarding the potential pitfalls and challenges associated with its integration into practice. The work sheds light on the complexity and learning curve of the recently released imageless burr-based RA-TKA system. This important information is intended to help surgeons accept this cutting-edge technology by providing advice on any errors and difficulties that can occur when integrating it into clinical practice. This information can help surgeons navigate the complexities of integrating this new burr-based robotic technology into knee replacement procedures, enabling them to make well-informed decisions and receive guidance.

CIRCULAR FRAME IN THE PRESENCE OF PRE-EXISTING ARTHROPLASTY: IS THERE AN UNACCEPTABLE RISK OF INFECTION?

IntroductionCircular external frames (CEF) are commonly used for a wide variety of indications, often when other devices are not appropriate. Circular frames are particularly associated with pin-site infection (PSI). Currently there is a gap in the available literature surrounding the risk of frame use with in-situ prosthetic joints. This retrospective study investigated the incidence of prosthetic joint infection (PJI) in a series of patients with in-situ arthroplasties treated with CEF.Materials & MethodsFrom a departmental database of 1052 frames performed from March 2007-March 2023, the outcomes of 34 patients (40 frames) with in-situ arthroplasties at the time of CEF were reviewed (mean follow-up 70 months). Patient identification was by review of all local and regional imaging. The primary outcome was development of PJI during or following CEF and subsequent need for surgical intervention. Secondary outcomes were development of superficial pin site or deep bone infection (without PJI).ResultsOf 40 frames used to treat 34 patients, no PJIs were detected. Average patient age was 67 (range 55–82). 22 had cardio-respiratory disease, 11 diabetes, 15 smoked and 8 were immunosuppressed. 53 arthroplasties were in situ at the time of treatment, 12 involving the same bone as the frame. Average time in frame was 253 days. 23 patients developed PSI, 2 required a further procedure for persistent deep bone infection not involving the arthroplasties.ConclusionsAlthough this study involves a relatively low numbers of patients, our results are reassuring that circular frame management in patients with in-situ arthroplasty does not represent an unacceptable risk of PJI. We hope to promote these findings and encourage multi-centre collaboration to expand on the available evidence to better answer this important yet under-reported clinical question.

Magnetic Resonance Imaging-Guided Frameless Stereotactic Injections of the Bilateral Cerebellar Dentate Nuclei in Nonhuman Primates: Technical Note.

Nonhuman primates (NHPs) are important preclinical models for evaluating therapeutics because of their anatomophysiological similarities to humans, and can be especially useful for testing new delivery targets. With the growing promise of cell and gene therapies for the treatment of neurological diseases, it is important to ensure the accurate and safe delivery of these agents to target structures in the brain. However, a standard guideline or method has not been developed for stereotactic targeting in NHPs. In this article, we describe the safe use of a magnetic resonance imaging-guided frameless stereotactic system to target bilateral cerebellar dentate nuclei for accurate, real-time delivery of viral vector in NHPs. Seventeen rhesus macaques (Macaca mulatta) underwent stereotactic surgery under real-time MRI guidance using the ClearPoint® system. Bilateral cerebellar dentate nuclei were targeted through a single parietal entry point with a transtentorial approach. Fifty microliters of contrast-impregnated infusate was delivered to each dentate nucleus, and adjustments were made as necessary according to real-time MRI monitoring of delivery. Perioperative clinical outcomes and postoperative volumes of distribution were recorded. All macaques underwent bilateral surgery successfully. Superficial pin site infection occurred in 4/17 (23.5%) subjects, which resolved with antibiotics. Two episodes of transient neurological deficit (anisocoria and unilateral weakness) were recorded, which did not require additional postoperative treatment and resolved over time. Volume of distribution of infusate achieved satisfactory coverage of target dentate nuclei, and only 1 incidence (2.9%) of cerebrospinal fluid penetration was recorded. Mean volume of distribution was 161.22 ± 39.61 mm3 (left, 173.65 ± 48.29; right, 148.80 ± 23.98). MRI-guided frameless stereotactic injection of bilateral cerebellar dentate nuclei in NHPs is safe and feasible. The use of this technique enables real-time modification of the surgical plan to achieve adequate target coverage and can be readily translated to clinical use.

Outcomes of Management of Severe Clubfoot among Children by Ilizarov External Fixator.

Clubfoot remains the most common birth defect involving the musculoskeletal system. There are various surgical and non-surgical treatment options available for the management of clubfoot. Using the minimally invasive Ilizarov external fixator method has been reported to have good success rates and fewer complications. This study aimed at analysing the morphological and functional outcomes of treating severe clubfoot by Ilizarov external fixator among children from July 2017 to March 2020. Thirty-two children who had either failed Ponseti / surgery or neglected with 44 clubfeet of Dieglio type III and type IV were included in the study. A short-leg walking cast was applied for an additional six weeks after removing of Ilizarov frame and additionally followed by an orthosis for another six weeks. Outcomes were measured by the functional rating system by Laaveg and Ponseti and interpretation done at 1 month and 12 months after the ankle-foot arthrosis. About 86.4% of the patients had good or excellent outcome scores. Pre and post-Demeglio scores and functional rating scores were statistically significant (p<0.001) by using Paired t-test. Complications included superficial pin site infections in 13 feet (29.54%), 5 feet (11.36%) had claw toes, 3 feet (6.81%) had linear skin necrosis and 2 feet (4.54%) had calcaneal fractures which were manageable with minor interventions. The study findings highlighted that the Ilizarov external fixator method can correct complex foot deformities of severe clubfoot with minimum morbidity. Further larger and long-term studies are needed to investigate the effects of the stiff hindfoot and possible degenerative changes on the function and symptoms of these patients as adults.

Outcomes of ankle joint distraction in a paediatric and young adult cohort presenting with symptomatic ankle arthritis.

Ankle arthritis in paediatric and young adult patients causes significant morbidity; therefore, joint-preserving procedures are preferable. Ankle joint distraction (AJD) is a technique that preserves the native joint. However, only short-term outcomes are reported in paediatric patients. Therefore, this study reports on intermediate-term outcomes in a paediatric cohort. Demographics for all patients who underwent AJD at two centres were prospectively collected. Case records were reviewed retrospectively for complications and further intervention. Mean joint space at baseline and follow-up radiographs were evaluated by two independent observers. All patients were contacted for completion of a Foot and Ankle Outcome Score (FAOS). Seven patients received AJD between February 2016 and June 2019. Median age at surgery was 15 years (9.0-24.6 years). Complications included one superficial pin-site infection and one patient death due to complications from juvenile idiopathic arthritis 6.2 years post-operatively. Two patients were converted to fusion, at 12.6 months and 26.2 months following frame removal; one patient underwent spontaneous fusion at 9 months following frame removal. The four patients who continued without further intervention achieved 2.59 mm mean joint space at last follow-up (0.65-5.08 mm) and FAOS of 35-79%. Mean follow-up length was 4.3 years (2.9-6.3 years) with final radiographs at mean 2.6 years. While recognising the limitations of this retrospective review, several patients had significant, sustained improvements in joint space with good clinical outcome. Complications for this procedure are minimal, and it is a potential joint-preserving option for managing end-stage ankle arthritis in young patients.

Headless cannulated screw and external fixator in the treatment of type C distal femur fractures: Effect of early mobilization on clinical outcomes.

Distal femur fractures occur due to high-energy trauma in young patients and with low-energy traumas in osteoporotic elderly patients. Implants selected for use in the treatment of distal femur fracture should provide stable fixation and allow early mobilization especially at elder patients. We aimed to investigate the effects of the headless cannulated screw and external fixator combination on the early mobilization of the patients and postoperative complications. Twenty-one patients with Type C distal femur fracture were included in the study.The fracture lines were temporarily fixed with K wires. After the fracture reduction with headless cannulated screws a tubular external fixator with carbon fiber rods was applied to bridge the knee joint. The external fixators were removed at the 6th week follow-up, and the patients were forced to perform knee flexion as much as they could tolerate. The 6th month KSS scores of the patients were 44.3 (34-60) and the 18th month KSS scores were 77.5 (60-88).Preoperative VAS score was 8(7-10) and postoperative VAS score was 4(3-6).Knee flexion of the patients at 6th months was 95.9 (80-110 degrees) and at 6th months knee flexion was 114.5 (100-125 degrees). Superficial pin site infection was observed at 4 patients and regressed with antibiotic therapy. Combination of cannulated screws with an external fixator for joint restoration in type C distal femur fractures allows early mobilization and reduces postoperative morbidity.

Functional And Radiological Outcome of Schatzker Type V and VI Tibial Plateau Fracture Treated with Closed Reduction and Ilizarov Fixation with or without Minimally Invasive Screw Supplementation

Introduction: Controversy exists as to the best treatment approach for high-velocity tibial plateau fractures. This study was done to assess the functional and radiological outcome of Schatzker type V and VI tibial plateau fractures treated with closed reduction and Ilizarov ring fixation with or without cancellous screw supplementation. Methods: An analytical cross sectional study was conducted among 25 cases of both closed and open Schatzker type V and VI tibial plateau fractures treated with closed reduction and Ilizarov ring fixation with or without minimally invasive cannulated cancellous screw supplementation. The outcome variables analyzed were union time, knee range of motion, American Knee Society Score (AKSS), Rasmussen’s Radiological Score (RRS), and complications. Data analysis was done using SPSS-20. P-value &lt;0.05 was considered as statistically significant. Results: There were 15 type V fractures, 10 type VI fractures, 21 closed fractures, and 4 open fractures. All the fractures united with a mean union time of 15.88 weeks (range 12-24). The mean American Knee Society score was 77.8 (range 68-95), Rasmussen’s radiological Score (RRS) 15.12 (range 10-18), and mean range of motion was 112.40 (range 90-135). Superficial pin site infection was present in 7 (28%) of the cases. There was no case of nonunion, deep infection, repeat surgery other than implant removal, or nerve palsy. Conclusions: Closed reduction and Ilizarov ring fixation with or without minimally invasive screw supplementation give rise to good to excellent functional and radiological outcomes in most of the cases in the treatment of Schatzker type V and VI tibial plateau fractures with minimal bone or soft tissue related complications.

Multifocal percutaneous pin fixation of talar neck fractures: An alternative to ORIF in the polytraumatized patient

PurposeUnique anatomy, precise articulations, fragile vascularity, and the demand for anatomic reduction make talar neck fractures challenging to treat, whether with screws and/or plates. Multifocal percutaneous pin fixation (MPPF) offers an alternative to ORIF, particularly in the polytraumatized patient. MethodsUnless an open lateral wound or medial malleolus fracture was present, a standard anteromedial approach was performed. K-wires placed within the talar head were used as joysticks to facilitate and finalize reduction. At least 3 wires were placed medially and 2 laterally across the talar neck. Incisions were closed in 2 layers, and either a well-padded short leg splint or adjunctive ankle-spanning external fixation was utilized. Patients remained non-weightbearing until K-wire removal in the office at approximately 6–8 weeks postoperatively. ResultsMPPF was performed in 7 patients, the majority of whom were female (6 of 7). The average patient age at the time of injury was 30.3 years (range 17–51 years). The median time of final follow up was 27 months. Comminution was present in all patients. Avascular necrosis (AVN) developed in 3 patients and non-union occurred in 2 patients. All patients developed subtalar posttraumatic arthritis, and 6 additionally developed tibiotalar arthritis. No patients underwent talectomy or osteotomy, and there were no superficial pin site infections or loosening of pins prior to scheduled removal. ConclusionsObtaining and maintaining an adequate reduction is possible with minimal soft tissue compromise through MPPF. Despite the complexity of the series, outcomes utilizing MPPF are comparable to those reported in the literature.

Orthopedic complications after osteotomy in patients with classic bladder exstrophy and cloacal exstrophy: a comparative study

The addition of pelvic osteotomy to the armamentarium of tools for correction of classic bladder exstrophy (CBE) and cloacal exstrophy (CE) has undeniably served as one of the most effective advancements in improving the likelihood of successful primary bladder closure. Osteotomy-related complications have been studied and documented extensively in patients with CBE, yet evaluation remains limited in CE concordant with its relative rarity. To compare orthopedic complications in patients with CBE and CE who underwent primary bladder closure with osteotomy. A prospectively maintained, IRB-approved database of 1401 exstrophy-epispadias patients was reviewed for patients with CBE or CE after primary closure and pelvic osteotomy performed at a single institution from 1975 to 2021. Failed closure was defined as dehiscence, bladder prolapse, or vesicocutaneous fistula at any point. Surgery or anesthesia-related complications were captured within 6 weeks of osteotomy or closure. A total of 146 patients were included in the analysis with 109 and 37 patients with CBE and CE, respectively. Between the CBE and CE cohorts, there were significant differences in median age at primary closure (68 days [IQR 10-260] vs 597 [448-734]; p<0.001), diastasis width (4cm IQR [3.8-4.6] vs 6.1 [5.0-7.2]; p<0.001), osteotomy at time of closure (99.1% vs 75.7%; p<0.001), and utilization of external hip fixation (67.9% vs 89.2%; p=0.011). There was no significant difference by gender, osteotomy technique, or hip immobilization technique. Regarding exstrophy closure outcomes, there were 5 failures in the CBE group and 1 in the CE group (p=1.000). Complications were experienced in 38.5% and 56.8% of CBE and CE patients (p=0.054) with a significant difference in orthopedic complications (primarily consisting of superficial pin-site infections) between the cohorts (4.6% vs 16.2%, p=0.031). There was no significant difference in grade 3 or higher complications between cohorts (5.5% vs 13.5%, p=0.147). This was the first study comparing orthopedic complications after osteotomy between CBE and CE, providing valuable insight into which factors vary among cohorts and which are associated with increased complication rates. Despite availability of high case numbers for these rare disorders, the analysis continued to be limited sample size and missing data for retrospective analysis. While exstrophy closure success and overall complications rates are similar in patients with CBE and CE, patients with CE experience more superficial pin-site infections after pelvic osteotomy. External hip fixation may be associated with the increase in orthopedic complications, though further research is required to elucidate the underlying cause of these complications.

The outcome of displaced pediatric supracondylar fractures of the elbow treated with lateral three divergent K wires

Introduction: Supracondylar fracture of the humerus is the commonest elbow injury in children, treated with closed reduction and percutaneous fixation. Crossed K-wires fixation is more biomechanically stable than lateral K – wires only. Recent biomechanical studies have shown that 3 lateral divergent K—wire fixation is as stable as cross K-wire fixation. Furthermore, lateral divergent fixation is associated with a good clinical outcome. Methods: A descriptive cross-sectional study was conducted in the department of orthopedics at People’s General Hospital, Kathmandu between the period of January 2018 to December 2020. Medical records of 76 supracondylar fractures of humerus Gartland type III and IV were reviewed out of which 46 patients were included in the study after meeting the inclusion criteria. Radiological assessment was done to assess fracture union and stability. Flynn's grading system was used for functional outcomes. Results: The mean age was 7.3 years (range 4 – 13 years). The boys were 32 (70%) and girls were 14 (30%). The follow-up was 9.2 months (range 3 – 12 months). At the final follow-up, the mean range of elbow motion at final follow up was 0.86 ± 4.58° - 135.86 ± 4.078°, the mean arc of motion was 139.9 ± 6.2°, and the mean carrying angle was 13.63± 32.15°. No iatrogenic ulnar nerve injury was noted. Five patients (10.8%) had superficial pin site infection, managed with local dressings after pin removal. According to Flynn’s grading system, 41 patients (89.1%) achieved excellent results, and one patient had poor results. None of them had chronic discharge after the wire removal. Conclusion: Closed reduction and percutaneous 3 lateral divergent K – wire fixation for type III and IV supracondylar fracture of humerus in children provides a stable configuration with good functional outcomes and avoids iatrogenic ulnar nerve injury.

The Incidence of Deep Infection Following Lower Leg Circular Frame Fixation with Minimum of 1-year Follow-up from Frame Removal.

AimSuperficial pin site infection is a common problem associated with external fixation, which has been extensively reported. However, the incidence and risk factors with regard to deep infection are rarely reported in the literature. In this study, we investigate and explore the incidence and risk factors of deep infection following circular frame surgery. For the purpose of this study, deep infection was defined as persistent discharge or collection for which surgical intervention was recommended.Materials and methodsThis study is retrospective review of all patients who underwent frame surgery between April 1, 2015 and April 1, 2019 in our unit with a minimum of 1 year follow-up following frame removal. We recorded patient demographics, patient risk factors, trauma or elective procedure, number of days the frame was in situ, location of infection and fracture pattern.ResultsThree-hundred and four patients were identified. Twenty-seven patients were excluded as they were lost to follow-up or had their primary frame surgery as a treatment for infection. This provided us with 277 patients for analysis. The mean age was 47 years (range: 9–89 years), the male to female ratio was 1.5:1, and 80% were trauma frames. Thirteen patients (4.69%) developed deep infection, and all occurred in trauma patients. Of the 13 patients who developed deep infection, 4 had infection before frame removal, and infection occurred in 9 after frame removal. Deep infections occurred in 8 patients within a year of frame removal and in one patient between 1 and 2 years of frame removal.Within the 13 frame procedures for trauma, 12 were periarticular multi-fragmentary fractures, 3 of which were open, and the remaining were an open diaphyseal fracture. The periarticular fractures were more likely to develop deep infection than diaphyseal fractures (p = 0.033). Twelve patients (out of 13) also had concurrent minimally invasive internal fixation with screws in very close proximity of the wiresConclusionThe rate of deep infection following circular frame surgery appears to be low. Pooled, multi-centre data would be required to analyse risk factors; however, multi-fragmentary, periarticular fracture and the requirement for additional internal fixation appear to be an associated factor.How to cite this articleTing J, Moulder E, Muir R, et al. The Incidence of Deep Infection Following Lower Leg Circular Frame Fixation with Minimum of 1-year Follow-up from Frame Removal. Strategies Trauma Limb Reconstr 2022;17(2):88–91.

Pin-Related Complications in Computer Navigated and Robotic-Assisted Knee Arthroplasty: A Systematic Review

BackgroundComputer-assisted navigation (CAN) and robotic-assisted (RA) knee arthroplasty procedures carry unique risks of tracking pin-related complications. This systematic review aimed to quantitatively assess the incidence, timing, treatment, and clinical outcomes of all tracking pin-related complications following CAN and RA knee arthroplasty. MethodsA systematic review was performed using PubMed, Cochrane Central and Scopus databases. All clinical studies that documented pin-related complications associated with the use of CAN or RA for total or partial knee arthroplasty were included. Descriptive statistics were analyzed when data were available. ResultsThirty-six studies were included: 18 case reports (25 cases) and 18 randomized controlled trials, cohort studies and case series i.e., non-case reports (7,336 cases). The most common pin-related complication among case reports was fracture (n = 22; 81%). The overall rate of pin-related complications among non-case reports was 1.4%. The intraoperative and postoperative complication with the highest incidence were pin dislodgement (0.6%) and superficial pin site infections (0.6%), respectively. Most postoperative complications were related to the tibial site (69%). All complications were effectively treated and resolved at follow-up. ConclusionPin-related complications following CAN and RA knee arthroplasty are relatively uncommon. While pin loosening, superficial infections and fractures have been most commonly documented, other complications such as vascular injury, myositis ossificans, and osteomyelitis can also occur. The potential for pin-related complications should be considered by arthroplasty surgeons, especially during early stages of adoption. Further studies investigating patient risk factors for pin-related complications are warranted.

A comparative study of functional outcome of intraarticular distal radius fractures treated with K wire versus conservative management

Background: Intraarticular distal radius fractures are commonly seen fractures of the upper extremity showing bimodal distribution in pediatric and elderly adults. The age distribution of distal radius fracture is typically peaks in the 5-14 year age group and also peaks in elderly patients more than 60 years of age. Aim: To compare the functional outcome of intraarticular distal radius fractures treated with k wire versus conservative management. Material and methodology: The study was conducted between July 2020 to December 2021 in the department of orthopaedics, RMMCH, 20 patients with intraarticular fractures of the distal radius were included in the study. 10 patients were treated with k wire/ligamentotaxis with k wire, 10 patients were treated with conservative methods. Follow up was done for a minimum period of 6 months, functional outcome was assessed using the Quick DASH Scoring system. Results: The functional outcome in the k wire group was 12.9, which was found to be better than the conservative group 17.49. No poor outcome was seen in the k wire group. 2 patients had a poor outcome in the conservative group. Malunion was found in 2 patients in the conservative group. No patients had malunion in k wire group. Superficial pin site infection was found in one patient. Stiffness was found in 1 patient in the k wire group and 3 patients in the conservative group.Conclusion: In our study, the functional outcome results were better in the patients managed with surgical intervention by percutaneous fixation using K wire/ligamentotaxis with k wire than in patients managed with the conservative method by closed reduction and cast immobilisation.

Management of Gustilo-Anderson IIIB open tibial fractures in adults-a systematic review.

Open tibial fractures are the most common open long bone fracture, despite this, the management of these complex injuries still remains a topic of discussion amongst orthopaedic surgeons. We searched the EMBASE, MEDLINE and Google Scholar and a systematic review of 7500 articles, leaving 23 after exclusion criteria were applied, in order to analyse the management of open tibial fractures. Infection was noted to be the most significant concern amongst authors, with definitive external fixation having a high rate of superficial pin-site infection and internal fixation having a high deep infection rate. It is essential to have a combined ortho-plastic approach to the management of these fractures as muscle flaps were the most common form of soft tissue coverage. A national pragmatic trial into the management of open tibial fractures is required looking at fixation methods and soft tissue coverage, with at least a 2-year follow-up in order to ascertain the most appropriate management of these fractures and patient-related outcomes.

Comparative evaluation of pinning and cast fixation vs. external fixation after lateral closing-wedge osteotomy for cubitus varus in children.

Cubitus varus has been regarded as a poor functional and cosmetic consequence of supracondylar humerus fracture in children. The aim of this study was to assess the clinical and radiologic outcomes of cubitus varus treatments based on fixation methods: Kirschner (K)-wire and cast fixation or external fixation. Forty consecutive patients with cubitus varus secondary to supracondylar fractures were retrospectively enrolled between October 2015 and December 2018. Following lateral closing-wedge osteotomy, those undergoing K-wire and cast fixation were included in group A (n = 21) and those who were treated with external fixation comprised group B (n = 19). We measured the bony union, elbow joint range of motion, and carrying angle. The clinical and radiographic results were assessed according to the Bellemore criteria. No significant difference was found between the 2 groups in terms of age, gender, operation duration, union time, and postoperative elbow range of motion (P > .05). A significant difference was noted, however, in postoperative carrying angle and results according to Bellemore criteria in group B (P < .05). No nonunion, myositis ossificans, or neurovascular injury was found at follow-up in the 2 groups. In group A, revision surgery was needed for residual varus in 1 patient and lateral condylar prominence was found in 2 patients. In group B, a superficial pin-site infection occurred in 2 patients, who were treated successfully with oral antibiotics. Both K-wire and external fixation after lateral closing-wedge osteotomy are reliable and effective for the treatment of cubitus varus in children. Compared with the K-wire method, external fixation achieves better functional and cosmetic results with a shorter learning curve.

Osteotomy in the newborn classic bladder exstrophy patient: A comparative study

Pelvic osteotomy is indicated in classic bladder exstrophy (CBE) patients with a wide pubic diastasis or non-malleable pelvis. While the safety of pelvic osteotomy in delayed and failed closures is established, there remains less clarity on their safety in newborns. The authors herein sought to present their experience with CBE patients who underwent pelvic osteotomy for assistance with bladder closure during both the newborn and delayed time periods. The authors hypothesize that pelvic osteotomy during exstrophy closure may be performed safely in newborns with few perioperative or post-operative negative sequelae. A prospectively maintained IRB-approved database was reviewed for CBE patients who underwent osteotomy during primary closure. Patient demographics, performing institution (authors' or outside), closure outcome, diastasis width, and post-operative complications were noted. Patient subgroups included newborn and delayed (>28 days of life) closures. Failure was defined as bladder dehiscence, prolapse, outlet obstruction, or vesicocutaneous fistula requiring reoperation. Orthopedic complications included nerve palsies, superficial pin-site infection, and bladder neck erosion by orthopedic hardware. Analyses were performed using a Chi-square test. 286 patients were included: 186 newborn and 100 delayed closures. The authors' institution performed 109 cases (44 newborn and 65 delayed). Within the overall newborn closure cohort, no significant differences were found in outcomes among the osteotomy types with success rates of 80%, 60.8%, and 71.4% in the combined, posterior iliac, and anterior innominate groups, respectively (p=0.24). In the delayed group, success rates were significantly different with rates of 100%, 72.4%, and 93.8% in the combined, posterior iliac, and anterior innominate groups, respectively (p<0.001). Febrile urinary tract infection (UTI) was the most common complication at 8% (23/286). Only 1.7% (5/286) of patients had orthopedic complications with 3 patients in the newborn cohort, 2 patients in the delayed cohort, and only one patient requiring reoperation. Orthopedic complications are rare in CBE patients who undergo osteotomies regardless of the closure period. No clinically significant difference in orthopedic complication rate was found between newborn and delayed closure periods. While current trends have moved toward delayed primary closures, there remains a role for osteotomy during exstrophy closure in select newborn patients and can be performed safely with few complications.

Comparison of K-wire versus screw fixation after open reduction of transitional (Tillaux and triplane) distal tibia fractures.

Our study aimed to compare the clinical and radiographic outcomes of transitional distal tibia fractures treated with K-wire fixation versus screw fixation after open reduction. A retrospective study was performed on all displaced transitional distal tibia fractures that underwent operative fixation. Following open reduction, surgical fixation was performed using either percutaneously inserted 2.0 mm K-wires, or 4.0 mm partially-threaded cannulated cancellous screws. Clinical and radiographic outcomes between the two groups were assessed using the modified Weber score. Other outcome measures assessed were surgical time, casting duration, follow-up duration and duration before return-to-sports. We recruited 49 patients with transitional distal tibia fractures requiring open reduction and surgical fixation. There were 18 patients in the K-wiring group (KWG), and 31 patients in the screw fixation group (SFG). All patients in both groups had excellent clinical and radiographic outcome based on the modified Weber's scoring, full radiological healing, and no residual displacement upon final follow up. The KWG had significantly shorter surgical time (41.0 min versus 75.1 min, P < 0.0001) and shorter follow-up duration needed before discharge (5.4 months versus 8.7 months, P = 0.024). However, they required a longer post-operative casting duration (7.3 weeks versus 5.3 weeks, P = 0.006). No significant difference was found for the duration before return to sports between both groups. Complications were few in this study group. Superficial pin site infection was noted in one patient in the KWG, and valgus deformity of the ankle was noted in one patient in the SFG. In our study, surgical treatment of transitional distal tibia fractures demonstrated equally excellent outcomes when treated by open reduction with either K-wire or cannulated screw fixation. Level of evidence: III.

Halo-gravity traction for the treatment of pediatric cervical spine disorders.

Halo-gravity traction (HGT) is an effective and safe method for gradual correction of severe cervical deformities in adults. However, the literature is limited on the use of HGT for cervical spine deformities that develop in children. The objective of the present study was to evaluate the safety and efficacy of HGT for pediatric cervical spine deformities. Twenty-eight patients (18 females) whose mean age was 11.3 ± 5.58 years (range 2-24.9 years) underwent HGT. Common indications included kyphosis (n = 12), rotatory subluxation (n = 7), and basilar invagination (n = 6). Three children (11%) received traction to treat severe occipitocervical instability. For these 3 patients, traction combined with a halo vest, with bars attached rigidly to the vest, but with the ability to slide through the connections to the halo crown, was used to guide the corrective forces and moments in a specific and controlled manner. Patients ambulated with a wheelchair or halo walker under constant traction. Imaging was done before and during traction to evaluate traction efficacy. The modified Clavien-Dindo-Sink classification was used to categorize complications. The mean duration of HGT was 25 days (IQR 13-29 days), and the mean traction was 29% ± 13.0% of body weight (IQR 19%-40% of body weight). The mean kyphosis improved from 91° ± 20.7° (range 64°-122°) to 56° ± 17.6° (range 32°-96°) during traction and corresponded to a mean percentage kyphosis correction of 38% ± 13.8% (range 21%-57%). Twenty-five patients (89%) underwent surgical stabilization, and 3 patients (11%) had rotatory subluxation that was adequately reduced by traction and were treated with a halo vest as their definitive treatment. The mean hospital stay was 35 days (IQR 17-43 days).Nine complications (32%) occurred: 8 grade I complications (28%), including 4 cases of superficial pin-site infection (14%) and 4 cases of transient paresthesia (14%). One grade II complication (4%) was seen in a child with Down syndrome and a preexisting neurological deficit; this patient developed flaccid paralysis that rapidly resolved with weight removal. Six cases (21%) of temporary neck discomfort occurred as a sequela of a preexisting condition and resolved without treatment within 24-48 hours. HGT in children is safe and effective for the gradual correction of cervical kyphosis, atlantoaxial subluxation, basilar invagination, and os odontoideum. Cervical traction is an additional tool for the pediatric spine surgeon if uncertainties exist that the spinal alignment required for internal fixation and deformity correction can be safely achieved surgically. Common complications included grade I complications such as superficial pin-site infections and transient paresthesias. Halo vest gravity traction may be warranted in patients with baseline neurological deficits and severe occipitocervical instability to reduce the chance of catastrophic movement.

Radiographic Outcomes of a Percutaneous, Reproducible Distal Metatarsal Osteotomy for Mild and Moderate Bunions: A Multicenter Study

Hallux valgus is a prevalent condition. Many open surgical methods of correction have been described. We performed a percutaneous, extra-articular distal metatarsal osteotomy for mild to moderate bunion deformity. The minimally invasive technique was used in 217 feet (180 patients; age 49 ± 4.7 years, mean ± standard deviation) at 4 centers in North America (Center 1: November 2012 to March 2017; Center 2: January 2010 to May 2016; Center 3: October 2013 to June 2016; Center 4: January 2015 to June 2017). The procedure was used in simultaneous bilateral cases in 28 patients (15.6%) and in nonsimultaneous bilateral cases in 9 patients (5.0%). Immediate postoperative weightbearing was used in all cases. The mean preoperative intermetatarsal angle, hallux abductus angle, and tibial sesamoid position were 14.6° ± 3.5°, 30.7° ± 7.8°, and 5.4 ± 1.4, respectively. At final follow-up of 9.3 ± 6.1 months, the mean intermetatarsal angle, hallux abductus angle, and tibial sesamoid position were 4.7° ± 2.8°, 8.4° ± 6.1°, and 2.0 ± 1.0, respectively (p < .0001 for all comparisons). No major complications were noted. All 217 osteotomies achieved union; 3 feet (1.4%) in 3 patients (1.7%) experienced asymptomatic malunion. Superficial pin-site infection was seen in 42 (19.4%) of the 217 feet (39 patients, 21.7%). The radiographic results of this percutaneous technique appear to be reproducible across multiple centers, and the technique is useful when correcting intermetatarsal and hallux abductus angles. This percutaneous osteotomy for realignment of the first ray allows immediate postoperative weightbearing and, in this initial review, appears to be safe and effective, even in simultaneous bilateral cases.

Comparison of Kirschner wires and Cannulated screw internal fixation for displaced lateral humeral condyle fracture in children

Background: Lateral condyle fracture of the distal humerus is the second most common injury around the elbow.&#x0D; Aims and Objective: The purpose of the study was to compare Kirschner wires (K-wire) and Cannulated cancellous (CC) screw for internal fixation of displaced lateral humeral condyle fracture in children.&#x0D; Materials and Methods: Forty-six patients with a displaced lateral condyle fracture of humerus were included in the study. Patients were treated with open reduction and internal fixation either with two 1.8mm K-wires or one 4mm CC screw. Fractures were classified according to Milch classification and clinical outcomes were evaluated according to criteria of Hardacre et al.&#x0D; Results: There were 23 patients in each group with the mean age of 6.57 years (range 2 to 12 years). Milch type II was common (n= 34) than Milch type I (n=12). Fracture union was observed at mean 4.13 weeks in the CC screw and 4.61 weeks in K-wire group.(p value = 0.026). On an average the CC screws were removed at 13.57 weeks and K-wires were at 4.57 weeks. The mean follow-up was 13.83 months in CC screw and 12.52 months K-wire group. Three patients (6.5%) had superficial pin site infection and 2 patient (4.3%) had lateral condyle prominence in the K-wire group and only one lateral condyle prominence (2.2%) was observed in the CC screw group. According to the Hardacre et.al criteria CC screw group were excellent in 20 (87%) and good in 3 (13%) patients whereas 13 (56.5%) excellent and 10 (43.5%) good results were found in the K-wire group. (p value = 0.022).&#x0D; Conclusion: Open reduction and internal fixation with either K-wires or cannulated cancellous screw for displaced lateral condyle fracture of humerus are both effective treatment methods but screw fixation provides absolute stability at the fracture site enhancing the fracture healing, reduces the probability of lateral prominence and allows early range of motion and activity in the affected elbow.