Open reduction for hip dislocation in children with arthrogryposis multiplex congenital: Outcomes of a systematic review.

Introduction: The incidence of hip dislocation (HD) in arthrogryposis multiplex congenital ranges from 15 to 30 %. Besides a stable hip, the ambulation potential of an AMC child is also dependent on severity of associated knee and foot deformations. The primary objective of this review is to determine the proportion of ambulators in AMC children treated by open reduction for HD. Methods: We searched major electronic bibliographic databases for reports on the treatment of HD among AMC children. Based on the surgical approach for open reduction of HD in AMC children, we divided the included studies into groups 1 (Anterior approach open reduction) and 2 (Medial approach open reduction). Results: We pooled 59 children/94 hips in this review from 7 studies. We identified 45 children/71 hips and 14 children/23 hips with a mean age of 20 (4-64) and 4.5 (0.5-11) months in groups 1 and 2, respectively. There were 97 % (44) and 92 %(Obeidat et al., 2011) 13 ambulators in groups 1 and 2, respectively. 47 % and 36 % of hips in groups 1 and 2 required additional procedures besides open reduction for redislocation and maintenance of hip reduction. 31 %22 and 13 %(Fisher et al., 1970 Feb) 3 of the hips sustained avascular necrosis in group 1 and 2. Conclusion: Children with AMC associated HD can be expected to ambulate with and without assistance in 90 % of the cases however, the foot and knee problems also need concomitant management. In children less than 6 months of age the medial approach based open reduction may be more efficacious and less complicating than anterior approach based open reduction however, at a later age anterior approach based open reduction is more effective due to need for pelvic and femur sided additional procedures.

The Ideal Orthopaedic Surgeon: Comparing Patient Preferences of Surgeon Attributes to Notions Held by Orthopaedic Postgraduates.

Introduction: Stereotypes have been a barrier to providing patients a diverse orthopaedic workforce. Our goal was to identify stereotypes and disparities among doctors and their patients regarding the attributes that should determine a competent orthopaedic surgeon. Materials and Methods: A cross-sectional descriptive multicenter study was conducted in India. Tailored questionnaires were administered to patients and orthopaedic postgraduates to determine the attributes they believe patients prefer in their orthopaedic surgeon. Likert data and data on preferred sex of the surgeon were analyzed as categorical data sets using frequency statistics. Participants were asked to rank surgeon attributes and analysis was based on frequency of an item among top 5 surgeon attributes. Results: 304 patients and 91 orthopaedic postgraduates participated in the study. 70.4% and 73% of patients and 27.5% and 29.6% of postgraduates preferred an orthopaedic surgeon with greater physical strength as an outpatient consultant or operating surgeon respectively. 81% of patients had no preference of the sex of their doctor. 56% of postgraduates felt patients would prefer a male operating surgeon, none felt their patient would prefer female orthopaedic surgeon. 92.3% of the female postgraduates felt patients would prefer a male orthopaedic surgeon. Patients most often ranked years of experience, surgical outcomes, time spent with patients, reputation, and physical strength in their top 5 surgeon attributes and sex, religion, and community were given least importance. Conclusion: Diversity among the orthopaedic workforce is necessary to optimize patient care. It is our collective responsibility to educate our patients and trainees and redress the misconceptions and stereotypes that plague our profession. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-023-00988-2.

Ultrasound-Guided Manipulation does not Prevent Malalignment Over Landmark-Based Fracture Reduction in Distal Radius Fracture (Colles).

Introduction: This systematic review aims to determine the relative risk of distal radius (Colles) fracture (DRF) malalignment between ultrasound (USG)-guided and conventional/landmark guided/blind manipulation and reduction (M&R). Methods: We searched 3932 records from major electronic bibliographic databases on USG-guided manipulation of DRF. Studies with randomized, quasi-randomized, and cross-sectional study designs meeting the inclusion criteria were included in this review. USG and landmark-guided DRF manipulations were named cases and controls, respectively. The Newcastle-Ottawa Scale was used to assess the quality of included studies. Results: Thirteen and nine studies were analysed for qualitative and quantitative analysis in this review. Nine hundred fifty-one DRF patients (475 cases and 476 controls) from 9 studies with mean ages of 51.52 ± 11.86 (22-92) and 55.82 ± 11.28 (18-98) years for cases and controls were pooled for this review. The pooled relative risk estimate from the studies included in the meta-analysis was 0.90 (0.74-1.09). There was a 10% decrease in the risk of malalignment with USG than the landmark guided M&R of DRF. The I2 statistic estimated a heterogeneity of 83%. Sensitivity analysis revealed a relative risk of 1.00 (0.96-1.05). Conclusion: The USG-guided manipulation does not prevent malalignment over the landmark-based manipulation of DRF. The risk of bias across the included studies and heterogeneity of 83% mandates further unbiased, high-quality studies to verify the findings of this review.

MRI Features and Treatment for Idiopathic Chondrolysis of the Hip (ICH) in Children: Outcomes of a Systematic Review.

Background: The purpose of this paper was to review the MRI features and treatment for idiopathic chondrolysis of the hip (ICH) in patients aged 18 years or less. Methods: We included studies published in English up to August 2021. We accessed major electronic bibliographic databases on ICH that described MRI features, treatment, or both. We used the Joanna Briggs Institute (JBI) Critical appraisal checklist for case reports for Risk of bias assessment. Results: We pooled 136 hips (125 participants) from 35 studies with 11.6 ± 3.4 years mean age. We had 46, 8, and 106 hips to assess ICH's MRI, pharmacological, and operative interventions. Geometric marrow edema (GME) (P < 0.01), diffuse marrow edema (DME) (P < 0.05), diffuse cartilage loss (DCL) (P < 0.05), and joint effusion (P < 0.05), were significantly associated with time in first MRI reviews. GME (P < 0.01) and focal cartilage loss (FCL) (P < 0.01) decreased significantly between two MRI reviews at median time of 1.75 (IQR 0.93-4.25) and 12.5 (IQR 3.75-19.5) months. Diffuse cartilage loss (P < 0.01) and degenerative changes (P < 0.01) increased significantly between the two MRI reviews. Etanercept, Methotrexate, and Botulinum Neurotoxin A drugs were used by 3, 3, and 1 report to treat ICH. Capsulectomies, total hip arthroplasty, arthrodiastasis, arthrodesis, arthroscopy operations treated 45, 18, 5, 5, and 2 hips. Discussion: GME may be the most specific and early MRI feature in diagnosing ICH. GME and DME show an inverse relationship over time. So, it is with FCL and DCL. Despite reports on the efficacy of biologics, immunomodulators, and operations, early and late ICH management remains controversial due to poor quality studies. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-022-00684-7.

Corrective derotation osteotomies to treat congenital radioulnar synostosis in children: results of a systematic review and meta-analysis.

Background: The primary objective of this review is to estimate the rotational correction after corrective derotation osteotomies (CDO) for congenital radioulnar synostosis (CRUS). The secondary objective of this review is to identify the complications with CDO in CRUS. Methods: We included studies in the English literature from electronic bibliographic databases Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, Directory of Open access journals (DOAJ), EMBASE, MEDLINE, ProQuest, PubMed, and Scopus up to December 2020 that determined the effects of CDO in CRUS for two or more cases with a mean follow-up of 1 year or more. We used the National Institutes of health quality assessment tool for case series (interventional) and Modified Coleman methodology Score for assessment of risk of bias in the included studies. Results: We pooled 383 forearms (318 participants) from 23 studies with mean age of 6.28 ± 1.75 years. The mean pronation deformity was 72.83 ± 15.64° from 22 studies. The CDO derotated forearm to 10.4 ± 5.90° of mean pronation in 12 studies and 13.47 ± 9.51° of mean supination in nine studies. One study corrected the forearms to a neutral position. The mean derotation from CDO was 73.13 ± 16.54° (35° supination to 130° pronation). The overall mean difference was - 68.26° [95% CI - 86.87, - 49.66] of correction favoring supination. There were eight transient nerve palsies and six compartment syndromes from synostosis site osteotomies (four studies). Discussion: We had poor-quality studies at a high risk of bias on the described tools of assessment. We could estimate the directional effect of CDO in CRUS favoring correction from pronation to supination; however, due to the heterogeneity among studies, we cannot comment on the most efficient and least harmful CDO techniques. The single bone osteotomies seem to be efficient, simple, and reportedly low on complications but need evaluation. We cannot define the indications for correction and expected improvement in functional outcomes from osteotomy techniques. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-021-00582-4.

Transient cortical blindness in fat embolism syndrome---a diagnostic enigma.

Fat embolism syndrome (FES) is a serious life-threatening manifestation of the fat embolism phenomenon characterized by Bergman's triad of dyspnea, petechiae and mental confusion. While fat embolization into systemic circulation is common, FES occurs in a meagre 0.05%-3% of patients having isolated long bone fractures. Though visual symptoms are commonly attributed to fat embolism retinopathy and is a later occurrence, it may not always be the case. Cortical blindness has been seldom reported in association with FES, and less so as a presenting complaint. Furthermore, no previous literature has described the same in context of an isolated tibia fracture. We report a 20-year-old gentleman with an isolated right tibia shaft fracture who developed sudden onset diminution of vision in both eyes less than 24 h following trauma with no other complaints. Lack of any remarkable ophthalmoscopic findings or other symptoms left us with a diagnostic conundrum. He later went on to develop altered mentation, hypoxia and generalized tonic-clonic seizures with subsequent MRI revealing multiple cerebral fat emboli also involving both occipital lobes. Supportive measures were instituted and his general condition as well as vision gradually improved following which he underwent plate fixation of the fracture under spinal anaesthesia. The perioperative period was uneventful and he was discharged following staple removal. At one month of follow-up, the patient had no residual visual field defects or neurological deficits. Though FES is rare among isolated tibia fractures, this clinical catastrophe may strike in any unsuspected setting thereby warranting a high index of suspicion to ensure early diagnosis and improved patient outcomes.

Clinical and laboratory profile in confirmed vs. suspected septic arthritis patients and its relevance in decision making: A comparative cross-sectional study.

PURPOSE: There were 10%-30% of patients with adult-onset septic arthritis (SA) exhibiting sterile synovial fluid (SF), and the uncertainty in the determining diagnosis of these patients posed a challenge in management. The purpose of this study was to investigate the differences between confirmed (Newman A) and suspected (Newman B & C) SA in adults. METHODS: This was a descriptive study with a cross-sectional study design conducted at a tertiary referral centre from July 2016 to February 2019. Patients aged over 18 years presented to the emergency department with clinical features suggestive of SA and were scheduled to undergo arthrotomy and joint lavage by the treating surgeon were included in the study. Patients with prosthetic joint infections and open joint injuries were excluded. Patients' demographic data, clinical features and laboratory parameters were collected. The clinical and laboratory profile (blood and SF) of the adult patients presenting with features suggestive of SA based on Newman criteria was statistically analyzed by SPSS version 20 software and Microsoft Excel. The categorical variables were expressed as proportions while the continuous variables were expressed as mean (SD) or median (IQR) depending upon the normality of distribution. The difference between the two groups for categorical variables was assessed using the Chi-square test and the difference for continuous variables was assessed using the unpaired t-test and the Mann-Whitney test depending upon normality. A p value < 0.05 was considered significant. RESULTS: Thirty-six patients were divided into confirmed (n = 19) or suspected (n = 17) SA for assessment based on SF culture. The median (IQR) age of the patients was 50 years (37-60 years). There was no significant difference in demographic, clinical and laboratory parameters between the concerned groups. Eight patients presented with fever. Among the confirmed SA cases, 8 were negative for C-reactive protein and 6 had synovial white blood cell count <50,000. Staphylococcus species were isolated in 8 cases. The most common risk factors for SA were chronic kidney disease (25.0%), diabetes mellitus (25.0%), pharmacologic immunosuppression (16.7%), recent joint surgery (11.1%) and distant site infection (11.1%). CONCLUSION: SA is an orthopaedic emergency that needs prompt and aggressive treatment to prevent catastrophic complications. Confirmed and suspected cases of SA exhibit similar demography, clinical features and laboratory parameters at presentation which may mislead the treating surgeon. Management should be based on sound clinical judgment in the event of failure to culture microorganisms.

Radiological assessment of congenital talipes equinovarus (clubfoot): Is it worthwhile?

The lack in consensus with regard to qualitative use of standard radiographs and their predictive value in evaluating congenital talipes equinovarus among infants continues to be apparent in clinical practice. Since standard radiographs continue to play a role in the assessment of clubfoot it is essential to ensure that the values measured are reliable and reproducible keeping in mind acceptable tolerances for clinical application. This study was undertaken to assess the inter-observer and the intra-observer reliability in estimation of talocalcaneal and talo-first metatarsal angles on standard radiographs done according to Simon's method. The study was conducted by consecutively selecting eleven children with unilateral idiopathic congenital clubfoot who presented to our tertiary care hospital with a paediatric orthopaedic service unit. Only those with unilateral idiopathic clubfoot with persistent deformity at the age of 3 months were included. The data obtained from three observers on two separate occasions was analysed by the method proposed by Bland and Altman to assess intra and inter observer variability in the measurements. The results of the present study suggest a significant difference between the measurements on two occasions by the same observer. The difference was constant and the level of experience of the observer had no significance. Also, there was a marked inter observer variability as evident from the calculation of limit of agreement. Therefore, radiological assessment of the type and degree of malalignment in these cases is insufficient as it does not possess the accuracy required in evaluation and further management.

Radiological Outcomes of Distal Radius Fractures Managed with 2.7mm Volar Locking Plate Fixation-A Retrospective Analysis.

INTRODUCTION: Distal radius fractures accounts for around 15% of all fractures diagnosed and treated in the emergency rooms. These fractures usually result secondary to high velocity injury such as a motor vehicle accident or fall on an out stretched hand. In the elderly, it is a common fragility fracture. Volar Locking Compression Plates (LCP) is effective devices for fixation of the distal radius fractures. There is a lacuna with regard to literature on the 2.7 mm volar LCP and the current study retrospectively assesses the postoperative radiological outcomes. AIM: To measure the radiological outcomes in patients with displaced distal radius fractures managed with 2.7 mm volar LCP fixation using Sarmiento's Modification of Lindstorm Criteria. MATERIALS AND METHODS: A retrospective study was conducted in the Department of Orthopaedic Surgery at Kasturba Medical College Allied Hospitals, Mangalore from May 2014 to July 2016. All displaced distal radius fractures of skeletally mature patients who underwent volar locking plate fixation between May 2014 to July 2016 and follow up with X-rays at six weeks and three months were included as part of the study. The study comprised of 20 patients and fractures were classified using the AO and Melone's classification systems. The radiological outcome was scored based on Sarmiento's Modification of Lindstorm Criteria. RESULTS: Post operative check X-rays were analysed at immediate post operative, six weeks and three months. The mean immediate post operative radial shortening, decrease in radial deviation and loss of palmar tilt were 4.08±2.23, 5.91±4.01and 4.11±3.29 respectively. The corresponding values at last follow up were 4.71±2.31, 7.9±5.13 and 4.91±3.32 respectively. No statistically significant difference (p=0.930;874;716) in radial shortening, decrease in palmar angulation and loss of radial deviation was seen till the final follow up. Sarmiento's Modification of Lindstorm Criteria showed a good radiological outcome in 60% followed by fair in 25% and excellent in 15%. CONCLUSION: Use of 2.7 mm volar LCP showed good to excellent post operative radiological outcomes in majority of the cases. The fracture reduction achieved in the immediate post operative period is maintained throughout the follow up duration.

Perspective of Orthopedists on Pain Management in Osteoarthritis: A Qualitative Study.

CONTEXT: Osteoarthritis (OA) is a degenerative disorder characterized by pain, stiffness, and loss of mobility of the joint. As the most prevalent form of arthritis and a leading cause of impairment, it is imperative to understand the treating doctor's perception of pain relief among these patients. OBJECTIVES: To assess orthopedists' perspectives on pain management in OA. MATERIALS AND METHODS: In this qualitative study, a guide-based interview was conducted on 15 orthopedists of a tertiary care hospital and audio-recorded simultaneously. A grounded theory approach was adopted for data transcription with an inductive approach for thematic manual analysis. RESULTS: Five themes emerged - (1) quality of life: OA produces significant disease burden causing severe impairment; (2) pain management: although patients usually demand immediate pain relief, a multipronged approach to treatment emphasizing on physiotherapy and surgery rather than analgesics is needed. Most participants preferred individual discretion while others felt the need for systematizing pain management; (3) precautions/side effects of treatment: paracetamol is often prescribed due to its better benefit - adversity profile as compared to nonsteroidal anti-inflammatory drugs and weak opioids; (4) barriers: participants expressed several barriers to optimal pain management; (5) counseling: Participants concurred that counseling would improve patients' quality of life. CONCLUSIONS: Participants agreed that OA being associated with debilitating pain and impairment requires optimal pain management for improving patients' quality of life. As crucial as counseling is, it is often compromised due to the large outpatient load. The doctors concurred that a multi-disciplinary team approach is needed to integrate and optimize pain management in OA.

Prevalence of Hyponatremia in Palliative Care Patients.

INTRODUCTION: Hyponatremia is an undertreated finding in clinical practice. It is the most common electrolyte abnormality. Hyponatremia can be asymptomatic or can cause symptoms ranging from nausea and lethargy to convulsions and coma. Palliative care patients have a multitude of symptoms and there are several contributing factors towards this. Hyponatremia could be one of the contributing factors. Looking at the prevalence of hyponatremia would highlight the magnitude of the problem and would prompt healthcare professionals to investigate and treat hyponatremia in palliative care patients, which in turn might reduce symptoms such as fatigue and nausea. This could improve the quality of life in palliative care patients. AIM: To assess the prevalence of hyponatremia among patients referred for palliative care in a tertiary care hospital. METHODOLOGY: This is a descriptive study, with retrospective analysis of consecutive patient charts for 5 years. The sodium levels at the time of referral for palliative care, was reviewed. Inferential statistics for the result was calculated using the Z-test. RESULTS: Of the 2666 consecutive patient charts that were reviewed, sodium values were recorded in 796 charts. Among the recorded charts, 28.8 % of patients showed hyponatremia at the time of referral which was significant with a P value of 0.000 (<0.05). Of these, 61.1 % had malignancy as their diagnosis and the rest had nonmalignant diseases, ranging from trauma to chronic obstructive pulmonary disease. CONCLUSIONS: Prevalence of hyponatremia is significant in palliative care patients. A prospective study looking at the causes and clinical outcomes associated with hyponatremia in palliative care patients is needed.