Comparison of Surgical and Conservative Treatments for Gartland Type II Supracondylar Humerus Fractures: Evaluation of the Need for Surgical Treatment.

BACKGROUND: Supracondylar humerus fractures (SHFs) are common pediatric injuries, with type II fractures being a topic of debate regarding optimal treatment. Our goals are to compare the functional and radiographic outcomes of conservative and surgical treatment of type II SHFs and their subgroups and to identify parameters for determining the optimal treatment option. METHODS: We retrospectively reviewed a total of 55 patients (23 conservative, 32 surgical) between 2010 and 2020. The mean follow-up was 66 months. Neurovascular status, range of motion, complications, and functional scores (Mayo elbow, Quick DASH) were evaluated. We performed radiographic assessment on initial, postreduction, and final follow-up radiographs using the humerocondylar angle (HCA), Baumann angle, and anterior humeral line (AHL). RESULTS: Neither groups nor subgroups showed significant differences in clinical and functional outcomes. HCA was significantly higher in the operative group than in the conservative group. The subgroup analysis revealed that the HCA difference resulted from the difference between the conservative IIb and operative IIb subgroups. None of the patients required a corrective osteotomy, but 1 patient initially treated conservatively underwent operative treatment due to loss of reduction. CONCLUSIONS: Reconstructing the sagittal, coronal, and rotational alignment in type II SHFs led to good mid-term results in the range of motion and functional scores for the elbow joint, whether conservative or surgical treatment was used. A limited range of remodeling might be expected in the long term. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Identifying Risk Factors for Open Reduction in Pediatric Supracondylar Humerus Fractures.

BACKGROUND: Supracondylar humerus fractures (SCHFs) are the most common injuires of the elbow in children, often categorized by the Gartland classification. While type 1 and 2 fractures commonly managed conservatively, type 3 and 4 fractures typically require surgical treatment. Although closed reduction and percutaneous pinning have shown success, open reduction may be required in cases where adequate reduction cannot be achieved. This study aims to identify radiological and clinical risk factors associated with transitioning from closed reduction to open reduction in Gartland type 3 and 4 SCHF in children. STUDY DESIGN AND METHODS: We retrospectively analysed 159 patients operated on between 2014 and 2022 for Gartland type 3 and 4 SCHF. Parameters including age, gender, injury severity, time to surgery, neurovascular damage, medial spike angle, fracture-skin distance, medial-lateral deviation, rotation, fracture level, and Baumann angle were evaluated. RESULTS: A total of 159 SCHF in children aged 3 to 12 years, classified as Gartland type 3 (106 patients, 66.6%) and type 4 (53 patients 33.4%), underwent surgical intervention. Notably, 46 patients (28.9%) initially managed with closed reduction exhibited failure, prompting the necessity for conversion to open reduction. Injury severity, lateral deviation, advanced age, low medial spike angle, and low fracture tip-to-skin distance were found to be factors that could potentially increase the need for open reduction ( P <0.05). Logistic regression analysis showed that the low medial spike angle, flexion type injury, and low fracture type increased the likelihood of open surgery ( P <0.05). Sex, side, duration to surgery, and Baumann angle showed no significant associations. CONCLUSIONS: SCHF commonly necessitate surgical intervention in children. Although the risk factors for failed closed reduction and the need for open surgery have been discussed in the literature, there is no consensus. Preoperative planning, particularly for patients with specific factors like lateral deviation, advanced age, low medial spike angle, low fracture-to-skin distance and high injury severity, should consider potential open surgery requirements. LEVEL OF EVIDENCE: Level III.

Single Versus 3-incision Triple Pelvic Osteotomy: Comparison of Clinical and Radiologic Results.

BACKGROUND: Triple pelvic osteotomy (TPO) is indicated when the anatomic and functional realignment of the hip joint is needed. Although the traditional approach for TPO involves a separate incision for ischial cut, there has been a trend for single-incision TPO in recent years. This study aims to compare the clinical and radiologic results of 2 different approaches. METHODS: Forty-two hips of 39 patients treated using TPO with a minimum of 24 months of follow-up were included in our cohort. Demographics, perioperative, and radiologic parameters were evaluated. Harris Hip Score and International Hip Outcome Tool were used for clinical evaluation. RESULTS: A single anterolateral incision approach was used in 18 hips (17 patients), whereas a 3-incision approach was used in 24 hips (22 patients). The mean follow-up was 4.7 years in the 3-incision group and 3.8 years in the single-incision group ( P =0.43), with mean surgery age at 8.7 years (range, 5.4 to 12) for single-incision and 9.7 years (range, 7.7 to 11.7) for 3e-incision ( P =0.22). There were no significant differences observed between the 2 groups concerning radiographic measurements, complications, and functional scores. The mean surgical time was 118.6 minutes in the single-incision group and 97.9 minutes in 3-incision group ( P =0.036). Mean intraoperative blood loss was 181.7 ml in the single-incision group and 243.4 ml in 3-incision group ( P =0.028). Three-incision group demonstrated significantly higher intraoperative blood loss, leading to lower hemoglobin values ( P =0.042). CONCLUSION: The single-incision TPO demonstrated similar outcomes compared with the traditional 3-incision approach in terms of radiologic correction and functional improvement. The single-incision technique exhibited advantages such as reduced intraoperative blood loss and potential benefit of decreased pain due to fewer scars. However, it required a longer surgical time compared with the 3-incision approach. Surgeons should consider patient-specific factors and their expertise when selecting the most appropriate approach for each case. LEVEL OF EVIDENCE: Level III-retrospective comparative series.

Elastic Stable Intramedullary Nailing in Length Stable Versus Unstable Pediatric Femoral Shaft Fractures: A Comparison of Clinical, Radiographic, and Pedobarographic Outcomes.

BACKGROUND: Pediatric diaphyseal femoral fracture (PDFF) is one of the most common injuries requiring hospitalization. Elastic stable intramedullary nailing (ESIN) is commonly used for PDFFs in ages 5 to 11. The optimal treatment method for length unstable PDFF is a subject of ongoing debate. This study aimed to compare clinical, radiographic, and pedobarographic outcomes of ESIN between length stable and unstable PDFF. METHODS: We retrospectively reviewed patients undergoing ESIN treatment for isolated PDFF between 2016 and 2021. Exclusion criteria were (1) history of ipsilateral or contralateral lower extremity fractures, (2) highly comminuted or segmental fractures, (3) body weight >50 kg, and (4) comorbidities affecting bone quality, range of motion, or neurologic status. The patients were divided into 2 groups according to length stability. Clinical, radiographic, and pedobarographic data were then assessed to compare groups. RESULTS: Twenty-five patients were included (17 length stable and 8 length unstable PDFF) with a mean age of 73.6±17.8 months. There was no significant difference between groups in age, side of injury, body weight, follow-up duration, and nail-canal diameter ratio. Mean deformity in the fracture site in the early postoperative x-rays was not significantly different between groups ( P =0.661). After a mean follow-up of 27.8±14.2 months (range, 12-67), there was no significant difference in mechanical axis deviation, distal femur joint orientation angle, or limb-length discrepancy in both groups. The pedobarographic assessment revealed that the length unstable group had a significantly higher external foot progression angle in the injured extremity (9.8°±6.9° vs. 1.3°±5.6°, P =0.031). However, the length stable group had no significant difference in the foot progression angle (4.9°±5° vs. 3°±4.3°, P =0.326). There was no significant difference in either group for other pedobarographic parameters. CONCLUSION: ESIN is a safe and effective option for length-unstable PDFF, yet attention should be paid to the rotational alignment. Although significant external rotation deformity occurs in length-unstable PDFF, it has no implications for the other pedobarographic parameters. LEVEL OF EVIDENCE: Level IV.

Does the Sleeper Plate Application for Temporary Epiphysiodesis Make Life Easier or Complicated? Increased Risk of Tethering.

BACKGROUND: The present study aims to investigate the frequency of recurrence and tethering effect after only metaphyseal screw removal (sleeper plate technique) compared with the conventional complete plate removal in the treatment of lower extremity deformities with guided growth surgery. METHODS: Seventy-two patients (107 limbs) treated by an 8-plate hemiepiphysiodesis technique around the knee joint were evaluated. After the desired correction, only metaphyseal screw was removed (sleeper plate group) in 35 limbs (25 patients), whereas both screws and plate were removed (plate removal group) in 72 limbs (47 patients). An increase of 5 degrees or more in joint orientation angles in the direction of the initial deformity was considered as recurrence. The rate of rebound, tethering, and maintenance of correction in groups was analyzed at the latest follow-up (mean of 49 mo). RESULTS: The mean age of the patients was 97 months (range: 80 to 129 mo) at the time of index surgery. After a mean of 49 months (range: 16 to 86), 17 (48.5%) limbs maintained the desired stable correction in the sleeper plate group compared with 59 stable limbs (72.2%) in the plate removal group ( P <0.001). There was no statistically significant difference regarding recurrence between the sleeper plate group and the plate removal group (34.3% vs. 27.8%, respectively) ( P =0.216). Reinsertion of the metaphyseal screw was possible 8/12 limbs, and the remaining 4 limbs underwent further surgeries. There were 6 limbs (17.3%) of tethering in the sleeper plate group, and 4/6 limbs required further corrective surgeries. The remaining 2 limbs with slight tethering did not require further surgeries. CONCLUSIONS: Removing only metaphyseal screw increases the risk of tethering. In addition, reinsertion of the screw may not be possible in all cases due to bony growth, and further corrective surgeries may be necessary. Close follow-up is required if the sleeper plate technique is to be applied. LEVEL OF EVIDENCE: Level III.

Intraoperative medial wall disruption in Dega pelvic osteotomy: Does it effect the radiographic outcome at medium-term?

OBJECTIVES: To compare the radiographic outcomes of our patients who encountered medial wall disruption, with those who did not while undergoing Dega osteotomy. METHODS: We retrospectively reviewed the records of 95 hips with developmental dysplasia of the hip who were treated with Dega pelvic osteotomy. Hips were divided into 2 groups according to medial wall disruption: group A included the hips with medial wall disruption, while group B included the hips without disruption. Preoperative, immediate postoperative, 12 weeks and last follow-up anteroposterior radiographs of the pelvis were reviewed for changes in the acetabular index (AI) between groups. RESULTS: There were 22 hips in group A and 73 hips in the group B. Preoperative (34.6 versus [vs] 37.2, p=0.231), postoperative (17.9 vs 18.4, p=0.682), 12th week (18 vs 18, p=0.504) and last follow-up (13.3 vs 15.1, p=0.097). The acetabular index measurements were comparable between the groups. Corrections achieved during surgery, and during the follow-up period were also comparable between the two groups, indicating no loss of radiographic correction caused by medial wall disruption. Ninety one percent of the patients in group A and 90% of group B achieved good or excellent results according to the Severin classification (p=0.944). CONCLUSION: Our study shows that disruption of the medial wall did not have a significant detrimental effect on radiographic correction when performing Dega osteotomy.

Complex rigid foot deformity correction with hexapod external fixator system.

PURPOSE: Complex rigid foot deformities include three-plane deformities and usually presents with poor soft tissue coverage. In the last decades, gradual correction with computer-assisted fixator became an appropriate option for the treatment rigid foot deformities. This study aims to report our experience about treatment of complex foot deformities using Smart Correction fixator system®. METHODS: We retrospectively analyzed 13 complex rigid foot deformities of ten consecutive patients treated with Smart Correction fixator system® from 2016 to 2020. Primary outcomes were classified as good, fair, and poor according to previously determined criteria. The outcomes were also assessed with The Manchester-Oxford Foot Questionnaire (MOXFQ). Non-parametric analysis (Wilcoxon test) for continuous variables and the Fisher's exact test for categorical variables were used. RESULTS: Plantigrade foot was achieved in all patients after correction program. Supramalleolar osteotomy was applied in nine feet, midfoot osteotomy was applied in two feet, hindfoot osteotomy was required in one foot, and only soft tissue distraction performed in two feet. Two patients had recurrent deformity managed by further acute corrections. The mean MOXFQ scores improved from 72.7 preoperatively to 24.8 at last follow-up. CONCLUSIONS: Present study shows that SCF the reliable option for the treatment of complex foot deformities, which also facilitates three-plane correction and concomitant lengthening with gradual soft tissue balance.

Fixation techniques in lower extremity correction osteotomies and fractures in mild-to-severe osteogenesis imperfecta patients: evaluation of the results and complications.

INTRODUCTION: Osteogenesis imperfecta is a genetic disorder leading to multiple fractures and deformities. Intramedullary rods have been used in the surgical treatment of osteogenesis imperfecta for decades. Complication rates reported by current techniques have been high. This study aimed to examine the results of intramedullary fixation combined with plate and screw technique in patients with osteogenesis imperfecta compared to isolated intramedullary fixation. METHODS: Between 2006 and 2020, forty patients who had surgical treatment for deformities or fractures of the femur, tibia or both with at least two years of follow-up after surgery were included in the study. Patients were divided into groups according to fixation methods. Group 1 was intramedullary fixation only (Titanium Elastic Nail [TEN], Rush Pin, and Fassier-Duval Rod), and Group 2 was intramedullary fixation combined with plate and screws. Medical records and follow-up radiographs were reviewed to evaluate healing and callus formation, types of complications and infection rates. RESULTS: The total number of operated lower extremities of these forty patients was 61 (45 femur and 16 tibia). The mean age of the patients was 9.3 ± 4.6 years. Mean follow-up duration of the patients was 4.4 ± 1.7 years. Thirty-seven (61%) were in Group 1, and 24 (39%) were in Group 2. There was no statistically significant difference in callus formation time between Group 1 and Group 2 (p = 0.67). Complications occurred in 21 of 61 surgeries. While 17 of these complications were in Group 1, 4 were in Group 2 (p = 0.01). CONCLUSION: Intramedullary fixation combined with the plate and screw technique in children with osteogenesis imperfecta is successful considering the complications and revision requirements.

Accuracy of the hexapod external fixator in treating tibial angular deformities with or without limb length discrepancy: a retrospective study.

OBJECTIVE: Hexapod external fixator systems allow simultaneous deformity correction in multiple planes as well as limb lengthening. The aim of this study is to evaluate the accuracy of a hexapod frame (smart correction frame) in different types of tibial deformities requiring correction with or without lengthening. METHODS: A total of 54 tibial angular deformities and limb length discrepancies operated with a hexapod frame between January 2015 and January 2021 were classified into four groups: "Group A ( n  = 13): only lengthening," "Group B ( n  = 14): lengthening and uniplanar correction," "Group C ( n  = 16): only uniplanar correction," and "Group D ( n  = 11): biplanar correction." The accuracy of angular deformity correction/lengthening was calculated by dividing the actual correction/lengthening achieved after frame removal by the preoperative planned lengthening/correction. RESULTS: The lengthening accuracy in Group A and Group B was 96.3 ±â€…7.1% and 95.7 ±â€…5.9%, respectively ( P  = 0.685). The angular deformity correction accuracy was 85.1 ±â€…9.9% for Group B, 85.2 ±â€…13.9% for Group C, and 80.2 ±â€…18.4% for Group D ( P  = 0.852). A revision program was performed in six cases (1 in Group B, 1 in Group C, and 4 in Group D) for full correction of the deformities. CONCLUSION: The accuracy of tibial lengthening is high with the hexapod frame and is minimally affected by simultaneous deformity correction; however, the accuracy of angular correction slightly reduces as the deformity becomes more complex. Surgeons should be aware that reprogramming may be required after complex deformity correction.

The Fate of Overcorrection After Hemiepiphysiodesis in Valgus Deformities Around the Knee.

BACKGROUND: Tension band plating is widely used in the surgical treatment of coronal plane deformities around the knee. The rebound phenomenon after implant removal is a common complication of this technique. Overcorrection of joint orientation angles is a method to minimize the effect of the rebound phenomenon. This study aims to investigate the natural course of overcorrected joint orientation angles after plate removal in patients with genu valgum deformity. METHODS: Patients who underwent hemiepiphysiodesis with tension band plating due to genu valgum deformity between 2010 and 2019 were retrospectively analyzed. Mechanical lateral distal femoral angles (mLDFA) and mechanical medial proximal tibial angles were calculated before plate application, before implant removal, and at the last follow-up. At the implant removal, mLDFA>90 degrees and mechanical medial proximal tibial angles <85 degrees were accepted as overcorrected. RESULTS: Seventy-two segments from 45 patients were included. For femoral valgus deformities (n=59), the mean mLDFAs at index surgery, implant removal, and the last follow-up were 79.8±3.9 degrees, 95.5±3.7 degrees, and 87.3±5.1 degrees, respectively. In the more and less than 10 degrees rebound groups, the median age of patients at index surgery were 66 and 101 months ( P =0.04), the mLDFA during implant removal were 97.8 degrees and 94.4 degrees ( P =0.005), and the mean amount of correction in mLDFA was 17 degrees and 13 degrees ( P =0.001), respectively. At the last follow-up, joint orientation angles were found to be still overcorrected in 16 (22%), within normal limits in 36 (50%), and undercorrected in 20 (28%) segments. Ten (13%) segments required additional surgery due to residual deformity. CONCLUSIONS: Overcorrection with tension band plating is an effective modality in the treatment of genu valgum deformity. Rebound after plate removal increases as the age at index surgery decreases and the amount of conscious overcorrection increases. Most segments return to normal joint orientation angle limits after overcorrection. We recommend a mean of 5 degrees routine overcorrection in patients with genu valgum deformity to overcome the rebound phenomenon and to make future interventions easier if ever needed. LEVEL OF EVIDENCE: Level III.

Outcomes of Limb Lengthening With Computer-assisted Hexapod External Fixators in the Treatment of Fibular Hemimelia.

BACKGROUND: Fibular hemimelia (FH) represents the most common deficiency of the long bones and is associated with multiple deformities. Reconstructive treatment with external fixators in FH restores normal lower extremity alignment and length with plantigrade feet for a balanced and effective gait. The aim of this study is to evaluate the outcomes of lower limb lengthening and simultaneous tri-plane deformity correction with a computer-assisted hexagonal external fixator in children with FH. METHODS: A retrospective review was performed for FH cases treated with a computer-assisted hexagonal external fixator in a tertiary referral center. Leg length discrepancy (LLD), interphyseal angles, tibiocalcaneal distances, healing index (HI), and callus shapes were analyzed for radiologic evaluation, and the Pediatric Quality of Life Inventory (PedsQL) was used for functional assessment. Limbs with HI <50 days/cm, PedsQL >75, and without regenerate fractures were considered successful lengthenings. RESULTS: Twenty-four limbs of 23 patients were included. The limbs were lengthened for a mean of 7.24 cm (range, 4.7 to 15.6). The initial LLD of 5.6 cm (range, 0.5 to 19 cm) increased to 1.7 cm (range, 0.1 to 6 cm), and the mean interphyseal angle was 12.7 degree (range, 1.5 to 54.2 degree), tibiocalcaneal distance was 0.85 cm (range, 0.1 to 1.7) at final follow-up. The most common regenerated bone morphology was cylindrical, as seen in 11 limbs (45.8%). The average PedsQL score was 83.5 (range, 69.5 to 96.7). Sixteen limbs (66.7%) had successful lengthening at their first, and 4 limbs (80%) had successful lengthening at their second surgeries. Seven limbs had complications requiring surgical intervention (29.1%), with 3 (12.5%) regenerate fractures after external fixators removal. CONCLUSIONS: Limb reconstruction with computer-assisted hexapod fixators is a successful and reliable option for the treatment of LLD in FH, and patients demonstrate good functional outcomes. Surgeons should be aware of potential complications and should utilize prophylactic measures when necessary. LEVELS OF EVIDENCE: Level III, retrospective comparative study.

Femoral lengthening using limb reconstruction system augmented with only one antegrade flexible nail in children: early results.

Several techniques have been described for decreasing the duration of external fixator use, augmenting stability, and minimizing complications. The purpose of the present study was to evaluate the clinical results and complications of femoral lengthening procedures using the Limb Reconstruction System (LRS) in combination with a single antegrade flexible intramedullary nail (FIN). Femoral lengthening with LRS and FIN was applied to 14 patients (aged 6-16 years) between 2017 and 2021. The etiology was a congenital femoral deficiency in 12 patients and post-traumatic growth arrest in two. A single nail was inserted antegradely through the trochanteric apophysis in each patient. Radiographs and medical records of the patients were assessed retrospectively. The mean lengthening achieved was 4.8 ±â€…1.0 cm. The mean duration of external fixation was 181 days (range 139-248 days) and the mean healing index was 39.6 ±â€…12.1 days/cm. The mean values of mechanical medial proximal tibial angle, mechanical lateral distal tibial angle, mechanical lateral proximal femoral angle, and mechanical lateral distal femoral angle were within the normal range at the last follow-up. Seven of the 14 cases had a regenerate deformity that caused a displacement of more than 2 mm in the mechanical axis deviation, none of them was greater than 10 mm and considered clinically insignificant. Fracture was seen in two limbs with regenerate deformity. This study suggests that LRS in combination with only one FIN may be an effective alternative for femoral lengthening, with acceptable complication rates.

Closed versus medial open reduction in the treatment of developmental dysplasia of the hip under age 1: A retrospective comparative study.

OBJECTIVE: This study aimed to compare the mid-term results of closed reduction (CR) versus medial open reduction (MOR) in the treatment of children with developmental dysplasia of the hip (DDH) under age 1. METHODS: Thirty-four patients with DDH (41 hips) were included in this retrospective study with a mean follow-up of 4.2 years (range: 2-6.9 years). All hips were then divided into 2 groups based on the treatment type: the CR group (20 hips) and the MOR group (21 hips). All hips from both groups were assessed with post-spica magnetic resonance imaging (MRI) in the first 24 hours, and reinterventions were recorded. Medial dye pool width was also measured. RESULTS: Age at the time of reduction was similar between the CR and MOR groups (6.6 ± 1.3 months vs. 6.7 ± 1.6 months). There was no significant difference between groups regarding avascular necrosis rate and further corrective surgery (FCS) requirement (P=.454, .697). The appropriate reduction was seen at 38/41 hips. Three hips in the CR group had revealed dislocation in post-spica MRIs and required re-intervention, and none of the hips in the MOR group required re-intervention (P=.107). Medial dye pool width in 3 planes showed no significant difference between MOR and CR. CONCLUSION: There is no difference in the avascular necrosis rate and FCS requirements between CR and MOR under age 1. Post-spica MRI is a favorable tool for evaluating reduction after CR, but its efficacy after MOR is questionable.

Assessment of early Achilles tenotomy in the newborn idiopathic pes equinovarus.

We aimed to evaluate the clinical and radiological results of early Achilles tenotomy which was performed before Ponseti method in PEV deformities. 37 feet of 26 patients with Dimeglio type 3 and 4 deformities were included in the study. Unlike the classical Ponseti method, patients underwent a mini-open Achilles tenotomy before the first cast. 6-month follow-up of the foot deformities were assessed using Dimeglio classification clinically and lateral talocalcaneal and tibiocalcaneal angles radiologically. There were 20 male and 6 female patients with the median age of 14 days (4-37 days) and 11 bilateral and 15 unilateral deformities. The average follow-up period was 7 months (6-12 months). The mean Dimeglio scores before the Achilles tenotomy and Dimeglio score at the 6 th month follow-up were 14 (11-16) and 4 (4-6) for the right feet, 13 (10-16) and 4 (4-6) for the left feet respectively. The mean number of casting was 3.8 ± 0.4 for right feet and 3.7 ± 0.4 for left feet. The mean talocalcaneal angle was 24 ± 8.2 degrees for the right feet and 27 ± 8.2 degrees for the left feet. The mean tibiocalcaneal angle was 69 ± 12 for the right feet and 72 ± 14 degrees for the left feet. Early Achilles tenotomy can decrease the total number of cast for deformity correction in Ponseti method and provide good clinical and radiological outcomes at 6 th month follow-up in severe PEV deformities according to Dimeglio classification.

An Alternative Fixation Option for Subtrochanteric Femur Fractures in Children: Adult Proximal Humerus Plate.

BACKGROUND: Subtrochanteric femur fractures are unstable injuries due to strong muscle forces on the proximal femur. The ideal fixation device is controversial in the treatment of subtrochanteric femur fractures in children. The aim of this study is to evaluate the clinical and radiological outcomes of subtrochanteric femur fractures in children treated with an adult proximal humerus plate. METHODS: A total of 9 patients [mean age at surgery, 8.3 years (range: 7 to 12); mean follow-up period, 28.1 months (range: 12 to 56)] who underwent surgery due to a subtrochanteric femur fracture and treated with an adult proximal humerus between January 2017 and December 2021 were retrospectively evaluated. Four of the patients had a pathological fracture associated with a benign bone tumor while 5 patients had a nonpathological fracture. The clinical and radiological outcomes were assessed using the Flynn scoring system at the latest follow-up. Time to union and complications were recorded. RESULTS: All patients demonstrated a solid fusion of the fracture site and were able to bear full weight at the latest follow-up. The mean time to union was 8.2 weeks (range: 6 to 10). Based on the Flynn scoring system at the latest follow-up, seven patients had excellent clinical outcomes and two patients had satisfactory outcomes. Two patients had limb length discrepancy, and one patient had coxa valga and a limb length discrepancy of 16 mm. There were no patients with nonunion, infection, implant failure, osteonecrosis of the femoral head, and heterotopic bone formation. CONCLUSION: This study suggests that the adult proximal humerus plate may be an effective alternative fixation option in the treatment of subtrochanteric femur fractures in children, including pathological fractures. LEVEL OF EVIDENCE: Level IV, Case series.

Treatment of calcaneonavicular coalition accompanied by an accessory anterolateral talar facet.

The association of accessory anterolateral talar facet (AALTF) and tarsal coalition has been reported recently. However, there is no report in the literature examining the clinical outcomes of operative treatment simultaneously addressing both AALTF and tarsal coalition. In this case series, we report the functional outcomes of operative treatment for both AALTF and calcaneonavicular coalition (CNC). Four male patients were admitted to our institution with foot pain. Radiographic examination revealed CNC and accompanying AALTF in all patients. Five feet of these four patients were operated simultaneously for AALTF and CNC. At the final follow-up, the mean Visual Analog Scale score was 1.7±2.4 (range, 0 to 5.5), the mean American Orthopedic Foot and Ankle Society score was 89.6±11.5 (range, 69 to 97), and the mean Foot Function Index was 15.4±19.1 (range, 0 to 43). In conclusion, simultaneous resection of CNC with AALTF seems to have good postoperative clinical outcomes. As AALTF can emerge along with CNC, every patient scheduled for CNC resection should be evaluated for AALTF.

Osseous Ilio-Trochanteric Bars as an Etiology of Hip Contracture in a Child with Congenital Contractures: A Case Report.

CASE: A 5-month-old female patient presented with bilateral lower-limb deformities. Hips were fixed at 100° abduction, 15° flexion and 45° external rotation, flexion contracture in the knees, and bilateral teratologic equinovarus deformities. Radiographs revealed ilio-trochanteric osseous bars as the etiology of hip contractures. Staged surgeries were undertaken. At 4 years of age, she could stand upright with orthoses and sit without support. CONCLUSION: This is the first study to report bilateral congenital ilio-trochanteric osseous bars, which were resected without recurrence. Even with a very low potential of walking, release of the contractures allows for better function and possible wheelchair-dependent mobility in the future.

The efficacy of two-hole tension band plates in the treatment of lower extremity limb length discrepancy.

The main purpose of our study was to investigate the efficacy of dual two-hole tension band plates in the treatment of lower extremity limb length discrepancy (LLD). We retrospectively reviewed patients who underwent epiphysiodesis utilizing dual two-hole tension band plates due to lower extremity LLD between January 2012 and June 2018. The efficacy of epiphysiodesis was defined as the inhibited percentage of the expected growth of the physis between two time intervals and was calculated between 0-6 months and 6-18 months as the primary outcome. The relationship of efficacy of epiphysiodesis with time intervals, bone segments, physeal coverage percentage by the screws, age and interscrew angle and physeal health was also assessed. A total of 11 patients' 17 bone segments (9 femurs and 8 tibias) with a mean age of 8.7 ± 2.3 were included. The mean efficacy of the epiphysiodesis in the first 6 months for femurs was 23 ± 20 % (range, 0-53%) and for tibias was 21 ± 19 % (range, 0-53%); between 6 and 18 months it was 27 ± 19 % (range, 0-56%) for femurs and 15 ± 19 % (range, 0-50%) for tibias. In the first 6 months, physeal coverage percentage by the screws (r = 0.503, P = 0.04) and age (r = -0.534, P = 0.027) had a strong correlation with the epiphysiodesis efficacy. Dual two-hole tension band plating has variable efficacy in the treatment of LLD. Age and physeal coverage percentage by the screws could be related to epiphysiodesis efficacy.

Multiplanar correction of proximal tibial recurvatum deformity with tibial osteotomy and computer assisted fixator.

BACKGROUND: Several treatment modalities including open wedge osteotomies and Ilizarov reconstruction have been described for treatment of Proximal tibial recurvatum (PTR). However, the literature lacks information regarding the multiplanar correction of PTR using the computer assisted hexapod external fixator. The aim of the study is to present the results of PTR treatment with a computer assisted fixator systems. METHODS: There were three female and three male patients (10 lower extremities) with a mean age of 20.6 years (7.3 to 25.2y) in the study group. The angle of genu recurvatum (aGR), the tibial plateau tilt angle (aTP), the mechanical posterior proximal tibial angle (mPPTA) and sagittal mechanical axis deviation (MADs) was measured for the sagittal plane assessment. RESULTS: Preoperative sagittal assessment showed that the mean aGR was 28.9°±6.8°, mean aTP was 64.5°±10.2° and mean mPPTA was mPPTA was 114.1° ±10.3°. At the final follow-up there was a significant correction (p < 0.05 for aGR, aTP and mPPTA). Mean MADs was improved from 66.1 ± 14.2 mm to 16.6 ± 5.1 mm (p:0.005). Mean A:B ratio was 0.92 ± 0.13 preoperatively and 0.89 ± 0.14 postoperatively (p:0.37). Nine out of 10 knees had valgus deformity and mean preoperative tibiofemoral anatomic angle (TFA) was improved from 10.8°±3.7° valgus to 6.5°±1.7° valgus. CONCLUSION: The treatment of PTR deformity with a computer-assisted hexapod external fixator is safe and effective. It provides multiplanar correction of the deformity with a high precision and the patellar alignment remains stable during the correction.

Preliminary results of rigid fixation (locking plate/screw) after triple pelvic osteotomy without a hip spica cast: A modified fixation method in 21 patients.

OBJECTIVES: The aim of this study is to investigate whether rigid fixation after triple pelvic osteotomy (TPO) utilizing a 3.5-mm locking plate and screws without hip spica cast can provide enough stability and prevent correction loss in pediatric patients with developmental dysplasia of the hip (DDH) and Legg-Calvé-Perthes disease (LCPD). PATIENTS AND METHODS: A total of 21 hips of 21 pediatric patients (9 males, 12 females; mean age: 9.3±2.0 years; range, 6 to 14 years) who underwent rigid fixation with locking plate/screws after TPO for DDH and LCPD between June 2015 and October 2018 were retrospectively analyzed. Preoperative, immediate postoperative, and six-month follow-up anteroposterior radiographs were compared for the Wiberg's center-edge angle (CE), Sharp angle, acetabular coverage of the femoral head (ACFH), and center-head distance discrepancy (CHDD). The patient demographics, surgery time, perioperative complications were evaluated. RESULTS: Underlying diagnosis were DDH in 14 patients and LCPD in seven patients. In patients with DDH, postoperative evaluation showed significant increase in the mean CE angle (5.6±16.1° vs. 30.5±9.3°, respectively) and ACFH (46.4±16.8% vs. 84.5±12.1%, respectively), and a significant decrease in the mean Sharp angle (55.3±6.2° vs. 35.6±7.8°, respectively) and CHDD (14.6±10.7% vs. 6.2±5.6%, respectively). The final follow-up revealed that there was no correction loss in these parameters. In the patients with LCPD, postoperative evaluation showed a significant increase in the mean CE (20.1±11.1° vs. 38.3±9.6°, respectively) and ACFH (62.9±18% vs. 91.4±10.1%, respectively), and a significant decrease in the mean Sharp angle (46±3.6° vs. 25.2±5.5°, respectively). The final follow-up revealed that there was no correction loss in radiological parameters. No perioperative complications were noted. CONCLUSION: Our study results suggest that rigid fixation construct with a 3.5-mm locking plate and screws without hip spica cast can provide adequate stability to allow early mobilization following TPO in children without any loss of correction, until bony healing at the osteotomy sites.