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BACKGROUND: Patients who have undergone corrective surgery for adolescent idiopathic scoliosis (AIS), especially those with a major lumbar curve, may have persistent postoperative coronal imbalance (PCI) due to an insufficient ability to compensate for lumbar curve overcorrection. However, the optimal amount of curve correction required to prevent PCI remains uncertain. Therefore, this study aimed to evaluate the use of the intraoperative crossbar coronal-balancing technique as a strategy to minimize the risk of PCI in patients with AIS with a major lumbar curve (Lenke type-5 and 6 curves), and to confirm that the tilt angle of the lowest instrumented vertebra (LIV), intraoperatively and at the final follow-up, could be predicted from the preoperative supine right-side-bending (RSB) radiograph that was used to guide the correction. METHODS: This study involved 39 patients with Lenke 5 or 6 AIS who underwent posterior spinal fusion and had a minimum 2-year follow-up. The median age was 14 years, 15% were male, and all were of Malaysian ethnicity: 84.6% Chinese, 12.8% Malay, and 2.6% Indian. The LIV tilt angle measured on the preoperative supine RSB radiograph, adjusted according to the pelvic obliquity (PO) measured on the erect radiograph (α angle), was used as a guide for the intraoperative LIV tilt angle (ß angle). Following curve correction, the crossbar was centered over the sacrum intraoperatively. The position of the C7 vertebra was then assessed relative to the crossbar, and the amount of correction was adjusted to ensure that the proximal portion of the crossbar bisected the C7 vertebra under fluoroscopy. Outcomes included the coronal balance distance (CBD) and the LIV tilt angle at the final follow-up (δ angle). RESULTS: Only 2 (5.1%) of the patients in the cohort had PCI at the final follow-up. At that time, the mean CBD was -6.6 ± 9.2 mm and the mean δ angle was -12.4° ± 4.8°. There were no significant differences between the α and ß angles (p = 0.799) or between the α and δ angles (p = 0.705). The α angle correlated strongly with the ß angle (ρ = 0.707) and the δ angle (ρ = 0.730, p < 0.001). CONCLUSIONS: The intraoperative crossbar coronal-balancing technique was shown to be an effective method to minimize the risk of PCI in patients with AIS with a major lumbar curve. Guided by the α angle measured preoperatively, this approach may help facilitate the determination of the optimal intraoperative LIV tilt angle (ß), which corresponds to the LIV tilt angle at the final folow-up (δ). LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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BACKGROUND AND PURPOSE: Developmental dysplasia of the hip (DDH) affects around 1.5% of newborns in Sweden with few late detected cases (0.12 per 10,000). The most common treatment for DDH in Sweden is with the von Rosen splint, with radiographs at 3 and 12 months of age. Little is known about the remodeling of acetabular dysplasia following treatment initiated in the neonatal period. We aimed to examine the correlation between the acetabular index (AI) at 3 and 12 months. METHODS:  We included 228 patients with early detected DDH with dislocatable hips (Barlow) and dislocated hips (Ortolani), treated with the von Rosen splint at Skåne University Hospital 2003-2019. The treatment length was 6 weeks for 96 children and 12 weeks for 132 children. We calculated the correlation between AI at 3 and 12 months using Pearson correlation (r) and the mean difference, both with 95% confidence intervals (CI). RESULTS:  The correlation between AI at 3 and 12 months was moderate, r = 0.43 (95% confidence interval [CI] 0.35-0.50), with changes in AI that differed widely. The mean AI was 23.9° (CI 23.5-24.3) at 3 months and 24.9° (CI 24.6-25.3) at 12 months with a difference of 1.0° (CI 0.6-1.3). CONCLUSION:  The correlation between AI at 3 and 12 months was moderate, with non-clinical difference for both 6 and 12 weeks of treatment. The small increase in mean AI was most likely explained by a low AI at 3 months after 12 weeks of treatment.

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BACKGROUND: Acromioclavicular (AC) joint dislocations are common in young athletes. The optimal management of Rockwood type 3 injuries, which involve a complete tear of both the AC and coracoclavicular (CC) ligaments, remains controversial. PURPOSE/HYPOTHESIS: The purpose of this study was to compare the clinical outcomes of surgical and nonoperative treatment of type 3 AC joint dislocations. The hypothesis was that surgical treatment would result in superior functional outcomes. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 70 patients (mean age, 31.2 ± 8.1 years) with acute type 3 AC joint dislocations were randomized to the surgical (modified Weaver-Dunn technique) (n = 35) and nonoperative treatment group (n = 35). The inclusion criteria were as follows: adults aged >18 years diagnosed with grade 3 AC dislocation within 21 days of the injury; no history of AC dislocation or previous surgery in the affected shoulder; and no associated fractures involving the acromion, coracoid, or clavicle. The exclusion criteria were as follows: failure to adhere to the follow-up schedule; improper performance of radiological examinations; or noncompliance with the prescribed rehabilitation protocol. Ten patients were lost to follow-up, resulting in a final sample size of 60 patients (30 per group). The primary outcome was the Disabilities of the Arm, Shoulder, and Hand (DASH) score at 12 months. Secondary outcomes included the University of California-Los Angeles (UCLA) score, scapular dyskinesis, range of motion, radiographic alignment, cosmetic satisfaction, return to sport, and complications. Follow-up was conducted over 24 months. All statistical tests were 2-tailed, and P < .05 was considered statistically significant. No adjustments were made for multiple comparisons because of the exploratory nature of secondary outcomes. RESULTS: No significant differences were found in DASH scores (11.4 vs 10.63; P = .179) at final follow-up. The surgical group showed significantly higher UCLA scores (36.07 vs 33.74; P < .001) and lower rates of cosmetic dissatisfaction (14.8% vs 44%; P = .017), although the range of motion, return to sport, scapular dyskinesis, and complication rates did not differ between groups. CONCLUSION: Surgical management of type 3 AC joint dislocations resulted in similar DASH scores and range of motion compared with nonoperative management, although some secondary outcomes-including higher UCLA scores and cosmetic satisfaction scores-favored surgery.The trial was registered in the Brazilian Registry of Clinical Trials (RBR-4r6jhy6).

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OBJECTIVE: The purpose of this retrospective study was to investigate the differences in clinical efficacy and radiographic outcomes of the double-triangle locking compression plate (DT-LCP) and the T-shaped locking compression plate (T-LCP) fixation systems in open-wedge high tibial osteotomy (OWHTO). METHODS: A retrospective analysis was conducted on the clinical data of 127 patients who underwent OWHTO at the Affiliated Hospital of Qingdao University between January 2019 and May 2020. Patients were divided into two groups based on the different steel plate fixation systems used: the DT-LCP group with 65 patients and the T-LCP group with 62 patients. Both groups underwent clinical and radiographic assessments preoperatively and at 5 years postoperatively. Clinical assessments were performed using the Visual Analog Scale (VAS), the Lysholm score, and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Radiographic evaluations included measurements of the hip-knee-ankle angle (HKA), medial proximal tibial angle (MPTA), weight-bearing line ratio (WBLR), joint line convergence angle (JLCA), and tibial posterior slope (PTS) to assess lower limb alignment correction postoperatively. The compensatory changes in adjacent joints were evaluated by measuring the hip abduction angle (HAA), talar tilt angle (TIA), and Carton-Deschamps index (CDI) in both groups. Complications were also analyzed for both groups. RESULTS: At the 5-year follow-up, the complication rate was 20% in the DT-LCP group and 24.19% in the T-LCP group (χ2 = 0.324, p = 0.569). All radiographic measures of coronal alignment (HKA, MPTA, WBLR and JLCA) improved significantly from baseline in both groups (p < 0.001). After adjustment for pre-operative values, ANCOVA showed no between-group difference in HKA or JLCA (p = 0.319 and p = 0.287, respectively). MPTA and WBLR reached statistical significance, but with small effect sizes (MPTA: 0.89°, 95% CI 0.28-1.51; WBLR: 0.06, 95% CI 0.03-0.08). PTS increased similarly in both groups (effect - 0.80°, 95% CI - 1.95 to 0.34, p = 0.114). Compensatory changes in adjacent-joint parameters (HAA, TIA and CDI) did not differ between groups: HAA 0.21° (95% CI - 0.13 to 0.55, p = 0.226), TIA - 0.50° (95% CI - 1.43 to 0.42, p = 0.151), and CDI 0.08 (95% CI - 0.01 to 0.17, p = 0.225). Peri-operatively, the DT-LCP group outperformed the T-LCP group, with smaller incision, shorter operative time, less intra-operative blood loss (all p < 0.001) and lower hospitalization cost (p = 0.014). Clinical scores (VAS, WOMAC and Lysholm) improved markedly in both cohorts (p < 0.001), with no significant between-group differences in the magnitude of improvement (all p > 0.05). CONCLUSION: This study demonstrates that both DT-LCP and T-LCP achieve favorable clinical outcomes after OWHTO, as evidenced by significant reductions in mean VAS scores and improvements in WOMAC and Lysholm ratings. The two fixation systems provide reliable correction in both the coronal and sagittal planes, with good alignment of lower-limb parameters such as HKA and MPTA, showing excellent durability and safety. Satisfactory functional results were obtained with either implant. However, the DT-LCP group demonstrated superior peri-operative performance, with a significantly lower incidence of implant-related irritation, thereby reducing the need for secondary hardware removal and resulting in a lighter economic burden.

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PURPOSE: Radial head fractures (RHF) plate fixation has been associated with chronic pain and stiffness. This study aimed to evaluate if the new generation of anatomic low-profile locking-plates (ALPLP) allows to obtain satisfactory results lowering the complication rate and the need for reintervention. METHODS: Fifty-seven patients treated with ALPLP for RHF were analyzed: 24 were Mason II fractures and 33 were Mason III fractures. Post-operative and follow-up radiographs, range of motion and clinical scores (MEPS, DASH and ASES-e) were evaluated. Complications and reinterventions were recorded. The statistical analysis was performed using the ANOVA with post-hoc Tukey and Chi-squared test. RESULTS: The mean follow-up was 5 years. The mean ROM was 9°-140° in extension-flexion and 81°-81° in pronation-supination; the mean MEPS, DASH and ASES-E were 98, 3 and 93.9, respectively. Eight patients underwent reinterventions during follow-up, two patients developed asymptomatic nonunions. Significant differences were observed between Mason II and Mason III patients as for flexion and between patients who underwent "in situ" or "on table" reconstruction in terms of MEPS. Degenerative changes appeared to be significantly more frequent in RHF with involvement of the articular surface with respect to isolated neck RHF. CONCLUSION: The main indications for osteosynthesis with ALPLP were a Mason II fracture with sinking of the head-neck junction and a multifragmentary Mason III fracture without radial neck comminution; with these indications, ALPLP provide satisfactory results in most cases, allowing to preserve the radial head in 96.5% of cases. The anatomical reduction of fracture, the sub-equatorial positioning of the plate in the "safe zone", the reconstruction of the annular ligament without excessive tension and the early rehabilitation are the four main factors that affect results.

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The aims of this study were to establish the radiographic features of distal radial fracture malrotation on bone models and then assess the prevalence of distal radial malalignment in a series of extra-articular fractures in adults. We cut distal radial bone models and simulated pronation and supination malrotation in different positions of dorsal angulation. We also reviewed 160 displaced distal radial fractures in 158 adults assessing any malrotation immediately following fracture and after closed reduction. Malrotation was more obvious on lateral than posteroanterior radiographic images. Following a distal radial fracture, we noted malrotation in 58 (36%); 47 (33%) were either into supination or pronation, six definitely into supination and five clearly in pronation. Eleven were not manipulated. Of the remainder, 44 (of 149) (30%) were malrotated, 35 were into pronation or supination and 10 were into pronation. Malrotation was not associated with an ulnar styloid fracture. Distal radial fracture malrotation appears common but underappreciated. Future studies would be needed to determine if malrotation would affect clinical outcome.Level of evidence: V.

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Dorsiflexory wedge first metatarsal osteotomies play a pivotal role in the structural correction of a symptomatic plantarflexed first ray often in the setting of a forefoot driven hindfoot varus deformity. Restoration of Meary's angle can provide surgeons intraoperative radiographic visualization of correction in addition to clinical correction of forefoot valgus deformity. This procedure is performed at the proximal metaphysis of the first metatarsal distal to the first tarsometatarsal joint. It typically is performed in conjunction with additional hindfoot osseous and soft tissue procedures. There exists a plethora of fixation options with high reported union rates.

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BACKGROUND: Patients with congenital scoliosis may develop a large, unbalancing "compensatory" curve as they grow, which can be severely deforming. It is important to identify characteristics of patients who develop a "dominant" compensatory curve (one that is larger than the congenital curve) to help identify patients who may benefit from prophylactic treatment. METHODS: By searching the Pediatric Spine Study Group database, we identified 307 patients 18 years and above with congenital scoliosis who had preoperative radiographs taken during at least 2 years of natural growth (period of no bracing or surgery). Seventeen patients (6%) had a dominant compensatory curve, and 290 had no compensatory curve or one that was smaller than the congenital curve. Of those 290 patients, 100 were randomly selected to serve as a control group, which we refer to as the "nondominant curve group." We analyzed the type of congenital anomaly and its vertebral level, as well as the major curve angles of the congenital and compensatory curves at initial and latest follow-up. We compared vertebral level and type of anomaly between groups using χ 2 tests. Alpha = 0.05. RESULTS: The congenital anomaly was at L4 or more caudal in 18% of patients in the dominant curve group and no patients in the nondominant curve group ( P <0.001). Similarly, the congenital anomaly was at T6 or more cranial in 59% of patients in the dominant curve group and 28% of patients in the nondominant curve group ( P <0.001). At the latest follow-up, the dominant curve group had a mean (and SD) congenital curve of 55±19 degrees and a compensatory curve of 73±24 degrees. The frequencies of wedge, hemivertebrae, and bar vertebral anomalies did not differ between groups. CONCLUSIONS: In pediatric patients with congenital scoliosis, a dominant compensatory curve was associated with vertebral anomaly at L4 or caudal, or T6 or cranial. These findings can help clinicians prioritize prophylactic treatment for patients who may be at high risk for developing a dominant compensatory curve. LEVEL OF EVIDENCE: Level III.

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BACKGROUND: This study aimed to compare various ankle alignment parameters in the hip-to-calcaneus (H-C) view and conventional whole-leg standing radiographs. METHODS: We retrospectively reviewed 61 patients with end-stage ankle arthritis (Takakura stage 3b/4) who underwent ankle arthrodesis. Preoperative H-C views and conventional radiographs were used to measure the hip-knee-ankle angle, weight-bearing line percentage, talar tilt, and medial distal tibial angle. The percentage of the H-C axis crossing the talus was also analyzed for asymmetry and correlated with the tibiocalcaneal angle, talar tilt, and hip-knee-ankle angle. RESULTS: Strong correlations were observed between the H-C view and conventional radiographs for the hip-knee-ankle angle (r = 0.88), weight-bearing line percentage (r = 0.90), and talar tilt (r = 0.87). The H-C axis asymmetry showed a strong correlation with tibiocalcaneal angle (r = -0.96). CONCLUSIONS: The H-C view is a reliable tool for assessing hindfoot and lower limb alignment in end-stage ankle arthritis. LEVEL OF EVIDENCE: III.

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PURPOSE: This study aimed to evaluate the diagnostic importance of ultrasonic imaging by assessing the thickness of the plantar fascia (F) and fat pad (FP) at different locations in the plantar region for the diagnosis of plantar fasciitis. Furthermore, the study sought to determine the correlation between angular measurements derived from direct radiography and measurements obtained via ultrasound imaging. METHODS: The study measured the intermetatarsal angle(IMA), 1st metatarsophalangeal angle(MTPA), 1st interphalangeal angle(IPA), and medial longitudinal arch angle(MLAA) in weight-bearing foot radiographs of 94 patients (23 males and 71 females) with unilateral plantar fasciitis. The control group comprised asymptomatic feet from the same individuals. Fat pad and plantar fascia thicknesses were assessed with ultrasonic imaging(USG) at three different points. A proportion was established between fascia(F) and fat pad(FP) thicknesses. The study examined the correlations between USG and direct radiography measurements, both within and between groups. RESULTS: A statistically significant difference was observed between the study group and the control group in various measurements. These include IMA measurements, plantar fascia thickness, and F/FP ratio measured at the calcaneal tubercle, as well as fascia thickness, fat pad thickness, and F/FP ratio measured in the midpoint of the medial arch (p = 0.024; p = 0.001; p = 0.001; p = 0.001; p = 0.008; p = 0.001 p<0.05 respectively). A significant correlation was discovered in the study group between F/FP measures in the calcaneal tubercle and MLAA. CONCLUSION: Our study revealed a noteworthy correlation between plantar fasciitis and an increase in plantar fascia thickness, an increase in the plantar fascia/fat pad ratio, and a decrease in the fat pad thickness measured at three distinct points. In our study, it was seen that the diagnosis of plantar fasciitis can be made with USG alone, which is a fast, cost-effective and easy-to-apply method by evaluating the thickening of the plantar fascia, the reduction in fat pad thickness, and their relative proportions. LEVEL OF EVIDENCE: Level III, Cross-Sectional Prospective Observational Study.

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BACKGROUND: Overlength of the lesser toes can lead to pain at the distal toe end and painful hammer and claw deformities. Fusion or resection of proximal interphalangeal joints are commonly used to address overlength, while sacrificing joint mobility. A Z-type shortening osteotomy of the proximal phalanx (SOPP) was developed as a joint-sparing alternative. METHODS: We outline this novel technique and retrospectively analyzed preliminary data from 13 patients (including 9 women) with a mean age of 42 years who underwent Z-type SOPP. Patients rated their postoperative satisfaction and assessments of radiographs and complications were made up to 1-year post-SOPP. RESULTS: Of 29 toes in total, mean postoperative shortening was 6.4 mm (range, 4-11 mm) and all showed complete union at 1 year. All patients were satisfied with the surgery and only two reported limited joint mobility. There were no reports of infection and delayed wound healing. CONCLUSION: Z-type SOPP appears to be an effective and safe joint sparing treatment for lesser toe overlength in the short term. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

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BACKGROUND CONTEXT: Lumbar spinal canal stenosis (LSCS) presents with various radiographic findings, often including concurrent degenerative changes. Prior studies have investigated the effects of individual radiographic findings and parameters separately using conventional methods such as logistic regression. However, applying these independent effects to real-world patients remains challenging due to an unknown interaction effect among multiple degenerative radiographic findings. PURPOSE: To identify distinct patient phenotypes based on preoperative radiographic findings using unsupervised clustering and to evaluate their associations with postoperative patient-reported outcomes and reoperation rates. STUDY DESIGN: Retrospective cohort study. PATIENT SAMPLE: Patients undergoing single-level lumbar decompression. OUTCOME MEASURES: Oswestry Disability Index (ODI), Short Form-12 physical component scale (SF-12 PCS), reoperation rates. METHODS: Unsupervised clustering was performed using preoperative radiographic data from standing X-ray imaging and magnetic resonance imaging (MRI). Variable selection was optimized through preliminary correlation analysis, causal assessment using a directed acyclic graph, and expert review. A multivariable mixed-effects model was used to assess the impact of cluster membership on postoperative outcomes. Reoperation rates were compared using Kaplan-Meier survival analysis and Cox proportional hazards models. RESULTS: Unsupervised clustering identified 4 distinct clusters base on 10 radiographic variables: cluster 1 as "Young and Less Degenerative Spine" (cluster Y), cluster 2 as "Combined Coronal and Sagittal Spondylosis" (cluster CS), cluster 3 as "Coronal Spondylosis Characterized by Laterolisthesis" (cluster C), and cluster 4 as "Sagittal Spondylosis Characterized by Degenerative Spondylolisthesis" (cluster S). Multivariable regression analysis, adjusting for comorbidity, sex, and body mass index have revealed cluster C demonstrated slower improvement in ODI (ß = 5.4, SE = 2.7, p=.043) and SF-12 PCS (ß=-2.9, SE=1.4, p=.045) compared to cluster Y. Regarding reoperation, cluster CS showed the highest hazard ratio (24.3%, HR=4.18, 95% CI: 1.48-13.07, p=.007) compared to cluster S with the lowest reoperation rate (6.8%). CONCLUSION: Unsupervised clustering based on preoperative radiographic findings identified 4 distinct degenerative phenotypes in LSCS. Patients with coronal spondylosis was associated with slower improvements in disability and function compared to those with minimal degeneration. Additionally, patients with combined sagittal and coronal degeneration exhibited the highest reoperation rates. These findings highlight the clinical relevance of coronal and sagittal degeneration in surgical decision-making.

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BACKGROUND: The Infinity with Adaptis Total Ankle System (Stryker, Mahwah, NJ) is a low-profile, fixed-bearing implant that became available for use in October 2019. The aim of this study was to describe the early clinical and radiographic outcomes of the Infinity with Adaptis implant at minimum 2-year follow-up. METHODS: A retrospective review of 71 ankles that underwent primary total ankle arthroplasty (TAA) with Infinity with Adaptis implants between November 2019 and November 2021 at a single institution was completed. Chart review was performed to identify complications, reoperations, and revision procedures. Preoperative and postoperative radiographs were measured to assess tibiotalar alignment and identify periprosthetic lucencies, cysts, or subsidence. Patient-Reported Outcomes Measurement Information System (PROMIS) scores were collected preoperatively and at 1 and 2 years postoperatively to assess clinical outcomes. RESULTS: At final follow-up (average 2.7 ± 0.6 years), 68 of the 71 ankles remained implanted (95.8%). Three ankles were revised within 1.5 years of the index procedure (1 for talar component loosening and 2 for infection). There were an additional 5 (7.0%) reoperations at an average of 16.0 (range: 1.1-37.1) months postoperatively. Patients demonstrated both clinically and statistically significant improvements in preoperative to 1-year postoperative PROMIS scores (P < .0001). There was no statistically significant improvement in scores from 1 to 2 years postoperatively. There was improvement in radiographic alignment from the preoperative to postoperative radiographs (P < .001), and tibial component lucency was observed in 20 of 71 without progressive global lucency during the study window. CONCLUSION: Patients who underwent total ankle arthroplasty with the Infinity with Adaptis Total Ankle Replacement demonstrated significant improvements in radiographic and clinical outcomes at a minimum of 2-year follow-up with 95.8% (68/71) implant retention and a tibial lucency rate of 28.2% in this cohort. These observational findings warrant mid- to long-term surveillance to determine the clinical significance of early lucencies and the durability of this design's porous-surface osseointegration.

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PURPOSE: Medial opening wedge high tibial osteotomy (MOWHTO) is an effective procedure for managing isolated medial compartment osteoarthritis (OA) with varus malalignment. This study investigates the effect of radiographic OA severity on the clinical outcomes and survivorship of MOWHTO. METHODS: A retrospective analysis of a prospectively maintained single-centre database of 1170 knee osteotomies, between 2002 and 2022, was conducted. Adult patients who underwent MOWHTO for symptomatic unicompartmental medial knee OA, with varus knee malalignment, who had failed conservative management were included. Patients were stratified into four groups according to the radiographic OA severity of the medial compartment based on the Kellgren Lawrence (KL) grading system. Multiple patient-reported outcome measures (PROMs) were recorded preoperatively and at 2 and 5 years postoperatively. The delta values between preoperative and 2 and 5-year postoperative PROMs scores were calculated and compared with their reported minimal clinically important difference (MCID) scores. Deformity analysis was undertaken preoperatively and postoperatively. The rate of conversion to arthroplasty, and 5- and 10-year survivorship were recorded, as well as the hazard ratio (HR) of OA KL grade on survivorship. RESULTS: A total of 605 cases were included in the study: KL1 group (n = 71), KL2 group (n = 203), KL3 group (n = 210) and KL4 group (n = 121). There was no intergroup significant difference in the demographics. The mean follow-up for the whole series was 13.2 ± 3.8 years. There was an intergroup significant difference in the mechanical tibiofemoral angle (mTFA), joint line convergence angle (JLCA), and Mikulicz point (all p < 0.001). A more varus TFA was noted in patients with more advanced OA grades: KL1 -4.8° ± 2.7°, KL2 -5.5° ± 2.9°, KL3 -5.7° ± 3.1° and KL4 -6.8° ± 3.1°. Similarly, there was a lower Mikulicz percentage in higher KL grades: KL1 25.5 ± 12%, KL2 25.0 ± 12.7%, KL3 21.9 ± 13.2% and KL4 17.7 ± 13.9%. Clinically, there were significant improvements across all PROMs and achievement of MCID in KOOS, OKS and VAS pain in all groups. No significant difference in survival outcomes was observed between the four OA KL grade groups (p = 0.8). CONCLUSION: MOWHTO was associated with durable survivorship and excellent patient-reported outcomes across the spectrum of radiographic OA severity. However, the extent to which MOWHTO may delay the need for total knee arthroplasty requires confirmation through longer term, prospective studies. Symptomatic patients with early-stage OA (Kellgren-Lawrence Grade 1) should be counselled on the potential for more limited functional gains following the procedure. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

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ABSTRACT: Total hip arthroplasty (THA) is a transformative procedure in addressing hip arthritis. However, managing acetabular defects remains challenging, particularly in neglected developmental dysplasia of the hip cases due to altered hip anatomy. A middle-aged female presented with bilateral hip arthritis secondary to dysplasia. She was planned for staged bilateral THA. Intraoperatively, we noted a shallow acetabulum with a posterior superolateral defect and significant uncoverage of the cup. The defect was reconstructed using autologous femoral head graft and screws fixation along with contracture releases. Postoperative bilateral outcome scores showed significant improvement at 6 months and 2 years, with neutral limb length discrepancy. Follow-up radiographs showed successful graft integration and implant stability. This technique offers the advantages of biological integration, improved implant stability, enhanced joint survivorship, and improved quality of life. In situations, where acetabular augments are unavailable or cannot be used owing to financial constraints, this technique proved to be an effective method.

RésuméL'arthroplastie totale de la hanche (PTH) est une intervention révolutionnaire dans le traitement de l'arthrose de la hanche. Cependant, la prise en charge des lésions acétabulaires reste complexe, notamment dans les cas de dysplasie développementale négligée de la hanche due à une altération anatomique de la hanche. Il s'agit d'une femme d'âge moyen présentant une arthrite bilatérale sévère secondaire à une dysplasie. Une PTH bilatérale progressive a été envisagée. En peropératoire, nous avons constaté un acétabulum peu profond avec une lésion postéro-supérolatérale et une importante découverte de la cupule. La lésion a été reconstruite par greffe autologue de tête fémorale et fixation par vis, ainsi que par libération des contractures. Les scores de résultats bilatéraux postopératoires ont montré une amélioration significative à 6 mois et 2 ans, avec une inégalité de longueur des membres neutre. Les radiographies de suivi ont montré une intégration réussie du greffon et une stabilité de l'implant. Cette technique offre les avantages de l'intégration biologique, d'une meilleure stabilité de l'implant, d'une meilleure survie articulaire et d'une meilleure qualité de vie. Dans les situations où les prothèses acétabulaires ne sont pas disponibles ou ne peuvent être utilisées en raison de contraintes financières, cette technique s'est avérée efficace.

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PURPOSE: We have been performing radial shortening osteotomies for patients with negative ulnar variance and Lichtman stage 2 or higher Kienböck disease. Although we previously reported the results of this procedure 10 years after surgery, reports on follow-up beyond 10 years remain scarce. This study aimed to investigate the results of radial shortening osteotomy for Kienböck disease based on long-term clinical and radiographic outcomes for a minimum of 20 years after surgery. METHODS: The cohort comprised seven patients with eight wrists treated between 1991 and 2002, whose average age at the time of surgery was 25.9 years (range: 17-44 years). The preoperative Lichtman classification was stage 3A in one wrist, 3B in five, and stage 4 in one; the mean preoperative ulnar variance was -2.2 mm (range: -1.0 to -3.5 mm). Changes in pain, range of motion, grip strength, modified Mayo Wrist Score, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and radiographs were evaluated from 10 years after surgery to the last follow-up at least 20 years after surgery. RESULTS: Pain remained reduced in all patients at 20 years after surgery. Improvements in wrist extension and flexion observed 10 years after surgery were maintained at the last follow-up. Grip strength at 10 years after surgery was maintained at the last follow-up. The mean modified Mayo wrist score and the mean DASH score were maintained from 10 years after surgery to the last follow-up. Radiography showed no progression of lunate collapse in any case, although one case showed progression of degeneration in the radiocarpal joint and the distal radioulnar joint. CONCLUSIONS: Good clinical results observed in patients 10 years after radial shortening osteotomy are likely to remain stable at 20 years after surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

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This research aims to investigate femoral neck anteversion (FNA) on the less involved side in unilateral cerebral palsy (CP) and examine its impact on hip rotation during gait. Sixty-nine patients with unilateral CP, with a mean of 21 years, were included study. Static and dynamic hip rotation ranges were quantified via physical examination and three-dimensional motion analysis. Patients were stratified into five levels of involvement according to modified Winters' classification. FNA differences between modified Winters' classification types and correlation with static and dynamic hip rotation were analyzed. Hip morphology was classified based on the Melbourne Cerebral Palsy Hip Classification Scale E&R. Regarding FNA, our analysis suggested a moderate correlation ( r  = 0.61, P  < 0.05) between both sides. Hip dysplasia was found in 20.5 and 23.1% of the less involved and more involved sides, respectively, in 39 patients. Increased FNA was associated with increased static hip internal and decreased external rotation for both sides ( P  < 0.05). A positive correlation was observed between FNA and dynamic hip rotation on the more involved side ( P  < 0.05). Conversely, on the less involved side, FNA showed no significant correlation with pelvic, hip, or knee rotation. This study demonstrates that in unilateral CP, the less involved side is also significantly affected, a moderate correlation exists between the two sides, and both hips may exhibit dysplasia. These findings underscore the necessity for a comprehensive bilateral clinical assessment. Long-term surveillance of both hips and consideration of the less involved side for surgical planning may be warranted.

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BACKGROUND: Many pediatric injuries can be diagnosed with one radiograph. Because of health care costs and radiation risks, provider prudence while ordering radiographs is crucial. Although clinical guidelines like Ottawa Ankle Rules (OAR) and Ottawa Knee Rules (OKR) exist, the decision to order radiographs often bypasses clinical judgment. The purpose of this study was to conduct a review of the radiographic practices of providers. METHODS: This was a retrospective cohort of 179 pediatric patients with an extremity injury. Detailed chart review was performed on patients regarding demographics, HPI, physical exam, radiographs, and follow-up. Primary outcomes included radiographs and their relationship to the physical examination. Specifically, knee, ankle, and foot complaints were examined in relation to OAR and OKR. Predictor variables included age, sex, ordering provider, and location of presentation. RESULTS: At least one set of unnecessary radiographs was performed in 139 (86.3%) of 161 patients with documentation of physical examination. Decreased age was significantly associated with outcomes: unnecessary knee and foot radiographs per OAR and OKR, having completely negative radiographs, having unnecessary radiographs performed, and having zero radiographs indicated. Increased age was correlated with an increase in unnecessary radiographs ordered. Neither provider type nor location of triage showed significant outcomes. CONCLUSIONS: There is a significant number of patients that are not receiving a proper screening before radiographic orders. Providers should return to physical examination and the utilization of clinical guidelines to best serve their patients, while understanding some of the ways that age may negatively impact their habits. LEVEL OF EVIDENCE: Level III-retrospective diagnostic study.

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Lane and Sandhu introduced a radiological score to evaluate bone union in animal and human models after experimental bone grafting. We introduce an extension of the Lane and Sandhu Scoring system to serve as a more granular system for robust bone healing assessment in clinical research. We describe the application of this scoring system in the context of an autologous cell-based osteogenic implant (NVD003) designed to improve the rate of bone union. Images from four participants with congenital pseudoarthrosis of the tibia (CPT) and 9 adults with recurrent osseous non-union after conventional surgery were obtained. All participants underwent NVD003 implantation. An extended version of the Lane and Sandhu scoring system (eLSS; range from 0 to 12) was employed to assess bone formation, union, and remodeling by two independent readers longitudinally, with final adjudication in cases of > 1 point disagreement. Interobserver agreement was assessed using quadratic weighted kappa. 206 exams (170 radiographs and 36 CT scans) were studied across the two pathologies (81 scans for participants with CPT and 125 scans for participants with recurrent osseous non-union). Overall agreement between the expert readers was found to be 0.84 (95% CI: 0.79, 0.89), with comparable agreement found per modality (radiographs [0.85] and CT images [0.76]) and per pathology (CPT [0.83] and recurrent osseous non-union [0.84]). These results support that the eLSS has sufficient reliability to warrant further consideration for clinical trial use. Additional studies with a greater number of subjects, raters, and variety of use cases are required to validate and optimize this method. Level of Evidence: III.

RESUMEN

Aims: Total excision of the femur and its reconstruction pose a substantial challenge in children. We present the long-term results of total femoral excision and type BIIIa rotationplasty in children. Methods: A total of 18 patients who had undergone a type BIIIa rotationplasty over a period of 20 years were included in the study. Their mean age at the time of surgery was 7.1 years (3.3 to 11). Two patients underwent a hip disarticulation in the perioperative period. Five died in the first two years from surgery. The mean follow-up of the remaining 11 patients was 124 months (24 to 244). We evaluated their long-term radiological, functional, and oncological outcomes and measured any limb length discrepancy at final follow-up. Results: The hip was stable in eight of 11 patients. Radiologically appreciable remodelling of the proximal tibia was seen in all patients. At final follow-up, four patients had reached skeletal maturity, five were adolescents (aged 12 to 17 years), and two were still pre-adolescent (aged < 12 years). The mean shortening in the skeletally mature patients was 2.25 cm (0 to 4). Limb length was measured in four of the five adolescent patients: the mean shortening was 0 cm (-1 to +1). Other than the two patients who underwent a hip disarticulation in the immediate perioperative period, no patient needed a subsequent surgical procedure. None of the patients had a local recurrence. The five-year probability of overall survival was 70% (95% CI 51 to 96). The mean Musculoskeletal Tumor Society score was 23 (22 to 23). The mean Toronto Extremity Salvage Score calculated in nine patients was 91 (82 to 100). Conclusion: A type BIIIa rotationplasty is a reliable option for reconstruction after total femoral excision in children. Long-term follow-up shows good functional and oncological outcomes, without the need for additional surgical procedures.