Madeleine Willegger

Management of pediatric bone and joint (B&J) infections typically entails inpatient admission for appropriate workup, antibiotic therapy, and in some cases, surgical debridement. Re-admission and re-operation are reported in up to 26% of children. A recent retrospective review of our institutional data revealed 29% of patients with septic arthritis (SA) or osteomyelitis (OM) had unplanned returns to the emergency department (ED) after discharge from hospital. Unplanned ED visits pose significant costs and additional burden to the healthcare system and affected families. In order to improve the quality and efficiency of care for children with B&J infections at our institution, a quality improvement (QI) initiative was implemented to eliminate unplanned ED visits that included routine C-Reactive Protein (CRP) monitoring and scheduled follow-up appointments. A multidisciplinary care pathway for children with B&J infections was implemented in September 2021 and patients admitted with SA, OM, subperiosteal or intraosseous abscess were prospectively followed until June 2022. Specialists in pediatric orthopedics, infectious diseases (ID) and pediatric medicine were involved in pathway development and patient care. The QI pathway comprised routine CRP measurements on admission and every 3 days throughout their stay, and a standardized outpatient follow-up schedule including telephone, virtual and in-person visits with orthopedics and ID (Figure 1). The primary outcome measures were unplanned ED visits after discharge, re-admission, and re-operation rates. These results were compared to a retrospective cohort of children with B&J infections treated between June 2018 and August 2021. Forty-five children aged 3 weeks to 17.9 years (mean 6.8 years) were treated and followed according to the pathway. Mean CRP at admission was 65.8 mg/L (range 1.5–224.7). Twenty-three had OM (51.1%), 2 OM with intraosseous abscess (4.4%), 5 OM with subperiosteal abscess (11.1%), and 17 SA (37.7%). Twenty-two children (48.9%) were treated with antibiotics, 22 (48.9%) had surgical and antibiotic management, and one (2.2%) underwent interventional radiology biopsy and antibiotics. Adherence to CRP monitoring after admission occurred in 93.3%, with 42 patients having at least one CRP result immediately prior to discharge. Mean follow-up was 16.4 weeks (range 2.4–52.1). Eight patients (17.7%) had unplanned returns to the ED. The most common reasons were fever and pain. Of these, 4 patients (8.9%) were re-admitted and one patient (2.2%) was re-admitted twice. Three (13.6%) of the 22 surgically treated patients underwent re-operation, two during their initial hospital admission, and one a month later on re-admission. Re-operation and re-admission rates in the retrospective cohort were similar at 15% and 8%, respectively. By implementing a multidisciplinary approach for the treatment and follow-up of children with B&J infections, unplanned ED visits were reduced from 29% to 18% within 10 months. While re-operation and re-admission rates did not change from the preceding years, by reducing the number of unplanned ED visits, the pathway significantly lessened the burden and costs to the health care system, patients and their families. For any figures or tables, please contact the authors directly.

The posterior calcaneal displacement osteotomy (PDCO) is a surgical procedure to correct hindfoot valgus or varus deformities by translating the calcaneal tuberosity medially or laterally, respectively. Traditionally PDCO is performed through an open lateral approach. Minimally invasive techniques are evolving and becoming more popular with reported decreases in wound complications, nerve injuries, and swelling in adult patients. The aim of this study is to report clinical and patient reported outcomes comparing PDCO through an open (O-PDCO) versus a minimally invasive approach (MI-PDCO). A consecutive series of PCDO performed by a single paediatric foot and ankle surgeon was reviewed. All calcaneal osteotomies were part of a complex foot and ankle reconstructive procedure including clubfoot, flatfoot, cavovarus and neurological deformities. Radiographic and clinical outcome data including neurovascular injury and wound complications was collected. The O-PDCO was performed through an oblique incision over the lateral calcaneal tuberosity and performed with an oscillating saw and osteotomes. The percutaneous osteotomy for the MI-PDCO was done through a 5mm incision and using a narrow, low-speed, high torque, cortical self-irrigating burr under fluoroscopic guidance. Bony fixation was achieved with K-wires or screws. (Figure 1) Post-operatively, patients were immobilized in a non-weight bearing cast for 6 weeks. Twenty-nine calcaneal osteotomies in 23 patients aged 8 to 18 years (mean 12.9) were included. Pre-operative deformities included 11 hindfoot varus for clubfoot, 9 flatfoot, 7 cavovarus and 2 hindfoot valgus for overcorrected clubfoot. Eleven osteotomies were performed open (O-PDCO) and 18 minimally invasive (MI-PDCO). Mean overall follow-up time was 17.9 months (range 4.6–35.5). Mean displacement of the calcaneal tuberosity was 8.6mm (range 7.4–13.0) in the O-PDCO group and 7.3mm (range 5.5–10.0) in the MI-PDCO group based on intra-operative Harris views, respectively. No delayed union, non-union, or growth disturbance was observed. There were 2 minor wound healing issues in the O-PDCO (18.1%) and none in the MI-PDCO (0%) group. Six feet had nerve paresthesias: two (1 sural and 1 tibial nerve) were in the O-PDCO (18.1%) and four sural nerve irritations were in the MI-PDCO (22.2%) group. All of them improved or resolved during follow-up. No vascular injuries occured, and no revision surgeries were required in either group. The Child version Oxford Ankle Foot Questionnaire for Children (OxAFQ-C) resulted in improved scores in all 3 domains in both groups, especially in the domains school/play there was an increase of 0.25 in the O-PDCO and 0.15 in the MI-PDCO group. Minimally invasive posterior calcaneal displacement osteotomy is a safe technique to correct paediatric hindfoot deformities. Deformity correction power was effective in O-PDCO and MI-PDCO. There were fewer wound healing complications in the minimally invasive group, but temporary post-operative paresthesias are common in both techniques. This is the first clinical data on the use of minimally invasive calcaneal osteotomy in a paediatric patient population for complex deformity corrections. MI-PDCO could become the gold standard procedure in paediatric hindfoot reconstructions. It has great potential in complex deformity corrections with multiple concurrent osteotomies to reduce wound complications. For any figures or tables, please contact the authors directly.

Background: Over the last 30 years, total ankle arthroplasty (TAA) has become a viable surgical option for end-stage ankle arthritis ^1,2 . The aim of TAA is to relieve pain and preserve ankle joint range of motion, which, by definition, shields adjacent joints ^3–6 . Alignment is essential for the longevity and survival of TAA, since malalignment of TAA components can cause abnormal loading patterns with subsequent polyethylene wear and early implant failure ^7–12 . Therefore, patient-specific instrumentation with higher accuracy of tibial and talar component placement and shorter operative times has major advantages in TAA ¹³ . This present video article describes the use of CT-based patient-specific instrumentation for TAA implantation. Description: On the basis of preoperative CT scans (PROPHECY Ankle CT Scan Protocol; Wright Medical Technology), a surgical plan is created with comments from an engineer that include the sizing and positioning of TAA implant components (INFINITY with ADAPTIS Technology Total Ankle System; Wright Medical Technology). This plan is reviewed by the surgeon with the opportunity for corrections and adjustments. After approval, the patient-specific cut guides for the TAA are manufactured. TAA with patient-specific cut guides is performed with the patient under general anesthesia, usually with a popliteal and saphenous nerve block for intraoperative and postoperative pain management. The patient is positioned supine with a bump underneath the ipsilateral hip in order to align the foot in neutral rotation. A thigh tourniquet is applied and set at 275 mmHg. Landmarks for the incision are outlined on the skin and the leg is exsanguinated. An anterior approach with a standard central incision is made, creating full-thickness skin flaps medially and laterally. Dissection of the superficial peroneal nerve (SPN) branches should be avoided. The interval between the tibialis anterior tendon and the extensor hallucis longus tendon is entered, and the neurovascular bundle with the deep peroneal nerve (DPN) and the anterior tibial artery is protected and retracted laterally. Hohmann retractors are placed medial and lateral, taking care not to place too much tension on the skin. The anterior distal tibia and the dorsal talus are cleaned of all soft tissues, periosteum, and possible residual cartilage in order to obtain a good cortical read. The patient-specific cut guides (INFINITY PROPHECY, Total Ankle System; Wright Medical Technology) are placed first at the distal tibia and are fixed with temporary pins. Anteroposterior (AP) and lateral fluoroscopic images are made in order to confirm alignment of the tibial alignment guide, which should be neutral relative to the mechanical tibial axis. Once the position is appropriate, the guide is switched to the tibial resection guide, followed by tibial resection with use of an oscillating saw. The patient-specific talar alignment guide is then placed and fixed with pins. Pins are placed through the anterior pin holes, and the guide is switched to the cut guide. AP and lateral fluoroscopic images are made in order to check the talar resection. The talar resection guide will not necessarily be the same size as that used during the tibial resection. A lamina spreader is inserted, and ligament balancing is performed. The posterior capsule can be released at this time if it is tight. Next, the tibial trial is placed over the pins and the appropriate AP positioning of the tibial component is determined and checked on lateral fluoroscopy. Once the position is set, the broaches for the pegs are inserted and tapped in with a mallet. A talar dome trial is inserted together with a polyethylene insert trial, which should engage with the tibial trial. The talar component alignment and rotation are checked clinically as well as under fluoroscopy. Under axial compression and ankle dorsiflexion and plantarflexion, the talar component will rotate into its anatomic position. Two 2.4-mm Steinmann pins are utilized to fix the talar trial component temporarily. The talar resection guide is placed. Temporary fixation screws are placed and tightened by hand. The chamfer cuts are made with an oscillating saw. The talar pilot guide is placed, and the talar reamer is utilized to plunge cut in order to prepare the talar surface. Once this is finished, the pins and the guides are removed, and the residual bone is removed with use of a rongeur. Irrigation is performed with a saline solution. The definitive components are opened, and the tibial component is implanted first and impacted. The tibial pegs must be in the prepared holes. Verification that the component is fully seated is confirmed under lateral fluoroscopic imaging. The talar component is then inserted and impacted. A trial polyethylene liner is inserted, and varus and valgus stress and range of motion are tested. The liner size is then determined. The liner insert guide rail is attached, and the liner is slid into the joint space. With a gentle tap on the liner with the impactor, the fixed-bearing mechanism is locked. Finally, osteophytes, which could block the range of motion, are removed. Final fluoroscopic images are made. After copious irrigation, the wound is closed in layers. Sterile dressings are placed over the wounds, and a padded tri-slab splint is fashioned to immobilize the limb in neutral ankle dorsiflexion. Alternatives: Nonoperative alternatives include shoe wear modification, the use of NSAIDs, physiotherapy, physical therapy, the use of an orthosis, ankle bracing, and intra-articular injections. Operative alternatives include joint-preserving osteotomies and ankle arthrodesis (AA) (arthroscopic or open). Rationale: In comparison to ankle arthrodesis, prospective and retrospective cross-sectional studies showed that several patient-reported outcomes were greater after TAA than after AA, without a significant difference in revision rates and complications ^14–17 . The anterior approach is the most commonly used approach for TAA and gives the surgeon the best exposure of the ankle joint. Varus and valgus deformity of >15° is a relative contraindication, and >20° deformity is an absolute contraindication for TAA ¹⁸ . If these deformities are not addressed appropriately, long-term survival may be impaired. Multiple studies have shown that malalignment of TAA components can induce high joint contact pressures and therefore lead to early implant failure ^7–12 . Patient-specific instrumentation in TAA may improve accuracy of implant positioning. Performing TAA using patient-specific cut guides enables the surgeon to plan intra-articular deformity correction, template bone resection, and implant alignment and sizing according to the patient’s unique anatomy. Cut guides are based on preoperative CT scans and are single-use instrumentation guides to mark bone cuts for tibial and talar component positioning. Minimal bony resection to preserve the bone stock for future possible revision surgeries is essential, especially in younger patients with end-stage ankle arthritis (< 55 years). Additionally, operative time and fluoroscopy time has been decreased compared with the traditional standard referencing guide technique in TAA ¹³ . Longer operative times have been shown to place patients at higher risk for wound complications in TAA ¹⁹ , which could be reduced by performing TAA with patient-specific cut guides. Expected Outcomes: Patients start weight-bearing at 2 weeks postoperatively, which is approximately 4 weeks earlier than patients who undergo ankle arthrodesis ¹⁷ . Patient expectations are more likely to be met by TAA than by ankle arthrodesis ²⁰ . Gait analysis has shown that walking speed is faster after TAA compared with ankle arthrodesis. Hindfoot and forefoot sagittal motion is greater following TAA, and gait also more closely resembles the patient’s natural gait ²¹ . Analysis of prospective data showed that in the presence of complex deformity or adjacent joint arthritis, as determined by the Canadian Orthopaedic Foot and Ankle Society (COFAS) classification (COFAS 3 and 4 ankles), patient-reported outcomes were better in patients undergoing TAA compared with ankle arthrodesis. In cases of ankle arthritis without deformity, TAA yielded higher patient-reported outcome measures compared with open ankle arthrodesis. Nevertheless, patients who underwent TAA had a significantly higher rate of additional surgical procedures. TAA patients in general have also been shown to have higher reoperation rates, at around 6% to 7% within a 2-year follow-up window ^15,17 . Long-term follow-up data on TAA have shown revision rates between 16% and 54%; however, these rates were for older implant designs, and these numbers might not be applicable for the implant utilized in the presently described technique ^22,23 . The Infinity TAA has shown a revision rate of 3% after a 3-year follow-up study ²⁴ . Infection rates after primary TAA have ranged from 1.4% to 2.4% ²⁵ . Important Tips: Acronyms and Abbreviations: TAA = total ankle arthroplasty NSAID = nonsteroidal anti-inflammatory drug CT = computed tomography COFAS = Canadian Orthopaedic Foot and Ankle Society AA = ankle arthrodesis SPN = superficial peroneal nerve DPN = deep peroneal nerve ER = extensor retinaculum TA = tibialis anterior EHL = extensor hallucis longus AP = anteroposterior DVT = deep vein thrombosis

Background: The reproducible measurement of tibial torsion (TT) is essential for the diagnosis and evaluation of rotational deformities of the tibia, particularly in the planning of tibial derotational osteotomy. While various CT-based methods for determining the distal tibial axis have been described for adult patients, rotational Magnetic Resonance Imaging (MRI) represents a radiation-free alternative, especially for assessing lower limb rotation in pediatric patients. The aim of this study was to analyze the reliability of TT measurements as well as to investigate potential differences in the application of rotational MRI within a pediatric orthopedic cohort. Methods: In this retrospective study, 78 lower legs from 39 patients aged 4 to 18 years who underwent rotational MRI were included. Measurements for TT were performed using the Jend method, the Waidelich method, and the bimalleolar method. Reliability assessments were conducted by three different examiners, and the results were determined using the intraclass correlation coefficient (ICC). Results: All three methods demonstrated excellent interobserver reliability. The highest intraobserver reliability was achieved using the bimalleolar method (ICC: 0.947). When comparing the assessment of TT, the Jend method showed the highest mean values (34°, standard deviation (SD) 11.0°) followed by the Waidelich method (29°, SD 10.2°) and the bimalleolar method (26°, SD 9.9°). Measurement methods showed a mean difference of up to 8° (p < 0.001). Conclusions: Rotational MRI is a feasible radiation-free option to assess tibial torsion in pediatric and adolescent patients. All tested methods show excellent inter- and intraobserver reliability. Notably, significant differences were found between the measurement methods, with the bimalleolar method showing lower mean values. This has to be taken into account for preoperative planning of rotational and derotational tibial and supramalleolar osteotomies.

Background: Balance and gait are critical for functional recovery and fall prevention following total hip (THA) and knee arthroplasty (TKA). Despite improvements in pain and joint function, residual impairments often persist. The Timed Up and Go (TUG) test and Tinetti Performance-Oriented Mobility Assessment (POMA) objectively measure postoperative mobility and balance, while patient-reported outcome measures (PROMs) assess perceived function and well-being. This study longitudinally evaluates functional measurement and PROMs to explore their interrelationships and compare recovery trajectories in THA and TKA cohorts. Methods: In this prospective study, 22 THA and 21 TKA patients were assessed preoperatively and at 4–6 days, 6 weeks, 3 months, and 12 months postoperatively using TUG, Tinetti, Hip Disability and Osteoarthritis Outcome Score (HOOS), Knee Injury and Osteoarthritis Outcome Score (KOOS), and clinical scores (Harris Hip Score (HHS) for THA, Knee Society Score (KSS) for TKA). Pearson correlation assessed relationships between measures. Results: Both cohorts demonstrated significant immediate postoperative declines in balance and mobility, recovering to baseline by 6 weeks and surpassing it by 3 and 12 months (p < 0.001). PROMs showed earlier and sustained improvements. Objective balance and mobility measures showed minimal correlation with PROMs but were highly interrelated from 6 weeks onward. Conclusions: THA and TKA patients experience early postoperative balance impairments, suggesting heightened fall risk, with functional recovery lagging behind perceived well-being, highlighting the need for cautious rehabilitation strategies.

Intramedullary nail fixation is a routine procedure for treatment of intertrochanteric fractures. Aseptic technique is vital for reducing postoperative complications, as intraoperative glove perforations increase the risk of surgical site infections. The aim of this study was to determine the incidence of surgical glove perforation during intramedullary nailing of intertrochanteric fractures and to identify surgery-specific steps at risk. A prospective series of 148 short intramedullary nail implantations was analysed. Intraoperative glove perforations and causative events were recorded. All gloves from the scrubbed surgical team were collected and examined for micro- and macroperforations. 1771 gloves were tested. A total of 341 perforations in 309 gloves were detected, resulting in an overall glove perforation rate of 17%. Surgeon experience had no influence on the overall incidence of glove perforations. Usage of the awl and insertion of the proximal locking screw resulted in 33.9% of all detected glove perforations. Perforation rate significantly increased with operative time (p = 0.003). Regular glove changing after surgery-specific risk-steps and during longer surgeries could decrease the rate of glove perforations during intramedullary nailing of intertrochanteric fractures and reduce the risk of potential septic contamination or even disease transmission for both, the surgeon, and the patient.

Background: Graf ultrasound screening is considered an established method for early detection of developmental dysplasia of the hip (DDH). Although characterized by a high degree of standardization to allow for good reproducibility of results, examination-related factors may still affect sonographic measurements. The relative tilt angle between the hip and the probe is a potential pitfall as it significantly influences sonographic measurements and consequently classification of DDH according to Graf. Objectives: Evaluation of an electronic guidance system developed to reduce relative tilt angles and increase reliability and comparability in ultrasound screening of DDH. Materials and Methods: Twenty-five newborns were examined using a prototype guidance system, which tracks the position of the transducer and the pelvis to calculate the relative tilt angles. Two ultrasound images were obtained, one conventionally and the other one using the guidance system. Subsequently, relative roll and pitch angles and sonographic measurements were determined and analyzed. Results: The relative inclination angles in the conventional group ranged from −12.6° to 14.3° (frontal plane) and −23.8° to 32.5° (axial plane). vs. −3.7° to 3.0° and −3.2° to 4.5° in the guidance system group. The variances were significantly lower in the guidance system-assisted group for both planes (p < 0.001 and p < 0.001, respectively). The optimized transducer position showed significant effects and consequently significantly reduced alpha angles were observed (p = 0.001, and p = 0.003). Conclusions: The guidance system allowed a significant reduction in the relative tilt angles, supporting optimal positioning of the transducer, resulting in significant effects on Graf sonographic measurements. This technique shows great potential for enhancing the reproducibility and reliability of ultrasound screening for DDH.