T-condylar fractures of the distal humerus in children: does early motion affect final range of motion?

Purpose

T-condylar fractures of the distal humerus are infrequent injuries in children. There are little data regarding outcomes in this age group. The adult literature demonstrates a high rate of postinjury stiffness. We describe a large series of T-condylar fractures in children and set out to identify factors that influence the postoperative range of motion (ROM) in children. Our hypothesis was that starting motion early (<3 weeks) would favorably influence the postoperative ROM.

Methods

Patients were identified based on the Current Procedural Terminology (CPT) code for ORIF of supracondylar distal humerus fractures with intracondylar extension (24546). Patient records and radiographs were reviewed to determine the demographics, fracture characteristics, surgical approach and fixation, and postoperative immobilization time. Our outcome measure was ROM in flexion/extension at 3 months, 6 months, 1 year, and final follow-up. Patients were analyzed by Morrey’s criteria of −30° extension and 130° flexion to assess for postoperative elbow stiffness.

Results

Thirty-eight potential patients from 1992 to 2010 were identified with specific T-condylar patterns. Twelve patients were excluded due to insufficient follow-up or lack of final ROM data. Our cohort included 26 patients (average age 13.4 years). The average postoperative immobilization time was 3.4 weeks (range 0.9−12 weeks). At the final follow-up, patients had −12° average extension and 130° average flexion. Nine patients (35 %) were stiff and 17 patients (65 %) had functional motion postoperatively. At 3 and 6 months, starting motion early yielded better flexion and extension ROM. Late-motion patients obtained similar results at the 1-year follow-up. Open fractures, gender, and age were all not significantly associated with elbow stiffness in our series, given the limited numbers.

Conclusion

Early ROM was associated with an earlier gain of functional motion without clear adverse consequences. Despite similar findings at the final follow-up, practitioners should consider instituting early ROM protocols to decrease the duration of stiffness and potential disability for the child and the family.     

Treatment of perforated appendicitis in children: what is the cost?

Background/PurposeWe compared direct hospital costs and indirect costs to the family associated with immediate appendectomy or initial nonoperative management for perforated appendicitis in children.MethodsFrom June 2009 through May 2010, 61 prospectively identified families completed a cost diary, documenting the numbers of missed school days for the child and missed employment days for the adult caregiver(s) over the treatment course. Hospital costs were obtained from hospital financial databases. Mann-Whitney U tests and Fisher exact tests were used to compare outcome measures for each treatment strategy.ResultsPatients treated by initial nonoperative management had a significantly longer median length of stay (9 days vs 7 days, P = .02) and a significantly greater median total hospital cost per patient ($31,349 vs $21,323, P = .01) when compared with those treated by immediate appendectomy. There was no significant difference in median number of missed school days (9 days vs 10 days, P = .23) or missed employment days for adult caregiver(s) (5 days vs 7 days, P = .18) between treatment strategies.ConclusionsPatients with perforated appendicitis treated by initial nonoperative management had a greater length of stay and a significantly greater total hospital cost but were not burdened by significantly greater indirect costs compared with those treated by immediate appendectomy.     

Hip precautions after hemiarthroplasty: what is happening in the UK and at what cost?

INTRODUCTION

The aim of this study was to observe current practice of the use of hip precautions following hemiarthroplasty for hip fractures in England and to audit the cost of hip precautions in this patient group.

METHODS

A telephone review was undertaken of all units identified by the National Hip Fracture Database as receiving centres for hip fractures across England to ascertain current practice in the use of hip precautions. A prospective audit of occupational therapy (OT) practice including the cost of equipment provision and OT time was carried out locally.

RESULTS

All 174 units in England were successfully contacted. Practice varied between centres but hip precautions were in use at 78% of centres. Prior to stopping hip precautions at the local hospital, we audited the costs associated with their use. Mean equipment costs per patient decreased by £12 (from £49 to £37, range: £0–£83) and mean OT time per patient decreased by 1.5 hours (from 8 hours to 6.5 hours, range: 1–22 hours) following removal of hip precaution guidelines. A mean of 0.25 days'' discharge delay (range: 0–4 days) due to equipment provision was identified prior to removing hip precautions with no discharge delay following.

CONCLUSIONS

This study has highlighted the variation in practice across the country and inconsistency with the advice published by the British Orthopaedic Association and British Geriatrics Society in the ‘Blue Book’ (The Care of Patients with Fragility Fracture). Hip precautions are unnecessary after hemiarthroplasty, cost money both in therapist time and equipment provision and increase the length of hospital stay. Nevertheless, they continue to be used by three-quarters of trauma hospitals in England.     

Surgical treatment of ingrown toenails in children: what is best practice?

INTRODUCTION

Surgery for ingrowing toenails carries a significant re-operation rate. We reviewed our departmental figures to assess the optimal management of these patients.

PATIENTS AND METHODS

We performed a 10-year retrospective review of all patients undergoing surgery for ingrown toenails (IGTN) in order to determine the operations most commonly used and the re-operation rate of each of these procedures.

RESULTS

A total of 880 procedures were performed on 414 patients. The median age at operation was 8.5 years. About half (48%) of children underwent two or more procedures with wedge excision and phenol application being the most common initial and repeat procedure. Recurrent surgery was most likely following plain avulsion or wedge avulsion without phenol application. Excision of the nailbed with phenol application had the lowest recurrence rate at 18.4%.

CONCLUSIONS

We recommend wedge resection with phenol application as first-line treatment with simple avulsion reserved for severely infected toes. Total nail bed excisions should be reserved for patients with significant on-going morbidity associated with IGTN. Families must be made aware of the likely outcome of IGTN surgery and the choice of operation must be tailored to the individual.     

Diagnosis and staging of malignant bone tumours in children: what is due and what is new?

PurposeAlthough malignant bone tumours in children are infrequent, it is important to know how to properly diagnose and stage them, in order to establish an adequate treatment.MethodsWe present a review of the diagnostic workflow of malignant bone tumours in children, including history and clinical examination, imaging, laboratory tests and biopsy techniques. Moreover, the two most commonly used staging systems are reviewed.ResultsHistory, clinical examination and laboratory tests are nonspecific for diagnosing malignant bone tumours in children. Radiographs remain the mainstay for initial diagnosis, with MRI the modality of choice for local assessment and staging. Fluorine-18 labelled fluoro-deoxy-glucose-positron emission tomography scans provide a noninvasive method to assess the aggressiveness of the tumour and to rule out metastasis and is replacing the use of the bone scintigraphy. Biopsy must be always performed under the direction of the surgeon who is to perform the surgical treatment and after all diagnostic evaluation has been done. Staging systems are useful to study the extent of the tumour and its prognosis. They are expected to evolve as we better understand new molecular and genetic findings.ConclusionWhen a malignant bone tumour is suspected in a child, it is essential to make a correct diagnosis and referral to an experienced centre. Following an appropriate workflow for diagnosis and staging facilitates, prompt access to treatment improves outcomes.Level of EvidenceLevel V Expert opinion     

Preventing venous thrombosis in critically ill children: what is the right approach?

Background: The incidence of venous thromboembolic (VTE) events in children has increased in recent years (J Neurosurg, 101, 2004, 32; J Thromb Haemost, 1, 2003, 1443) yet there is currently no consensus as to what VTE prophylaxis, if any, should be applied to the pediatric population. Objectives/Aims: Our aim was to audit current practice in pediatric VTE prophylaxis across England and Wales and to advocate simple measures for prevention. We illustrate the importance of the condition with a series of cases from the South West Paediatric Burns and Neurosurgical Services based in Bristol. Methods: Every pediatric intensive care unit (PICU) and burns center admitting children in England and Wales was invited to participate in a structured telephone questionnaire designed to find out how VTE in children were being prevented. We performed a literature review of specific risk factors and management of these factors. Results: Only one of the 24 units surveyed had written guidelines specific for children. Four other units used modified adult guidelines in older children. In the remaining 19 units that had no written guidelines, decisions regarding prophylaxis were based on individual cases and consultant‐led. Conclusion: There is no consensus in England and Wales as to which VTE prophylactic measures should be applied in patients <18 years of age. The National Institute for Health and Clinical Excellence (NICE) guidelines apply to adults only. Given the rarity of VTE events in children, it is unlikely that randomized controlled trials will provide the answer. We therefore propose that simple empirical measures be formally implemented in critically ill children to reduce the risk of developing this important but under‐recognized condition.     

Outcome assessment in total knee arthroplasty: is the clinical measurement of range of motion a reliable measurable outcome variable?

AIM: The aim of this clinical study was to investigate the reliability of the clinical assessment (visual and goniometric) of the range of motion of the knee joint. METHOD: 30 patients were assessed concerning the range of motion of their knee joints by visual and goniometric measurements. Assessment was performed by three investigators. The obtained data were used to analyse the intra- and interobserver reliability. Statistical analysis was performed using the Spearman coefficient of correlation [r (s)]. RESULTS: Intraobserver agreement was consistent across observers regarding the visual and goniometric assessment of flexion (r (s) > 0.6), whereas reliability was uniformly low for both measurements regarding the assessment of extension (r (s) < 0.6). Interobserver agreement was consistent across all three goniometric and two out of three visual assessments regarding the measurement of flexion (r (s) > 0.6); the interobserver reproducibility of extension, however, was uniformly low both for the visual and goniometric measurements (r (s) < 0.6). CONCLUSION: Reliability of clinical assessment of range of motion should be taken critically into consideration whilst performing classical function-related scoring systems when measuring outcome after total joint arthroplasty, since these scoring systems are strongly based on a valid and reliable assessment of range of motion.     

Hip osteoarthritis: where is the pain?

BACKGROUND: Pain radiating below the knee is typically thought to originate from the lumbosacral spine rather than degenerative hip pathology. We investigated the lower limb distribution of pain using body image maps in 60 patients awaiting primary hip arthroplasty and in 60 patients awaiting spinal decompression for confirmed spinal stenosis. The perception of 33 orthopaedic registrars regarding distribution of hip pain was also assessed. RESULTS: Groin and buttock pain are significantly more common in hip osteoarthritis. The presence of groin pain is 84.3% of those sensitive for hip dysfunction with a specificity of 70.3%. Patients with hip osteoarthritis had pain below the knee in 47% of cases whereas 88.5% of orthopaedic trainees believed hip pain did not radiate below the knee. Radiographic features of osteoarthritis within the hip joint, visual analogue pain score or Oxford Hip Score have no significant association with a patient's distribution of hip pain. CONCLUSIONS: Hip pain referred below the knee is common with a degenerate hip joint and follows the distribution of the saphenous nerve, which branches from the femoral nerve. Radiographic deterioration of a hip joint does not correlate with pain distribution or patient dysfunction as measured by the Oxford Hip Score.     

Inflammation in uremic patients: what is the link?

Uremic patients suffer to an extremely high degree from cardiovascular disease. Cardiovascular disease results mainly from atherosclerotic remodeling of the arterial system. Inflammation is considered to contribute significantly to development of atherosclerosis, and albeit many different factors may lead to inflammation, generation of enhanced oxidative stress is believed to be an important common feature of pro-inflammatory causes. Studies in the general population without renal disease could clearly show that markers of inflammation, in particular C-reactive protein, predict the cardiovascular risk. In this review article, we discuss the presence and the predictive value of inflammation in patients with end-stage renal disease, and analyze whether uremic patients are exposed to specific pro-inflammatory and pro-oxidative conditions. Particular emphasis is set on oxidative stress induced by oxidatively modified lipoproteins and angiotensin II. Based on pathophysiological considerations valid for uremic patients, we discuss therapeutical options that might help to reduce cardiovascular disease in uremic patients.     

Severity of osteoporosis: what is the impact of co-morbidities?

The co-morbidity profile varies widely across postmenopausal women with osteoporosis, and comorbidities often adversely affect the management of osteoporosis. There is a need for detailed information on the co-morbidities that may affect the course of osteoporosis by increasing the risk of subsequent fractures or inducing multiple fractures. We consequently reviewed the literature on the most common co-morbidities in adults older than 50 years of age, with special attention to published meta-analyses. We found that osteoporosis severity was increased not only by conventional risk factors, but also by a number of conditions including inflammatory bowel and joint diseases with or without glucocorticoid therapy, breast cancer and prostate cancer treated with chemotherapy or hormone therapy, diabetes (chiefly type 1), and celiac disease. Studies suggest an adverse impact of moderate renal failure and depression, although their methodological weaknesses preclude definitive conclusions. In practice, these co-morbidities should be taken into account when evaluating the fracture risk and making treatment decisions.     

Restitution of the aortic valve: what is new, what is proven, and what is obsolete?

Restitution strategies of the insufficient aortic valve belong to the clinical armamentarium. To date, the accumulated body of evidence comprises 126 articles dealing with restitution strategies on the insufficient aortic valve with concomitant aortic surgery. In a cumulative analysis an almost identical number of reimplantation (506) and remodeling (489) procedures were found in the literature, whereas 357 patients underwent aortic valve resuspension. The cumulative results tend to favor the reimplantation technique in terms of longevity of the reconstruction, particularly in congenital degenerative disorders of the aortic wall, whereas remodeling appears to exhibit a more physiologic behavior of the reconstructed valve and re-suspension serves as a simplified approach particularly in acute type A dissection. Although restitution of the native aortic valve has its place in current treatment options, the accumulated worldwide numbers indicate that it is not yet routinely implemented in the vast majority of cardiac institutions.     

Obstructed defaecation: what is the role of rehabilitation?

Aim The study was designed to evaluate the results of rehabilitative treatment in patients suffering from obstructed defaecation. Method Between January 2008 and July 2010, 39 patients (37 women, age range 25–73 years; and two men, aged 57 and 67 years) affected by obstructed defaecation were included in the study. After a preliminary clinical evaluation, including the Obstructed Defaecation Syndrome (ODS) score, defaecography and anorectal manometry were performed. All 39 patients underwent rehabilitative treatment according to the ‘multimodal rehabilitative programme’ for obstructive defaecation. At the end of the programme, all 39 patients were reassessed by clinical evaluation and anorectal manometry. Postrehabilition ODS scores were used to categorize patients arbitrarily into three classes, as follows: class I, good (score ≤ 4); class II, fair (score > 4 to ≤ 8); and class III, poor (score > 8). Results After rehabilitation, there was significant improvement in the overall mean ODS score (P < 0.001). Thirty (76.9%) patients were included as class I (good results), of whom eight (20.5%) were symptom free. Five (12.8%) patients were considered class III. A significant postrehabilitative direct correlation was found between ODS score and pelvic surgery (ρ_s = 0.54; P < 0.05). Significant differences were found between pre‐ and postrehabilitative manometric data from the straining test (P < 0.001), duration of maximal voluntary contraction (P < 0.001) and conscious rectal sensitivity threshold (P < 0.02). Conclusion After rehabilitation, some patients become symptom free and many had an improved ODS score.     

What is the Role of Magnetic Resonance Imaging in the Evaluation of Total Hip Arthroplasty?

MRI has been shown to be an extremely effective instrument in the management of painful hip arthroplasty. Its superior soft tissue contrast and direct multiplanar acquisition compared to computerized tomography (CT) and radiographs allows for reproducible visualization of periacetabular osteolysis, demonstrating compression of neurovascular bundles by extracapsular synovial deposits. In addition, MRI can often elucidate etiology of neuropathy in the perioperative period and is further helpful in evaluating the soft tissue envelope, including the attachment of the hip abductors, short external rotators and iliopsoas tendon. A further advantage of MRI over CT is its lack of ionizing radiation. Most importantly, MRI can disclose intracapsular synovial deposits that precede osteoclastic resorption of bone.