Antibiotic impregnated cement coated intramedullary nail (ACCIN) using bronchoscopy tubing: technical tips, case series and a review of the literature.

Antibiotic impregnated cement coated intramedullary nails (ACCINs) have been used in clinical practice for many years and have been shown to help eradicate infection in tibial osteomyelitis while providing stability. We present a novel technique for preparation using bronchoscopy tubing, as well as technical tips and a review of the literature, for ease of preparation and potential subsequent retrieval.

Management of Traumatic Nerve Palsies in Paediatric Supracondylar Humerus Fractures: A Systematic Review.

Purpose: Up to 12% of paediatric supracondylar humerus fractures (SCHFs) have an associated traumatic nerve injury. This review aims to summarize the evidence and guide clinicians regarding the timing of investigations and/or surgical interventions for traumatic nerve palsies after this injury. Methods: A formal systematic review was undertaken in accordance with the Joanna Briggs Institute (JBI) methodology for systematic reviews and PRISMA guidelines. Manuscripts were reviewed by independent reviewers against the inclusion and exclusion criteria, and data extraction, synthesis, and assessment for methodological quality were undertaken. Results: A total of 51 manuscripts were included in the final evaluation, reporting on a total of 510 traumatic nerve palsies in paediatric SCHFs. In this study, 376 nerve palsies recovered without any investigation or intervention over an average time of 19.5 weeks. Comparatively, 37 went back to theatre for exploration beyond the initial treatment due to persistent deficits, at an average time of 4 months. The most common finding at the time of exploration was entrapment of the nerve requiring neurolysis. A total of 27 cases did not achieve full recovery regardless of management. Of the 15 reports of nerve laceration secondary to paediatric SCHFs, 13 were the radial nerve. Conclusions: Most paediatric patients who sustain a SCHF with associated traumatic nerve injury will have full recovery. Delayed or no recovery of the nerve palsy should be considered for exploration within four months of the injury; earlier exploration should be considered for radial nerve palsies.

Hip reconstruction in cerebral palsy: Lessons from a single center and 137 hips.

Background: This large, retrospective, single-center study aimed to compare the outcomes of unilateral hip reconstruction and bilateral hip reconstruction in children with non-ambulatory cerebral palsy and ascertain risk factors for recurrent instability and reoperation. Method: We performed a retrospective review of 137 hip reconstructions performed for patients with cerebral palsy. Preoperative and postoperative clinical and radiological parameters were documented, including hip migration percentage, acetabular index, the Gross Motor Function Classification System, the Melbourne Cerebral Palsy Hip Classification System, hip abduction, and pelvic obliquity. Results: Overall, 49 patients underwent bilateral hip reconstruction, and 37 patients underwent unilateral hip reconstruction. In the unilateral hip reconstruction group, the reconstructed hip remained stable (with a migration percentage < 33%) in 59% of patients compared to 74.4% of the more affected hips in the bilateral hip reconstruction group (p = 0.02). Of the unreconstructed hip in the unilateral hip reconstruction group, 74.4% remained stable (with a migration percentage < 33%), compared to 78.8% of the less affected hips in the bilateral hip reconstruction group. A level pelvis was maintained at final follow-up in significantly more patients in the bilateral hip reconstruction group than the unilateral hip reconstruction group (p = 0.002). Further surgical intervention was performed in 41% of the unilateral hip reconstruction group, compared with 11.5% in the bilateral hip reconstruction group (p = 0.001). Surgery performed under the age of 8 years and not performing an acetabular osteotomy were found to be risk factors for recurrent instability in all groups. Conclusion: Our series suggests that in terms of recurrent instability after hip reconstruction in cerebral palsy, protective factors against this complication include bilateral hip reconstruction, hip reconstruction after 8 years of age, and the use of an acetabular osteotomy.

Management of iatrogenic ulnar nerve palsies after cross pinning of pediatric supracondylar humerus fractures: A systematic review.

Purpose: Up to 4% of patients who undergo cross pinning of a pediatric supracondylar humerus fracture sustain an iatrogenic ulnar nerve palsy (IUNP). This study aims to summarize the evidence regarding the management of IUNP in this setting, and to identify if early intervention (early wire removal or exploration) leads to faster and/or more complete recovery of the ulnar nerve. Methods: A formal systematic review was undertaken, with databases searched including Ovid Medline, Embase and Cochrane central. This was performed in accordance with JBI methodology and PRISMA guidelines. Results: In all, 26 articles were included in final evaluation, reporting a total of 179 IUNP. In all, 153 cases (85%) were managed expectantly, reporting full recovery at final follow-up (average 4.5 months) in 140 cases (91%). There were 26 cases of IUNP which were managed with early wire removal and/or exploration, of which 22 had full recovery (85%). There were 17 cases of 179 (9%) which did not have full recovery. Conclusion: The majority of IUNP are managed expectantly, with approximately 90% achieving full recovery at final follow-up. The literature does not support early wire removal and/or exploration, possibly because the damage to the nerve is done at the time of wire placement.

Outcomes of early versus delayed weight-bearing with intramedullary nailing of tibial shaft fractures: a systematic review and meta-analysis.

PURPOSE: Early weight bearing (EWB) is often recommended after intramedullary nailing of tibial shaft fractures, however, the risks and benefits have not been critically evaluated in a systematic review or meta-analysis. Therefore, the aims of this study were to perform a systematic review and meta-analysis comparing EWB and delayed weight-bearing (DWB) after intramedullary nailing of tibial shaft fractures and assess the relationship between weight-bearing, fracture union and healing. METHOD: This review included studies comparing the effects of EWB, defined as weight-bearing before 6 weeks, and DWB on fracture union and healing. PubMed, Embase, CINAHL, and the Cochrane Library were searched from inception to 9 May 2021. Risk of bias was assessed using the Down's and Black Checklist and Cochrane Risk of Bias Tool 2.0. Data were synthesised in a meta-analysis, as well as narrative and tabular synthesis. RESULTS: Eight studies were included for data extraction and meta-analysis. The analysis produced mixed results and found a significant decrease in mean union time (-2.41 weeks, 95% confidence interval: -4.77, -0.05) with EWB and a significant Odd's Ratio (OR) for complications with DWB (OR: 2.93, 95% CI: 1.40, 6.16). There was no significant difference in rates of delayed union, non-union, re-operation and malunion. CONCLUSION: The included studies were of moderate risk of bias and demonstrated shorter union time and fewer complications with EWB. However, current evidence is minimal and has significant limitations. The role of EWB in high-risk patients is yet to be examined. Further well-designed, randomised studies are required on the topic.

Re-fractures of the paediatric radius and/or ulna: A systematic review.

BACKGROUND: Fractures of the radius and/or ulna are one of the most common injuries in children. Evidence identifying risk factors for refracture, however, has not been summarised in a systematic review. Guidance for counselling patients and parents to minimise the risk of refracture is limited. The aims of this study are to 1) to determine if casting time 6 weeks or less is a risk factor for refracture after paediatric radius and/or ulna fractures, 2) to identify other risk factors for refracture after paediatric radius and/or ulna fractures and 3) to develop more accurate guidelines for counselling parents after a radius and/or ulna fracture in their child. METHODS: A thorough search was performed in accordance with the Joanna Briggs Institute (JBI) guidelines for systematic review. JBI Critical Appraisal checklists were used for risk of bias assessment. RESULTS: Diaphyseal both-bone fractures treated non-surgically should be casted for longer than 6 weeks. Surgically treated patients can be casted for less than 6 weeks. Diaphyseal and greenstick fractures have a higher risk of refracture. Residual angulation and incomplete healing in greenstick fractures may lead to a higher risk of refracture. Gender does not affect refracture risk. Falls, use of wheeled vehicles, playground activities and trampolining confer high-risk of refracture. Refracture risk is greatest up to 9 months from initial fracture. CONCLUSION: Further case-controlled studies with sub-group analysis are required to further investigate risk factors for refracture after radius and/or ulna fractures in children.

Effectiveness of operative versus expectant management on recovery of nerve palsies in pediatric supracondylar fractures: a systematic review protocol.

OBJECTIVE: The objective of this review is to evaluate the effectiveness of operative versus expectant management on recovery of nerve palsies after pediatric supracondylar fracture of the humerus or after surgery for supracondylar fracture of the humerus. INTRODUCTION: Supracondylar humerus fractures are the most common fracture of the elbow in children. These fractures have a high risk of complications from both the trauma itself and the treatment. Up to 12% of patients will have associated nerve injury, but there is insufficient information regarding the timing of investigation of and intervention in a persistent nerve palsy. This review aims to summarize the evidence and guide clinicians regarding the timing of investigation and/or surgical intervention for persistent nerve palsies after supracondylar humerus fractures in the pediatric population. INCLUSION CRITERIA: This review will include pediatric patients with ipsilateral upper limb nerve palsy after supracondylar fracture of the humerus or after surgery for a supracondylar fracture of the humerus without preexisting nerve palsies. METHODS: A comprehensive database search will be undertaken in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. The trial registers to be searched will include PROSPERO and AllTrials. The search strategy will include the keywords pediatric/paediatric, supracondylar, nerve injury/palsy/palsies, fracture, and humerus. Titles and abstracts will be screened by independent reviewers for suitability against the inclusion criteria, with accepted publications then being assessed in full with data extraction, synthesis, and assessment of methodological quality, using standardized critical appraisal tools from JBI. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42019121581.

Subjective and objective outcome measures after total knee replacement: is there a correlation?

BACKGROUND: Although various methods for quantifying outcomes following total knee replacement (TKR) are used, there are few studies of the relationships between patient reported scores and functional tests. This paper aims to assess the relationships between commonly used outcome scores after TKR through a prospective cohort study. METHODS: Twenty-four patients who had undergone unilateral TKR were assessed using four patient-reported outcome scores as well as objective measurements of knee laxity, quadriceps muscle strength and the Timed Up and Go Test. All scores and measures were correlated using the Pearson product moment correlation coefficient using the lower one-sided 95% confidence interval. A level of significance of P < 0.05 was selected. RESULTS: The Timed Up and Go Test was the only objective measure to demonstrate a statistically significant correlation (r = -0.557 to -0.770, P = 0.0001-0.005) with patient-reported scores. CONCLUSION: A comprehensive assessment of outcomes after TKR requires both subjective and objective assessments. Walking ability and speed are important to the TKR patient and are representative of their pain and function.