Limb occlusion pressure versus standard tourniquet inflation pressure in minor hand surgery: a randomized controlled trial.

BACKGROUND: In minor hand surgery, tourniquet is typically inflated to 250 mmHg. The pressure may be too high and cause unnecessary adverse effects. Limb occlusion pressure plus safety margin or recommended tourniquet pressure (RTP), has been reported as optimal pressure to provide bloodless field in limb surgeries. This study aimed to compare the RTP with the standard tourniquet pressure of 250 mmHg in minor hand surgery. METHODS: A double-blinded randomized control trial was conducted from July to December 2019 and June 2020 to May 2021. Patients were randomly assigned into two groups: RTP and 250 mmHg with 3:1 ratio allocation. The outcomes were measurement of cuff pressure reduction, time to develop of tourniquet pain and discomfort, pain score, discomfort score, motionless and bloodless of operative field determined by the surgeon's satisfaction. RESULTS: A total of 112 patients were included, 84 were in RTP and 28 were in 250 mmHg group. Mean of tourniquet pressure was significantly lower in the RTP group (228.3 ± 17.2 mmHg) (P < 0.001). Even though, time to develop pain was not significantly different, the RTP group reported significantly less pain and discomfort, according to the pain score (P = 0.02) and discomfort score (P = 0.017). The RTP group provided better motionless field, while both groups equally created a bloodless field. CONCLUSION: The RTP significantly reduced tourniquet related pain and discomfort during minor hand surgeries. It provided better motionless operative field and adequate bloodless field. Therefore, the RTP should be considered as optimal tourniquet pressure for minor hand surgeries. TRIAL REGISTRATION: TCTR20210519001 (retrospectively registered). LEVEL OF EVIDENCE: I.

Factors for selective ultrasound screening in newborns with developmental dysplasia of the hip (DDH).

Background: Hip ultrasound screening for DDH provides better sensitivity compared to physical examination. Due to a lower prevalence and limited resources, selective hip ultrasound in newborns at risk could be considered a proper screening protocol in Thailand and Asian countries. Objective: This study was aimed to evaluate risk factors and define criteria for selective screening. Methods: A case-control study was conducted in 2020. All newborns with hip ultrasound screening were included. Cases were defined as newborns with abnormal hip ultrasounds, while controls were those with normal studies. Inter and intra-rater reliability were evaluated. All factors were analyzed using univariate and multivariate logistic regression. The model performance was tested by Hosmer-Lemeshow goodness of fit. Internal validity was performed by the split data method. Area under the receiver operating characteristic (ROC) curve was estimated. Results: Ninety-five newborns (29 cases and 66 controls) were included. Eighty percent of cases and 58% of controls were female. The gestational age was 36.6 and 37.7 weeks in case and control, respectively. Female, breech presentation, positive Ortolani test, positive Barlow test, and limited hip abduction were significant factors with odds ratio of 2.82, 5.12, 34.21, 69.64, and 5.48, respectively. The final model included breech presentation, positive Ortolani test, and positive Barlow test. The model cut-off value 15.02 provided sensitivity (93.10%) and specificity were (80.30%). The area under the ROC curve was 0.9308. The split data remained significant internal validity for all factors with p-value < 0.05. Conclusion: Careful history taking and physical examination are essential to identify the risk factors for DDH. Newborns with breech presentation, positive Ortolani test and positive Barlow test should be screened by hip ultrasound.

The ankle kinematic reference of normal gait pattern in Thai adults.

Objective: This study was aimed to establish the reference values of ankle kinematics and factors associated with ankle kinematics of healthy Thai adults. Methods: A prospective cohort was conducted among healthy volunteers aged between 18 and 40 years and evaluated gait analysis between 2016 and 2020. After applying the modified Halen Hayes marker set, participants were assigned to walk 8-10 rounds with their preferred speed. Demographic data i.e., age, gender and body mass index (BMI) and ankle kinematics (varus-valgus, dorsiflexion-plantar flexion, foot progression, and ankle rotation) using motion analysis software were recorded and analyzed. Results: 98 volunteers (60 females and 38 males) aged 28.6 ± 5.4 years with body mass index 21.2 ± 2.0 kg/m2 were included. The average ranges of ankle kinematics entire gait cycle were varus-valgus -1.62 to 3.17 degrees, dorsiflexion-plantar flexion 0.67 to 14.52 degrees, foot progression -21.73 to -8.47 degrees, and ankle rotation 5.22 to 9.74 degrees. The ankle kinematic data in this study population was significantly different from the normal values supplied by OrthoTrak software of the motion analysis program, especially more ankle internal rotation at mid-stance (5.22 vs. -12.10 degrees) and terminal stance (5.48 vs. -10.74 degrees) with P < 0.001. Foot progression significantly exhibited more external rotation for 1.5 degrees on the right compared to the left side, and for 5 degrees more in males than females. One increment in age was significantly correlated with ankle internal rotation at mid-swing (coefficient 0.21 degrees, P = 0.039). BMI had no statistical association with ankle kinematics. Statistical parametric mapping for full-time series of angle assessments showed significantly different foot progression at initial contact and terminal stance between sides, and our ankle kinematics significantly differed from the reference values of the motion analysis program in all planes (P < 0.05). Conclusion: The reference of ankle kinematics of Thai adults was established and differences between sides and the normal values of the motion analysis program were identified. Advanced age was associated with ankle internal rotation, and male gender was related to external foot progression. Further studies are needed to define all-age group reference values.

Amelioration of osteogenesis in iPSC-derived mesenchymal stem cells from osteogenesis imperfecta patients by endoplasmic reticulum stress inhibitor.

AIM: Osteogenesis imperfecta (OI) is a hereditary connective tissue disorder primarily caused by mutations in COL1A1 or COL1A2, which encode type I collagen. These mutations affect the quantity and/or quality of collagen composition in bones, leading to bone fragility. Currently, there is still a lack of treatment that addresses disease-causing factors due to an insufficient understanding of the pathological mechanisms involved. MAIN METHODS: Induced pluripotent stem cells (iPSCs) were generated from OI patients with glycine substitution mutations in COL1A1 and COL1A2 and developed into mesenchymal stem cells (iPS-MSCs). OI-derived iPS-MSCs underwent in vitro osteogenic induction to study cell growth, osteogenic differentiation capacity, mRNA expression of osteogenic and unfolded protein response (UPR) markers and apoptosis. The effects of 4-phenylbutyric acid (4-PBA) were examined after treatment of OI iPS-MSCs during osteogenesis. KEY FINDINGS: OI-derived iPS-MSCs exhibited decreased cell growth and impaired osteogenic differentiation and collagen expression. Expression of UPR genes was increased, which led to an increase in apoptotic cell death. 4-PBA treatment decreased apoptotic cells and reduced expression of UPR genes, including HSPA5, XBP1, ATF4, DDIT3, and ATF6. Osteogenic phenotypes, including RUNX2, SPP1, BGLAP, and IBPS expression, as well as calcium mineralization, were also improved. SIGNIFICANCE: MSCs differentiated from disease-specific iPSCs have utility as a disease model for identifying disease-specific treatments. In addition, the ER stress-associated UPR could be a pathogenic mechanism associated with OI. Treatment with 4-PBA alleviated OI pathogenesis by attenuating UPR markers and apoptotic cell death.

Novel questionnaire to enhance brace wear adherence in patients with adolescent idiopathic scoliosis and the relationship of the quality of life.

Bracing is an effective non-operative treatment, in patients with adolescent idiopathic scoliosis (AIS). The relationship between patients' quality of life (QOL) and brace wear adherence has been reported. This study aims to determine brace wear adherence for AIS patients with novel questionnaire. A nested case-control study was conducted, included patient age 10-18 years, coronal Cobb angle 20-50°, and Risser grade 0-3. Correlation between patients' QOL and the average hours of daily brace-wear were determined. Patients were divided into 3 groups based on brace wear adherence and were compared. QOL domains associated with the incompleteness of brace-wearing were determined by Cox proportional-hazards regression. Mean age of patients was 13.3 years (range 11-17.3 years) with initial Cobb angle of 33.5° (range 20-48°). There were significant negative correlations between total QOL scores and brace wearing time. Increased social domain scores was significantly associated with less brace wearing time (HR 1.5, 95% CI 1.12-2.04). Significant correlations between patients' QOL and the average hours per day of brace wear. Poor social QOL have a significant impact on brace wear adherence.

Network meta-analysis of management of trigger thumb in children.

To estimate and rank cure and recurrence rates between conservative and operative treatments for trigger thumb in children. A systematic review was conducted by searching PubMed and Scopus. Eligible criteria were comparative studies included non-syndromic trigger thumbs, aged up to 10 years, reported at least 20 thumbs and followed up at least 12 months. Two assessors independently extracted data and appraised for cure, recurrence rates among observation, stretching, splinting, open surgery, and percutaneous surgery. We assessed the risk of bias in non-randomized studies of interventions. A network meta-analysis, and probability of being the best outcomes were estimated with surface under the cumulative ranking curves (SUCRA). From 6853 searched articles, eight studies (799 children and 981 thumbs) were included. Mean age was 1.87-2.83 years and average followed up time was 1-5.7 years. Open surgery, percutaneous release, splinting, and stretching had higher cure rate than observation; pooled risk ratio (95% confidence interval) of 2.06 (1.53-2.78), 1.79 (1.26-2.53), 1.76 (1.30-2.36), and 1.37 (0.93-2.03), respectively. Percutaneous release increased risk of recurrence 3.29 times (1.42-7.60) when compared with open surgery. The best cure rates were open surgery (SUCRA = 95) followed by splint (SUCRA = 63.4), and percutaneous technique (SUCRA= 62.8). The highest recurrence rates were percutaneous (SUCRA = 97.3), and open surgery (SUCRA = 62.4). Splint is the most appropriate intervention for pediatric trigger thumb. After failed conservative methods, open surgery is considered for operative treatment. Level of evidence: Therapeutic study level II-III.

Using humeral nail for surgical reconstruction of femur in adolescents with osteogenesis imperfecta.

Osteogenesis imperfecta (OI) is a rare inherited connective tissue disorder caused by mutation of collagen which results in a wide spectrum of clinical manifestations including long bone fragility fractures and deformities. While the treatment for these fractures was recommended as using intramedullary fixation for minimizing stress concentration, the selection of the best implant in the adolescent OI patients for the surgical reconstruction of femur was still problematic, due to anatomy distortion and implant availability. We are reporting the surgical modification by using a humeral nail for femoral fixation in three adolescent OI patients with favorable outcomes.

Radial Neck Fractures in Children and Adolescents: An Examination of Operative and Nonoperative Treatment and Outcomes.

BACKGROUND: Although most pediatric radial neck fractures can be treated with either immobilization alone or closed reduction and immobilization, a small subset result in permanent loss of motion despite surgical management. We sought to characterize the most problematic fractures and correlate final outcomes with both presenting fracture characteristics and the reduction achieved through surgical intervention. METHODS: One hundred ninety-three consecutive children with a radial neck fracture, satisfactory initial treatment data, and follow-up range-of-motion (ROM) data presenting between 1999 and 2012 to our level 1 trauma center were evaluated. The O'Brien classification was used to evaluate angulation on radiographs. Final ROM outcomes were categorized into excellent, good, fair, and poor. ROM data were not used in the operative group if follow-up was <12 weeks (<6 wk in the nonoperative group) or if there was no follow-up after cast removal. RESULTS: Thirteen percent of all patients presenting with radial neck fractures required operative treatment (average age 9.1 y). Of patients treated operatively with adequate ROM data, 26.4% healed with fair or poor outcomes. Patients requiring open management were of older average age (average 10 y old, P=0.02) and had a significantly greater risk of a fair or poor ROM outcome than those treated with closed operative techniques (P=0.02). Patients treated nonoperatively were of a younger average age than those in the operative cohort (8.2 vs. 9.1 y, P=0.03). Patients treated operatively were more likely to develop complications (P=0.004); however, presence of a complication was not predictive of fair or poor outcomes in either the operative (P=0.117) or nonoperative (P=0.264) groups. CONCLUSIONS: Older children are more likely to have more severely displaced radial neck fractures requiring open surgical management, thus resulting in a greater risk of fair or poor outcomes. In the series as a whole, more complications were seen when operative management was required. Final outcomes were not shown to be significantly related to preoperative displacement, postoperative reduction, presence of associated injuries, energy of injury, or treatment complications. LEVELS OF EVIDENCE: Level III­therapeutic.

Traumatic Injury in a Child with Scurvy: A Case Report.

This case report aimed to describe the clinical presentation, treatments and prognosis of a child who had scurvy and traumatic injury of the left thigh. A 30-month-old boy had presented with left hip pain two weeks after falling down on the floor while walking. He developed pain, warmness of the left hip and thigh, and finally was unable to bear weight. He also had a high fever gingival hemorrhage, dental caries, petechiae, positive rolling test and limited range of motion of the left hip. The radiographs revealed Wimberger's ring and Frenkel line as scurvy. Vitamin C supplement had been prescribed for one week. However, there was no clinical response and magnetic resonance imaging (MR) suggested subperiosteal abscess as well as osteomyelitis of bilateral femurs and tibias. Debridement and biopsy of the left femur were performed and found only subperiosteal blood. A clinical improvement was noted on the second day after surgery. Vitamin C level was reported at 0.03 mg/dl which was very low. Bacterial culture was negative and the pathological findings were callus formation with hemorrhage. The patient continued the treatment for two months and all conditions were healed eventually. In severe scurvy with trauma, prolonged subperiosteal hematoma was susceptible to infection, and may need debridement simultaneously with vitamin C supplement to shorten the clinical course.

Shaft-Condylar Angle for surgical correction in neglected and displaced lateral humeral condyle fracture in children.

PURPOSE: To assess the outcome after using the Shaft-Condylar angle (SCA) as intraoperative reference for sagittal plane correction in displaced lateral humeral condyle fractures in children presented 3-weeks after injury. METHODS: Ten children, with delayed presentation of a displaced lateral humeral condyle fracture and undergoing surgery during 1999-2011, were reviewed. The goal was to obtain a smooth articular surface with an intraoperative SCA of nearly 40° and nearest-anatomical carrying angle. They were allocated into two groups according to the postoperative SCA [Good-reduction group (SCA=30-50°), and Bad-reduction group (SCA<30°, >50°)] and the final outcomes were then compared. RESULTS: All fractures united without avascular necrosis. The Good-reduction group (n=7) showed a significant improvement in final range of motion and functional outcome compared to the Bad-reduction group (n=3) (p=0.02). However, there was no significant difference in pain, carrying angle and overall outcome between both groups. CONCLUSION: SCA is a possible intraoperative reference for sagittal alignment correction in late presented displaced lateral humeral condyle fractures.

Meta-analysis of hypercoagulability genetic polymorphisms in Perthes disease.

Perthes disease is an osteonecrosis of the femoral epiphysis with unclear etiology. This study aimed to systematically review the association between genetic determinants of hypercoagulability (Factor V Leiden, prothrombin II, and methylenetetrahydrofolate reductase; MTHFR) and Perthes disease. PubMed and Scopus searched from inception to January 2012, data extraction and quality assessment were performed. The odds ratio (OR) for the allele effect was pooled, and heterogeneity and publication bias were assessed. Twelve case-control studies met inclusion criteria and had sufficient data for extraction. There were 824 cases and 2,033 controls with a mean age range of 6.1-14.7 years. The prevalence of the minor allele in controls was 0.015 (95% confidence interval (CI): 0.008, 0.023), 0.012 (95% CI: 0.008, 0.017), and 0.105 (95% CI: 0.044, 0.167) for factor V Leiden, prothrombin II, and MTHFR, respectively. The factor V Leiden allele increased the risk of Perthes with a pooled OR of 3.10 (95% CI: 1.68, 5.72), while prothrombin II and MTHFR had non-significantly pooled OR 1.48 (95% CI: 0.71, 3.08), and 0.97 (95% CI: 0.72, 1.30), respectively. The factor V Leiden mutation is significantly related to Perthes disease, and its screening in at-risk children might be useful in the future.

Chondroblastoma and chondromyxoid fibroma.

Chondroblastoma and chondromyxoid fibroma are benign but locally aggressive bone tumors. Chondroblastoma, a destructive lesion with a thin radiodense border, is usually seen in the epiphysis of long bones. Chondromyxoid fibroma presents as a bigger, lucent, loculated lesion with a sharp sclerotic margin in the metaphysis of long bones. Although uncommon, these tumors can be challenging to manage. They share similarities in pathology that could be related to their histogenic similarity. Very rarely, chondroblastoma may lead to lung metastases; however, the mechanism is not well understood.

Meta-analysis of pinning in supracondylar fracture of the humerus in children.

OBJECTIVES: The purpose of this study was to compare the outcomes of lateral pinning versus cross pinning in pediatric supracondylar humerus fractures. DATA SOURCES: The Cochrane library, MEDLINE, CINAHL, specific orthopaedic journals, abstracts/papers from conferences and meetings, and reference lists of articles were searched from inception to September 2007. STUDY SELECTION: All randomized controlled trials and cohort studies comparing outcomes (ie, loss of fixation, iatrogenic ulnar nerve injury, and Flynn criteria) between crossed and lateral pinning were identified. DATA EXTRACTION: Two authors independently assessed methodological quality and extracted data by using a standardized data extraction form. DATA SYNTHESIS: Heterogeneity among studies was assessed using the Q test. Pooled relative risk was estimated using the Mantel-Haenszel method. Eighteen of 1829 studies were included with 1615 supracondylar fractures (837 and 778 children with cross and lateral pinning, respectively). The average age was 6.1 ± 0.9 years. The risk of iatrogenic ulnar nerve injury was 4.3 (95% confidence interval, 2.1-9.1) times higher in cross pinning compared with lateral pinning. There was no significant difference for loss of fixation, late deformity, or Flynn criteria between the two types of pinning. CONCLUSIONS: Lateral pinning is preferable to cross pinning for fixation of pediatric supracondylar humerus fractures as a result of decreased risk of ulnar nerve injury.

Congenital vertical talus in multiple pterygium syndrome.

BACKGROUND: Congenital vertical talus (CVT) is a rare foot deformity, but it is a commonly associated anomaly in patients with multiple pterygium syndrome (MPS). If left untreated, it can cause pain and morbidity, which will affect the patient's ambulation and quality of life. The aim of this study was to assess the prevalence of CVT among patients with MPS, to characterize the clinical and radiological features and examine the outcome of treatment. METHODS: We reviewed the medical records from 1969 to 2009, and detected 14 patients with a diagnosis of MPS. Data regarding clinical findings, radiographs, associated anomalies, and treatment were collected and analyzed. RESULTS: CVT was seen in 10 of 14 patients (71%). All of them had bilateral involvement. Eight of the 10 (80%) were girls, and 3 of these 10 (30%) were nonambulatory patients. All 7 ambulatory patients had manipulation and casting, followed by a single-stage surgical release. The mean age at surgery was 3.0 ± 3.7 years (range, 3 mo-9 y 2 mo). At the last follow-up, all of the 7 patients (100%) had painless plantigrade feet and a reduced talonavicular joint, and none had recurrence of the deformity. The overall mean follow-up was 6 years (range, 2-19 y) and the mean age at the last follow-up was 9 years (range, 2-23 y). The commonly associated anomalies were scoliosis (93%), tethered cord (14%), hip dislocation (43%), cardiac (29%), respiratory (43%), and gastrointestinal anomalies (29%). CONCLUSIONS: CVT is common in MPS. The other common anomalies included scoliosis, hip dislocation, and respiratory problems. Treatment with manipulation and casting followed by, a single-stage surgical release resulted in a good outcome.