Femoral head reduction osteotomy for the treatment of late sequela of Legg-Calvé-Perthes disease and Perthes-like femoral head deformities.

Femoral head reduction osteotomy (FHRO) was described to treat misshapen femoral head that is causing intraarticular hip pain. The published literature showed discrepancies in patient selection, surgical techniques, and decision to perform concurrent acetabular osteotomy. Very few studies used Standardized Outcome Measures (SOMs). This study aims to describe the technique of FHRO and report the results of our series of 22 patients using SOMs and compare them to former peer-reviewed articles. Twenty-two hips in 22 patients with hip pain caused by mishshapen femoral were treated with FHRO with or without triple pelvic osteotomy (TPO). Patients with poor hip range of motion and significant hip joint arthritis were excluded. The mean patient age was 15.8 (range, 9.2-23.9). Clinical results were reported using the HHS. Radiographical results were reported by comparing Lateral Center Edge Angle (LCEA), extrusion index, Tonnis angle, head size percent, sphericity index, and distance from tip of trochanter to center of femoral head. The mean follow-up was 3.2 years. Only 5 patients received TPO. The HHS showed statistical improvement from 62.0 to 81.6 (The median interquartile range 63.5-88.5). Five patients had HHS less than 70 at the latest follow up. All radiographic parameters except the Tonnis angle, showed statistically significant improvement. FHRO with or without pelvic osteotomy is a good salvage procedure for patients presenting with misshapen femoral head with intraarticular hip pain, who still have good preoperative ROM with no signs of hip arthritis. Level of evidence: IV.

Fusion Revision Surgery With Reamer-Irrigator-Aspirator to Harvest Autograft After Spinal Pseudarthrosis.

Background and purpose Spinal pseudarthrosis (SPA) is a common complication after attempted cervical or lumbosacral spinal fusion surgery. Revision surgeries usually necessitate bone graft implementation as an adjunct to hardware revision. Iliac crest bone graft is the gold standard but availability can be limited and usage often leads to persistent postoperative pain at the donor site. There is scant literature regarding the use of reamer-irrigator-aspirator (RIA)-harvested bone graft in lumbar spinal fusion. This is a collaborative study between orthopedic surgery and neurosurgery departments to utilize femur intramedullary autograft harvested using the RIA system as an adjunct graft in SPA revision surgeries. Materials and methods A retrospective review was conducted at a single center between August 2014 and December 2017 of patients aged ≥ 18 years and diagnosed with cervical, thoracic, or lumbar SPA who underwent revision fusion surgery using femur intramedullary autograft harvested using the RIA system. Plain radiographs and CT scans were utilized to confirm successful fusion. Results Eleven patients underwent 12 SPA revision surgeries using the RIA system as a source for bone graft in addition to bone morphogenetic protein 2 (BMP-2) and allograft. The mean amount of graft harvested was 51.3 mL (range: 20-70 mL). Nine patients achieved successful fusion (81.8%). The average time to fusion was 9.1 months. Four patients (36.4%) had postoperative knee pain. Regarding patient position and approach for harvesting, 66.7% (n = 8) of cases were positioned prone and a retrograde approach was utilized in 91.7% (n = 11) of cases. Interpretation This is the first case series in known literature to report the RIA system as a reliably considerable source of autologous bone graft for SPA revision surgeries. It provides a useful adjunct to the known types of bone grafts. Patient positioning and the approach choice for graft harvesting can be adjusted according to the fusion approach and the surgeon's preference.

Allogeneic blood transfusion and AIS surgery: how the NSQIP database can improve patient safety.

PURPOSE: Describe the experience of one institution in modifying allogeneic blood transfusion protocols for AIS surgery in response to the results of ACS-NSQIP-PEDS comparative data in a retrospective cohort study. METHODS: NSQIP data demonstrated that AIS patients at our hospital had a significantly greater risk of ALBT compared to similar institutions (OR 4.1). The ALBT protocol was then revised to initiate transfusion based on Hb/Hct level, clinical hypotension and/or discussion between surgeon and anesthesiologist. A retrospective analysis of perioperative ALBT and autologous cell salvage blood transfusion (CSBT) rates was performed for patients undergoing surgery before (Group A) and after (Group B) the implementation of the revised protocol. RESULTS: Two hundred and ninety patients constituted the study cohort, with 92 patients in Group A and 198 in Group B. Average total blood transfusion (ALBT + CSBT) per patient was significantly lower for Group B than Group A (313 ml vs. 650 ml, p < 0.01). ALBT per patient of Group B was significantly lower than Group A (85 ml vs. 324 ml, p < 0.01). 48% of patients received ALBT in Group A compared to only 18% in Group B. CONCLUSION: Recognition of excessive allogeneic transfusion rates in our institution through comparative data from the ACS-NSQIP-PEDS database resulted in the modification of transfusion parameters that led to a decrease in allogeneic transfusion rates for AIS patients. The current study highlights the value of a large, well-curated surgical database in optimizing clinical protocols and potentially improving overall surgical morbidity.

Chronic Quadriceps Tendon Rupture Reconstruction with Sartorius Muscle Transfer: A Report of Five Cases.

Disruption of the knee extensor mechanism is an unfavorable situation because efficient mobilization requires a functioning knee extensor apparatus. The purpose of this retrospective study was to report our technique of sartorius muscle transfer for restoration of extension mechanism function and the outcomes of five patients. Patients with ruptured knee extensor mechanism secondary to trauma or knee arthroplasty-related issues were studied retrospectively. In all patients, sartorius muscle was transferred to restore the quadriceps tension deficit. Increase in the knee active range of motion, increase in the extensor mechanism power by one grade on Medical Research Council scale, and improvement in the extension lag were observed in all patients. The sartorius muscle transfer can be a reliable option to restore the knee extensor mechanism in chronic quadriceps tendon injuries. Our initial results are promising and showed improvement of the extensor mechanism muscle power, increased knee active range of motion, and decreased knee extension lag. The complications we observed did not impair the successful outcome of the sartorius transfer and were anticipated given the complexity of the studied cases. We encourage additional studies of sartorius muscle transfer to treat chronic quadriceps tendon injuries.

Post-retrieval functionality testing of PRECICE lengthening nails: The "Sleeper" nail concept.

INTRODUCTION: PRECICE intramedullary magnetic lengthening nails, introduced in 2011, have changed the landscape of long bone limb lengthening. The implants have a stroke ranging from 5 to 8 cm, but it may be desirable to perform part of the lengthening at one treatment, allow bone healing, leave the implant in place, dormant, and then return one or more years later to re-lengthen with the same implant. We call this the "sleeper" nail concept. This strategy may be gentler for the joints and soft tissues. Would the nail mechanism still be functional one or more years later? METHODS: We tested 102 intact, consecutively explanted nails. Using a "fast magnet," the male part was lengthened to 5 mm short of its maximum stroke capacity and retracted back to 35 mm (all nails start with the male part exposed 30 mm). The nails passed the test if the male part succeeded in lengthening to 5 mm short of the maximum stroke capacity and back to 35 mm (or only retract in case fully deployed at testing). During our testing, the nails were prevented from reaching their full capacity of lengthening/retraction to avoid jamming the gears. Failure was defined as the inability or partial ability to complete the process. RESULTS: Eighty-six nails (84.3%) performed successfully according to our testing standard. When comparing successful and failed nails in terms of nail type, generation, diameter, length and in vivo interval, there was no statistical significance. Comparing both groups in terms of status at testing (fully deployed or not) showed statistical significance with 9 of the 16 failed nails fully deployed at testing (p < 0.001). CONCLUSION: Dormant PRECICE nails can be reactivated for further lengthening. The results imply that full deployment may damage the mechanism, making future re-use by retracting and then re-lengthening unsuccessful. The candidate nails for this purpose should not have any signs of clear damage (bending or breakage) and should not have been fully deployed. However, surgeons and patients should be aware of the need for possible nail exchange if the "sleeper" nail fails to wake up. LEVEL OF EVIDENCE: Level IV case series analysis of retrieved surgical implants.

How Accurate is the Multiplier Method in Predicting the Timing of Angular Correction After Hemiepiphysiodesis?

PURPOSE: The purpose of the study was to validate the accuracy of the Multiplier Method (MM) in predicting the timing of angular correction after hemiepiphysiodesis and to determine the role of using skeletal age when calculating those predictions. METHODS: This retrospective study included 131 physes in 77 patients treated with hemiepiphysiodesis to gradually correct a coronal plane deformity before skeletal maturity. To compare the MM's predictions to the actual treatment duration, the "desired angular correction" was considered the actual achieved angular correction determined from the "endpoint x-ray" (last x-ray before implant removal). We measured the bone length and width of the growth plate from the preoperative x-ray and calculated the MM's prediction of the duration of treatment based on the MM formula. We compared the predicted duration to the observed duration of treatment for each case. The difference was calculated by subtracting the observed duration from the predicted duration. The result was the "absolute difference," which is the number of months over or under predicted by the MM. RESULTS: The mean absolute difference between the MM's predicted duration and the observed duration was 2.31 months, which was highly significant (P≤0.001). The MM's prediction agreed with the observed duration of treatment (ie, zero absolute difference) in 15% of the predictions, 69% were under predicted, and 16% were over predicted. Sixty-eight percent of the absolute differences were within 3 months regardless of the direction of error. The mean difference was relatively less in genu varum cases and was statistically significant (P=0.047). Comparing the mean difference using chronological age and skeletal age in the formula showed no statistically significant difference. CONCLUSIONS: The MM has a tendency to under predict. Therefore, doing a guided growth right before skeletal maturity should be started 2 to 4 months earlier than suggested by the MM. Moreover, our data did not show that the bone age gave more accurate predictions than chronological age. LEVEL OF EVIDENCE: Level IV.