OBJECTIVE: The purpose of the European consensus was to provide recommendations for the treatment of patients with a painful degenerative varus knee using a joint preservation approach. Part II focused on surgery, rehabilitation and complications after tibial or femoral correction osteotomy.
METHODS: Ninety-four orthopaedic surgeons from 24 countries across Europe were involved in the consensus, which focused on osteotomies around the knee. The consensus was performed according to the European Society for Sports Traumatology, Knee Surgery and Arthroscopy consensus methodology. The steering group designed the questions and prepared the statements based on the experience of the experts and the evidence of the literature. The statements were evaluated by the ratings of the peer-review groups before a final consensus was released.
RESULTS: The ideal hinge position for medial opening wedge high tibial osteotomy (MOW HTO) should be at the upper level of the proximal tibiofibular joint, and for lateral closing wedge distal femoral osteotomy (LCW DFO) just above the medial femoral condyle. Hinge protection is not mandatory. Biplanar osteotomy cuts provide more stability and quicker bony union for both MOW HTO and LCW DFO and are especially recommended for the latter. Osteotomy gap filling is not mandatory, unless structural augmentation for stability is required. Patient-specific instrumentation should be reserved for complex cases by experienced hands. Early full weight-bearing can be adopted after osteotomy, regardless of the technique. However, extra caution should be exercised in DFO patients. Osteotomy patients should return to sports within 6 months.
CONCLUSIONS: Clear recommendations for surgical strategy, rehabilitation and complications of knee osteotomies for the painful degenerative varus knee were demonstrated. In Part 2 of the consensus, high levels of agreement were reached by experts throughout Europe, under variable working conditions. Where science is limited, the collated expertise of the collaborators aimed at providing guidance for orthopaedic surgeons developing an interest in the field and highlighting areas for potential future research.
METHODS: Level II, consensus.

BACKGROUND: The rationale for the use of mini-implants for partial resurfacing in the treatment of femoral chondral and osteochondral lesions is still under debate. The evidence supporting best practise guidelines is based on studies with low-level evidence. A consensus group of experts was convened to collaboratively advance towards consensus opinions regarding the best available evidence. The purpose of this article is to report the resulting consensus statements.
METHODS: Twenty-five experts participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted via an online survey of two rounds, for initial agreement and comments on the proposed statements. An in-person meeting between the panellists was organised during the 2022 ESSKA congress to further discuss and debate each of the statements. A final agreement was made via a final online survey a few days later. The strength of consensus was characterised as: consensus, 51-74% agreement; strong consensus, 75-99% agreement; unanimous, 100% agreement.
RESULTS: Statements were developed in the fields of patient assessment and indications, surgical considerations and postoperative care. Between the 25 statements that were discussed by this working group, 18 achieved unanimous, whilst 7 strong consensus.
CONCLUSIONS: The consensus statements, derived from experts in the field, represent guidelines to assist clinicians in decision-making for the appropriate use of mini-implants for partial resurfacing in the treatment of femoral chondral and osteochondral lesions.
METHODS: Level V.

The Musculoskeletal Tumor Society, in partnership with American Society of Clinical Oncology and American Society for Radiation Oncology, has developed a clinical practice guideline to assist providers with the care of patients with metastatic carcinoma and myeloma of the femur. The guideline was developed by an Expert Panel consisting of representatives of all three organizations by American Academy of Orthopaedic Surgeons (AAOS) methodologists using the AAOS standardized guideline development process. A systematic review of the available evidence was conducted, and the identified evidence was rated was rated for quality and potential for bias. Recommendations were developed based on this evidence in a standardized fashion. The guideline was approved by the guideline approval bodies of all three organizations. Thirteen recommendations were synthesized covering relevant subtopics such as imaging, use of bone-modifying agents, radiation therapy, and surgical reconstruction. The consensus of the expert panel was that bone-modifying agents may assist in reducing the incidence of femur fracture, regardless of tumor histology. The panel recommended the use of radiation therapy to decrease the rate of femur fractures for patients considered at increased risk. The panel recommended arthroplasty be considered to improve patient function and decrease the need of postoperative radiation therapy in patients with pathologic fractures in the femur.

The American Academy of Orthopaedic Surgeons (AAOS) created an evidence-based clinical practice guideline for the care of pediatric diaphyseal femur fractures in 2010. Our institution implemented checklists based off these guidelines embedded in a standardized EMR order. The purpose of this study was to describe compliance with checklist completion and to assess safety improvement in a large urban pediatric hospital.
Retrospective and prospective data were collected from 2 years before and 5 years after checklist implementation. This included the patient safety checklists from August 2011 through August 2016. Patients aged 0 to 18 years with a diaphyseal femur fracture were queried from the EMR and included in this study. Patient charts were reviewed for complications, including nerve injury, pressure sore, leg length discrepancy, loss of reduction, failure of fixation, nonunion, delayed union, and infection. Compliance rates were reported based on the AAOS clinical practice guidelines.
A total of 313 patients for the postchecklist period were reviewed in this study. Of 219 patients eligible for inclusion, 198 had checklists completed (group B). This group was compared with 100 patients with diaphyseal femur fractures from the period before implementation of the checklist (group A). We found no statistical difference in the number of patients with complications between groups (12% in both groups, P = 0.988). Postoperative checklists demonstrated that 89.9% of patients (178/198) received age-appropriate treatment consistent with the AAOS guideline recommendations after implementation of the checklist. Before the checklist implementation (group A), 94% (94/100) adhered to the guidelines.
This study reveals high compliance rates with the AAOS evidence-based clinical practice guideline for the management of pediatric femur fractures. Implementing standardized checklists is possible by embedding them into the EMR. Implementation of checklists did not improve compliance or patient outcomes.

BACKGROUND: Recent studies demonstrate considerable deviation from the American Academy of Orthopaedic Surgeons (AAOS) evidence-based guidelines for the treatment of pediatric diaphyseal femur fractures (PDFFs). This study aimed to determine if expert-consensus can be reached on a principle-based classification to be applied broadly to a wide variety of PDFF scenarios and if outcomes correspond to adherence to the classification.
METHODS: A 2-stage study was performed. First, a survey of experts using a principle-based approach to PDFF. We conducted a survey of 17 thought-leaders (criteria≥20 y\' experience+authors of the seminal pediatric femur fracture studies) who were asked to classify 15 cases of PDFF using the principle-based classification for agreement. Next, we conducted a retrospective review of 289 consecutive PDFF treated (2011-2015) at a level 1 pediatric trauma center. For each case, we compared the actual treatment and proposed \"ideal\" principle-based classification. We then compared clinical results and outcome data points including the length of stay, physician visits, and hospital charge data.
RESULTS: A substantial (κ=0.7) expert-agreement was noted for assigning treatment principles with near-perfect (κ=0.93) agreement on conservative versus surgical management. We obtained agreement on employing a flexible implant (κ=0.84) rigid fixation (κ=0.75) and damage control philosophy (κ=0.64). Suboptimal clinical results were noted in 43% of the undertreated patients (24/56), 18.8% of the adequately treated, and 14.3% of overtreated (P<0.01) patients. An increasing trend for the length of hospital stay and a number of clinic visits was noted as the treatment class increased (P<0.01). Charges were 4.2 times higher for an episode of operative versus nonoperative care (P<0.01). Rigid fixation (class 4) had significantly (P=0.01) higher total and material charges than flexible fixation (class 3).
CONCLUSIONS: The proposed classification has a substantial agreement among thought-leaders. Clinical results demonstrated significantly more suboptimal results in undertreated fractures, compared with ideally treated or more invasively treated fractures. More invasive treatments led to increased burden to families and the system in terms of length of stay and hospital charges.
METHODS: Level III.

To determine whether patient-specific finite element (FE) computer models are better at assessing fracture risk for femoral bone metastases compared to clinical assessments based on axial cortical involvement on conventional radiographs, as described in current clinical guidelines.
Forty-five patients with 50 femoral bone metastases, who were treated with palliative radiotherapy for pain, were included (64% single fraction (8Gy), 36% multiple fractions (5 or 6x4Gy)) and were followed for six months to determine whether they developed a pathological femoral fracture. All plain radiographs available within a two month period prior to radiotherapy were obtained. Patient-specific FE models were constructed based on the geometry and bone density obtained from the baseline quantitative CT scans used for radiotherapy planning. Femoral failure loads normalized for body weight (BW) were calculated. Patients with a failure load of 7.5 x BW or lower were identified as having high fracture risk, whereas patients with a failure load higher than 7.5 x BW were classified as low fracture risk. Experienced assessors measured axial cortical involvement on conventional radiographs. Following clinical guidelines, patients with lesions larger than 30mm were identified as having a high fracture risk. FE predictions were compared to clinical assessments by means of diagnostic accuracy values (sensitivity, specificity and positive (PPV) and negative predictive values (NPV)).
Seven femurs (14%) fractured during follow-up. Median time to fracture was 8 weeks. FE models were better at assessing fracture risk in comparison to axial cortical involvement (sensitivity 100% vs. 86%, specificity 74% vs. 42%, PPV 39% vs. 19%, and NPV 100% vs. 95%, for the FE computer model vs. axial cortical involvement, respectively).
Patient-specific FE computer models improve fracture risk assessments of femoral bone metastases in advanced cancer patients compared to clinical assessments based on axial cortical involvement, which is currently used in clinical guidelines.

OBJECTIVE: To assist clinicians in assigning gestational age based on ultrasound biometry.
RESULTS: To determine whether ultrasound dating provides more accurate gestational age assessment than menstrual dating with or without the use of ultrasound. To provide maternity health care providers and researchers with evidence-based guidelines for the assignment of gestational age. To determine which ultrasound biometric parameters are superior when gestational age is uncertain. To determine whether ultrasound gestational age assessment is cost effective.
METHODS: Published literature was retrieved through searches of PubMed or MEDLINE and The Cochrane Library in 2013 using appropriate controlled vocabulary and key words (gestational age, ultrasound biometry, ultrasound dating). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies written in English. There were no date restrictions. Searches were updated on a regular basis and incorporated in the guideline to July 31, 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.
METHODS: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).
RESULTS: Accurate assignment of gestational age may reduce post-dates labour induction and may improve obstetric care through allowing the optimal timing of necessary interventions and the avoidance of unnecessary ones. More accurate dating allows for optimal performance of prenatal screening tests for aneuploidy. A national algorithm for the assignment of gestational age may reduce practice variations across Canada for clinicians and researchers. Potential harms include the possible reassignment of dates when significant fetal pathology (such as fetal growth restriction or macrosomia) result in a discrepancy between ultrasound biometric and clinical gestational age. Such reassignment may lead to the omission of appropriate-or the performance of inappropriate-fetal interventions.
UNASSIGNED: RECOMMENDATIONS.

OBJECTIVE: The objective of this study was to measure the dimensions and the angulations of the femur and tibia for arthritic knees that were scheduled for total knee surgery. The purpose was to provide information for the design of surgical instruments such as cutting guides. Instruments made using three-dimensional printing were a particular consideration because of the variations in sizing that are possible.
METHODS: Sixty-six frontal plane EOS radiographs were obtained of patients with osteoarthritis who were under consideration for total knee arthroplasty. The images were imported into computer-assisted design software. The anatomic and mechanical axes and the joint lines were constructed for the femur and tibia. The angles between the axes and lines and key dimensions including the femoral canal diameters were measured.
RESULTS: The angle between the anatomic and mechanical axes was 5.5° ± 1.4°, the femoral joint line sloped 2.2°, and the tibial joint line 4.3° to the mechanical axes. The values were similar to non-arthritic knees except for a higher tibial slope. The femoral canal diameter at 150 mm from distal was 19 ± 5 mm.
CONCLUSIONS: In a total knee replacement procedure, aligning perpendicular to the mechanical axis results on average about 2° more valgus and 2° to 3° tilt of the joint line. Instruments could be calibrated for individual patients, but the maximum variations based on long-term follow-up should be recognized. A multi-diameter system is needed for the femoral intramedullary rod to limit errors to 1° or less.

Prior studies indicate that one factor that may contribute to total hip arthroplasty failure due to mechanically assisted crevice corrosion at the femoral head-trunnion junction is the method of femoral head fixation.
Up-to-date on-line surgical technique guides describing fixation of the prosthetic femoral head of common implants of the 4 largest manufacturers as well as 2 minor manufacturers were identified. The information given regarding preparation and fixation of the femoral head was evaluated and compared.
A total of 24 surgical technique guides were evaluated. Most guides (22/24) addressed fixation technique; of these, 19 of 22 suggested cleaning and 20 of 22 suggested drying the trunnion prior to affixing the femoral head. The manner of fixation, however, varied widely and there was no single technique advocated.
The majority of surgeon education materials do not specify a single technique for assembly of the head femoral component in total hip arthroplasty. If the method of fixation is indeed important, efforts should be made to identify the best technique, and improve and unify the surgical technique instructions.

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