Moving forward through consensus: protocol for a modified Delphi approach to determine the top research priorities in the field of orthopaedic oncology.

INTRODUCTION: Orthopaedic oncology researchers face several obstacles in the design and execution of randomised controlled trials, including finite fiscal resources to support the rising costs of clinical research and insufficient patient volume at individual sites. As a result, high-quality research to guide clinical practice has lagged behind other surgical subspecialties. A focused approach is imperative to design a research programme that is economical, streamlined and addresses clinically relevant endpoints. The primary objective of this study will be to use a consensus-based approach to identify research priorities for international clinical trials in orthopaedic oncology. METHODS AND ANALYSIS: We will conduct a 3-phase modified Delphi method consisting of 2 sequential rounds of anonymous web-based questionnaires (phases I and II), and an in-person consensus meeting (phase III). Participants will suggest research questions that they believe are of particular importance to the field (phase I), and individually rate each proposed question on 5 criteria (phase II). Research questions that meet predetermined consensus thresholds will be brought forward to the consensus meeting (phase III) for discussion by an expert panel. Following these discussions, the expert panel will be asked to assign scores for each research question, and research questions meeting predetermined criteria will be brought forward for final ranking. The expert panel will then be asked to rank the top 3 research questions, and these 3 research questions will be distributed to the initial group of participants for validation. ETHICS AND DISSEMINATION: An ethics application is currently under review with the Hamilton Integrated Research Ethics Board in Hamilton, Ontario, Canada. The results of this initiative will be disseminated through peer-reviewed publications and conference presentations.

The Accordion Maneuver: A Noninvasive Strategy for Absent or Delayed Callus Formation in Cases of Limb Lengthening.

The distraction osteogenesis (DO) technique has been used worldwide to treat many orthopaedic conditions. Although successful, absent or delayed callus formation in the distraction gap can lead to significant morbidities. An alternate cycle of distraction-compression (accordion maneuver) is one approach to accelerate bone regeneration. The primary aim of our study is to report our experience with the accordion maneuver during DO and to provide a detailed description of this technique, as performed in our center. The secondary aim is to present a review of the literature regarding the use of accordion maneuver. We reviewed the database of all patients undergoing limb lengthening from the year of 1997 to 2012. Four patients (6.15%) out of 65 showed poor bone regenerate in their tibiae and therefore accordion maneuver was applied for a mean of 6.75 weeks. Of these, three patients have had successful outcome with this technique. The literature showed that this technique is successful approach to trigger bone healing. However, details of how and when to apply this combination of distraction-compression forces were lacking. In conclusion, the accordion technique is safe noninvasive approach to promote bone formation, thus avoiding more invasive surgical procedures in cases of poor callus formation in limb lengthening.

Dega osteotomy for the correction of acetabular dysplasia of the hip: a radiographic review of 21 cases.

BACKGROUND: The Dega osteotomy is a versatile procedure that is widely used to treat neuromuscular hip dysplasia. There is a paucity of the English language literature on its use in acetabular dysplasia seen in developmental dysplasia of the hip (DDH). METHODS: A retrospective radiographic and chart review was performed for all patients diagnosed with DDH who underwent a modified Dega osteotomy between March 1995 and December 2008 at the Shriners Hospital for Children or the Montreal Children's Hospital (Montréal, Canada) by 2 orthopaedic surgeons. Radiographic parameters were measured at the preoperative, immediate postoperative, and final follow-up time points. These parameters included the acetabular index, center edge angle, Reimer's extrusion index, Shenton line, and grading by the Severin classification. RESULTS: A total of 20 patients (21 hips), of which 18 were female, underwent a modified Dega osteotomy at an average age of 55.6 months (range, 20 to 100 mo). Of the 21 hips (1 bilateral and 19 single cases), 9 hips involved the right side and 12 hips involved the left side. Before surgery, 9 patients had a subluxated hip, 7 patients had a dislocated hip, and 5 patients had a dysplastic hip. Ten hips underwent concomitant procedures including 10 open reductions with capsulorraphy. The acetabular index improved from 37 degrees (SD 8) preoperatively to 19 degrees (SD 8) on the date of last visit. The center edge angle improved from 2 (SD 17) to 25 degrees (SD 12). CONCLUSIONS: The results of this study demonstrate that the modified Dega osteotomy produces near-normal lateral coverage parameters in children with DDH. LEVEL OF EVIDENCE: Therapeutic study, clinical case series: level IV.

Clinical and patient-reported outcomes of patients with four major lower extremity arthroplasties.

Few studies report the outcomes of patients treated with total joint arthroplasty of both hips and both knees. We present the outcomes of 14 patients with total joint arthroplasty of both hips and both knees using validated outcome measures. Eleven patients (79%) were satisfied at final review. Ten patients (71%) required revision surgery of at least one joint. Clinical, functional, radiographic, and patient-reported outcomes were consistent with previously reported outcomes in the literature. Mean Timed Up and Go test was 32 seconds (6-158). Mean Berg Balance Scale was 38.5 (4-55). Good outcomes can be achieved in this group of patients with high levels of satisfaction despite the frequent need for revision surgery. Importantly, it was recognized that these patients have a high risk of falls and must be educated in measures for fall prevention.

Correction of proximal tibial recurvatum using the Ilizarov technique.

BACKGROUND: Genu recurvatum is a debilitating deformity of the knee that can progress during growth and lead to significant deformity if left untreated. Recurvatum can be osseous, ligamentous, or mixed. Osseous genu recurvatum is most often due to asymmetrical growth arrest of the proximal tibial physis affecting primarily the tibial tubercle. Several methods have been described in the literature regarding the correction of this deformity; nevertheless, there is a paucity of knowledge of the correction of proximal tibial recurvatum using the Ilizarov technique. METHODS: A retrospective chart and radiographic review of all patients treated by distraction osteogenesis with angular correction distal to the tibial tubercle using an Ilizarov external fixator was performed. A total of 9 patients were treated during the study period and the average age at the time of surgery was 14.3 years (range, 7-16 y). There were 3 female patients and 6 male patients. Four cases were due to deformity secondary to trauma and the treatment thereof, 2 patients had spondyloepiphyseal dysplasia, and 3 patients had unknown etiology. The angle of recurvatum (RG) and the angle of tilt of the tibial plateau (RT) preoperatively measured 28 degrees (range, 18 to 32 degrees) and 69 degrees (range, 60 to 82 degrees), respectively. At final follow-up, the RG and RT measured 7 degress (range, 4 to 12 degrees) and 93 degrees (range, 86 to 100 degress), respectively. Using the scoring system of Lecuire and colleagues, the overall results were good to excellent at a mean follow-up of 4.4 years. CONCLUSIONS: Correction of osseous proximal tibial recurvatum by the Ilizarov method, allows obtaining an improved sagittal mechanical axis in the lower extremity.