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Study Design: Imaging supine sagittal alignment study. Objective: Our goal was to determine differences between plain radiographs and computed tomography (CT) scans in supine sagittal alignment and to establish supine reference Cobb angles for both. Summary Of Background Data: Few studies have compared plain radiographs versus CT scans with regard to sagittal spine alignment. None have utilized supine patients. Methods: Fifty sequential blunt trauma individuals who had routine clearance of the thoracolumbar spine had their plain radiographs and CT scans reviewed independently by 2 spine surgeons. The Cobb method was utilized to determine angles at each spine level from T4 to L5. All imaging was obtained in the supine position, and no patient had acute ligamentous or bony pathology. Intraclass correlation coefficients (ICCs) were utilized to determine intraobserver, interobserver, and method reliability. Results: Every level within the thoracic region was kyphotic, with a peak at T6. The lumbar region demonstrated a fairly linear progression from a near-neutral alignment at L1 to approximately 50° of lordosis at L5. The intraobserver reliability was consistent, with ICCs for Observer 1 plain radiographs at 0.653, Observer 2 plain radiographs at 0.891, Observer 1 CT scans at 0.677, and Observer 2 CT scans at 0.648. The interobserver reliability was very high, with ICCs for plain radiographs at 0.902 and 0.895 for CT scans. Finally, method reliability (between plain radiographs and CT scans) was excellent as well, with ICCs of 0.808 for Observer 1, 0.781 for Observer 2, and 0.817 after averaging the 2 observers. Conclusion: The results from this study provide a supine reference for sagittal spine alignment using the Cobb method for both CT scans and plain radiographs. It also demonstrates the high degree of reliability between measurements from 2 imaging sources and various observers as shown with the ICC values. [ABSTRACT FROM AUTHOR]

Background: Malignant tumors of the proximal part of the fibula are rare. We sought to analyze the presenting characteristics, postoperative complications, and local recurrences of malignant tumors in the proximal part of the fibula in a large series of patients.Methods: We identified 112 histologically confirmed malignant tumors of the proximal part of the fibula from the time period between 1910 and 2007. The sex ratio was nearly equal (fifty-four male, fifty-eight female). The average age of the patients was 27.6 years, and the average follow-up period was 5.7 years.Results: Osteosarcoma (44%) was the most common diagnosis. Pain (86%), palpable mass (51%), and peroneal nerve symptoms (12%) were the most common presenting symptoms. One hundred and three (92%) of 112 underwent curative surgical treatment. The two most common procedures were amputation in fifty (45%) of 112 patients and Malawer type-II resection in twenty-four (21%) of 112 patients. Deliberative sacrifice of the peroneal nerve was performed in seventy-four patients (66%). Postoperative complications occurred in fourteen (12.5%) of 112 patients, including wound issues (ten of 112), peroneal nerve palsy despite nerve preservation (two of twenty-nine), and posterior tibial artery thrombosis (two of 112). No long-term knee instability was seen in the fifty-three patients who underwent resection with lateral collateral ligament reconstruction. Fifty-six patients (50%) developed distant metastases and twelve (11%) had local recurrences.Conclusions: Osteosarcomas are the most common malignant tumor of the proximal fibula. Complication rates are modest and long-term knee instability was not seen in patients undergoing reconstruction of the lateral collateral ligament. Local recurrence following resection is not uncommon and metastatic dissemination is the main cause of death. This series represents the largest collection of such tumors for which there is extended follow-up and data on surgical complications. [ABSTRACT FROM AUTHOR]

Background: Previous studies report elevated serum titanium (Ti) levels in children with spinal implants. To provide additional data on this topic, we sought to assess serum ion levels at multiple timepoints in pediatric patients with growing spine devices, spinal fusion instrumentation, and extremity implants placed for fracture treatment. We hypothesized that serum Ti, cobalt (Co), and chromium (Cr) levels would be elevated in pediatric patients with growing spine devices compared with patients with extremity implants., Methods: Pediatric patients undergoing any primary spine implant placement, those with spine implant revision or removal surgery and patients with other appendicular implant removal had serum Ti, Co, and Cr ion levels drawn at the time of surgery. Fifty-one patients (12 growing spine devices, 13 fusions, and 26 extremity implants) had one set of labs, 31 of whom had labs drawn both preoperatively and postoperatively. Biopsies obtained from tissue specimens at the time of implant revision were analyzed histologically for the presence of metal debris and macrophage activity., Results: Patients with growing spine implants had elevated serum Ti (3.3 vs. 1.9 ng/mL, P=0.01) and Cr levels (1.2 vs. 0.27 ng/mL, P=0.01) in comparison to patients with fusion rods or extremity implants. With respect to patients with extremity implants, patients with growing spine devices had elevated serum Ti (3.3 vs. 0.98 ng/mL, P=0.013), Co (0.63 vs. 0.26 ng/mL, P=0.017), and Cr levels (1.18 vs. 0.26 ng/mL, P=0.005). On matched pairs analysis, patients who had labs drawn before and after spine implantation had significant increase in serum Ti levels (0.57 vs. 3.3 ng/mL, P=0.02). Histology of tissue biopsies adjacent to growing spine implants showed presence of metal debris and increased macrophage activity compared with patients with extremity implants., Conclusion: Serum Ti, Co, and Cr levels are elevated in children with spinal implants compared with those with extremity implants, particularly in those with growing spine devices. However, the clinical significance of these findings remains to be determined., Level of Evidence: Level II-prospective comparative study., Competing Interests: Outside of the study, T.A.M. reports consulting activities with Orthopaediatrics, Medtronic, Zimmer and stock ownership in Viking Scientific. A.N.L. reports consulting activities with Orthopaediatrics, Medtronic, Depuy, and Globus. The remaining authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Multimodal analgesia is standard practice for total knee arthroplasty; however, the role of regional techniques in improved perioperative outcomes remains unknown. The authors hypothesized that peripheral nerve blockade would result in lower pain scores and opioid consumption than two competing periarticular injection solutions., Methods: This three-arm, nonblinded trial randomized 165 adults undergoing unilateral primary total knee arthroplasty to receive (1) femoral catheter plus sciatic nerve blocks, (2) ropivacaine-based periarticular injection, or (3) liposomal bupivacaine-based periarticular injection. Primary outcome was maximal pain during postoperative day 1 (0 to 10, numerical pain rating scale) in intention-to-treat analysis. Additional outcomes included pain scores and opioid consumption for postoperative days 0 to 2 and 3 months., Results: One hundred fifty-seven study patients received peripheral nerve block (n = 50), ropivacaine (n = 55), or liposomal bupivacaine (n = 52) and reported median maximal pain scores on postoperative day 1 of 3, 4, and 4.5 and on postoperative day 0 of 1, 4, and 5, respectively (average pain scores for postoperative day 0: 0.6, 1.7, and 2.4 and postoperative day 1: 2.5, 3.5, and 3.7). Postoperative day 1 median maximal pain scores were significantly lower for peripheral nerve blockade compared to liposomal bupivacaine-based periarticular injection (P = 0.016; Hodges-Lehmann median difference [95% CI] = -1 [-2 to 0]). After postanesthesia care unit discharge, postoperative day 0 median maximal and average pain scores were significantly lower for peripheral nerve block compared to both periarticular injections (ropivacaine: maximal -2 [-3 to -1]; P < 0.001; average -0.8 [-1.3 to -0.2]; P = 0.003; and liposomal bupivacaine: maximal -3 [-4 to -2]; P < 0.001; average -1.4 [-2.0 to -0.8]; P < 0.001)., Conclusions: Ropivacaine-based periarticular injections provide pain control comparable on postoperative days 1 and 2 to a femoral catheter and single-injection sciatic nerve block. This study did not demonstrate an advantage of liposomal bupivacaine over ropivacaine in periarticular injections for total knee arthroplasty.

Restoration of thumb opposition in the setting of peripheral nerve or brachial plexus injury is critical to upper limb function. When commonly utilized opposition donors are unavailable for clinical use, the pronator teres represents a good and reliable tendon for restoration of thumb opposition. Here we describe our rational and technique for pronator teres opposition transfer using Guyon's canal as a pulley.

Background: There is a subset of blunt trauma patients that present with symptoms suspicious for cervical spine injury or with unreliable clinical exams whose initial plain radiographs or cervical computed tomography (CT) scan are negative. Uncertainty remains, however, because no gold standard has been established for definitively clearing the cervical spine of injury in this patient cohort. Individual studies have detailed the use of magnetic resonance imaging (MRI) in this patient population without conclusive results., Methods: Comprehensive database searches were conducted for prospective or retrospective diagnostic studies of blunt trauma patients who were entered into a cervical spine clearance protocol that included MRI. Inclusion criteria were minimum 30 patients with clinically suspicious or unevaluatable cervical spines, clinical follow-up as the gold standard, data reported to allow the collection of true positives, true negatives, false positives, and false negatives, MRI obtained within 72 hours of injury, and plain radiographs that disclosed nothing abnormal of the cervical spine with or without a CT scan that disclosed nothing abnormal. Log odds meta-analysis of the sensitivity, specificity, positive, and negative predictive value of MRI was performed., Results: Five Level I diagnostic protocols, enrolling 464 patients receiving MRI, were included. There were zero false negatives in the five studies resulting in a negative predictive value of 100%. Log odds meta-analysis produced a 94.2% positive predictive value (95% confidence interval [CI] 75.0, 989), 97.2% sensitivity (95% CI 89.5, 99.3), and 98.5% specificity (95% CI 91.8, 99.7). Ninety-seven (97 of 464, 20.9%) patients had abnormalities identified by MRI that were not identified by plain radiographs with or without CT., Conclusion: A magnetic resonance image that did not disclose anything abnormal can conclusively exclude cervical spine injury and is established as a gold standard for clearing the cervical spine in a clinically suspicious or unevaluatable blunt trauma patient. An accurate number of false positive MRI scans cannot be determined.