Search

The deleterious effects of hypoalbuminaemia in the peri-operative period are well documented. We aimed to review serum albumin levels in a cohort of orthopaedic trauma patients to determine the prevalence of hypoalbuminaemia. Secondarily, we aimed to identify factors associated with an increased risk of hypoalbuminaemia. A retrospective cross-sectional study was performed of data collected prospectively at a regional hospital serving primarily a rural population in South Africa. Two hundred ninety-five patients were included in the study. Twenty-nine per cent of the cohort was found to have hypoalbuminaemia. Femur neck fractures (p < 0.001), intertrochanteric fractures (p = 0.004), tibial plateau fractures (p = 0.034) and polytrauma (p = 0.013) were associated with hypoalbuminaemia. The mean albumin level was lower in HIV-positive patients when compared to HIV-negative patients (35.7 g/L vs 37.5 g/L, p = 0.007). The presence of comorbidities other than HIV, like diabetes mellitus (p = 0.001), previous pulmonary tuberculosis (p = 0.034) and chronic renal failure (p = 0.007) was associated with hypoalbuminaemia. In this cohort of orthopaedic trauma patients from rural South Africa, we found a 29% prevalence of hypoalbuminaemia at the time of presentation. High-risk subgroups include patients with pre-existing comorbidities and increased age, as well as patients presenting with polytrauma, femoral neck, intertrochanteric femur or tibial plateau fractures.

Objectives Our observational study's objective was to determine how effective guided growth with tension-band plates was to correct the deformity in Blount's disease. Methods We reviewed the records of 14 children (18 limbs) with Blount's disease who were treated with tension-band plates as the only surgical intervention at a single institution over eight years. Five children (seven limbs) had infantile Blount's disease with Langenskiold stage ≤2. Nine children (11 limbs) had late-onset Blount's disease. Results The mean age at operation was 7.2 years (SD, 3.1, range, 2.9-11.8). The tension-band plate effectively corrected the varus deformity in 78% (14/18) of limbs. Correction to normal mechanical alignment was achieved in 67% (n = 12) of limbs at a mean of 18 months (SD, 7, range, 9-31). Failure to achieve correction of the mechanical axis was due to delayed implant removal and overcorrection in 11% (2/18), mechanical failure due to screw fixation failure in 11% (2/18) and in 6% (1/18) due to a misplaced epiphyseal screw. There was a greater magnitude of correction in the Infantile Blount's disease group (mean, 26°, SD, 9°) when compared to the children with late-onset Blount's disease (13°, SD, 4°) (P = 0.021). The mean correction rate was 1.8°/month in the Infantile Blount's disease group and 0.7°/month in the late-onset Blount's disease group, respectively (P = 0.014). Conclusion Our findings support the use of tension-band plating in Blount's disease. Further research is required to determine the ideal indications and to investigate the long-term outcome of guided growth in Blount's disease. Level of evidence Level 4.

To evaluate the results in terms of correction and complications from gradual correction with a computer-assisted hexapod circular external fixator in a mixed cohort of children with Blount's disease.A retrospective review was performed of the correction and complications of 19 children (25 limbs) with recurrent infantile (IBD) and late-onset Blount's disease (LOBD) treated by gradual correction with a hexapod external fixator. The correction was measured by the medial proximal tibial angle (MPTA), anatomic posterior proximal tibial angle (aPPTA) and anatomic tibio-femoral angle (TFA). Obesity was present in 76% (19/25) of cases. Fifteen limbs were classified as infantile Blount's disease and 10 limbs as late-onset Blount's disease. The mean age was 12.5 years (range 7-17 years).The mean pre-operative MPTA of 59° (SD 13°, range 33-79°) was corrected to a mean of 86° (SD 5°, range 77-93°). The mean pre-operative aPPTA of 64° (SD 14°, range 33-84°) was corrected to 79° (SD 6°, range 70-90°). The median pre-operative rotation of 15° internal rotation was corrected to normal (0-15° of external rotation). Eight out of 25 limbs had severe deformities with varus or procurvatum greater than 40° or both. The mean pre-operative TFA of 28° varus (SD 13°, range 4-53°) was corrected to 1.8° valgus (SD 6°, range 14° varus to 13° valgus). The median follow-up was 19 months (range 6-67 months). The alignment after correction was "good" in 55% (11/20), "acceptable" in 35% (7/20) and "poor" in 10% (2/20).The median duration for correction was 16 days (IQR 11-31 days, range 7-71 days). The median number of prescribed correction programmes was 1 (IQR 1-2, range 1-5). The mean total time in the frame was 136 days (SD 34 days, range 85-201 days).All patients developed minor pin track infections that resolved with oral antibiotics (Category 1 complications). Four patients developed complications that necessitated modification of the treatment plan (Category 2 complications). In two cases, treatment objectives could not be achieved (Category 3 complications). Two patients treated before skeletal maturity developed recurrent genu varum.Gradual correction with a computer-assisted hexapod external fixator may be a useful technique for correcting recurrent IBD or LOBD even in children with severe deformities. The results of gradual correction were similar in the two groups. While complications occur, most can be mitigated by timely intervention during the correction phase of treatment. Recurrence remains a concern if correction is performed before skeletal maturity.4.Mare PH, Marais LC. Gradual Deformity Correction with a Computer-assisted Hexapod External Fixator in Blount's Disease. Strategies Trauma Limb Reconstr 2022;17(1):32-37.

BACKGROUND Late-presenting or recurrent infantile Blount disease (IBD) is characterized by knee instability because of medial tibial plateau depression, multiplanar proximal tibial deformity, and potential distal femoral deformity. The surgical treatment strategy includes medial elevation osteotomy to stabilize the knee, together with proximal tibial osteotomy to correct alignment, and lateral epiphysiodesis to prevent a recurrence. This study's primary aim was to describe the clinical outcomes of medial elevation osteotomy for the management of late-presenting and recurrent IBD. METHODS The authors reviewed the records of 48 children (64 limbs) who had medial elevation osteotomies and lateral epiphysiodesis, combined with proximal tibial realignment in 78% (50/64) of cases in the same setting. IBD was bilateral in 33% (16/48), 77% (37/48) were female individuals, and 42% (20/48) were obese. RESULTS The mean age at surgery was 8.6 years (SD, 1.6; range, 5.8 to 12.8). The mean preoperative tibiofemoral angle (TFA) was 28±11 degrees (8 to 55 degrees), and the mean angle of depression of the medial plateau (ADMP) was 49±8 degrees (26 to 65 degrees). Distal femoral valgus was present in 27% (17/62) and varus in 10% (6/62) children. At a median follow-up of 3.2 years (range, 1 to 6.2 y), the median TFA was 1-degree valgus (interquartile range, 7-degree varus to 5-degree valgus), whereas the ADMP was corrected to 25±8 degrees (8 to 45 degrees). Obesity was associated with more severe deformity as measured by TFA (P

Background This study aimed to determine the recurrence rate in infantile Blount disease (IBD) in a cohort of patients treated with a tibial osteotomy; and also to identify which factors were associated with recurrence. Methods We reviewed the records of 20 patients, under the age of 7 years, with IBD (35 involved extremities) treated by proximal tibial realignment osteotomy to physiological valgus at a single institution over 4 years. We then analyzed the data to determine the rate of recurrence and identify the risk factors for recurrence. Results The mean age of the included patients was 4.2 years (range, 2 to 6 y). We observed a recurrence rate of 40% (n=14) at a mean follow-up of 42 months (range, 21 to 72 mo). Knee instability [odds ratios OR, 6.6; 95% confidence interval (CI), 2.0-22.2], Langenskiold stage (OR, 6.3; 95% CI, 2.0-19.4), and severity of the deformity, as measured by medial physeal slope (MPS) (OR, 1.2; 95% CI, 1.1-1.4), were associated with recurrence. On multiple logistic regression analysis, MPS remained the most relevant predictor of recurrence. Receiver operating curve analysis showed that an MPS ≥60 degrees predicted recurrence with a sensitivity of 79% and specificity of 95% (area under the curve=0.925). Postoperatively, increased varus alignment on weight-bearing as measured by the tibio-femoral angle was indicative of knee instability and associated with increased odds of recurrence (OR, 1.5; 95% CI, 1.1-1.9; P=0.004). Conclusions We observed a recurrence rate of 40% in children with IBD under 7 years treated with acute correction to a tibio-femoral angle of 5 to 10 degrees valgus through a dome proximal tibial osteotomy. Knee instability, Langenskiold stage, and MPS were associated with recurrence. Cases with an MPS ≥60 degrees seem to be particularly at risk for recurrence. Further research is needed to validate these findings. Level of evidence Level IV.

Purpose This systematic review determined the reported treatment strategies, their individual success rates, and other outcome parameters in the management of critical-sized bone defects in fracture-related infection (FRI) patients between 1990 and 2018. Methods A systematic literature search on treatment and outcome of critical-sized bone defects in FRI was performed. Treatment strategies identified were, autologous cancellous grafts, autologous cancellous grafts combined with local antibiotics, the induced membrane technique, vascularized grafts, Ilizarov bone transport, and bone transport combined with local antibiotics. Outcomes were bone healing and infection eradication after primary surgical protocol and recurrence of FRI and amputations at the end of study period. Results Fifty studies were included, describing 1530 patients, the tibia was affected in 82%. Mean age was 40 years (range 6–80), with predominantly male subjects (79%). Mean duration of infection was 17 months (range 1–624) and mean follow-up 51 months (range 6–126). After initial protocolized treatment, FRI was cured in 83% (95% CI 79–87) of all cases, increasing to 94% (95% CI 92–96) at the end of each individual study. Recurrence of infection was seen in 8% (95% CI 6–11) and amputation in 3% (95% CI 2–3). Final outcomes overlapped across treatment strategies. Conclusion Results should be interpreted with caution due to the retrospective and observational design of most studies, the lack of clear classification systems, incomplete data reports, potential underreporting of adverse outcomes, and heterogeneity in patient series. A consensus on classification, treatment protocols, and outcome is needed to improve reliability of future studies.

Aim To conduct a systematic review and meta-analysis comparing the incidence of fracture-related infections (FRI) following surgical management of closed and open fractures in HIV-positive and HIV-negative patients. Methods A systematic literature search was conducted using MEDLINE, ProQuest, Web of Science, The Cochrane Library and Scopus. Our own files and reference lists of identified key articles were also searched. We included studies where the primary outcome was the development of FRI in patients with open and closed fractures. Results Eleven studies were included for data synthesis. HIV-positive patients had a non-significant increase in FRI when compared to HIV-negative patients (in open and closed fractures combined). Open fractures treated in the pre-antiretroviral era had a 5.6 times greater risk for developing a FRI. In the post-antiretroviral era (1997 onwards) HIV-positive patients did not have a greater risk of FRI than HIV-negative patients for both open and closed fractures. The small retrospective natures of these studies, together with the heterogeneous outcome definitions used, are limitations to this study. Conclusion While there are few large prospective studies, the available data suggests that before the introduction antiretroviral therapy HIV infection was associated with a greater risk of FRI. In the post-antiretroviral era HIV infected patients did not show an increased risk of FRI.

This paper chronicles the development of business interruption (BI) insurance in the U.S. The origin of modern-day BI insurance is traced as it evolved from so-called “profits insurance” in the United Kingdom (UK) and an endorsement to basic fire insurance policies in the U.S. to stand-alone BI insurance as it is known today. This paper identifies significant legal rulings and insurance catastrophes that have served as inflection points for the development of BI insurance, as well as major policy formats that have provided cover for the disruption of business.