Total knee replacement (TKR) is one of the most common orthopaedic procedures performed, and enhanced recovery after surgery (ERAS) has been developed and incorporated into inpatient surgical pathways to improve patient outcomes. Under ERAS recommendations, multimodal prophylaxis has been used to help manage postoperative nausea and vomiting (PONV) following TKR. Dexamethasone is one of the commonly used for this and the anti-inflammatory properties could depress vagal activity, reducing postural hypotension (PH). The hypothesis of this study is that postoperative dexamethasone use is associated with lower rates of early postoperative PH following TKR surgery. In our institution, patients who undergo elective primary TKR are admitted on the day of surgery and follow a standardized ERAS protocol. Data on patients who underwent elective primary TKR under a single adult reconstruction team from September 2017 to March 2020 were reviewed and analyzed. A review of demographic characteristics, surgical data, postoperative medications, and postoperative notes was performed. Binary logistic regression was used to assess the effect of the use of dexamethasone on PH, with an adjusted odds ratio (OR) calculated after accounting for potential confounders. Of the 149 patients were included in the study, 78 had dexamethasone postoperatively, and 71 did not. Patients who had received dexamethasone were statistically less likely to suffer from PH (OR = 0.31, p = 0.03) and less likely to develop PONV (OR = 0.21, p = 0.006). Patients who had received dexamethasone were more likely able to participate in early physiotherapy (OR = 2.42, p = 0.14), and this result was statistically insignificant. The use of postoperative intravenous dexamethasone is significantly associated with lower rates of postoperative PH after TKR. However, more studies are required to assess the optimal dosing amount and frequency, as well as to assess other factors which can enhance early postoperative patient mobilization as part of our goals for ERAS. This therapeutic study reflects level of evidence III.

BackgroundProphylactic pinning of the uninvolved side after unilateral slipped capital femoral epiphysis (SCFE) is controversial. The alpha angle, a measurement of femoral head-neck aspherity, was proposed as a predictor of progression of contralateral SCFE with a treatment threshold of greater than 50.5°. The aim of this study was to evaluate its validity in our cohort of patients.MethodsA retrospective review of a 10-year series of patients who presented with unilateral SCFE was conducted. Minimum follow-up duration to identify contralateral progression was 18 months. Age, sex, ethnicity, and endocrinopathies were noted. Alpha angle measurements of the unaffected hip were performed by two independent observers. The average values of measurements were used for analysis. Univariate and multivariate logistic regression analyses were performed to identify predictors of contralateral progression. A receiver operating characteristic (ROC) curve was generated.ResultsThere were 43 patients with unilateral SCFE. Seven patients (16.3%) developed contralateral SCFE. There were 31 males (72.1%) and 12 females (27.9%). The mean duration from index surgery to contralateral fixation was 43.9 weeks (range, 16.2 to 77 weeks). The mean alpha angle was significantly higher in the patients with contralateral progression (mean, 50.7°; standard deviation [SD], 5.4°; range, 43.8° to 58.5°) than in the patients without progression (mean, 43.0°; SD, 4.2°; range, 33.0° to 52.5°; p < 0.001). The alpha angle was also identified as a statistically significant predictor of contralateral progression on multivariate analysis (p = 0.02). The intraclass correlation coefficient for interobserver reliability was moderately strong at 0.76 (95% confidence interval, 0.55 to 0.87). The area under the ROC curve was 0.88. The treatment threshold of 50.5° had a sensitivity of 0.43, specificity of 0.94, and number needed to treat (NNT) of 2.7. The ideal treatment threshold derived from the ROC curve was 49.0°, which had a sensitivity of 0.71, specificity of 0.89, and an NNT of 1.7.ConclusionsAlpha angle is a potential predictor of contralateral hip involvement in children with SCFE who may benefit from prophylactic hip fixation. Results from our series suggest a treatment threshold be 49.0°. However, given the limited sample size and moderately strong interobserver reliability, larger studies are needed to validate our findings.

Cast immobilization is a noninvasive and effective option in the treatment of fractures in children. However, its use can be associated with complications, such as pressure sores, skin infections, thermal injuries, and joint stiffness. In clinical practice, retained foreign objects in casts are not uncommon. This study aims to ascertain reasons for foreign objects being retained in casts and their effects on the skin. Eighteen children with retained foreign objects in their casts were identified and interviewed. Patient demographics, type of fracture and cast applied, nature of foreign body, and medical complications caused directly by the foreign object were also recorded for analysis. The foreign objects retained included coins, stationery, toy parts, cutlery, and hygiene items. The most common reason for their retention was to relieve itch, followed by accidental insertion and deliberate play. More than half of the children did not suffer complications, and the rest were all skin complications, with the most severe one being an infected skin ulcer that required oral antibiotics. Although the complications of retained foreign bodies are limited to the skin, they can worsen with delayed treatment. Cast care and itch reduction advice must be clearly communicated to patients and their caregivers. Foreign objects in casts must be emergently removed. Level of Evidence: Level 4 Evidence.

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