Use of cryotherapy in the postoperative management of paediatric anterior cruciate ligament reconstruction: a prospective randomised controlled trial.

To investigate the efficacy of cryotherapy in relieving postoperative pain and restoring knee range-of-motion (ROM) after paediatric anterior cruciate ligament reconstruction (ACLR). Patients undergoing primary ACLR were randomised into cryotherapy or non-cryotherapy groups. Those receiving cryotherapy were subjected to a standardised icing protocol. Icing schedules were used to assess compliance. Standard postoperative rehabilitation protocol was followed for both groups. Outcome measurements were visual analogue scale at rest and movement and knee ROM. Patients were assessed on postoperative day 1 (POD1), 1, 4 and 6 weeks. Twenty-one out of 42 patients received cryotherapy. Both groups were similar in demographics, surgical technique and use of intraoperative anaesthesia. Patients in the cryotherapy group reported lower overall mean pain scores throughout the study duration at rest (0.61 ±â€…1.70, 95% CI = 0.23-0.99 vs. 1.06 ±â€…2.03, 95% CI = 0.60-1.53) and on movement (2.19 ±â€…2.68, 95% CI = 1.59-2.79 vs. 3.13 ±â€…2.75, 95% CI = 2.51-3.75; P = 0.032). Knee flexion in the cryotherapy group showed better recovery of knee flexion from week 4 onwards. Improvement of knee flexion from POD1 is statistically significant at week 6 (98.7 ±â€…19.1°, 95% CI = 89.5-107.9 vs. 65.4 ±â€…49.9°, 95% CI = 42.7-88.1; P = 0.010) and overall mean (71.2 ±â€…35.9°, 95% CI = 61.2-81.1 vs. 45.3 ±â€…55.5°, 95% CI = 30.4-60.2; P = 0.005). The cryotherapy group reported statistically significant better degree of overall mean knee extension (1.2 ±â€…3.3°, 95% CI = 0.5-2.0 vs. 2.6 ±â€…4.6°, 95% CI = 1.6-3.7; P = 0.032). The use of cryotherapy in postoperative ACLR recovery in paediatrics is a simple yet effective measure resulting in short-term pain relief and improvement in knee flexion.

Office 3D-printing in paediatric orthopaedics: the orthopaedic surgeon's guide.

BACKGROUND: 3D-printing, or additive manufacturing has become increasingly popular across scientific and engineering fields. The same trend has been observed in the medical field, with the main users being the dentists and the neurosurgeons. Within orthopaedic surgery, usage has been limited by accessibility and costs. The benefits of a 3D printed model in surgical planning and education in orthopaedic surgery is obvious, especially in fields like deformity correction and fracture fixation. METHODS: An in-house 3D-printing facility was set up, with workflow processes defined. We utilised the described workflow to 3D-print models for four paediatric orthopaedic patients with differing pathologies. RESULTS: These case examples show how 3D-printing of surgical models was easily performed, and they are useful in various clinical scenarios within paediatric orthopaedics. The steps involved in the process are accurately detailed, and are reproducible by any orthopaedic surgeon. The benefits of the application of 3D models in the deformity assessment and surgical planning of these cases are discussed individually. CONCLUSIONS: An in-house 3D-printing facility is useful in paediatric orthopaedics due to the variety of complex pathologies and anatomy. We have shown that it is easy to set up with a defined work process. We advocate the application of this emerging technology into every orthopaedic practice.

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.

Combined lateral condyle mass and olecranon fractures: A proposed treatment algorithm and surgical technique.

Combined lateral condyle mass and olecranon fractures are infrequently seen. These cases are easily missed, and only 12 previous cases are detailed in the English medical literature. The decision for surgical fixation usually depends on the amount of displacement of the individual fractures. However, the optimal surgical approach or technique for open reduction and internal fixation has not been agreed upon. We present three original case reports and analyse them together with all other known cases in the English literature. We discuss how to avoid missing these combined fractures and propose a treatment algorithm based on the different permutations of the fracture displacement. Our detailed surgical approach (using a posterior 'olecranon osteotomy' approach) is also described.

Prophylactic fixation or surveillance: predicting subsequent displacement of lateral condyle of humeral fractures based on soft tissue swelling.

BACKGROUND: Nondisplaced or minimally displaced fractures (≤2 mm) of the lateral condyle of the humerus (LCH) could undergo subsequent displacement (>2 mm), which would be a potential surgical indication. We describe a new method to quantify soft tissue swelling in LCH fractures and to identify a threshold value to predict subsequent displacement of LCH fractures. We hypothesized that the larger the soft tissue swelling, the more likely a subsequent displacement would occur. METHODS: Elbow x-ray images (anteroposterior view) at initial presentation in 87 patients with subsequent displacement and in 87 patients with no subsequent displacement were compared. All fractures were initially nondisplaced or minimally displaced. The lateral elbow swelling-to-humeral shaft diameter (LES-H) ratio was measured. A threshold value for diagnosing a subsequent displacement was identified from the receiver operating characteristic curve analysis. RESULTS: Both groups had similar age (subsequent displacement: 5.1 ± 2.3 years vs. no subsequent displacement: 5.7 ± 3.2 years; P = .459). The LES-H ratio was significantly larger in the subsequent displacement group (1.8 ± 0.4 vs. 1.4 ± 0.4, P < .001). The area under the receiver operating characteristic curve was 0.728, which was moderately accurate in predicting subsequent displacement. A threshold LES-H ratio of 1.90 had a sensitivity of 41.4% and specificity of 90.8% in diagnosing subsequent displacement. The odds ratio of having subsequent displacement with LES-H ratio of ≥1.90 was 6.1 (95% confidence interval, 2.7-13.8; P < .001). CONCLUSION: The LES-H ratio could be used to objectively quantify soft tissue swelling in LCH fractures. An LES-H ratio of ≥1.90 was used as threshold value to predict subsequent displacement.

Midterm functional outcomes in operatively treated adolescent Lisfranc injuries.

This study evaluates the midterm outcomes of Lisfranc injuries in adolescents operatively treated with Kirschner wire or screw fixation. Eight adolescent patients with Lisfranc injuries operatively treated in a single institution were included in this study. The mean duration of follow-up was 3.8 years. Analysis of radiographs with respect to the degree of initial displacement and final reduction was carried out in terms of the intermetatarsal distances. All cases were scored functionally using the American Orthopaedic Foot and Ankle Society Midfoot Scale. We concluded that most operatively treated cases of adolescent Lisfranc injuries will do well at the midterm follow-up, with a mean American Orthopaedic Foot and Ankle Society Midfoot score of 93.4. LEVEL OF EVIDENCE: Level 4 (Case series).

Severity of playground-related fractures: more than just playground factors?

INTRODUCTION: Despite the establishment of playground safety standards, playground-related injuries are still a significant cause of extremity fractures in Singapore. This prospective study evaluates the dimensions and characteristics of our playgrounds, and their effect on fracture severity in an Asian population. We aim to correlate various playground risk factors with severity of the fractures and give recommendations on future safety standards. Our data also allows us to compare the demographics of patients in our study group with that collected in our earlier study in 2004. METHODS: From June 2005 to 2006, children who presented with extremity fractures to KK Women's and Children's Hospital after a playground injury were enrolled. Their clinical data were collected prospectively. Relevant playground details were collected on-site independently by another investigator. For analysis of severity, fractures were "major" if they required reduction or operative fixation and were "minor" if they did not. RESULTS: Supervision at time of injury, especially from the child's parents or siblings, resulted in a lower likelihood of "major" fractures (P=0.002, likelihood ratio=1.97). Conversely, supervision from grandparents or maids was found to result in a higher likelihood of "major" fractures. Increased weight of patients was directly related to severity of fractures (P=0.000), and a body mass index (BMI) of less than 19.8 kg/m resulted in lower likelihood of "major" fractures (P=0.010, likelihood ratio=2.22). Height of equipments and other playground-related factors were not linked to severity of fractures. CONCLUSIONS: Supervision at the playground, preferably from the child's parents or siblings, and keeping a child's BMI within limits as guided by the BMI charts, may potentially reduce the occurrence of severe fractures. LEVEL OF EVIDENCE: Level I-prognostic study.

Conservative treatment for juvenile osteochondritis dissecans of the talus.

PURPOSE: To assess outcome of 6 juvenile patients with osteochondritis dissecans (OCD) of the ankle treated conservatively. METHODS: Records of 4 males and one female aged 10.8 to 14.1 (mean, 12.3) years who underwent cast immobilisation and/or restriction of physical activities for OCD of the talus (4 on the left and 2 on the right) were reviewed. OCD lesions were graded using the Berndt and Harty classification. Functional outcome was assessed using the ankle-hindfoot score of the American Orthopaedic Foot and Ankle Society. Clinical and radiographic outcomes were assessed according to the Higuera classification. RESULTS: The mean follow-up period was 30.5 (range, 11-63) months. The mean ankle-hindfoot score was 90 (range, 86-100). Radiological resolution of OCD was noted in 2 ankles, although all ankles showed some degree of healing. All patients had resolution of pain after a mean of 7 (range, 3-12) months. According to the Higuera classification, clinical outcome was excellent in one and good in 5 ankles, whereas radiological outcome was excellent in 2, good in 2, and fair in 2 ankles. In one patient, the OCD of the right posteromedial talar dome resolved spontaneously. CONCLUSION: Almost all patients achieved good functional outcome after conservative management, regardless of the presence of radiological evidence of healing. Surgery should only be performed if the OCD is unstable.

Ultrasound-guided reduction of distal radius fractures.

INTRODUCTION: In our local emergency departments (EDs), manipulation and reduction (M&R) of distal radius fractures are performed by emergency doctors, with blind manual palpation, using postreduction x-rays to assess adequacy. We sought to study the effectiveness of ultrasound guidance in the reduction of distal radius fractures in adult patients presenting to a regional ED. METHODS: This was a before-and-after study. Eligible patients were adults older than 21 years who presented to the ED with distal radius fractures that required M&R. Sixty-two patients were prospectively enrolled from October 2007 until June 2008, and they underwent ultrasound-guided M&R. The control group was a retrospective cohort of 102 patients who presented from January to June 2007. They had M&R done using the blind manual palpation method. All M&R procedures were performed by doctors within the ED, and supervision was provided by senior emergency physicians. Ultrasound guidance was performed by the senior emergency physicians. RESULTS: Baseline characteristics between the ultrasound and control groups were similar. The rate of repeat M&R was reduced in the ultrasound group (1.6% vs 8.8%; P = .056). The postreduction radiographic indices were similar between the 2 groups, although the ultrasound group had improved volar tilt (mean, 5.93° vs 2.61°; P = .048). An incidental finding of a reduced operative rate was also found between the ultrasound and control groups (4.9% vs 16.7%; P = .02). CONCLUSION: Ultrasound guidance is effective and recommended for routine use in the reduction of distal radius fractures.