Surgical Technique: Closed Reduction and Percutaneous Pinning of Posterolaterally Displaced Supracondylar Humerus Fractures.

SUMMARY: Gartland type III posterolateral (IIIB) supracondylar humerus fractures are common among the pediatric population and can lead to concomitant injury, including compromise of the brachial artery and median nerve and long-term deformity, such as cubitus varus. These fractures can be difficult to reduce, and there is little consensus regarding the optimal technique for closed reduction and percutaneous pinning. Here, we discuss the management of Gartland III posterolateral supracondylar humerus fractures, including an in-depth technical description of the methods of operative fixation. We describe a lateral pin-only fixation technique for Gartland III posterolateral supracondylar humerus fractures that uses the intact periosteum during reduction of the distal fragment to assist in realigning the medial and lateral columns anatomically. We also discuss a safe method for placing a medial-based pin if there is persistent rotational instability at the fracture site after placement of the laterally based pins.

Perioperative Considerations in Osteogenesis Imperfecta: A 20-Year Experience with the Use of Blood Pressure Cuffs, Arterial Lines, and Tourniquets.

Osteogenesis imperfecta (OI) is a rare genetic connective-tissue disorder with bone fragility. To avoid iatrogenic fractures, healthcare providers have traditionally avoided using non-invasive blood pressure (NIBP) cuffs and extremity tourniquets in the OI population in the perioperative setting. Here, we hypothesize that these procedures do not lead to iatrogenic fractures or other complications in patients with OI. A retrospective study of all children with OI who underwent surgery at a single tertiary care children's hospital from 1998 to 2018 was performed. Patient positioning and the use of NIBP cuffs, arterial lines, and extremity tourniquets were documented. Fractures and other complications were recorded. Forty-nine patients with a median age of 7.9 years (range: 0.2-17.7) were identified. These patients underwent 273 procedures, of which 229 were orthopaedic operations. A total of 246 (90.1%) procedures included the use of an NIBP cuff, 61 (22.3%) an extremity tourniquet, and 40 (14.7%) an arterial line. Pediatric patients with OI did not experience any iatrogenic fractures related to hemodynamic monitoring or extremity tourniquet use during the 20-year period of this study. Given the benefits of continuous intra-operative hemodynamic monitoring and extremity tourniquets, we recommend that NIBP cuffs, arterial lines, and tourniquets be selectively considered for use in children with OI.

What Should I Wear to Clinic? A National Survey of Pediatric Orthopaedic Patients and Parents.

BACKGROUND: A number of factors have been shown to affect how surgeons are subjectively viewed, including their appearance in clinic. Patient preference for pediatric orthopaedic surgeon attire has not previously been studied, nor has its influence on initial perception of the surgeon. METHODS: At 5 pediatric regional sites across the United States, parents and patients presenting to the pediatric orthopaedic clinic were given anonymous surveys showing 8 photos of surgeons in different clinical dress including in business or scrub dress, each with or without white coat (WC). Subjects reported their demographics, single preferred photo, rated characteristics of the surgeons in each photo on a 5-point Likert scale, and answered specific questions on scrubs and WCs. The first consecutively completed 100 parent and 100 patient surveys were included from each site. RESULTS: One thousand surveys were collected from patients (500) and parents (500). The majority felt a surgeon's clinical dress would not affect how they are cared for (83%), and that it was ok to wear scrubs in clinic (90%). Overall, WC was preferred to those without no matter the age, but there was no difference between scrub and business choices. Of those stating a preference, woman in business and WC (24%) and woman in scrubs and WC (21%) were most selected, with the only geographic difference being the midwest's preference for man in business and WC. Females were more likely to prefer women photographs (P<0.0001). CONCLUSIONS: In general, pediatric orthopaedic patients and parents do not have a strong specific preference toward what their surgeon wears to clinic, including whether or not we are dressed in scrubs, but some initial biases exist. When asked to choose, the traditional WC worn over any attire is preferred, and female patients and parents uncover a preference for a surgeon of their own sex. LEVEL OF EVIDENCE: Level III.

Long-Term Outcomes in Anterior Cruciate Ligament Reconstruction: A Systematic Review of Patellar Tendon Versus Hamstring Autografts.

BACKGROUND: Much controversy still exists surrounding graft choice in anterior cruciate ligament (ACL) reconstruction. Over the past decade, an increase in comparative studies with longer follow-up has enhanced our understanding of current graft options and outcomes. PURPOSE: To describe the long-term comparative outcomes of ACL reconstruction with autograft bone-patellar tendon-bone (BPTB) versus autograft hamstring (HS) ACL reconstruction with regard to clinical and radiographic outcomes. STUDY DESIGN: Systematic review; Level of evidence, 2. METHODS: A search of the PubMed, MEDLINE, Cochrane, and Scopus databases was performed to identify studies in the English language with outcome data comparing ACL reconstruction utilizing autograft BPTB and autograft HS; only studies with a minimum 5-year follow-up were included. Outcome data included failure and complications, manual and instrumented laxity, patient-reported outcomes, and radiographic risk of osteoarthritis. RESULTS: Twelve studies with a total of 953 patients met the inclusion criteria. Of these studies, 8 were level 1 evidence and 2 were level 2. Mean follow-up was 8.96 years (range, 5-15.3 years). No differences in graft failure or manual or instrumented laxity were seen in any studies. Lower clinical outcomes scores and greater motion loss were seen in BPTB patients in 1 and 2 studies, respectively. Two of 4 studies reporting on anterior knee pain, and 3 of 7 that recorded kneeling pain found it more frequently among BPTB patients. One study found significantly increased reoperation rates in HS patients, while another found a similar result in BPTB, and 1 study reported a significant increase in contralateral ACL tears in BPTB patients. Three of 5 studies reporting on radiographic evidence of osteoarthritis noted significantly increased rates in BPTB patients. CONCLUSION: This systematic review comparing long-term outcomes after ACL reconstruction with either autograft BPTB or autograft HS suggests no significant differences in manual/instrumented laxity and graft failures between graft types. An increase in long-term anterior knee pain, kneeling pain, and higher rates of osteoarthritis were noted with BPTB graft use.

Development of a scale for estimating procedural distress in the newborn intensive care unit: the Procedural Load Index.

BACKGROUND: Infants in the newborn intensive care unit (NICU) are exposed to routine procedures that often cause distress and carry a negative burden or load on the infant's neurodevelopment. AIM: A ratio level index is introduced to estimate procedural load so as to begin to develop a system to monitor the intensity of distress associated with common NICU procedures. STUDY DESIGN: Two psychophysical methods, magnitude estimation (ME) and the general labeled magnitude scale (gLMS) were used to survey 86 clinicians via the internet to estimate the distress associated with 55 common NICU procedures. RESULTS: gLMS and ME estimations correlated highly across all procedures (r = 0.97). gLMS values were used to derive the procedural load index (PLI) as a ratio level estimation of procedural distress. CONCLUSION: The PLI ranks and differentiates distress among common NICU procedures more precisely than current tools. This methodology, if correlated with infant physiological indices and health outcomes, may be operationalized at the bedside to measure procedural distress, and help to guide the ideal timing to perform procedures and minimize their negative consequence.