Kishore Mulpuri

NSAID Exposure and Risk of Nonunion: A Meta-Analysis of Case–Control and Cohort Studies

Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used for postoperative pain control. However, concerns regarding the potential deleterious effects of NSAIDs on bone healing have compelled many physicians to avoid NSAIDs in patients with healing fractures, osteotomies, and fusions. We systematically reviewed and analyzed the best clinical evidence regarding the effects of NSAID exposure on bone healing. Medline, Embase, and Cochrane electronic databases were searched for prospective and retrospective clinical studies of fracture, osteotomy, and fusion studies of patients with NSAID exposure and nonunion as an outcome. Study quality was assessed using the Newcastle–Ottawa Scale. Data on study design, patient characteristics, and risk estimates were extracted. Pooled effect estimates were calculated. Subanalyses were performed by bone type and by NSAID dose, duration, and route of administration. In the initial analysis of 11 cohort and case-control studies, the pooled odds ratio for nonunion with NSAID exposure was 3.0 (95% confidence interval 1.6–5.6). A significant association between lower-quality studies and higher reported odds ratios for nonunion was observed. When only higher-quality studies were considered, seven spine fusion studies were analyzed, and no statistically significant association between NSAID exposure and nonunion was identified (odds ratio = 2.2, 95% confidence interval 0.8–6.3). There was no increased risk of nonunion with NSAID exposure when only the highest-quality studies were assessed. Randomized controlled trials assessing NSAID exposure in fracture, fusion, and osteotomy populations are warranted to confirm or refute the findings of this meta-analysis of observational studies.

Graft Tensioning in Anterior Cruciate Ligament Reconstruction: A Systematic Review of Randomized Controlled Trials

PURPOSE The purposes of this study were to (1) perform a systematic review of randomized controlled trials evaluating graft tensioning in anterior cruciate ligament (ACL) reconstruction, and (2) determine the scientific quality of published randomized controlled trials evaluating graft tensioning in ACL reconstruction. METHODS The search strategy included a computerized literature search, a citation search, and a manual search of key journals and conference proceedings. Eligible studies were randomized controlled trials evaluating the effect of graft tensioning on the outcomes of ACL reconstruction. Two reviewers independently performed the literature searches. The validity of the trials was scored using the Detsky quality scale. Consensus was achieved by a study committee of 3 investigators. RESULTS Five randomized controlled trials met the inclusion criteria. The mean standardized Detsky score was 61.3 +/- 15.2%. Only 2 of the studies scored >or=75%. All trials consisted of autogenous graft sources, with 3 involving a bone-patellar tendon-bone graft, 1 involving a 5-strand semitendinosus-polyester (5STP) graft, and 1 involving a semitendinosus-gracilis-polyester (STGP) graft. CONCLUSIONS Based on the evidence in this systematic review, there is a trend that suggests that 80 N of tension is the most effective amount of tension to apply during ACL reconstruction using hamstring-polyester graft sources. For ACL reconstruction using semitendinosus-gracilis or patellar tendon graft sources, there is no clear trend in terms of statistically significant or clinically relevant differences in terms of the amount of applied tension to apply to the graft during graft fixation. We are unable to provide recommendations as to the amount of tension to apply to 4-strand semitendinosus-gracilis autografts without polyester augmentation because there has been no randomized clinical trial conducted to determine the most effective amount of tension to apply when using this graft source.

Natural evolution of Perthes disease: a study of 610 children under 12 years of age at disease onset.

Records and 2,634 pairs of radiographs (anteroposterior and lateral) of 610 patients with Perthes disease were reviewed. The evolution of the disease was divided into seven stages (stages Ia, Ib, IIa, IIb, IIIa, IIIb, and IV) based on plain radiographic appearances. Intraobserver and interobserver reproducibility of this new classification system was assessed. The duration of each stage of the disease was noted. The stages at which epiphyseal extrusion and widening of the metaphysis occurred and the stages at which metaphyseal and acetabular changes appeared were identified. The shape and the size of the femoral head, the extent of trochanteric overgrowth, and the radius of the acetabulum were assessed in hips that had healed. The new classification system of the evolution of Perthes disease was reproducible and helped to identify when crucial events occur during the course of the disease. The median duration of each stage varied between 95 and 335 days. Epiphyseal extrusion and metaphyseal widening was modest in stages Ia, Ib, and IIa but increased dramatically after stage IIb. More than 20% extrusion occurred in 70% of the hips by stage IIIa. Metaphyseal changes were most frequently encountered in stage IIb, while acetabular changes were most prevalent in stage IIIa. At healing, only 24% of untreated patients had spherical femoral heads, while 52% had irregular femoral heads. The timing of epiphyseal extrusion, metaphyseal widening, and the appearance of adverse metaphyseal and acetabular changes suggest that femoral head deformation occurs by stage IIIa in untreated hips. Hence, if containment were to succeed, it should be achieved before this stage.

Optimal timing for containment surgery for Perthes disease.

To identify the optimal timing for containment surgery for Perthes disease, the outcomes following femoral osteotomy of 97 children were analyzed. Univariate and multivariate analyses were employed to identify variables that influenced the shape and size of the femoral head at healing. The timing of surgery was an important variable that had a bearing on the outcome. The chances of retaining a spherical femoral head were much higher in children operated on either during the stage of avascular necrosis or in the early part of the fragmentation stage than in those operated later. The authors conclude that containment surgery aimed at preventing femoral head deformation in Perthes disease should be performed before the advanced stage of fragmentation. Further, any study on the outcome of containment treatment of Perthes disease must consider the timing of containment as a variable that influences the outcome while interpreting the results.

Iatrogenic ulnar nerve injury after the surgical treatment of displaced supracondylar fractures of the humerus: number needed to harm, a systematic review

Background Supracondylar fractures of the humerus are common pediatric elbow injuries. Most displaced or angulated fractures are treated by closed reduction and percutaneous pinning, with either a crossed pin or lateral pin configuration. The purpose of this study was to conduct a systematic review to determine if there is an increased risk of iatrogenic nerve injury associated with the crossed pin configuration. Methods Relevant articles were identified by searching electronic databases and hand searching-related journal and conference proceedings. Within each trial, the risk of iatrogenic ulnar nerve injury was calculated for each pinning technique. For studies comparing crossed versus lateral pinning, the resulting trial-based differences in risk estimates were pooled using a random effects meta-analysis. A number needed to harm was determined using the pooled risk difference. Results Thirty-two trials consisting of 2639 patients were used in the pooled analysis. The pooled risk difference of iatrogenic ulnar nerve injury is 0.035 (95% confidence interval, 0.014-0.056), with a higher incidence of injury in the crossed pinning group. The weighed number needed to harm for the crossed pinning is 28 (95% confidence interval, 17-71). Conclusions The results of this review suggest that there is an iatrogenic ulnar nerve injury for every 28 patients treated with the crossed pinning compared with the lateral pinning. Further research is necessary to ensure that the optimal pinning technique is chosen to treat these factors. Level of Evidence Level III.

Blinded, prospective, randomized clinical trial comparing volar, dorsal, and custom thermoplastic splinting in treatment of acute mallet finger.

PURPOSE To compare volar, dorsal, and custom splinting techniques in acute Doyle I mallet finger injuries. METHODS We developed a radiographic lag measurement using the contralateral normal digit as an internal control for establishing the approximate preinjury maximal extension of the mallet finger. The difference in maximal distal interphalangeal joint extension between the injured and contralateral normal digit was defined as the radiographic lag difference. We randomized 87 subjects meeting the inclusion criteria to one of 3 splint types: volar padded aluminum splint, dorsal padded aluminum splint, and custom thermoplastic. Splints were continued for 6 weeks full-time. A total of 77 subjects were available for measurement of the primary outcome measure: radiographic lag difference at week 12. Secondary outcome measures were recorded at weeks 7 and 24. RESULTS No lag difference was demonstrated at week 12 (p = .12), although a trend suggesting superiority (closest value to 0 difference) of the custom thermoplastic splint was observed. The mean radiographic lag differences were -16.2 degrees (95% confidence interval [CI], -21.3 degrees to -11.0 degrees ) for the dorsal padded aluminum splint, -13.6 degrees (95% CI, -18.0 degrees to -9.2 degrees ) for the volar padded aluminum splint, and -9.0 degrees (95% CI, -14.5 degrees to 3.4 degrees ) for the custom thermoplastic splint. Secondary between-group analyses showed no differences for radiographic or clinical lag, Michigan Hand Outcome Questionnaire scores, or complications. Secondary analyses of the whole cohort suggested that clinical measurement overestimates true lag, increased lag occurs after discontinuation of splinting, and clinically measured improvement in lag is noted at week 24. CONCLUSIONS No lag difference was demonstrated between custom thermoplastic, dorsal padded aluminum splint, and volar padded aluminum splinting for Doyle I acute mallet fingers. Clinical measurement overestimates true lag in mallet injuries. Increased lag occurs after discontinuation of splinting. Increased age and complications correlate with worse radiographic lag.

Differences in risk factors between early and late diagnosed developmental dysplasia of the hip.

Background: Developmental dysplasia of the hip (DDH) is common, affecting 7.3 per 1000 births in South Australia. Clinical screening programmes exist to identify the condition early to gain the maximum benefit from early treatment. Although these screening programmes are effective, there are still cases that are missed. Previous research has highlighted key risk factors in the development of DDH. Objective: To compare the risk factors of cases of DDH identified late with those that were diagnosed early. Methods: A total of 1281 children with DDH born in 1988–1996 were identified from the South Australian Birth Defects Register. Hospital records of those who had surgery for DDH within 5 years of life were examined for diagnosis details. Twenty seven (2.1%) had been diagnosed at or after 3 months of age and were considered the late DDH cases (a prevalence of 0.15 per 1000 live births). Various factors were compared with early diagnosed DDH cases. Results: Female sex, vertex presentation, normal delivery, rural birth, and discharge from hospital less than 4 days after birth all significantly increased the risk of late diagnosis of DDH. Conclusions: The results show differences in the risk factors for early and late diagnosed DDH. Some known risk factors for DDH are in fact protective for late diagnosis. These results highlight the need for broad newborn population screening and continued vigilance and training in screening programmes.

The treatment of displaced supracondylar humerus fractures: evidence-based guideline.

Background: Supracondylar humerus fractures are widely considered the most common fracture of the elbow in children. Fractures can range from a less severe, nondisplaced type I fracture to a more severe, displaced type III fracture with no cortical contact. Type III fractures can lead to adverse physical, social, and emotional consequences if they are not treated effectively. The American Academy of Orthopaedic Surgeons recently carried out a systematic review of the literature to develop a clinical practice guideline. The guidelines provided answers for the following questions regarding the treatment for type III supracondylar fractures (1) which is the preferred treatment for displaced supracondylar fractures of the humerus: reduction and casting versus closed reduction and percutaneous pinning; (2) which is the preferred method for fixing displaced supracondylar fractures of the humerus: medial (crossed) versus lateral pinning; and lastly, (3) does open reduction cause increased stiffness or have a high rate of complication? The purpose of this paper is to summarize and highlight the major findings from this systematic review. Methods: PubMed, EMBASE, CINAHL, and The Cochrane Central Register of Controlled Trials were searched to locate 1726 relevant articles published from January 1966 to July 29, 2010. Of these, 44 met our criteria for inclusion and were reviewed systematically. Results: On the basis of the results from the systematic review: (1) we suggest closed reduction with pin fixation for patients with displaced (eg, Wilkins type II and III and displaced flexion) pediatric supracondylar fractures of the humerus. (2) The practitioner might use 2 or 3 laterally introduced pins to stabilize the reduction of displaced pediatric supracondylar fractures of the humerus. Considerations of potential harm indicate that the physician might avoid the use of a medial pin. (3) The practitioner might perform open reduction for displaced pediatric supracondylar fractures of the humerus after closed reduction if varus or other malposition of the bone occurs. Conclusions: Clearly, controversy exists regarding the best treatments for pediatric supracondylar humerus fractures. Properly designed randomized controlled trials comparing treatment options are necessary to determine optimal treatments. Level of Evidence: Level II.

Assessing Bone Microstructure at the Distal Radius in Children and Adolescents Using HR-pQCT: A Methodological Pilot Study

We examined the use of high-resolution peripheral quantitative computed tomography (HR-pQCT [XtremeCT; Scanco Medical, Switzerland]) to assess bone microstructure at the distal radius in growing children and adolescents. We examined forearm radiographs from 37 children (age 8-14 yr) to locate the position of the ulnar and radial growth plates. We used HR-pQCT to assess bone microstructure in a region of interest (ROI) at the distal radius that excluded the growth plate (as determined from the radiographs) in all children (n=328; 9-21 yr old). From radiographs, we determined that a ROI in the distal radius at 7% of bone length excluded the radial growth plate in 100% of participants. We present bone microstructure data at the distal radius in children and adolescents. From the HR-pQCT scans, we observed active growth plates in 80 males (aged 9.5-20.7 yr) and 92 females (aged 9.5-20.2 yr). The ulnar plate was visible in 9 male and 17 female participants (aged 11.2 ± 1.9yr). The HR-pQCT scan required 3 min with a relatively low radiation dose (<3 μSv). Images from the radial ROI were free of artifacts and outlined cortical and trabecular bone microstructure. There is currently no standard method for these measures; therefore, these findings provide insight for investigators using HR-pQCT for studies of growing children.

Intramedullary rodding in osteogenesis imperfecta.

The results of intramedullary rodding of long bones of 16 children with osteogenesis imperfecta, over a 10-year period, were analyzed. Sheffield elongating rods or non-elongating rods were used. The frequency of fractures was dramatically reduced after implantation of either type of rod, and the ambulatory status improved in all instances. The results were significantly better after Sheffield rodding with regard to the frequency of complications requiring reoperations and the longevity of the rods. Migration of the rods, encountered frequently, appears to be related to improper placement of the rods in the bone. It seems likely that if care is taken to ensure precise placement of a rod of appropriate size, several of these complications may be avoided.