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.

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.

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.

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.

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.

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.

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.

Further delineation of spondyloepimetaphyseal dysplasia Faden-Alkuraya type: A RSPRY1-associated spondylo-epi-metaphyseal dysplasia with cono-brachydactyly and craniosynostosis.

Our understanding of the molecular basis of the genetic disorders of the skeleton has steadily increased, as the application of high-throughput sequencing technology has expanded. One of the newcomers is Spondyloepimetaphyseal dysplasia Faden-Alkuraya type. In this study, we aimed to further delineate the clinical, radiographic, and molecular findings of this entity in five affected individuals from two unrelated families. All patients have short stature, extremity deformities, facial dysmorphism and intellectual disability. The skeletal hallmarks include (a) mild spondylar dysplasia, (b) epimetaphyseal dysplasia of the long bones associated with coxa vara and genu valgum, (c) brachymesophalangy with cone-shaped epiphyses, and (d) craniosynostosis. Unlike the previously reported clinical findings, all patients except one are normocephalic, and all share the clinical findings including craniosynostosis, varying degrees of intellectual disability, facial dysmorphism, and skeletal findings including pes planus, prominent heels, and pectus deformity. Interestingly one of the patients presented with a cemento-ossifying fibrous lesion of the maxilla. Whole exome sequencing revealed a novel homozygous [c.377delT] [p.Ile126fs*] frameshift mutation at exon 2 in one family, while Sanger sequencing revealed a novel homozygous splice site mutation [c.516+2T>A] at exon 4/intron 4 border of RSPRY1 in the other family. In conclusion; we provide further evidence that Spondyloepimetaphyseal dysplasia Faden-Alkuraya type is a RSPRY1-associated skeletal dysplasia with a distinctive phenotype composed of spondyloepimetaphyseal dysplasia, cono-brachydactyly, and craniosynostosis along with recognizable facial features and intellectual disability.

Treatment of the Upper Extremity Contracture/Deformities.

Patients with arthrogryposis multiplex congenita have a characteristic upper extremity resting posture consisting of internal rotation of the shoulders, elbow extension, flexed wrists, thumb-in palm deformities, and variable degrees of finger contractures. Treatment of these patients is aimed at improving independence and performance of activities of daily living. Although each area needs to be assessed independently for the most appropriate surgical procedure, often multiple areas can be addressed at the same operative setting. This limits the number of anesthetic exposures and cast immobilization time. The following is a synopsis of treatment strategies presented at the second international symposium on Arthrogryposis which took place in St Petersburg in September 2014.

Treatment of the Lower Extremity Contracture/Deformities.

Lower extremity deformities of patients with arthrogryposis multiplex congenita present a wide spectrum of severity and deformity combinations. Treatment goals range from merely ensuring comfortable seating and shoe wear, to fully independent and active ambulation, but the overarching intention is to help realize the patient's greatest potential for independence and function. Treatment of hip and knee contractures and dislocations has become more interventional, whereas treatment of foot deformities has paradoxically become much less surgical. This article synopsizes the treatment strategies presented in September 2014 in Saint Petersburg, Russia at the second international symposium on arthrogryposis.

Convex Hemiepiphysiodesis: Posterior/anterior in-situ Versus Posterior-only With Pedicle Screw Instrumentation: An Experimental Simulation in Immature Pigs.

STUDY DESIGN: Experimental study. BACKGROUND: Convex growth arrest (CGA) has been commonly used in the treatment of long-sweeping congenital deformities of the immature spine. As there are major drawbacks about the anterior procedure in the conventional CGA method, a new modification has been documented that using only posterior spinal approach with pedicle screw instrumentation. The aim of the study was to compare posterior-only CGA using pedicle screws with combined anterior/posterior in-situ CGA for the findings in histologic, radiologic, and manual palpation examinations in an immature pig model. METHODS: Twelve 10-weeks old pigs were grouped into 2. In group 1, posterior-only, pedicle screw instrumented CGA was performed on the left side of L1-L4 vertebrae. In group 2, conventional combined posterior and anterior CGA was performed to the left side of L1-L4 vertebrae without instrumentation. All animals were killed twelve weeks after surgery. T11-L5 segments were en-bloc resected and radiologic, histologic, and manual palpation examinations were done. RESULTS: Marked scoliotic (12.2±2.5 and 9.2±1.3 in group 1 and 2, respectively) and kyphotic (11.2±1.0 degrees for the group 1 and 12±5.2 degrees for the group 2, respectively) deformities were noted in both groups, which were caused by hemiepiphysiodesis effect. Anterior and posterior parts of group 2 and posterior part of group 1 demonstrated fusion in histologic and radiologic analyzes. In anterior part of the group 1, marked narrowing on the disk spaces and thinning of growth plates were noted in radiologicg examination, chondrocyte degeneration, and newly-formed bone trabeculae in disk-space were noted in histological examination. In manual palpation, no motion was detected in group 1 and motion was detected in only one segment of one animal in group 2. CONCLUSIONS: Anterior growth of the vertebrae can be controlled by application of posterior transpedicular screws and rod. Such an effect can eliminate the need for anterior surgical intervention in convex hemiepiphysiodesis procedures. CLINICAL RELEVANCE: The instrumented CGA technique provides a satisfactory epiphysiodesis effect both anteriorly and posteriorly, as previously demonstrated by clinical studies.

Reconstruction of foot and ankle defects with a free anterolateral thigh flap in pediatric patients.

BACKGROUND: There are a limited number of published studies describing reconstruction with an anterolateral thigh (ALT) flap following lower extremity injury in pediatric patients. The aim of this study was to present our experiences with the application of a free ALT flap not only in the reconstruction of soft tissue defects around the pediatric foot and ankle but also in patients with bone, tendon, and ligament injuries that require repair. MATERIALS AND METHODS: Reconstruction with a free ALT flap was performed in 11 pediatric patients (mean age, 8.9 years; range, 3-15 years) between November 2010 and February 2013. The modes of injury were as follows: six traffic accidents, three firearm accidents, one agricultural machinery accident, and one bicycle chain accident. A retrospective evaluation of the applied surgical procedures was performed: flap size, perforator type and number, placement area, site of anastomosis, closure of the donor site, complications, and flap survival. RESULTS: The mean size of the skin flap was 83.2 mm(2) (range, 48-117 mm(2)). Except for two patients, there were two perforators in the obtained flaps, which were 75% musculocutaneous and 25% septocutaneous. To strengthen the Achilles tendon in one patient, the ALT, together with the fascia lata, was raised as a composite flap. This flap was used as a "sensate flap" in three patients with defects in the heel area and as a "perforator flap" in seven patients. Anastomosis was performed in the anterior tibial artery in five patients and in the posterior tibial artery in six patients. Primary closure was performed for the donor site in all patients. Due to venous thrombus after 24 hours in one patient, reexploration was performed, and blood flow was regained with a vein graft. In the same patient, partial necrosis developed on the lateral edge of the flap; after debridement of the necrotic areas, closure was performed with a split thickness skin graft. After the ALT flap procedure, the primary flap survival rate was 90.9%. CONCLUSION: The free ALT flap could be a safe, reliable, and aesthetically appealing option for foot/ankle resurfacing in children after traumatic soft tissue loss. The ALT flap can cover a far greater area and provide the versatility needed to optimize soft-tissue coverage. CLINICAL QUESTION/LEVEL OF EVIDENCE: Level IV.

Surgical treatment of scoliosis in osteogenesis imperfecta with cement-augmented pedicle screw instrumentation.

STUDY DESIGN: A retrospective study. OBJECTIVE: To report the early postoperative results of scoliosis surgery in osteogenesis imperfecta (OI) patients utilizing all pedicle screw constructs and present a novel cementing technique to increase pedicle screw purchase in the osteoporotic OI spine. SUMMARY OF BACKGROUND DATA: Scoliosis surgery utilizing hooks and wire systems have high complication rates in OI. Pedicle screw fixation systems have the biomechanical advantage of 3-column fixation, and cement augmentation of pedicle screws provides additional pull-out strength in the osteoporotic OI spine. METHODS: The clinical and radiologic results of 10 consecutive OI patients treated with all pedicle screw instrumentation and fusion were retrospectively reviewed. The radiologic data included preoperative and postoperative major curve measurements: major curve Cobb angle, global coronal balance (GCB), apical vertebral translation (AVT), and the lowest instrumented vertebral (LIV) tilt. Operative findings included blood loss, surgery time, and additional procedures. All patients received intravenous pamidronate therapy preoperatively to increase bone mineral density. RESULTS: Ten patients with OI were operated on between 2005 and 2009. Seven had cement-augmented pedicle screw insertion at the proximal and distal foundations. The mean hospital stay was 10±7.5 days (range, 4-27 d) and the average follow-up period was 25.7±13.1 months (range, 14-50 mo). Mean preoperative and postoperative major Cobb angles were 83.7±23.8 and 40.3±14.6 degrees, respectively (48% correction; P<0.05). Mean preoperative and postoperative GCB deviations were 26.7±18.6 and 14.1±13.3 mm, respectively (P=0.097). Mean preoperative and postoperative AVTs were 69.3±29.1 and 29±12.2 mm, respectively (P<0.05). Preoperative and postoperative LIV tilts were 18.5±8.9 and 5.2±3.9 degrees, respectively (P<0.05). At the latest follow-up, the mean major curve Cobb angle was 37.7±13.1 degrees, the GCB deviation was 13.8±5.1 mm, the AVT was 31.7±13.3 mm, and the LIV tilt was 11.3±8.8 degrees. There was no difference between the early postoperative and the latest follow-up major curve Cobb angle, GCB deviation, AVT, or LIV tilt, indicating maintenance of correction. The mean blood loss was 23,75 mL (range, 800-45,00 mL). The mean operative time was 375.4 minutes (range, 262-491 min). The mean postoperative Scoliosis Research Society-22 patient-based outcome scores were 4.6±0.7 (out of 5). There were no instrumentation failures or permanent neurological deficits in this series. CONCLUSIONS: Pedicle screw instrumentation in OI scoliosis is safe and effective. Cement augmentation in these patients may help to increase the pedicle pull-out strength and decrease the screw failure rates, especially at the proximal and the distal ends of instrumentation.

Safety and efficacy of instrumented convex growth arrest in treatment of congenital scoliosis.

BACKGROUND: Anterior and posterior convex hemiepiphysiodesis is a widely used surgical alternative in the treatment of congenital scoliosis. This procedure has the disadvantage of the need for both anterior and posterior approaches. Furthermore, outcomes may be unpredictable. Posterior convex growth arrest (CGA) with pedicle screws at each segment on the convex side may obviate the need for anterior surgery and provides more predictable outcomes. This study retrospectively evaluates the safety and efficacy of instrumented posterior CGA in congenital scoliosis. METHODS: Patients who had posterior CGA with convex pedicle screw instrumentation for congenital scoliosis were evaluated retrospectively. Thirteen patients (6 male, 7 female) were included in the study. Preoperative, early postoperative, and last follow-up standing posteroanterior and lateral x-rays were evaluated. Cobb angles were recorded for the instrumented segment (main curve). Global thoracic kyphosis was measured between T2 and T12 on sagittal plane. These values were compared preoperatively, postoperatively, and at last follow-up. The T1-S1 vertical height and the height between the concave side pedicles of the upper and lower end vertebra of the main curve was also determined and recorded as the concave height. RESULTS: The average follow-up was 56.1±10 months (range, 36 to 74 mo) and the average age of the patients at the time of operation was 64.5±30.1 months (range, 15 to 108 mo). All patients were Risser zero at the time of surgery. The average curve magnitude was 49±10.9 degrees (range, 34 to 68 degrees) preoperatively, 38.3±9.7 degrees (range, 28 to 58 degrees) early postoperatively, and 33.5±12.4 degrees (16 to 52 degrees) at last follow-up. There was a significant difference between the preoperative and early postoperative main curve Cobb angle measurements (P=0.001). The average concave height was 94.2±20.2 mm in the early postoperative period and 104.7±21.7 mm at last follow-up (P=0.003). The average T1-S1 height was 292.1±67.1 mm in the early postoperative period and 363.9±94.5 mm at last follow-up (P=0.005). There was at least ≥5 degrees improvement in 9 of the 12 patients in the follow-up period after the index procedure. In 3 patients, the curve did not change and the correction was maintained. Curve progression was observed in 1 patient due to a technical error. There were no wound infections or instrumentation failures during follow-up. CONCLUSIONS: Instrumented CGA can safely be used in long sweeping curves of immature spines. Using this technique; thoracotomy, anterior procedure, and 2-stage surgery can be avoided. Moreover, it guarantees some degree of correction in all patients because of the instrumentation effect, eliminating the unpredictable nature of classic CGA. LEVEL OF EVIDENCE: Therapeutic level IV study.

Correction of lower extremity angular deformities in skeletal dysplasia with hemiepiphysiodesis: a preliminary report.

BACKGROUND: Lower extremity angular deformities are common in children with skeletal dysplasia and can be treated with various surgical options. Both acute correction by osteotomy with internal fixation and gradual correction by external fixation have been used with acceptable results. Recently, the Guided Growth concept using temporary hemiepiphysiodesis for correction of angular deformities in the growing child has been proposed. This study presents the results of temporary hemiepiphysiodesis using eight-Plates and medial malleolus transphyseal screws in children with skeletal dysplasia with lower extremity angular deformities. METHODS: Twenty-nine patients (50 lower extremities) with skeletal dysplasia of different types were treated for varus or valgus deformities at 2 centers. The mean age at the time of hemiepiphysiodesis was 10±2.9 years. A total of 66 eight-Plates and 12 medial malleolus screws were used. The average follow-up time between the index surgery and the latest follow-up with the eight-Plate in was 25±13.4 months. Erect long-standing anteroposterior and lateral view radiographs were obtained for deformity planning before the procedure. Angular deformities on radiograph were evaluated by mechanical axis deviation, mechanical lateral distal femoral angle, medial proximal tibial angle, and lateral distal tibial angle. Mechanical axis deviation was also expressed as a percentage to one half of the width of the tibial plateau, and the magnitude of the deformity was classified by determining the zones through which the mechanical axis of the lower extremity passed. Four zones were determined on both the medial and lateral side of the knee and the zones were labeled 1, 2, 3, and 4, corresponding to the severity of the deformity. A positive value was assigned for valgus alignment and a negative for varus alignment. RESULTS: Patients were analyzed in valgus and varus groups. There was correction in 34 of 38 valgus legs and 7 of 12 varus legs. In the valgus group, the mean preoperative and postoperative mechanical lateral distal femoral angles were 82.1±3.7 and 91.1±4.9 degrees, respectively (P<0.001). The mean preoperative and postoperative medial proximal tibial angles were 98.5±8 and 87.8±7.1 degrees, respectively (P<0.001). Six patients with bilateral ankle valgus deformities (12 ankles) underwent single-screw medial malleolus hemiepiphysiodesis. The mean preoperative and postoperative lateral distal tibial angles were 73.9±8.7 and 86.1±6.8 degrees, respectively (P<0.001). The numbers of plates in each anatomic location were not enough to make statistical conclusions in varus legs. Four patients in the valgus group and 3 patients in the varus group did not benefit from the procedure. Mechanical axes were in zone 2 or over in 94% of the legs preoperatively, whereas postoperatively, only 23% of the legs had mechanical axes in zone 2 or over in varus and valgus groups. CONCLUSIONS: Growth modulation with an eight-Plate is a relatively simple surgery and has low risk of mechanical failure or physeal damage. It can be performed in very young patients, which is an important advantage in skeletal dysplasia. Screw purchase is reliable even in the abnormal epiphysis and metaphysis. Our results show that Guided Growth using eight-Plates in skeletal dysplasia is safe and effective. LEVEL OF EVIDENCE: Level IV.

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.

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.

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.