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Off-label use is frequently practiced in primary and revision arthroplasty, as there may be indications for the application of implants for purposes outside the one the manufacturers intended.
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Under certain circumstances, patients may benefit from selective application of mix & match. This can refer to primary hip arthroplasty (if evidence suggests that the combination of devices from different manufacturers has superior results) and revision hip or knee arthroplasty (when the exchange of one component only is necessary and the invasiveness of surgery can be reduced).
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Within the EFORT ‘Implant and Patient Safety Initiative’, evidence- and consensus-based recommendations have been developed for the safe application of off-label use and mix & match in primary as well as revision hip and knee arthroplasty.
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Prior to the application of a medical device for hip or knee arthroplasty off-label and within a mix & match situation, surgeons should balance the risks and benefits to the patient, obtain informed consent, and document the decision process appropriately.
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Nevertheless, it is crucial for surgeons to only combine implants that are compatible. Mismatch of components, where their sizes or connections do not fit, may have catastrophic effects and is a surgical mistake.
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Surgeons must be fully aware of the features of the components that they use in off-label indications or during mix & match applications, must be appropriately trained and must audit their results.
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Considering the frequent practice of off-label and mix & match as well as the potential medico-legal issues, further research is necessary to obtain more data about the appropriate indications and outcomes for those procedures.
Cite this article: EFORT Open Rev 2021;6:982-1005. DOI: 10.1302/2058-5241.6.210080
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EFORT Open Rev 2021;6:823-824. DOI: 10.1302/2058-5241.6.212000
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Cubital tunnel syndrome (CuTS) is the second most common compression neuropathy of the upper limb, presenting with disturbance of ulnar nerve sensory and motor function.
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The ulnar nerve may be dynamically compressed during movement, statically compressed due to reduction in tunnel volume or compliance, and tension forces may cause ischaemia or render the nerve susceptible to subluxation, further causing local swelling, compression inflammation and fibrosis.
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Superiority of one surgical technique for the management of CuTS has not been demonstrated. Different techniques are selected for different clinical situations with simple decompression being the most common procedure due to its efficacy and low complication rate.
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Adjunctive distal nerve transfer for denervated muscles using an expendable motor nerve to restore the axon population in the distal nerve is in its infancy but may provide a solution for severe intrinsic weakness or paralysis.
Cite this article: EFORT Open Rev 2021;6:743-750. DOI: 10.1302/2058-5241.6.200129
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Cubital tunnel decompression is a commonly performed operation with a much higher failure rate than carpal tunnel release.
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Failed cubital tunnel release generally occurs due to an inadequate decompression in the primary procedure, new symptoms due to an iatrogenic cause, or development of new areas of nerve irritation.
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Our preferred technique for failed release is revision circumferential neurolysis with medial epicondylectomy, as this eliminates strain, removes the risk of subluxation, and avoids the creation of secondary compression points.
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Adjuvant techniques including supercharging end-to-side nerve transfer and nerve wrapping show promise in improving the results of revision surgery.
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Limited quality research exists in this subject, compounded by the lack of consensus on diagnostic criteria, classification, and outcome assessment.
Cite this article: EFORT Open Rev 2021;6:735-742. DOI: 10.1302/2058-5241.6.200135
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Department of Orthopaedic Surgery, Amphia Hospital Breda, The Netherlands
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Upper extremity arthritis in children can be treated with joint aspiration, arthroscopy or arthrotomy, followed by antibiotics. The literature seems inconclusive with respect to the optimal drainage technique. Therefore, the objective of this systematic review was to identify the most effective drainage technique for septic arthritis of the upper extremity in children.
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Two independent investigators systematically searched the electronic MEDLINE, EMBASE and Cochrane databases for original articles that reported outcomes of aspiration, arthroscopy or arthrotomy for septic arthritis of the paediatric shoulder or elbow. Outcome parameters were clinical improvement, need for repetitive surgery or drainage, and complications.
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Out of 2428 articles, seven studies with a total of 171 patients treated by aspiration or arthrotomy were included in the systematic review. Five studies reported on shoulder septic arthritis, one study on elbow septic arthritis, and one study on both joints. All studies were retrospective, except for one randomized prospective study. No difference was found between type of treatment and radiological or clinical outcomes. Aspiration of the shoulder or elbow joint required an additional procedure in 44% of patients, while arthrotomy required 12% additional procedures.
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Conclusion: Both aspiration and arthrotomy can achieve good clinical results in children with septic arthritis of the shoulder or elbow joint. However, the scientific quality of the included studies is low. It seems that the first procedure can be aspiration and washout and start of intravenous antibiotics, knowing that aspiration may have a higher risk of additional drainage procedures.
Cite this article: EFORT Open Rev 2021;6:651-657. DOI: 10.1302/2058-5241.6.200122
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Clínica Alemana, Santiago, Chile
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Growth modulation (GM) with tension-band plates (TBPs) by tethering part of the growth plate is an established technique for the correction of angular deformities in children, and it has increasingly supplanted more invasive osteotomies.
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Growth modulation with TBPs is a safe and effective method to correct a variety of deformities in skeletally immature patients with idiopathic and pathological physes. The most common indication is a persistent deformity in the coronal plane of the knee exceeding 10°, with anterior and/or lateral joint pain, patellofemoral instability, gait disturbance, or cosmetic concerns. GM has also shown good results in patients with fixed flexion deformity of the knee and ankle valgus.
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This paper reviews the history of the procedure, current indications, and recent advances underlying physeal manipulation with TBPs.
Cite this article: EFORT Open Rev 2021;6:658-668. DOI: 10.1302/2058-5241.6.200098
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Acute osteoarticular infections (AOI) should be treated as top emergencies. The first few days following the inception of infection are ultra-critical to long-term prognosis.
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A comprehensive road map for management of childhood AOI is still lacking despite recent advances in microbiology and imaging (magnetic resonance imaging). The many faces of childhood AOI warrant a multidiscipline approach to management.
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Laboratory and imaging findings of are still debatable and should not overshadow or delay a management plan based on the experienced physician’s clinical judgment.
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Ample evidence-based practice supports the use of a few days of intravenous antibiotic administration followed by oral therapy until correlative clinical and basic laboratory (acute phase reactants) results improve.
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The growing body of evidence on ‘high-risk’ children/neonates of AOI warrants continual clinical extra-vigilance in identifying these patient subsets.
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Open drainage and debridement remain the mainstay of treatment of septic hips, whereas for other joints the use of alternative surgical techniques should be individualized or on case-by-case basis.
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Because the consequences of misdiagnosis of AOI are usually grave and permanent, proactive treatment/overtreatment is justified in the event of unconfirmed but suspicious diagnosis.
Cite this article: EFORT Open Rev 2021;6:584-592. DOI: 10.1302/2058-5241.6.200155
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Hospital Base de Valdivia, Valdivia, Chile
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Universidad Austral de Chile, Valdivia, Chile
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Ankle fractures are common in children, and they have specific implications in that patient population due to frequent involvement of the physis in a bone that has growth potential and unique biomechanical properties.
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Characteristic patterns are typically evident in relation to the state of osseous development of the segment, and to an extent these are age-dependent.
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In a specific type known as transitional fractures – which occur in children who are progressing to a mature skeleton –a partial physeal closure is evident, which produces multiplanar fracture patterns.
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Computed tomography should be routine in injuries with joint involvement, both to assess the level of displacement and to facilitate informed surgical planning.
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The therapeutic objectives should be to achieve an adequate functional axis of the ankle without articular gaps, and to protect the physis in order to avoid growth alterations.
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Conservative management can be utilized for non-displaced fractures in conjunction with strict radiological monitoring, but surgery should be considered for fractures involving substantial physeal or joint displacement, in order to achieve the therapeutic goals.
Cite this article: EFORT Open Rev 2021;6:593-606. DOI: 10.1302/2058-5241.6.200042
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Cite this article: EFORT Open Rev 2021;6:387-389. DOI: 10.1302/2058-5241.6.210950
Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Plastic, Reconstructive and Hand Surgery, Nijmegen, The Netherlands
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Department of Plastic, Reconstructive, and Hand Surgery, Rotterdam, The Netherlands
Department of Rehabilitation Medicine, Rotterdam, The Netherlands
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Department of Plastic, Reconstructive, and Hand Surgery, Rotterdam, The Netherlands
Department of Rehabilitation Medicine, Rotterdam, The Netherlands
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Department of Plastic, Reconstructive, and Hand Surgery, Rotterdam, The Netherlands
Department of Rehabilitation Medicine, Rotterdam, The Netherlands
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Department of Plastic, Reconstructive, and Hand Surgery, Rotterdam, The Netherlands
Department of Rehabilitation Medicine, Rotterdam, The Netherlands
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Department of Rehabilitation Medicine, Rotterdam, The Netherlands
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Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Plastic, Reconstructive and Hand Surgery, Nijmegen, The Netherlands
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Routine outcome measurements as a critical prerequisite of value-based healthcare have received considerable attention recently. There has been less attention for the last step in value-based healthcare where measurement of outcomes also leads to improvement in the quality of care. This is probably not without reason, since the last part of the learning cycle: ‘Closing the loop’, seems the hardest to implement.
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The journey from measuring outcomes to changing daily care can be troublesome. As early adopters of value-based healthcare, we would like to share our 10 years of experience in this journey.
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Examples of feedback loops are shown based on outcome measurements implemented to improve our daily care process as a focused hand surgery and hand therapy clinic.
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Feedback loops can be used to improve shared decision making, to monitor or predict treatment progression over time, for extreme value detection, improve journal clubs, and surgeon evaluation.
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Our goal as surgeons to improve treatment should not stop at the act of implementing routine outcome measurements.
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We should implement routine analysis and routine feedback loops, because real-time performance feedback can accelerate our learning cycle.
Cite this article: EFORT Open Rev 2021;6:439-450. DOI: 10.1302/2058-5241.6.210012
