Aims

This study investigates the effects of intra-articular injection of adipose-derived mesenchymal stem cells (AdMSCs) and platelet-rich plasma (PRP) on lameness, pain, and quality of life in osteoarthritic canine patients.

Introduction

Alternative payment models for total hip arthroplasty (THA) were initiated by the Center for Medicare and Medicaid Services (CMS) to decrease overall healthcare cost by optimizing healthcare delivery. The associated shift of financial risk to participating institutions has been criticized to introduce patient selection in order to avoid potentially high cost of care. This study aimed to evaluate the impact of the Comprehensive Care for Joint Replacement (CJR) model on patient selection, care delivery and hospital costs at a single care center.

Introduction

Bundled reimbursement models for total knee arthroplasty (TKA) by the Center for Medicare and Medicaid Services (CMS) have resulted in an effort to decrease the cost of care. However, these models may incentivize bias in patient selection to avoid excess cost of care. We sought to determine the impact of the Comprehensive Care for Joint Replacement (CJR) model at a single center.

Purpose: Femur fractures in children have a significant impact on families and the hospital system in Canada. There are several methods for treating femur fractures in children. The purpose of this study was to determine which of two techniques: Flexible Femoral Nailing (FFN) or Trochanteric Antegrade Nail (TAN), are the most safe and efficacious.

Method: Hospital charts for all paediatric femur fracture patients between 1984 and 2006 treated with either FFN or TAN were reviewed. Demographic, clinical, radiographic and hospital stay data were collected and analyzed.

Results: Ninety-seven children (100 fractures) were reviewed. The average age of patients was 11.9 years (SD = 4.4). Fifty-two fractures were treated with FFN and 48 fractures were treated with TAN. No serious complications were encountered in either group, including AVN. Minor complications in the FFN group included three patients with mal-alignment, and one with shortening of the limb. Two patients in the TAN group had shortening of the fractured limb. No radiographic differences were noted. The median length of stay for patients treated with FFN was 3 days (IQR = 2) and for patients treated with TAN was 3 days (IQR = 2). Overall, there were no significant differences in the clinical findings (including complications), radiographic evaluations, or length of stay between FFN and TAN cohorts. The only significant difference between the groups was length of surgical time (p value < 0.001).

Conclusion: TAN is as safe and efficacious a treatment as FFN but requires addition operating room time, and hence hospital resources.

Scaphoid fractures are rare injuries in the pediatric population. A clinical and radiographic review over a six-year period at our institution revealed ninety-nine suspected scaphoid fractures. All of these patients presented with post-traumatic tenderness in the anatomic snuffbox and were treated with thumb spica cast immobilization. Only 9% of these patients demonstrated radiographic evidence of scaphoid fracture on initial presentation. At subsequent follow-up, six additional patients revealed radiographic evidence of scaphoid fracture. Positive predictive value of snuffbox tenderness for scaphoid fracture was 6% for patients with initially normal radiographs.

To review the clinical and radiographic results of suspected pediatric scaphoid fractures, as well as to determine the predictive value of anatomic snuffbox tenderness for occult fracture.

Pediatric scaphoid fractures are rare injuries that were found to be non-displaced and to involve the waist and distal scaphoid in most cases. Snuffbox tenderness had a positive predictive value of 6% in the identification of occult fracture.

In cases of suspected scaphoid fracture and normal radiographs, reliance on anatomic snuffbox tenderness alone will result in unnecessary immobilization in the majority of children.

Ninety-nine potential injuries were identified. Average age was 13.9 years. Although all patients in this group had tenderness in the snuffbox, only nine of the original x-rays revealed a true scaphoid fracture. The ninety “clinical scaphoid fractures” were immobilized for twenty-three days on average. Of these, only six demonstrated future radiographic evidence of fracture. No injuries required surgery for non-union.

All pediatric scaphoid fractures that were diagnosed clinically or radiographically at our institution between 1998 and 2003 were reviewed. Initial and follow-up radiographs were examined for evidence of fracture.

Given the sequelae of untreated scaphoid fractures in adults, tenderness in the snuffbox has been used to diagnose “clinical scaphoid fractures”. Although never validated in children, this test continues to be used in this population. As the natural history of scaphoid fracture in children is more favorable than in adults, reliance on snuffbox tenderness alone has resulted in the over-treatment of this injury.

The majority of pediatric proximal humerus fractures are successfully treated non-operatively. Significantly displaced fractures have traditionally been treated surgically with percutaneous pinning. This review of twenty-three surgically treated patients demonstrates a high rate of infection associated with percutaneous pinning. The technique of cannulated screw fixation offers a safe surgical alternative for the treatment of these fractures in the adolescent population.

To compare the results of percutaneous pinning to cannulated screw fixation for the treatment of pediatric proximal humerus fractures.

A high complication rate, including pin tract infection and loss of reduction, was observed in the percutaneous pinning group.

Given the rigid fixation afforded by cannulated screws and the minimal morbidity associated with proximal humeral physeal arrest in the older adolescent, this technique offers a safe alternative for the treatment of proximal humerus fractures.

Average age was 13.0 years for the pinning group and 14.7 years for the cannulated screw group. Regardless of fixation technique, all fractures healed completely with no difference in rates of physeal closure. Significant pin tract drainage was encountered in six of twenty patients treated with pinning: Two with Staphylococcus Aureus infection and one deep infection requiring surgical debridement. Loss of reduction and pin migration was noted in a seventh patient. The only complication observed in the cannulated screw group was a transient axial nerve paresthesia. There were no significant differences in operative time, rate of open reduction, or length of hospitalization (p> 0.05).

Twenty-three pediatric proximal humerus fractures treated operatively over a seven-year period were followed clinically and radiographically.

Thirty percent of the patients treated with pinning developed pin tract infections. Similar to femoral external fixation pins, proximal humeral pins also cross a large muscle group that may result in pin micro-motion. This may create persistent drainage that ultimately leads to infection.

Purpose: To review the orthopaedic manifestations and document the results of surgical intervention. Material and Methods: A review of all 22 children currently attending a specialist scleroderma clinic was performed. Disease extent was measured in terms of percentage body surface area (BSA) affected and all orthopaedic abnormalities were documented. The outcome of surgical intervention was evaluated.

Results: All children presented by the age of 12 and all but 2 had developed joint contractures of either the lower or upper limbs affecting function within 2yrs of diagnosis. Overall, lower limbs were more commonly affected than upper. Abdominal scleroderma led to a scoliosis in 75% of cases. The mean BSA affected was 35% (range 5-65%) with contractures more related to site of disease rather than extent. Pain was associated with lower limb contractures and loss of function with hand contractures. Limb length discrepancy (LLD) was common with a mean of 3cms (range 2-6.5cms). 8 children have had surgery. 7 developed wound healing problems. 50% of operations failed to correct the deformity and in a further 25% relapse has occurred. In the remaining 2 cases a good result was achieved. In addition, one epiphysiodesis has been performed and 3 are planned.

Conclusions: This is the largest known review of children with linear scleroderma. Joint contractures are common but poorly managed by conservative methods alone. Surgical intervention is difficult but early defini-tive treatment is recommended with subsequent aggressive splinting during growth whilst the disease is active. LLD must be corrected.