Classification of radial polydactyly based on physical characteristics.

BACKGROUND: Previous classifications in polydactyly of the thumb were by the level of duplication on radiography. This study aimed to develop a practical algorithm based on physical characteristics for treatment guidelines. METHODS: The polydactylies were stratified using four physical characteristics: floating, symmetry, dominant side, and joint angulation/nail size. The algorithm identified the hypoplastic type and then stratified the polydactylies as symmetric and asymmetric. The asymmetric type was divided into ulnar dominant and radial dominant. The symmetric type was divided into adequate type and inadequate type. The prediction of treatments was studied retrospectively by the distribution of surgical procedures in 500 patients with 545 affected thumbs, by the new classification and the Wassel-Flatt classification. RESULTS: Of the 545 polydactylies, 78 (14.5%) were categorized as the hypoplastic type, 369 (67.5%) as the ulnar-dominant type, 8 (1.5%) as the radial-dominant type, 70 (12.8%) as the symmetric adequate nail type, and 20 (3.7%) as the symmetric inadequate type. Treatments were excision and reconstruction in 403 polydactylies (73.9%), simple excision in 135 polydactylies (24.8%), and the Bilhaut-Cloquet procedure, ray amputation, and on-top plasty procedures were only performed in 7 polydactylies (1.3%). The distribution of surgical procedures was distinct among the new classification types and was similar among the Wassel-Flatt types. CONCLUSIONS: The new classification stratified polydactylies by physical findings in a stepwise manner. Though surgical technical details are not included, this simple classification is useful for paediatricians and parents to understand how a surgical decision is made. LEVEL OF EVIDENCE: Diagnostic Level IV.

Environmental factors associated with incidence of developmental dysplasia of the hip: a systematic review and meta-analysis.

BACKGROUND: Established associated factors for DDH include female sex, breech presentation, family history, congenital malformations, oligohydramnios, and maternal hyperthyroidism. However, evidence for environmental factors that may contribute to DDH is limited and inconsistent. METHODS: A systematic review of medical literature was conducted to collect data on environmental factors, including latitude, longitude, average yearly precipitation, average yearly temperature, minimum monthly temperature, and maximum monthly temperature, from all institutions that published articles on DDH. Univariate linear regression analysis was used to examine the correlation between environmental factors and DDH incidence, while multiple regression analysis was conducted to identify significant associated factors for DDH incidence. RESULTS: Data from a total of 93 unique manuscripts were analyzed, revealing a significant negative correlation between DDH incidence and temperature, including average yearly temperature (r = -0.27, p = 0.008), minimum monthly temperature (r = -0.28, p = 0.006), and maximum monthly temperature (r = -0.23, p = 0.029). Additionally, there was a significant positive correlation between DDH incidence and latitude (r = 0.27, p = 0.009), and a significant negative correlation between DDH incidence and average yearly precipitation (r = -0.29, p = 0.004). In the final multiple regression analysis, temperature, including average yearly temperature, minimum monthly temperature, and maximum monthly temperature, were identified as significant associated factors for DDH incidence. CONCLUSION: The findings of this study suggest an association between cold weather and DDH incidence. Further research should explore the link between cold weather and DDH incidence, offering insights into potential interventions for cold climates.

Soft Tissue Releases With Simultaneous Guided Growth Decrease Risk of Spastic Hip Displacement Recurrence.

BACKGROUND: Soft tissue release (STR) is an established treatment for spastic hip displacement, but recurrence of hip displacement is not uncommon. This study aims to (1) evaluate the recurrence of hip displacement after STR, (2) define associated factors of recurrence, and (3) elucidate the effects of guided growth on hip displacement recurrence. METHODS: The study subjects included 66 individuals with spastic cerebral palsy treated by STR with or without guided growth for hip displacement. The treatment goal was the maintenance of migration percentage (MP) to <40%. Recurrence was defined by a rebound of the MP by 5% or more after the first postoperative year. Children with recurrence were compared with those without recurrence using the Mann-Whitney U test and the χ 2 test. The risk factors for recurrence were evaluated using multiple logistic regression analysis. RESULTS: Nineteen individuals (29%) had a recurrence of hip displacement after the first postoperative year. They sustained a 2-fold increase in the rate of treatment failure ( P < 0.001) and reoperation ( P = 0.04). Age, sex, motor function, and preoperative radiographic parameters were comparable between individuals with and without recurrence. The use of guided growth was associated with less risk of recurrence than without (5% and 39%, respectively, odds ratio = 0.01 to 0.45, respectively) despite the similar risk of failure (35% and 48%, respectively, odds ratio = 0.15 to 4.82). CONCLUSIONS: Recurrence of the MP >5% after the first postoperative year is an important early indicator for failure to control MP to <40% and reoperation. Guided growth not only decreases coxa valga but also reduces the risk of recurrent hip displacement after STR. LEVEL OF EVIDENCE: Level III; case-control study.

Prediction of Surgical Outcomes of Radial Polydactyly From the Wassel-Flatt Type and Symmetry of Duplication.

BACKGROUND: The Wassel classification is commonly used for cases of radial polydactyly but has not been used to predict surgical outcomes. This study aimed to investigate the predictive factors of surgical outcomes using the Wassel type and symmetry of duplication. METHODS: Forty-five patients with 47 radial polydactylies were reviewed using the Japanese Society for Surgery of the Hand (JSSH) scores 4.6 years after minor thumb excision and reconstructive surgery. The symmetry index was defined as the metaphyseal width ratio of the minor thumb to the dominant thumb. The relationships between the JSSH scores and operation age, sex, side, follow-up duration, Wassel type, symmetric index, divergent angle, and joint angulation were analyzed by linear regression. RESULTS: The mean JSSH score of the 47 thumbs was 18.3 points (range, 15-20). Five thumbs had fair or poor outcomes (scores <17), all of which were Wassel type IV. The hypoplastic type had a better JSSH score (19.4) than other Wassel types. The symmetric index had a negative relationship with JSSH scores, especially for Wassel type IV (r=-0.68, P =0.001). Linear regression revealed that the symmetric index was the only independent factor significantly associated with JSSH scores among Wassel type IV polydactylies ( P <0.05). The receiver operating characteristic curve suggested a symmetric index <0.74 could predict good or excellent outcomes. CONCLUSION: The symmetry of the 2 duplicated thumbs is an important factor for surgical outcomes. The Wassel type IV polydactylies with a symmetric index >0.74 are at greater risk of fair or poor outcomes after excision and reconstruction, and further studies are warranted to confirm whether the Bilhaut-Cloquet procedure is a good choice. LEVEL OF EVIDENCE: Level IV-Case-control study.

Distal Femur Growth Modification Surgery Is Associated With Higher Surgical Wound Complication Rate.

BACKGROUND: Orthopaedic wound complications are often associated with extensive surgeries and patient medical conditions. However, we noticed wound complications in minor growth modification surgeries in children, including guided growth and epiphysiodesis. Herein, we report the complication rate and risk factors associated with pediatric growth modification surgeries. METHODS: This retrospective study reviewed surgical wound complications in 622 pediatric orthopaedic patients who underwent growth modification surgeries (418 children) or osteotomies (204 children) in the lower extremities in a single center between 2007 and 2019. The grades II and III complications assessed using the modified Clavien-Dindo-Sink complication classification system were compared between growth modification and osteotomy. Risk factors for complications, including the type of surgery, age, body mass index, neuromuscular disease, operation time, surgical sites per patient, surgical location, and implant types, were analyzed using the logistic regression. RESULTS: The complication rate was 6.9% per patient and 3.6% per surgical site (29 sites in 29 patients comprising 21 grade II and 8 grade III) in the growth modification group, which was >1.0% per patient and 0.6% per site in the osteotomy group (2 sites in 2 patients comprising 2 grade III infections; P =0.001). Among 418 patients with 797 surgical sites in the growth modification group, wound complications were associated with surgical location (5.2% at distal femur vs. 1.0% at proximal tibia, P =0.002) and implant type (0.5% using transphyseal screw vs. 4.3-10.5% using plates or staples, P =0.011). CONCLUSION: Surgical wound complication was associated with growth modification surgeries using plates or staples at the distal femur. Our results alert orthopaedic surgeons to this minor but unneglectable problem. Transphyseal screws may be the implant of choice for guided growth and epiphysiodesis at the distal femur in older children, considering the lower risks of wound complication. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Genu Valgum After Distal Femur Extension Osteotomy in Children With Cerebral Palsy.

BACKGROUND: Distal femur extension osteotomy (DFEO) is a common treatment for knee flexion contracture and crouch gait in patients with cerebral palsy (CP), but skeletally immature patients tend to develop genu valgum deformities after DFEO. This study aimed to report the tendency of valgus changes after DFEO and determine the risk factors for subsequent surgery for excessive genu valgum. METHODS: This retrospective case-control study included 25 children with CP who underwent DFEO in 44 limbs for knee flexion contractures ≥15 degrees at a mean age of 11.0 years. Radiologic measurements included the anatomic lateral distal femoral angle (aLDFA), anatomic tibiofemoral angle (aTFA), medial proximal tibia angle, and plate-condyle angle, postoperatively and at the latest follow-up. Age, sex, preoperative knee flexion contracture angle, Gross Motor Function Classification System level, and radiographic measurements were compared between children with and without subsequent guided growth for genu valgum. RESULTS: A significant valgus change was observed at the distal femur in the first postoperative year (aLDFA from 83.6 to 80.1 degrees, P<0.001; aTFA from 176.1 to 172.5 degrees, P<0.01; plate-condylar angle from 5.3 to 9.5 degrees, P<0.001). Valgus changes occurred in 36 of the 44 limbs (82%) by an average of -4.6 degrees in the aLDFA, and subsequent guided growth was performed in 5 patients (20%). Guided growth for genu valgum was associated with a greater postoperative valgus angle (aLDFA: 78.0 vs. 84.9 degrees, P<0.01) but not with age, Gross Motor Function Classification System level, or preoperative flexion contracture. CONCLUSIONS: Distal metaphyseal osteotomies and distally placed angled plates near the physis are associated with valgus changes following growth. We recommend making a slight varus alignment during DFEO to compensate for subsequent valgus changes. LEVEL OF EVIDENCE: Level III-therapeutic, retrospective comparative study.

The effectiveness of adding guided growth to soft tissue release in treating spastic hip displacement.

BACKGROUND: Guided growth at the proximal femur using one transphyseal screw corrects coxa valga and improves hip displacement in cerebral palsy. This study aimed to validate the effects of adding guided growth (GG) to soft tissue release (STR), in terms of decreasing the migration percentage (MP), compared to those with soft tissue alone. METHODS: This retrospective study comprised patients with cerebral palsy who underwent soft tissue release alone (Group STR) or soft tissue release plus guided growth (Group GG) for hip displacement (mean age, 8.1 years; mean follow-up, 4.9 years). Difference in the MP and rate of controlling MP <40% at 2 years postoperatively and rate of revision surgeries at 5 years postoperatively were compared between the groups. RESULTS: The two groups were comparable in age, side, and gross motor function level, but Group GG (n = 24) had more severe hip displacement preoperatively than did Group STR (n = 64). Group GG had a significantly greater 2-year decrease in the MP (-14.8% vs. -11.8%, p < 0.05) than did Group STR. Among patients with a pre-operative MP >50%, the rate of MP <40% was greater in Group GG (73%) than in Group STR (41%). Revision surgeries, mainly repeated guided growth and soft tissue release, were comparable between the groups. CONCLUSIONS: This is the first comparative study to support adding guided growth to soft tissue release, as it results in greater improvements in hip displacement than that with soft tissue release alone. Non-ambulatory patients or severe hip displacement with MP 50%-70% could benefit from this less aggressive surgery by controlling the MP under 40% without femoral osteotomy.

Double diapering facilitates hip maturation in newborns.

BACKGROUND: Double diapering may help to maintain a baby's hips in flexion and abduction posture, but the efficacy in facilitating hip maturation has never been verified. We investigated whether double diapering results in greater improvement of the alpha angle in newborn babies. METHODS: This prospective study enrolled newborns with Graf type IIa immature hips and assigned them to the double-diaper or single-diaper group by the day of birth in a week. Parents were instructed on proper hip positioning, except for diapering. Change in the alpha angle from newborn to 1 month after birth, rate of improvement to bilateral Graf type I hips in 1 month, and number of ultrasound examinations and orthopaedic clinic visits in the first year were compared between the two groups. RESULTS: Seventy newborns with 102 type IIa hips were included from January to December 2017. They were allocated to the double-diaper group (n = 33) and single-diaper group (n = 37). With a comparable sex ratio, gestational age, and newborn alpha angle, the double-diaper group had a greater increase of alpha angles in 1 month than the single-diaper group (+7.9° vs. +5.2°, t-test, p = 0.011). Twenty-eight babies in the double-diaper group (84.8%) and 20 babies in the single-diaper group (54.1%) improved to having bilateral Graf type I hips (chi-square test, p = 0.006). Under the same clinical management pathway, subsequent clinical visits and hip ultrasounds before 1 year were significantly reduced in the double-diaper group. CONCLUSION: Double diapering enhances hip maturation and reduces clinical costs in newborns with physiological immature hips, but the therapeutic role for hip dysplasia requires further study.

Cold Weather as a Risk Factor for Late Diagnosis and Surgery for Developmental Dysplasia of the Hip.

BACKGROUND: Newborn hip screening aims to prevent the late diagnosis of and subsequent surgical procedures for developmental dysplasia of the hip (DDH). Weather may affect how parents swaddle their babies in early life, but weather has never been formally regarded as a risk factor in hip screening. This study investigates the association between the incidence of surgically treated DDH and the outdoor temperature. METHODS: Surgical procedures for late-diagnosed DDH were investigated in 12 birth-year cohorts (1999 to 2010) using the Taiwan National Health Insurance Research Database. The number of children who underwent a DDH-related surgical procedure between 6 months and 5 years of age per total live births was evaluated as an outcome of hip screening. Trend and regression analyses were used to determine the association between the incidence of surgically treated DDH and birth year, birth month, and the temperature during the birth month and first 3 months of life. RESULTS: The mean incidence of surgically treated DDH was 0.48 per 1,000 live births (1,296 surgically treated patients per 2,712,002 live births). The incidence of surgically treated DDH among babies born in winter months (0.70 per 1,000) was significantly higher than that among babies born in summer months (0.32 per 1,000), and it was significantly correlated with mean temperature in the first 3 months of life (r2 = 0.91; p < 0.0001) and birth month (r2 = 0.68; p < 0.001). Multivariable regression revealed that external temperature in the first 3 months of life was the most significant factor (ß = -0.034 [95% confidence interval, -0.042 to -0.022]; p < 0.001) for the incidence of surgically treated DDH (adjusted r2 = 0.485). The trend of seasonal differences remained the same throughout the study years following implementation of the hip-screening policy. CONCLUSIONS: As the incidence of surgically treated DDH is the ultimate outcome of newborn hip screening, cold weather should be regarded as a risk factor and should be incorporated into future screening programs. Weather patterns of different geographical areas should be studied to determine if children born in the winter are at an increased risk for requiring a surgical procedure for DDH, and newborn hip-screening programs should be revised accordingly. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Tension band plates have greater risks of complications in temporary epiphysiodesis.

PURPOSE: This study aimed to compare the efficacy of decreasing leg-length discrepancy (LLD) and postoperative complications between tension band plates (TBP) and percutaneous transphyseal screws (PETS). METHODS: This retrospective study reviewed LLD patients who underwent temporary epiphysiodesis at the distal femur and/or proximal tibia from 2010 to 2017 (minimum two years follow-up). Efficacy of decreasing LLD was assessed one and two years postoperatively. Complications were classified with the modified Clavien-Dindo-Sink complication classification system. Knee deformities were assessed by percentile and zone of mechanical axis across the tibial plateau. RESULTS: In total, 53 patients (25 boys, 28 girls) underwent temporary epiphysiodesis (mean age, 11.4 years). The efficacy of decreasing LLD at two years between the TBP (n = 38) and PETS (n = 15) groups was comparable. Seven grade III complications were recorded in six TBP patients and in one PETS patient who underwent revision surgeries for knee deformities and physis impingement. Four grade I and two grade II complications occurred in the TBP group. The mechanical axis of the leg shifted laterally in the PETS group and medially in the TBP groups (+7.1 percentile versus -4.2 percentile; p < 0.05). Shifting of the mechanical axis by two zones was noted medially in four TBP patients and laterally in two PETS patients. CONCLUSION: More implant-related complications and revision surgeries for angular deformities were associated with TBP. A tendency of varus and valgus deformity after epiphysiodesis using TBP and PETS was observed, respectively. Patients and families should be informed of the risks and regular postoperative follow-up is recommended. LEVEL OF EVIDENCE: Level III.

Guided growth for caput valgum in developmental dysplasia of the hip.

This study reported guided growth for caput valgum deformity and subsequent hip development. Ten children with unilateral hip dysplasia had guided growth by one eccentric transphyseal screw at age 9.1 years with minimum 2 years of follow-up. The first change was decreasing articulotrochanteric distance and then increasing physis tilt angle and head-shaft angle by 1.5 years. The center edge angle that was significantly less than the normal side (18.3 vs. 24.8°) preoperatively became comparable between both the hips 2 years later. Rebounding of physis inclination after screw back out suggested mechanical tethering, rather than permanent physis closure, resulted in morphologic changes in the femur. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Treatment of displaced flexion-type pediatric supracondylar humeral fractures in the prone position.

PURPOSE: This study is to report a new method to reduce and fix the displaced flexion-type pediatric supracondylar fracture in the prone position. METHODS: Ten children with displaced flexion-type supracondylar humeral fractures treated between 2007 and 2013 were reviewed. There were three girls and seven boys, with a mean age of 9.5 years. The fracture was reduced by gentle traction of the forearm and gradual extension of the elbow in the prone position. Two or three crossed Kirschner wires (K-wires) were inserted percutaneously to secure the fracture reduction. Radiographic evaluation included the Baumann's angle and the lateral humerocapitellar angle. Clinical outcomes were assessed using the Flynn's criteria. RESULTS: Eight children had closed reduction and percutaneous K-wire fixation. The other two children required open reduction through a posterior triceps splitting approach. The mean Baumann's angle was 70.2° immediately after K-wires fixation and 69.5° after 3 months later. The mean lateral humerocapitellar angle was 38° immediately after K-wires fixation and 35.5° after 3 months later. The clinical outcome was excellent in nine children and poor in one child by the Flynn's criteria. CONCLUSION: Reduction of displaced flexion-type pediatric supracondylar humeral fractures by traction and gradual extension in the prone position is an effective and safe method. When reduction is still impossible or nerve incarceration is suspected, open reduction and release of the trapped nerve through a posterior triceps splitting approach are simply accessible.

Limits of Calcaneal Lengthening for Treating Planovalgus Foot Deformity in Children With Cerebral Palsy.

BACKGROUND: Calcaneal lengthening is used to correct symptomatic planovalgus foot deformity, but outcomes have been less satisfactory in children with cerebral palsy. This study aimed to define limits of calcaneal lengthening by analyzing the risk factors for undercorrection of deformity. METHODS: We retrospectively reviewed 20 cases of children with cerebral palsy who underwent calcaneal lengthening of 30 planovalgus feet at a mean age of 11.9 years. Foot deformities were evaluated by the anteroposterior talo-first metatarsal angle (normal, 10 ± 7.0 degrees), lateral talo-first metatarsal angle (normal, 13 ± 7.5 degrees), and lateral calcaneal pitch angle (normal, 17 ± 6.0 degrees) on standing foot radiographs. Among these parameters, a corrected foot was defined as 2 or 3 parameters being corrected to within a normal range, and an undercorrected foot was only 1 or no parameter being corrected to within a normal range. Factors were compared between the corrected group and undercorrected group for significant predictors, and cutoff values of predictors were calculated for use as a clinical guideline. RESULTS: Seventeen planovalgus feet were corrected satisfactorily by calcaneal lengthening, while the other 13 feet were undercorrected. Undercorrected feet had a greater preoperative anteroposterior talonavicular angle (33.7 vs 22.8 degrees, P = .001) and a smaller lateral calcaneal pitch (-1.7 vs 5.6 degrees, P = .03). A talonavicular angle of more than 24 degrees and calcaneal pitch less than -5 degrees were identified as cutoff values using a receiver operating characteristic curve. The predicted probability of undercorrection was 100% (9/9 feet) for 2 positive predictors, 50% (8/16 feet) for 1 positive predictor, and 0 (0/5 feet) for zero predictors. CONCLUSION: A talonavicular lateral subluxation of more than 24 degrees on the anteroposterior radiograph and a calcaneal pitch angle less than -5 degrees on the lateral radiograph were 2 independent predictors that could be used to identify a planovalgus deformity that would be beyond the corrective capacity of calcaneal lengthening to restore normal alignment. Level of Evidence Retrospective case control study, level III.

Clinical significance of anterior humeral line in supracondylar humeral fractures in children.

INTRODUCTION: Anterior humeral line (AHL) location is commonly used to evaluate sagittal alignment after fracture reduction in children with supracondylar humeral fractures. However, the position of the AHL for acceptable fracture reduction has not been validated by clinical outcome. The purpose of this study was to investigate the relationship between the location of AHL and range of elbow motion. PATIENTS AND METHODS: We retrospectively reviewed 101 children who underwent closed reduction and percutaneous pinning for Gartland type III supracondylar humeral fractures between January 2009 and June 2014. There were 67 boys and 34 girls, with a mean age of 7 years. The children were classified according to the location of the AHL three months postoperatively into five groups: anteriorly loss (n=6), anterior third (n=25), middle third (n=47), posterior third (n=21), and posteriorly loss (n=2). Range of elbow motion was measured by attending paediatric orthopaedic surgeons with a goniometer. Clinical and radiographic outcomes were compared among the five groups. RESULTS: The mean elbow extension angle was not significantly different among the groups (p=0.21). However, children with AHL anterior to the capitellum had less elbow flexion angle (125.8° vs. 131.2°, p=0.046) and less total range of elbow motion (128.3° vs. 135.7°, p=0.048) than children with AHL crossing the capitellum. When the AHL crossed the capitellum, the elbow flexion angle and total range of elbow motion were significantly decreased in children with AHL crossing the anterior third of the capitellum. The Flynn criteria were not significantly different among the central three groups (p=0.131). However, the Flynn criteria were significantly worse in children whose AHL missed the capitellum (p<0.001). The mean Baumann angle measured 3 months postoperatively was not significantly different among the groups (p=0.12). CONCLUSIONS: These findings demonstrate that children with AHL crossing the middle and posterior thirds of the capitellum appear to have slightly better early elbow flexion and total range of elbow motion. AHL crossing the anterior third of the capitellum can be an underreduction that has similar elbow motion as AHL anterior to the capitellum. AHL posterior to the capitellum is a warning sign of overreduction and should be avoided.

The posterior intrafocal pin improves sagittal alignment in Gartland type III paediatric supracondylar humeral fractures.

INTRODUCTION: Closed reduction and percutaneous Kirschner wire fixation are widely recommended for displaced supracondylar humeral fractures. However, the optimal K-wire configuration is still controversial. The purpose of this study was to compare the results of crossed pinning with or without a posterior intrafocal pin in Gartland type III supracondylar humeral fractures. PATIENTS AND METHODS: We retrospectively reviewed 93 children who underwent crossed pinning for Gartland type III supracondylar humeral fractures between January 2009 and December 2013. One surgeon preferentially added one posterior intrafocal pin onto the crossed pins in 35 children, and the other surgeons used standard crossed pinning technique in 58 children. Results were assessed by range of elbow motion and radiographic measures including the Baumann angle, the lateral humerocapitellar angle and the position of the anterior humeral line (AHL). RESULTS: The demographic data were comparable between the 2 groups. Children treated with the additional posterior intrafocal pin had greater range of elbow motion (138.7° vs. 133.6°, p=0.01) and had a greater lateral humerocapitellar angle (44.9° vs. 37.8°, p=0.01) measured 3 months postoperatively. The percentage of AHL position in the posterior third was significantly higher in children with the posterior intrafocal pin immediately after fixation (odds ratio [OR]: 6.26) and 3 months later (OR: 2.84). The percentage of AHL position in the anterior third was also significantly lower in children with the posterior intrafocal pin 3 months postoperatively (OR: 0.29). No pin site infection or nerve injury was associated with the additional posterior pin. CONCLUSIONS: Adding one posterior intrafocal pin to crossed pinning can facilitate fracture reduction and enhance fixation stability. Better sagittal alignment and elbow motion support this safe and effective technique in treating type III humeral supracondylar fractures.

Posterolateral approach for humeral lateral condyle fractures in children.

We proposed a simple posterolateral approach to the articular surface of the trochlea for fresh and late fractures of the humeral lateral condyle. Twenty consecutive cases, 16 fresh and four old fractures, were approached between triceps and anconeus before the age of 15 years. All fractures achieved union in 3 months. Nineteen cases were classified as excellent or good by the Hardacre score after 31.3 months of follow-up. One late fracture with elbow subluxation showed radiographic fragmentation of the capitellum and a fair clinical result. This simple optional approach offers good exposure of intra-articular fracture at the trochlea, especially for late fractures.

Guided Growth of the Proximal Femur for Hip Displacement in Children With Cerebral Palsy.

BACKGROUND: Guided growth by 1 eccentric transphyseal screw has been used to correct lower limb deformities. Pilot animal studies showed encouraging results in producing varus deformity in the proximal femur. The purpose of this study was to report the preliminary results of guided growth surgery to treat spastic hip displacement. METHODS: This case series study included consecutive patients who received soft-tissue release and guided growth at the proximal femur from January 2004 to May 2012 with minimal 2-year follow-up. Surgical indications were children with spastic cerebral palsy aged 4 to 10 years, a gross motor function classification system level IV or V, and hip displacement on 1 or both sides. Study outcomes were Reimer's migration percentage (MP) and the head-shaft angle (HSA). RESULTS: Nine children with 13 spastic displaced hips received surgery at the age of 6.2 years and were followed up for a mean of 45.6 months. The mean MP improved significantly from 52.2% preoperatively to 45.8% at 3 months, 40.3% at 1 year, and 37.1% at 2 years after operation. HSA was unchanged in the first 3 months, and deceased from 173.3 to 166.4 degrees at 1 year (P<0.01) and to 162.7 degrees at 2 years postoperatively. The screw was usually backed out from the femoral epiphysis in the second postoperative year, and no radiologic bony bar or other surgical complications occurred. CONCLUSIONS: The immediate postoperative improvement of MP was the result of soft-tissue release. From postoperative 3 months to 2 years, the HSA was reduced by 10.6 degrees and the MP further improved by 8.7%. Less surgical dissection, faster recovery of motion, and less comorbidity than varus osteotomy make guided growth surgery a treatment option for coxa valga in spastic hip displacement in nonambulant cerebral palsy children. LEVEL OF EVIDENCE: Level IV-therapeutic, case series.

Influence of obesity on surgical outcomes in type III paediatric supracondylar humeral fractures.

INTRODUCTION: Obesity was associated with poor treatment outcome in paediatric supracondylar humeral fractures. It is controversial about the association is related to more severe fractures in obese children or obesity directly affects treatment. The purpose of this study was to evaluate the influence of obesity on surgical outcomes after control of fracture severity. PATIENTS AND METHODS: This is a retrospective comparative study of 107 children treated for type III supracondylar humeral fractures between January 2009 and December 2013. Children were classified according to sex-specific body mass index (BMI)-for-age growth chart into 4 groups: underweight group (n=10); normal-weight group (n=71); overweight group (n=13); and obese group (n=13). Clinical outcomes were assessed using the Flynn criteria. Radiographic evaluation included the Baumann angle and the lateral humerocapitellar angle. Loss of reduction was defined by Skaggs' criteria. RESULTS: The mean age, sex, and Flynn criteria were comparable among the four BMI groups. Obese children were more likely to develop a varus change in the Baumann angle (p=0.017) and loss of reduction in varus (p=0.059) postoperatively. The risk for pin-related complications was significantly higher in overweight and obese children (p=0.013). CONCLUSIONS: Obesity was associated with more postoperative varus deformation and pin-related complications after surgical fixation for type III supracondylar fracture. These findings underline the importance of stable fixation and close post-operative monitoring in obese children.

Determinants of Hip Displacement in Children With Cerebral Palsy.

BACKGROUND: Coxa valga and femoral anteversion often are seen in patients with spastic hip displacement and osteotomy is recommended. However, the relationship between femoral deformities and hip displacement has not been clearly defined and other factors, such as joint motion and posture, should be considered before recommending treatment. QUESTIONS: For children with cerebral palsy with Gross Motor Function Classification System Level IV or V, we questioned (1) whether hip abduction range correlates with hip displacement, (2) what the relationships are between proximal femoral deformities and hip displacement, and (3) whether the patient with a windblown posture has greater degrees of femoral anteversion? METHODS: We retrospectively studied 31 consecutive children with cerebral palsy with Level IV or V gross motor function who underwent three-dimensional CT for preoperative assessment of hip displacement between January 2010 and December 2013. Among the children, 23 had a windblown posture and eight had symmetric hip motion. Femoral anteversion and true neck-shaft angle were measured from the three-dimensional CT images. Migration percentage was the dependent variable we chose to study in relation to femoral anteversion, neck-shaft angle, maximal hip abduction, and hip flexion contracture, using correlations and multiple linear regressions. Using ANOVA and Scheffé's post hoc tests, we analyzed and compared the data of 23 abducted hips and 23 adducted hips in the 23 children with windblown posture and in 16 displaced hips in the eight children with symmetric hip abduction. RESULTS: Greater migration percentage was associated with less hip abduction range (r = -0.86; p < 0.001). Femoral anteversion had a weak correlation (r = 0.28; p < 0.05) to migration percentage, and the association became insignificant after considering hip abduction motion. Adducted windblown hips had greater femoral anteversion than the symmetric displaced hips and abducted windblown hips (46° vs 36° and 38°, respectively; p < 0.05). CONCLUSIONS: Our study results did not support a relationship between femoral deformities and hip displacement after considering gross motor function and hip abduction motion. Greater femoral anteversion was noted in the adducted hips of patients with windblown posture, and derotation osteotomy is especially recommended. LEVEL OF EVIDENCE: Level III, diagnostic study.

Seasonal Temperature and Pin Site Care Regimen Affect the Incidence of Pin Site Infection in Pediatric Supracondylar Humeral Fractures.

Pin site infection is a common complication after fracture fixation and bone lengthening, and daily pin site care is recommended. Weather is a strong environmental factor of infection, but few articles studied the issue of weather and pin site infection. We performed a prospective comparative study of 61 children with supracondylar humeral fractures treated by closed reduction and percutaneous pinning. The patients were divided into high-temperature season or low-temperature season by the months they received surgery. The patients within each season were further allocated to 2 groups by the different postoperative pin site care methods of daily care or noncare. The infection rate per patient was significantly higher in the high-temperature season compared to low-temperature season (45% versus 19%, P = 0.045). In the high-temperature season, the infection rate per patient was significantly higher in the daily care group versus the noncare group (70% versus 20%, P = 0.001). In the low-temperature season, the infection rate per patient was not significantly different in the daily care group versus the noncare group (10% versus 27.3%, P = 0.33). We recommend that careful monitoring of infection signs, rather than pin site cleaning, would be appropriate in the treatment of pediatric supracondylar humeral fractures, especially during the summer months.