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Cataract surgery pain management in light of the opioid crisis and how ophthalmologists can help make a positive impact with the use of non-opioid options is discussed. Cataracts are a leading cause of preventable blindness globally. Although care varies between developing and industrialized countries, surgery is the single effective approach to treating cataracts. From the earliest documented primitive cataract removals to today's advanced techniques, cataract surgery has evolved dramatically. As surgical techniques have developed, so have approaches to surgical pain management. With current cataract surgical procedures and advanced technology, anesthesia and intraoperative pain management have shifted to topical/intracameral anesthetics, with or without low-dose systemic analgesia and anxiolysis. Despite this, pain and discomfort persist in some patients and are underappreciated in modern cataract surgery. Although pain management has progressed, opioids remain a mainstay intraoperatively and, to a lesser extent, postoperatively. This article discusses the evolution of pain management in cataract surgery, particularly the use of opioids and the associated risks as well as how ophthalmology can have a positive impact on the opioid crisis. [ABSTRACT FROM AUTHOR]

Case: A 15-year-old boy with a right femur length discrepancy secondary to infection underwent hardware removal 1-year status-post right femur osteotomy with placement of an antegrade intramedullary magnetic lengthening nail after successful lengthening of 4.2 cm. During hardware removal, dissociation between the proximal (outer) and distal (inner) components of the device was observed. The distal component was removed using an endoscopic pituitary rongeur after considering multiple possible techniques. Conclusions: In the event of nail disconnection during removal of an intramedullary implant, we recommend use of a long pituitary rongeur to retrieve the distal nail component. [ABSTRACT FROM AUTHOR]

Presbyopia is the most common refractive disorder for people older than 40 years. It is characterized by a gradual and progressive decrease in accommodative amplitude. Many surgical procedures for the correction of presbyopia exist, with additional procedures on the horizon. This review describes the prevalent theories of presbyopia and discusses the available surgical options for correction. Financial Disclosure Proprietary or commercial disclosures are listed after the references. [ABSTRACT FROM AUTHOR]

The article describes an approach to managing patient expectations for laser in situ keratomileusis (LASIK), photorefractive keratectomy (PRK), and phakic intraocular lenses (PIOLs). Topics include PIOLs providing an alternative to keratoablative procedures, particularly for patients with high degrees of myopia and limited astigmatism, PRK performed by modern lasers officially approved only for LASIK, and setting appropriate patient expectations for the rate at which vision will improve.

The article offers step-by-step instructions for performing operative management of chronic symptomatic os subfibulare in children involving ligament repair and fragment excision for strict surgical indications.

Background: A single-leg, walking hip spica cast has been shown to be a safe and effective treatment for a low-energy femoral shaft fracture in young children. We designed a prospective cohort trial comparing walking and traditional hip spica casting to determine whether a walking hip spica cast was superior to a traditional hip spica cast following a low-energy femoral shaft fracture in children one to six years old. Methods: We studied forty-five consecutive low-energy femoral shaft fractures during a three-year period in children one to six years old. Three surgeons treated their patients with a walking hip spica cast, and three other surgeons treated their patients with a traditional spica cast. Complications and subsequent interventions were recorded prospectively. Caregivers were asked to complete the validated Impact on Family Scale as well as a ten-item questionnaire developed by the authors at the time of cast removal. Results: Forty-five patients with a low-energy fracture were enrolled in the study. Nineteen patients were treated with a walking hip spicacast and twenty-six, with a traditional hip spica cast. The two cohorts were similar with respect to age, length of hospital stay, time to initial callus formation, and time to fracture union. Two children treated with a traditional hip spica cast and no children in the walking hip spica group returned to the operating room for the treatment of spontaneous loss of fracture reduction. Five of the nineteen children treated with a walking hip spica cast and one of the twenty-six treated with a traditional hip spica cast required wedge adjustment of the cast in the clinic to treat fracture malalignment (p = 0.04). One patient treated with a walking hip spica cast required repeat reduction in the operating room because of overcorrection during wedge adjustment. The malunion rate did not differ significantly between the groups (three of twenty-six in the traditional hip spica group compared with none of nineteen in the walking hip spica group). All patients treated with a walking hip spica cast were able to crawl in the cast, and 71% (twelve of seventeen) were able to walk. Use of the traditional hip spica cast resulted in a significantly greater care burden for the family as measured with use of the Impact on Family Scale (43.3 for the traditional hip spica group compared with 35.6 for the walking hip spica group, p = 0.04). Insurance-funded ambulance transportation was needed for eleven of the twenty-six patients treated with a traditional hip spica cast compared with none of the nineteen patients treated with a walking hip spica cast (p = 0.001). Conclusions: The walking hip spica cast and the traditional hip spica cast resulted in similar orthopaedic outcomes, and the walking hip spica cast resulted in a lower care burden for the family. Surgeons and families should be aware that use of a walking hip spica cast rather than a traditional hip spica cast may be associated with a greater likelihood that wedge adjustment of the cast will be necessary to treat fracture malalignment. [ABSTRACT FROM AUTHOR]

Unlabelled: Circular fixators have been used successfully to correct multiplanar deformities but are often cumbersome and may be difficult to apply. We determined whether a monolateral fixator, which allows for correction of angular deformity and displacement in three planes, can correct lower extremity deformities to within normal radiographic means (anatomic lateral distal femoral angle, anatomic medial proximal tibial angle, and tibial femoral angle). We retrospectively reviewed the clinical records and radiographs of 22 consecutive patients (25 limbs) who underwent deformity correction using a new multiaxial monolateral external fixator. The patients were 4 to 16 years of age. We had a minimum 1.2-year followup (mean, 2.14 years; range, 1.2-3.1 years). Those with primary femoral and tibial deformities had improvements in the mean deviation from normal of the anatomic lateral distal femoral angle, anatomic medial proximal tibial angle and tibial femoral angle. Patients with Blount's disease had improvements in the mean anatomic medial proximal tibial angle from 59.9 masculine to 87.8 masculine. Five patients had complications (two pin site infections, one premature consolidation, one knee flexion contracture, one recurrence of varus). Six patients developed secondary deformities, all of which were corrected using the primary or secondary hinge. We conclude this fixator can produce satisfactory results with relatively few complications.Level Of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Congenital anterolateral bowing of the tibia is a pre-pseudarthrosis stage of congenital pseudarthrosis of the tibia and is associated with a substantial risk of fracture and pseudarthrosis. We evaluated the results of prophylactic bypass grafting performed in combination with bracing to prevent fracture and pseudarthrosis. Methods: This retrospective series included ten patients with pre-pseudarthrosis of the tibia treated, between 1991 and 2002, with prophylactic bypass grafting with an allograft fibula placed posteromedially in a stress-bearing fashion. The average patientagewas 2.3 years at the time of diagnosis, 3.6 years at the time of surgery, and ten years at the time of final follow-up. The mean duration of follow-up was seventy-eight months. Brace protection was recommended at the time of diagnosis and was continued after the operation until maturity. Despite the bracing, a low-energy fracture developed and partially healed priorto the bypass grafting in one patient. The remaining nine patients had no fractures prior to the bypass grafting. At the time of final follow-up, the patients were examined clinically and radiographically for the presence of a fracture or pseudarthrosis and for residual deformity, including malalignment, ankle and knee joint abnormalities, and leg length discrepancy. Results: No patient had either a fracture or a pseudarthrosis of the tibia at the time of follow-up. All grafts united to the tibia at both ends. Complications included an allograft fracture in three patients, which healed in all; allograft resorption in one patient; and pseudarthrosis of the ipsilateral host fibula in one patient. At the time of final follow-up, a mean of 9 mm (range, 0 to 37 mm) of leg length discrepancy was found. A corrective osteotomy was done for four patients (three because of ankle valgus and one because of diaphyseal deformity). Conclusions: In this small series of ten patients with congenital anterolateral bowing of the tibia treated with bypass strut grafting and long-term bracing, there were no cases of pseudarthrosis of the tibia. Distal tibial deformity may persist throughout the growth period and require operative correction in patients treated with this procedure. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Unlabelled: The purpose of this study was to define the acetabular changes associated with coxa vara and determine how these acetabuli differ from those of a normal hip. Charts and radiographs of 33 patients with coxa vara with a mean age of 6 years (range, 2-15 years) were retrospectively reviewed. The diagnosis was developmental coxa vara in 21 patients and congenital femoral deficiency in 12. Radiographic measurements, including acetabular index, sourcil slope, center edge angle, migration index, and medial joint space, were compared with those of 29 hips in the control group. The inclination of the acetabulum or acetabular slope (as measured by the acetabular index and sourcil slope) was significantly increased in the hips with coxa vara as compared with those in the control group. Both parameters have a statistically significant inverse correlation with the degree of varus, ie, the greater the varus of the proximal femur, the greater the upsloping of the acetabulum. Joint subluxation, as measured by the center edge angle, migration index, and medial joint space, showed little difference from that of control subjects.Level Of Evidence: Level III, diagnostic study. [ABSTRACT FROM AUTHOR]

Background: Prophylactic pinning of the radiographically and clinically normal contralateral hip in a patient with a unilateral slipped capital femoral epiphysis remains controversial. The purpose of this study was to identify the prevalence of chondrolysis and osteonecrosis and the degree of slip severity in contra- lateral hips with a subsequent slipped capital femoral epiphysis to determine whether the outcome or complications on the contralateral side were greater than the risks of prophylactic pinning. Methods: The medical records of the patients operated on between 1993 and 2003 at a single hospital for treatment of a slipped capital femoral epiphysis were retrospectively evaluated. The severity and the chronicity of the slips were graded. Only children who initially had had a unilateral slip and had been followed for a minimum of twenty-four months or until skeletal maturity were included in the analysis for detection of a subsequent contralateral slip. Patients with more than twelve months of follow-up were included in the analysis for detection of osteonecrosis and chondrolysis. Results: Two hundred and twenty-seven patients had a unilateral slipped capital femoral epiphysis at the time of the primary admission. A subsequent slip developed in the contralateral hip of eighty-two children (36%) within a mean of 6.5 months. Eighteen of the contralateral slips were of moderate or severe severity, with a potential for a poor outcome due to a risk of osteoarthritis in the future. Osteonecrosis or chondrolysis, each an established complication with a poor long-term prognosis, developed in five of the patients with a subsequent contralateral slip. [ABSTRACT FROM AUTHOR]

Osteochondromas are the most common benign bone tumor; nonetheless, the natural history is poorly understood as a result of the low threshold for resection and the fact that many of these lesions are asymptomatic and therefore never diagnosed. We report a case of spontaneous regression of a solitary osteochondroma and review the literature. We believe the likelihood of spontaneous regression should be better understood by orthopaedic surgeons and taken into account in the decision process of whether to remove osteochondromas surgically. [ABSTRACT FROM AUTHOR]

Background: Titanium elastic nails are commonly used to stabilize femoral fractures in school-aged children, but there have been few studies assessing the risks and benefits of this procedure compared with those of traditional traction and application of a spica cast. This prospective cohort study was designed to evaluate these two methods of treatment, with a specific focus on the first year after injury, the period when the treatment method should have the greatest impact. Methods: Eighty-three consecutive children, six to sixteen years of age, were studied prospectively. Factors that were analyzed included clinical and radiographic data, complications, hospital charges, and outcome data. Outcome and recovery were assessed both with the American Academy of Orthopaedic Surgeons Pediatric Outcomes Data Collections Instrument, version 2.0, and according to a series of important recovery milestones including the time to walking with aids, time to independent walking, time absent from school, and time until full activity was allowed. Results: Thirty-five children (thirty-five fractures), with a mean age of 8.7 years, were treated with traction and application of a spica cast, and forty-eight children (forty-nine fractures), with a mean age of 10.2 years, were treated with titanium elastic nails. All fractures healed, and no child sustained a complication that was expected to cause permanent disability. At one year after the fracture, eighty of the children had acceptable alignment and no inequality between the lengths of the lower extremities. The remaining three children, who had an unsatisfactory result, had been treated with traction and a spica cast. Twelve patients (34%) treated with traction and a cast had a complication com- pared with ten patients (21%) treated with titanium elastic nails. Compared with the children treated with traction and a cast, those treated with titanium elastic nails had shorter hospitalization. [ABSTRACT FROM AUTHOR]

Examines the factors affecting the incidence of congenital clubfoot. Association of clubfoot and amniocentesis; Casual relationship of vascular dysplasia with clubfoot deformity; Difficulty in assessing the torsion clinically in patient with club foot.

Background: Some children have persistent pain and instability following inversion injuries of the ankle. Radiographs may reveal a small osseous fragment distal to the lateral malleolus, suggesting an avulsion injury of the anteriortalofibular ligament and/or calcaneofibular ligament. The avulsion injury may involve an os subfibulare, causing ligamentous laxity and chronic pain resulting from nonunion. This situation must be differentiated from an asymptomatic os subfibulare, which is a normal anatomic variant in 1% of children. The purpose of this study was to evaluate the intraoperative findings and long-term outcomes of patients treated operatively for symptomatic avulsion injunes or a symptomatic os subfibulare. Methods: Twenty-three patients presented with chronic ankle pain and instability, tenderness anterior and distal to the lateral malleolus, and imaging studies (magnetic resonance imaging and/or stress radiographs) suspicious for avulsion injury of the anterior talofibular ligament and/or calcaneofibular ligament. After unsuccessful nonoperative treatment, all patients underwent excision of the osseous fragments, anatomic reconstruction of the anterior talofibular ligament with use of drill holes through the lateral malleolus, and a modified Brostrom procedure. Results: The mean age of the patients was 10.4 years (range, eight to thirteen years) at the time of injury and 13.6 years (range, eight to seventeen years) at the time of surgery, representing a mean delay in diagnosis and treatment of 3.2 years. At a mean follow-up of 4.5 years (range, 2.1 to 13.2 years), the mean Foot and Ankle Outcome Score was 91.4 (range, 87 to 98) out of 100, with all but one patient returning to the preinjury recreational level. Only one patient had a long-term complication. Conclusions: In children with chronic pain and instability associated with an os subfibulare, surgical excision of the os subfibulare combined with reconstruction of the anterior talofibular ligament and a modified Brostrom procedure was effective in restoring ankle stability, eliminating pain, and permitting return to the preinjury functional level. [ABSTRACT FROM AUTHOR]

A preface to "International Ophthalmology Clinics" is presented.

Introduction: Seymour physeal fractures of the distal phalanx of the Hallux in children are common but rarely described in the literature. There is limited literature investigating how these fractures should be specifically treated. Generally, good results are reported when open fractures are treated with debridement and antibiotics. This large retrospective review evaluates incidence of infection and compares outcomes of various treatments for Seymour physeal fractures of the distal phalanx of the Hallux in children., Methods: This study included patients ≤18 years of age treated for Seymour fractures of the Hallux between January 1, 2007, and November 20, 2018, at a single tertiary-care urban children's hospital. Demographic, injury, and treatment data were obtained via a retrospective review of electronic medical records, including closed versus open fracture status, time to treatment, and whether antibiotics were prescribed and taken. Initial radiographic imaging was examined by a single attending surgeon for angulation (degrees) and widening (mm). Outcome variables included the development of infection and the rate and success of healing., Results: One hundred thirty-eight patients were included in our analysis. Most (84/138, 61%) fractures were closed and treated successfully without antibiotics. Treatment for open fractures varied greatly, with many of these fractures undergoing an incision and drainage procedure (I&D) (33/54, 61%) and antibiotic prescription (43/54, 76%). Most (47/54, 87%) open fractures did not develop infection. However, 7/54 open fractures presented with an active infection. Four out of seven (29%) of these fractures did not receive any treatment before infection presentation. Two others who presented with infection both had delayed antibiotics and neither underwent I&D. Fractures that either presented with or developed an infection presented significantly later than those fractures that did not develop infection (P<0.001). Neither angulation nor displacement correlated to the time of healing or development of infection., Conclusions: In our large cohort, the majority of open Seymour fractures of the Hallux treated in a timely manner did not develop infection, regardless of treatment. However, open fractures that presented multiple days after injury had an increased incidence of infection. Thus, for open fractures, we recommend timely antibiotics and I&D. Closed fractures may be treated conservatively, with no indication for reduction or use of antibiotics., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Estimating the appropriate tendon length and associated skin incision needed to achieve a plantigrade foot without compromising function are essential steps in open Achilles tendon lengthening. Here we describe a technique using basic surgical instruments referencing anatomic landmarks without the need for radiographs. The center of ankle rotation in the sagittal plane is found referencing the tip of the medial malleolus. This point is translated to the plantar surface of the foot, and a straight instrument in line with the foot is used to make a mark at the posterior calcaneal fat pad. The straight instrument is then rotated (representing the plantar surface of the foot) as if dorsiflexing the ankle along the axis of the transposed tibiotalar joint from a plantar-flexed position to the desired final position and a second mark is made at the posterior heel. The distance between the marks is measured, representing the amount of Achilles lengthening required. The skin incision and tendon limb lengths area a sum of the operative correction and the amount of desired tendon overlap, typically 2 cm of tendon overlap is optimal to allow for suture fixation, ensure tendon healing, and maintain the integrity of the repair. A Z-type lengthening is then performed using this tendon limb length. This technique allows an accurate and simple approach to lengthening the Achilles tendon. In this way the ideal tendon limb length is selected to optimize function while minimizing incision length, associated wound complications, inadequate lengthening, and overlengthening. Level of evidence: Technical note, Level V.

Purpose of Review: To provide a concise review of the literature regarding potential management strategies of ocular thermal and chemical injuries., Recent Findings: After experiencing a serious ocular surface burn, either thermal or chemical, the goal of therapy is to restore a normal ocular surface and corneal clarity. If extensive corneal scarring and/or limbal stem cell deficiency are present, techniques such as limbal stem cell grafting, amniotic membrane transplantation and possibly a keratoprosthesis can be employed to help restore vision. This article will review the literature available and discuss how these techniques have improved the prognosis of patients with serious thermal and chemical injuries., Summary: Ocular thermal and chemical injuries are a true ocular emergency and require immediate and intensive evaluation and treatment. The sequelae of an ocular burn can be severe and particularly challenging to manage. Improvements in the understanding of the pathophysiology of a radiant energy or chemical injury as well as advancements in ocular surface reconstruction have provided hope for patients in whom would otherwise have a dismal visual prognosis.

Background: Treatment for severe/relapsing Blount disease is controversial. The purpose of this study is to assess the safety and efficacy of acute medial plateau elevation with concurrent tibial gradual osteotomy., Methods: This study is a retrospective review of 16 patients (22 limbs) treated by combined plateau elevation and tibial osteotomy for the treatment of Blount disease. We measured the tibiofemoral angle, medial proximal tibial angle, and the plateau angle., Results: All measurements improved significantly preoperatively to postoperatively. The tibiofemoral angle from 29 degrees varus to 3 degrees of valgus, anatomic medial proximal tibial angle from 55 degrees to 86 degrees, and the plateau angle from 37 degrees to 12 degrees (P<0.05). Five patients were considered to have failed which appeared to be the result of undercorrection and subsequent recurrence of the tibial osteotomy and not the plateau elevation., Conclusions: The double osteotomy for Blount disease achieved significant improvement in all patients recurrence appeared to be because of under correction and subsequent worsening of the tibial osteotomy and not collapse of the plateau elevation., Level of Evidence: IV.