A pilot hole does not reduce the strains or risk of fracture to the lateral cortex during and following a medial opening wedge high tibial osteotomy in cadaveric specimens

Aim

It has been suggested that the use of a pilot-hole may reduce the risk of fracture to the lateral cortex. Therefore the purpose of this study was to determine the effect of a pilot hole on the strains and occurrence of fractures at the lateral cortex during the opening of a high tibial osteotomy (HTO) and post-surgery loading.

Materials and Methods

A total of 14 cadaveric tibias were randomized to either a pilot hole (n = 7) or a no-hole (n = 7) condition. Lateral cortex strains were measured while the osteotomy was opened 9 mm and secured in place with a locking plate. The tibias were then subjected to an initial 800 N load that increased by 200 N every 5000 cycles, until failure or a maximum load of 2500 N.

Results

There was no significant difference in the strains on the lateral cortex during HTO opening between the pilot hole and no-hole conditions. Similarly, the lateral cortex and fixation plate strains were not significantly different during cyclic loading between the two conditions. Using a pilot hole did not significantly decrease the strains experienced at the lateral cortex, nor did it reduce the risk of fracture.

Conclusions

The nonsignificant differences found here most likely occurred because the pilot hole merely translated the stress concentration laterally to a parallel point on the surface of the hole.

Cite this article: K. Bujnowski, A. Getgood, K. Leitch, J. Farr, C. Dunning, T. A. Burkhart. A pilot hole does not reduce the strains or risk of fracture to the lateral cortex during and following a medial opening wedge high tibial osteotomy in cadaveric specimens. Bone Joint Res 2018;7:166–172. DOI: 10.1302/2046-3758.72.BJR-2017-0337.R1.

Avascular necrosis in children with cerebral palsy after reconstructive hip surgery

PURPOSE

Progressive hip displacement is one of the most common orthopaedic pathologies in children with cerebral palsy (CP). Reconstructive hip surgery has become the standard treatment of care. Reported avascular necrosis (AVN) rates for hip reconstructive surgery in these patients vary widely in the literature. The purpose of this study is to identify the frequency and associated risk factors of AVN for reconstructive hip procedures.

METHODS

A retrospective analysis was performed of 70 cases of reconstructive hip surgery in 47 children with CP, between 2009 and 2013. All 70 cases involved varus derotation osteotomy (VDRO), with 60% having combined VDRO and pelvic osteotomies (PO), and 21% requiring open reductions. Mean age at time of surgery was 8.82 years and 90% of patients were Gross Motor Function Classification System (GMFCS) 4 and 5. Radiographic dysplasia parameters were analysed at selected intervals, to a minimum of one year post-operatively. Severity of AVN was classified by Kruczynski's method. Bivar- iate statistical analysis was conducted using Chi-square test and Student's t-test.

RESULTS

There were 19 (27%) noted cases of AVN, all radio- graphically identifiable within the first post-operative year. The majority of AVN cases (63%) were mild to moderate in severity. Pre-operative migration percentage (MP) (p = 0.0009) and post-operative change in MP (p = 0.002) were the most significant predictors of AVN. Other risk factors were: GMFCS level (p = 0.031), post-operative change in NSA (p = 0.02) and concomitant adductor tenotomy (0.028).

CONCLUSION

AVN was observed in 27% of patients. Severity of displacement correlates directly with AVN risk and we suggest that hip reconstruction, specifically VDRO, be performed early in the 'hip at risk' group to avoid this complication.

Beta-Catenin Haplo Insufficient Male Mice Do Not Lose Bone in Response to Hindlimb Unloading

As the β-catenin pathway has been shown to be involved in mechanotransduction, we sought to determine if haploinsufficiency would affect skeletal response to unloading. It has previously been shown that deletion of both alleles of β-catenin in bone cells results in a fragile skeleton highly susceptible to fracture, but deletion of one allele using Dmp1-Cre (Ctnnb1^+/loxP; Dmp1-Cre, cKO HET) has little effect on the 2 mo old skeleton. We found that under normal housing conditions, trabecular bone volume was significantly less in 5 mo old male cKO HET mice compared to controls (Ctrl/HET:Tb. BV/TV = 13.96±2.71/8.92±0.95%, Tb.N. = 4.88±0.51/3.95±0.44/mm, Tb. Sp. = 0.20±0.02/0.26±0.03mm, a 36%, 19% and 30% change respectively) but not in females suggesting an age and gender related effect. Before performing suspension experiments and to control for the environmental effects, animals with the same tail attachment and housing conditions, but not suspended (NS), were compared to normally housed (NH) animals. Attachment and housing resulted in weight loss in both genders and phenotypes. Cortical bone loss was observed in the cKO HET males (NH/NS, Ct BV/TV: 90.45±0.72/89.12±0.56%) and both diaphyseal (0.19±0.01/0.17±0.01mm) and metaphyseal (0.10±0.01/0.08±0.01mm) thickness, but not in female cKO HET mice suggesting that male cKO HET mice are susceptible to attachment and housing conditions. These results with transgenic mice emphasizes the importance of proper controls when attributing skeletal responses to unloading. With suspension, cKO HET male mice did not lose bone unlike female cKO HET mice that had greater trabecular bone loss than controls (Ctrl 9%:cKO HET 21% decrease Tb. N; Ctrl 12%:cKO HET 27% increase Tb. Sp.). Suspended and non-suspended mice lost weight compared to normally housed animals. Taken together, the data suggest a protective effect of β-catenin against the effects of stress in males and partial protection against unloading in females.

Fracture prediction and the definition of osteoporosis in children and adolescents: the ISCD 2013 Pediatric Official Positions

The ISCD 2007 Pediatric Official Positions define osteoporosis in children on the basis of fracture history and low bone density, adjusted as appropriate for age, gender, and body size. The task force on fracture prediction and osteoporosis definition has reviewed these positions and suggests modifications with respect to vertebral fracture and the definition of a significant fracture history and draws attention to the need to consider degree of trauma as a factor that may modify fracture risk prediction.

Automatic determination of patellofemoral kinematic parameters through X-ray image processing

Examination of plain Merchant-view X-rays of the patellofemoral joint is often used to diagnose patellofemoral joint malalignment and to qualify the pathology. As digital image processing becomes more widespread, an image processing algorithm is being developed for medical personnel to easily display, manipulate and analyze digitized plain Merchant-view X-ray films on personal computers. The method provides measurement of the kinematic parameters: sulcus angle (SA), patellofemoral congruence angle (PFC), lateral patellar angle (LPA), patellar rotation angle (PR), and lateral patellar displacement (LPD). Smooth edges of the patella and the femur are obtained by using image enhancement, edge detection and morphological thinning techniques based on the thresholds chosen manually for boundary detection. Six landmarks for determining the kinematic parameters are marked automatically on the edges of patella and femur. Parameter measurements for twelve X-ray films of six patients are calculated for analysis and comparison with hand calculated parameters. The goal is develop an algorithm that can evaluate the geometry of the patellofemoral joint, and is cost effective.

Assessment of quadriceps muscle performance by hand-held, isometric, and isokinetic dynamometry in patients with knee dysfunction

One component of patient evaluation is muscle performance assessment. The purpose of this study was: 1) to determine the difference and correlation between hand-held, isometric, and isokinetic dynamometry test results in patients with knee dysfunction and 2) to determine the effect of pain during such testing. Bilateral quadriceps strength in 23 subjects with unilateral knee dysfunction was tested using concentric and eccentric isokinetic dynamometry at 60 degrees/sec, isometric dynamometry, and hand-held dynamometry, both at 60 degrees of knee flexion. Pain ratings were obtained before, during, and after each test. Statistical analysis revealed a significant difference between involved and uninvolved limbs for eccentric isokinetic dynamometry (p = 0.002) and hand-held dynamometry (p = 0.005); no difference was found between limbs for the concentric isokinetic and isometric dynamometry (p > 0.05). Mean percent deficits in quadriceps strength ranged from 11 to 18%, with no significant difference found between testing modes. Pearson product moment correlations ranged from 0.34 to 0.76 when comparing testing modes. No significant difference existed in pain scores before, during, and after each mode of testing. It was concluded that large variation existed between different testing modes, which results in different conclusions regarding the strength of the quadriceps in patients with knee dysfunction.

Lack of variation in the nucleotide sequence corresponding to the transmembrane domain of the beta-amyloid precursor protein in Alzheimer's disease

The nucleotide sequence corresponding to the APP transmembrane domain and flanking regions of charged amino acids was determined for 91 patients with histologically confirmed Alzheimer's disease, 9 patients with dementias of other etiologies, and 14 controls who had no identifiable brain disease. Twenty-eight of the AD patients had a first-degree relative with dementia. No mutations were detected among the 100 demented patients. However, one of the 14 controls exhibited a change in the 3' base of codon 716 which would not be expected to result in an amino acid substitution at this position.

Effects of patella taping on patella position and perceived pain

Anterior knee pain syndrome (AKPS) represents a significant challenge for the sports medicine clinician. One proposed etiological factor for AKPS is poor vastus medialis obliquus (VMO) control, resulting in lateral glide of the patella. Patella taping has been advocated to increase VMO control. The purpose of this study was to determine the effects of patella taping on patella position and perceived pain. Twelve subjects (age = 29 +/- 9 yr; weight = 70.9 kg +/- 17.8; height = 174.0 cm +/- 8.1) with AKPS currently using patella taping procedures with a decrease in their symptoms participated. Each subject had Merchant's view x-rays taken pre- and post-taping while performing an isometric quadriceps contraction to determine patella rotation and patella congruency angles. Subjects also completed a visual analog pain scale after performing a 0.2 m (8") step-down both pre- and post-taping. Paired t-tests revealed no significant change in patellofemoral congruency (P = 0.98) and patella rotation angles (P = 0.80). Significant reduction (50%) in subject pain level was revealed by the visual analog scale (t(15) = 4.99; P < 0.0005). Results demonstrate that patella taping significantly reduced the perceived pain levels during a 0.2-m step-down; however, this reduction in pain was not associated with patella position changes.

Telephone advice nurse: identifying critically-ill patients

Patients who are admitted to Intensive Care Units (ICUs) have usually been critically ill at home first. The telephone advice nurse may be the first person they contact for help when they get sick. This nurse has to distinguish rapidly between critical and non-critical patients. You might find this role a challenging career option.