Surgical Decision Making for Mild-to-Moderate Cubital Tunnel Syndrome.

Purpose: The management of ulnar neuropathy remains unclear as there are neither consensus guidelines nor compelling data available to inform optimal treatment. Identifying patients in the mild-to-moderate group that would benefit most from surgery is challenging as their symptoms can be subtle and less debilitating. This study investigated predictors of surgical intervention among patients presenting with McGowan mild or moderate cubital tunnel syndrome (CuTS). Methods: This is an institutional review board-approved study. Patients evaluated from March 2016 to July 2022 were included if they were diagnosed with McGowan mild or moderate CuTS and underwent concurrent electrodiagnostic and ultrasound evaluations. Patient demographics, symptom presentation, and clinical and diagnostic test findings were analyzed. Variables were analyzed using Student t test, Mann-Whitney U test, or Pearson's chi-square test. Multivariable logistic regression was used to assess the association of covariates and surgery. Results: Seventy-three patients and 103 elbows were identified. The mean age and body mass index were 51 years and 26.9, respectively. Most patients were men, right-handed, and unilaterally symptomatic in the dominant hand. Twenty-six elbows were surgically treated. Bivariable analyses by surgical treatment showed that patients who underwent surgery more often had positive electrodiagnostic findings including motor nerve conduction velocity <50 m/s and a >10 m/s conduction velocity difference across the forearm compared with elbow. Fifty-nine cases were categorized as electrodiagnostically normal. Of the electrodiagnostically normal cases, 29 had positive findings of CuTS on ultrasound. Logistic regression model showed that electrodiagnostically severe cases had 3.7 times higher odds of being surgically treated than normal counterparts (adjusted odds ratio, 3.7; 95% CI, 1.11-12.6; P = .03). Conclusions: Not many differences in objective findings identify patients who should receive operative treatment. In addition to test results, more subjective findings from patients such as patient-reported level of impairment may be able to bridge this gap in surgical decision making. Clinical relevance: This study contributes to treatment decision making for mild and moderate CuTS.

Outcomes, Including Graft Tears, Contralateral Anterior Cruciate Ligament Tears, and All-Cause Ipsilateral Knee Operations, are Similar for Adult-type, Transphyseal, and Partial Transphyseal Anterior Cruciate Ligament Reconstruction Using Hamstring Autograft in Pediatric and Adolescent Patients.

Purpose: To compare hamstring autograft primary anterior cruciate ligament reconstruction (ACLR) techniques including adult-type/anatomic, transphyseal, and transphyseal techniques by (1) ACL graft tear, (2) contralateral ACL tear, and (3) all-cause ipsilateral reoperation. Methods: A retrospective, single-surgeon review was performed including all ACLR with hamstring autograft in pediatric and adolescent patients from 2011 to 2019. Minimum 2-year follow-up was required for patients unless a tear or reoperation was sustained before that time point. Data collected included demographics and baseline surgical variables, type of reconstruction, sporting activity, and deviations from rehabilitation protocols. Comparisons were made among hamstring autograft reconstruction groups (adult-type/anatomic, transphyseal, and partial transphyseal) for primary outcomes of graft tear, contralateral ACL tears, and all-cause ipsilateral knee reoperations, including hardware removal. Secondary surgeries performed with different surgeons were noted. Results: In total, 214 patients of age 15.2 ± 2.0 years with 4.1 ± 1.7-year follow-up were included. Overall graft tear rate was 11.7% (11.0% adult-type vs 19.1% transphyseal vs 5.6% partial transphyseal; P = .18). On univariate analyses, all-cause ipsilateral reoperation did not differ by technique (21.3% vs 31.0% vs 33.3%; P = .20), and neither did contralateral ACL tear (8.1% vs 9.5% vs 0%; P = .17). 21.7% of ipsilateral revision ACLRs (all adult-type) and 16.7% of patients with any reoperations had subsequent procedures performed with a different surgeon. Conclusions: The graft tear rates in primary hamstring autograft ACLRs in the adolescent population did not significantly differ by technique (11.0% vs 19.1% vs 5.6% in adult-type, transphyseal, and partial transphyseal reconstructions, respectively). Furthermore, contralateral ACL tears (8.1% vs 9.5% vs 0%) and all-cause (including > 1/4 hardware removal) ipsilateral knee reoperations (21.3% vs 31.0% vs 33.3%) did not statistically differ. Higher powered studies may detect statistical significance in the observed differences in this study. Level of evidence: Level IV, therapeutic case series.

Proximal Humerus Fractures in the Pediatric Population.

PURPOSE OF REVIEW: The purpose of this review is to review recent literature focusing on proximal humerus anatomy, epidemiology of these fractures, diagnosis and treatment options, and clinical outcomes. RECENT FINDINGS: Non- or minimally displaced proximal humerus fractures treated nonoperatively do not lead to short- or long-term complication and do not cross over to operative treatment. There is a higher rate of operative management with older age, increased injury severity score, treatment at an adult hospital, and private insurance. Operative management is preferred with closed or open reduction and percutaneous pinning, but elastic nailing and plate fixation are other options with good postoperative outcomes. Pediatric proximal humerus fractures occur after fall onto the affected shoulder or arm. Diagnosis is usually made with radiographs. Understanding the proximal humerus anatomy is critical to the proper management of these injuries to aid reduction and predict remodeling potential. There is considerable debate around the management of proximal humerus fractures in the pediatric population. Treatment is based on patient age, fracture displacement, and remodeling capacity. Nonoperative management is successful in younger patients or less displaced fractures, and operative management is usually considered in older patients with more displaced fractures.

Diagnosis and Management of Osteomyelitis in Children: A Critical Analysis Review.

The most common causative organism of pediatric osteomyelitis is Staphylococcus aureus, although, more recently, organisms such as Kingella kingae and methicillin-resistant S. aureus have been increasing in prevalence. Magnetic resonance imaging is the best diagnostic imaging modality for pediatric osteomyelitis given its high sensitivity and specificity. Most cases of early osteomyelitis without a drainable abscess can be adequately treated with a short course of intravenous antibiotics followed by at least 3 weeks of oral antibiotics. Surgical management of pediatric osteomyelitis is usually indicated in the presence of an abscess and/or failed treatment with antibiotic therapy. Clinical examination, fever, and C-reactive protein testing should be used to guide the conversion to oral antibiotics, the total antibiotic regimen duration, and the need for an additional debridement surgical procedure.

Congenital pseudarthrosis of the clavicle: surgical decision making and outcomes.

BACKGROUND: Congenital pseudarthrosis of the clavicle (CPC) is a rare entity in which the primary ossification center of the clavicle fails to coalesce. The natural history of CPC is unknown, and there is controversy regarding surgical vs. conservative treatment. METHODS: A retrospective review of 47 pediatric patients treated for CPC was performed. The Quick Disabilities of the Arm and Shoulder (QuickDASH) survey and the Patient Reported Outcomes Measurement Information System (PROMIS) upper extremity domain were used to assess overall patient satisfaction, function, and quality of life after treatment. RESULTS: Twenty-four of 47 (51%) patients underwent surgical treatment. Of these, 9 patients (38%, 9/24) underwent surgery at <18 months of age using suture fixation alone, whereas the older 15 surgical patients (15/24, 62%) were treated with plate fixation. The younger surgical cohort had a nonunion rate of 43% (3/7) compared with 13% (2/15) in the older cohort. All surgical patients had resolution of preoperative symptoms. Eleven (11/24, 46%) surgical subjects responded to the follow-up survey. Upper extremity function normalized according to the QuickDASH survey (score of 0 for all subjects). The median PROMIS upper extremity domain score was 55, which was also in the normal range. CONCLUSIONS: This series of CPC patients improves our understanding of treatment options and outcomes of surgical treatment. All surgical patients had resolution of preoperative symptoms. Patients treated surgically with stable fixation at an older age had higher rates of union than those treated in infancy with suture fixation. Patient-reported outcomes were favorable overall.