Bone xenotransplantation: A review of the history, orthopedic clinical literature, and a single-center case series.

BACKGROUND: One-half of all orthopedic surgeries require bone grafting for successful outcomes in fusions, reconstructive procedures, and the treatment of osseous defects resulting from trauma, tumor, infection, or congenital deformity. Autologous bone grafts are taken from the patient's own body and remain the "gold standard" graft choice but are limited in supply and impart significant patient morbidity. Xenograft bone is an attractive alternative from donors with controlled biology, in large supply and at a theoretically lower cost. Clinical results with xenograft bone for orthopedic applications have been mixed in the limited clinical trials published. METHODS: In the current review, we introduce fundamental principles of bone grafting, systematically review all orthopedic clinical studies reporting outcomes on patients transplanted with xenograft bone, and we present our own clinical results from patients grafted with bovine bone in foot and ankle reconstructive procedures. RESULTS: Thirty-one clinical studies were identified for review and the majority (47%) were from spine surgery literature. Favorable results were reported in 44% of studies while 47% of studies reported poor outcomes and discouraged use of xenograft bone products. In our own clinical series, xenograft failed to integrate with host bone in 58% of cases and persistent pain was reported in 83% of cases. CONCLUSIONS: This is the first systematic review of clinical results reported after bone xenotransplantation for orthopaedic surgery applications. Current literature does not support the use of xenograft bone products and our institution's results are consistent with this conclusion. Our laboratory has reported promising pre-clinical results with a xenograft product derived from porcine cancellous bone, but additional testing is required before considering clinical translation.

Effect of Facilitated Discharge in Pediatric Orthopedic Patients at an Academic Medical Facility.

INTRODUCTION: Because health care reimbursement is being linked to discharge quality and patient satisfaction, this quality improvement initiative reviewed the outcomes of embedding a pediatric nurse practitioner within the resident team at an academic medical facility. METHODS: The project was completed at a pediatric orthopedic unit at a large Southeastern U.S. academic medical facility. During the intervention, the pediatric nurse practitioner student completed daily rounds, communicated with the resident team, assessed readiness for discharge, provided patient education, and ensured that comprehensive discharge materials were completed. RESULTS: Analyses were completed for 219 patients (pre-intervention, n = 116; post-intervention, n = 103). Patient satisfaction was measured for provider communication and discharge. All areas experienced improvement, with provider communication benchmarks obtained. Ambulatory call volume decreased from 97 to 45 calls/100 patients. DISCUSSION: This study shows that embedding a pediatric nurse practitioner into the resident team helped improve patient satisfaction and reduce ambulatory workload by decreasing call volume.

Imaging of the elbow in children with wrist fracture: an unnecessary source of radiation and use of resources?

BACKGROUND: Anecdotally accepted practice for evaluation of children with clinically suspected or radiographically proven wrist fracture in many urgent care and primary care settings is concurrent imaging of the forearm and elbow, despite the lack of evidence to support additional images. These additional radiographs may be an unnecessary source of radiation and use of health care resources. OBJECTIVE: Our study assesses the necessity of additional radiographs of the forearm and elbow in children with wrist injury. MATERIALS AND METHODS: We reviewed electronic medical records of children 17 and younger in whom wrist fracture was diagnosed in the emergency department. We identified the frequency with which additional radiographs of the proximal forearm and distal humerus demonstrated another site of acute injury. RESULTS: We identified 214 children with wrist fracture. Of those, 129 received additional radiographs of the elbow. Physical examination findings proximal to the wrist were documented in only 16 (12%) of these 129 children. A second injury proximal to the wrist fracture was present in 4 (3%) of these 129 children, all of whom exhibited physical examination findings at the elbow. No fractures were documented in children with a negative physical examination of the elbow. CONCLUSION: Although elbow fractures occasionally complicate distal forearm fractures in children, our findings indicate that a careful physical evaluation of the elbow is sufficient to guide further radiographic investigation. Routine radiographs of both the wrist and elbow in children with distal forearm fracture appear to be unnecessary when an appropriate physical examination is performed.

Hemiepiphysiodesis for correction of angular deformity in pediatric amputees.

BACKGROUND: Angular deformities at the knee are common in children with congenital or acquired below-knee or Syme amputations. These deformities can be well compensated and accommodated with prosthetic modifications. However, as children grow, these prosthetic modifications become more difficult and mechanical axis correction becomes necessary. These deformities have previously been treated with osteotomies and internal or external fixation devices, which necessitate prolonged periods without use of their prosthesis. This study examines the results of hemiepiphysiodesis to correct the mechanical axis and improve prosthetic fitting in a pediatric amputee population. METHODS: Mechanical axis correction using hemiepiphysiodesis in 22 pediatric Symes or transtibial amputees with 22 involved limbs were retrospectively reviewed. Hemiepiphysiodesis was performed with 8-plates (10), staples (6), or drilling and curetting (6). Postoperatively, children were allowed to resume prosthetic use after their wounds healed and they indicated no pain while wearing their prosthesis. Seventeen patients presented with valgus and 5 with varus deformity of their residual limb. Mean age at time of surgery was 11 years and 11 months (range, 7 y and 11 mo to 15 y and 8 mo). Mechanical axis deviation (MAD) was measured before initial surgery and again after hardware removal or physis closure. RESULTS: The mean preoperative MAD was -29.6 mm for the valgus deformities and +10.6 mm for the varus deformities. The mean postoperative MAD was +3.1 mm for the varus knees and -6.0 mm for the valgus knees The mean total mechanical axis correction was 21.8 mm. One patient failed to achieve any mechanical axis correction and 1 hardware failure (broken 8-plate) occurred. Most patients had the staples or 8-plates removed, either after correction was achieved and physes were still open, or due to hardware prominence after physeal closure. CONCLUSIONS: Hemiepiphysiodesis provides reliable correction of angular deformity in pediatric amputees. Surgical intervention while skeletally immature allows for correction using guided growth, without the need for osteotomy with internal or external fixation and the resultant disruptions in prosthetic wear. LEVEL OF EVIDENCE: Case Series, Level IV.

Chronic Monteggia fractures in children: outcome after treatment with the Bell-Tawse procedure.

Late recognition of Monteggia fracture-dislocations of the elbow continues to pose a treatment challenge. The 15 children in our series with such chronic injuries were all treated with the modified Bell-Tawse annular ligament reconstruction. At an average follow-up of 30 months, all regained flexion-extension arcs in the functional range and no nerve palsies were noted. Some loss of pronation and supination was common, but none had activity restrictions or functional deficits. Four children had recurrent, asymptomatic radial head subluxation; measuring 3-4 mm in the anterior direction. We recommend that late annular ligament reconstruction be considered for most chronic Monteggia fractures to improve long-term function and prevent the need for late excision of the painful, chronically dislocated radial head.