Notes

Itraconazole remedy with regard to child hemangioma: A pair of scenario reviews.
To assess diagnostic performance of dorsal tangential views (DTVs) to detect dorsal screw protrusion in clinical practice.

Prospective cohort study.

Level-1 trauma center.

Fifty consecutive patients undergoing volar plating for 50 distal radius fractures were prospectively included.

Fluoroscopic DTVs were routinely obtained, and screw revision was documented. Multiplanar reconstructions of postoperative CTs allowed for detection and quantification of dorsal screw penetration using reproducible measuring techniques.

Diagnostic performance (sensitivity, negative predictive value, positive predictive value, and accuracy) of DTV.

Intraoperatively, in 16 of 50 patients (32%), screws were revised based on DTV, with 13 of 218 screws (6.0%) being revised due to dorsal prominence. One screw was changed because DTV showed it was in the distal radioulnar joint. Postoperatively, in 10 patients (20%), the computed tomography revealed 12 additional screws penetrating ≥1 mm with an average of 1.8 mm (range 1.0-4.5 mm). DTV had a sensitivity of 52%, a negative predictive value of 95%, and accuracy of 95%. No ≥1-mm protruding screw remained in the third compartment.

In one-third of our patients, the incidence of protruding screws that can cause iatrogenic extensor tendon rupture was reduced by obtaining additional DTVs. Although DTV reduces the incidence of dorsal screw penetration considerably, this study reveals limited sensitivity. Therefore, one should keep in mind that dorsal screw penetration may go unnoticed on DTVs, and proper surgical technique remains paramount of DTV.

Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Diagnostic Level II. Selleckchem NVP-BEZ235 See Instructions for Authors for a complete description of levels of evidence.
To compare reoperation risk after total elbow arthroplasty (TEA) and open reduction internal fixation (ORIF) for intra-articular distal humerus fractures in elderly patients.

Retrospective comparative.

Five percent Medicare Part B claims database.

Patients older than 65 years of age with closed distal humerus fractures undergoing TEA or ORIF from 1996 to 2016.

TEA and ORIF.

Reoperation risk based on multivariate Cox proportional hazards modeling.

A total of 142 TEA and 522 ORIF cases were identified. TEA patients had a greater age and Charlson Comorbidity Index , as well as a higher prevalence of rheumatoid arthritis and osteoporosis than ORIF patients (P < 0.05). Although reoperation risk was lower for TEA than that for ORIF within the entire cohort (11.3% vs. 25.1%; hazard ratio = 0.49; P = 0.014), no significant difference was found for TEA and ORIF performed between 2006 and 2016 (12.6% vs. 18.4%; hazard ratio = 0.73; P = 0.380). The death rate was 65.5% in the TEA group at 3.6 years and 55.7% in the ORIF group at 4.9 years.

TEA was associated with a decreased reoperation risk compared with ORIF, although this difference did not exist for more recent procedures after popularization of the locking plate technology and half of the reoperations after ORIF were for instrumentation removal. The high death rate within several years of the index procedure may contribute to the low TEA revision rate beyond the short-term when following patients into the medium and long term. Further study comparing TEA and locked plating using prospective, randomized data with long-term follow-up and functional outcomes is warranted.

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
To characterize the literature on operative interventions for proximal humerus nonunions in adults. Second, to identify prognostic factors associated with outcomes for locked plate open reduction and internal fixation (ORIF).

PubMed, EMBASE, MEDLINE, Scopus, and Cochrane databases were searched for articles from 1990 to 2020.

Studies reporting outcomes of proximal humerus nonunions managed with ORIF, hemiarthroplasty (HA), total shoulder arthroplasty (TSA), or reverse TSA (RTSA) were included. Studies failing to stratify outcomes by treatment or fracture sequelae were excluded.

Two authors independently extracted data and appraised study quality using MINORS score.

Descriptive statistics were reported. Outcomes for ORIF and arthroplasty groups were not compared due to differing patient populations.

Thirty-seven articles were included, representing 508 patients (246 ORIF, 137 HA/TSA, and 125 RTSA). Patients managed by ORIF were younger with simpler fracture patterns than those managed by arthroplasty. Regarding ORIF, locked plates achieved highest union rates (97.0%), but clinical outcomes were comparable with all plate fixation constructs [forward flexion (FF) 123-144°; external rotation 42-46°; Constant score 75-84]. Complication and reoperation rates for ORIF were 26.0% and 14.6%, respectively. Furthermore, subgroup analysis of locked plate ORIF demonstrated shorter consolidation time with initial conservative fracture management (4.3 vs. 6.0 months) and autograft use (3.9 vs. 5.5 months). With arthroplasty, RTSA demonstrated greater forward flexion (109.4° vs. 97.2°) but less external rotation (16.5° vs. 36.8°) than HA/TSA. Complication and reoperation rates were 18.2% and 10.9% for HA/TSA and 21.6% and 14.4% for RTSA, respectively.

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
To investigate the presence of tibial nerve dysfunction (TND) in operatively treated talar neck fractures.

Retrospective chart review.

Urban Level-1 trauma center.

Sixty-four patients for a total of 65 talar neck fractures treated with open reduction and internal fixation between January 1, 2014, and May 1, 2018.

Incidence of TND.

Evidence of TND was documented in 20 of 65 cases (30.8%) of talar neck fractures. link2 There were no cases of TND associated with Hawkins I fractures, but TND was found in 7 of 32 Hawkins II fractures (21.9%), 10 of 24 Hawkins III fractures (41.7%), and 3 of 5 Hawkins IV fractures (60%). TND was reported in 11 of 19 open talar neck fractures (57.9%) (P = 0.002). TND was associated with tibiotalar dislocation (P = 0.017) but not subtalar dislocation (P = 0.17). TND did not occur in the absence of subtalar subluxation/dislocation. Of 18, a total of 6 (33.3%) reported partial recovery, and 6 (33.3%) reported full recovery within 6 months of the initial injury. By 12 months, of the 18, 8 (44.4%) reported partial recovery and 7 (38.9%) reported full recovery.

The tibial nerve and its distal branches are at risk of injury in the setting of displaced talar neck fracture, tibiotalar subluxation/dislocation, and open talar neck fracture with increasing risk among those with a higher Hawkins grade.

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
To compare union and complication rates in pediatric patients presenting with tibial shaft fractures treated with closed or open reduction before intramedullary stabilization.

Retrospective review.

Multiple pediatric trauma centers.

Pediatric patients presenting with tibial shaft fractures treated with intramedullary stabilization.

Intramedullary stabilization after closed or open reduction (percutaneous and open approach).

Union rates, infection rate (superficial and deep), and unplanned return to the operating room (OR).

One hundred sixty-six patients were included in this study. One hundred thirty-six patients presented with closed fractures, and 30 patients presented with open tibial shaft fractures. Thirty-seven of the 136 patients (27%) with closed fractures had their fracture specifically opened during surgical fixation. There was no statistical difference in radiographic union at 6 months between fractures electively opened and those treated with closed reduction alone 97% versus 98% (P = 0.9). No patient who underwent an open reduction developed infections or wound-healing concerns, whereas 2 of the 99 (2%) patients treated closed had superficial surgical site infections requiring additional treatment (P = 0.999). link3 There was no difference in unplanned return to OR between those who underwent open reduction at the time of intramedullary stabilization (P = 0.568).

Performing an open reduction in a closed pediatric tibial shaft fracture before intramedullary fixation does not increase the risk of surgical site infections or wound issues, delayed union, or unplanned return to the OR. An open reduction of a closed tibial shaft fracture for purposes of improving a reduction before intramedullary stabilization may be a safe and effective clinical practice.

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
To evaluate a combined technique for treating distal femoral bone defects after debridement of osteomyelitis, using an external fixator together with a short supracondylar nail.

Retrospective study.

Single tertiary referral center.

Between 2003 and 2018, 23 patients with a mean age of 37.2 years (26-56) underwent surgery with the same technique to manage postdebridement defects in the distal femur due to osteomyelitis. This involved acute shortening and intramedullary fixation of the defect site, together with relengthening from a proximal osteotomy using simultaneous external fixation. Radiographic union, range of motion of the hip and knee, external fixation time and external fixation index, and limb length discrepancy were assessed.

The mean follow-up was 51 months (18-192). Union was achieved in all patients without recurrence of infection during this follow-up period. The mean knee flexion was 120 degrees, and the mean extension deficit was 5 degrees at final follow-up. The mean limb length discrepancy improved from 5.5 cm (3-7) to 0.5 cm (0-2). The mean external fixation index was 29.2 d/cm (20-50), and the mean external fixation time was 115 days (90-150). Radiographic scores were excellent in 15 cases, good in 6, and fair in 2. Functional scores were excellent in 14 cases, good in 7, and fair in 2.

This combined strategy was an effective method for treating distal femoral segmental bone defects after debridement of osteomyelitis, with a high rate of union and acceptable complication rates.

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Perioperative fascia iliaca regional anesthesia (FIRA) decreases pain in hip fracture patients. The purpose of this study is to determine which hip fracture types and surgical procedures benefit most.

Prospective observational study compared with a retrospective historical control.

Patients older than 60 years who received perioperative FIRA were compared with a historical cohort not receiving FIRA.

This study was conducted at a Level 1 trauma center.

The primary outcome was morphine milliequivalents (MME) consumed during the index hospitalization. Fracture pattern-specific preoperative and postoperative MME consumption and surgical procedure-specific postoperative MME consumption was compared between the FIRA and non-FIRA groups.

A total of 949 patients were included in this study, with 194 (20.4%) patients in the prospective protocol group. There were no baseline differences between cohorts. Preoperatively, only femoral neck fracture patients receiving FIRA used fewer MME (P < 0.001). Postoperatively, femoral neck fracture patients receiving FIRA used fewer MME on postoperative day (POD) 1 (P = 0.
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