Proximal femoral varus osteotomy for Legg-Calvé-Perthes disease: Do age and lateral pillar classifications influence short-to-mid-term clinical and radiological outcomes?

INTRODUCTION: Proximal femoral varus osteotomy (FVO) is one of the most used treatment methods with acceptable outcomes for Legg-Calvé-Perthes disease (LCPD). We aimed to investigate the influence of age at disease onset and the Lateral Pillar classification on clinical and radiological outcomes of FVO surgery LCPD patients between 6-12years of age. HYPOTHESIS: Proximal FVO surgery in the early fragmentation phase of LCPD patients led to acceptable clinical and radiographic outcomes in a 3-year follow-up, regardless of preoperative age and Herring type. MATERIAL AND METHODS: Fifty patients with LCPD (Herring groups B, B/C, and C) who underwent FVO were retrospectively reviewed. We evaluated radiological [center-edge angle, extrusion index, epiphyseal index, acetabular index, articulo-trochanteric distance (ATD)] and clinical [hip abduction range of motion (ROM), Trendelenburg sign, pain, and Harris hip score (HHS)] outcomes with a follow-up of 37.3±10.5months (range: 24-180months). Finally, the overall treatment outcome was assessed using the Stulberg classification. RESULTS: The ROC curve analysis did not reveal any significant relationship between age and clinical or radiological outcomes, and there was no predictable age cut-off for surgical outcomes (p=0.13). No significant difference was found in Stulberg classification at the follow-up between patients with type B, B/C, and C of the lateral pillar (p>0.05). DISCUSSION: Our results demonstrated that open-wedge proximal FVO surgery in the early fragmentation phase of LCPD patients led to acceptable clinical and radiographic outcomes in a 3-year follow-up. Each sample of our study was very small and a lot of variables were measured, making this result not adequately strong enough to draw a robust conclusion. However, FVO surgery remains a possible suggestion for patients in the early fragmentation phase, and age and lateral pillar type may not be limiting factors. LEVEL OF EVIDENCE: IV; therapeutic retrospective cohort.

Surgical treatment of a nonunion following clavicle osteotomy in a child with a history of Erb's palsy: A case report.

INTRODUCTION AND IMPORTANCE: Erb's palsy defined as muscle weakness and loss of motion caused by a nerve condition in the shoulder and arm. Children with Erb's palsy might underwent clavicle osteotomy as an appropriate surgical treatment method. However, few number of these patients who underwent clavicle osteotomy experienced nonunion and complained of shoulder deformity and pain. The aim of the present case report was to present new surgical treatment of a nonunion following clavicle osteotomy in a child affected by Erb's palsy. CASE PRESENTATION: A six years old boy with a history of Erb's palsy who underwent clavicle osteotomy at age of 6 months was referred to hospital. There was a nonunion following clavicle osteotomy. The patient had right shoulder deformity and complained of its-related pain. To correct a nonunion following clavicle osteotomy in this case, middle third fibula auto grafting and fixing it to the cite of clavicle nonunion by pins was used. After five months of follow-up, a clavicle nonunion and shoulder deformity was thoroughly corrected. CLINICAL DISCUSSION: As clavicle osteotomy, the most commonly surgical method for Erb's palsy, has been demonstrated to not work effectively and cause nonunion in some cases, a new surgical method for correcting clavicle nonunion other than repeated clavicle osteotomy is needed. In the present case report, fibula auto grafting and fixing it to the cite of clavicle nonunion by pins was applied and demonstrated remarkable improvement. CONCLUSION: Totally, use of fibula auto grafting and fixing it to the cite of clavicle nonunion by pins might be an effective surgical treatment for such cases.

Distal femoral osteotomy and patellar tendon advancement for the treatment of crouch gait in patients with bilateral spastic cerebral palsy.

BACKGROUND: Crouch gait, or flexed knee gait, represents a common gait pattern in patients with spastic bilateral cerebral palsy (CP). Distal femoral extension and/or shortening osteotomy (DFEO/DFSO) and patellar tendon advancement (PTA) can be considered as viable options when knee flexion contractures are involved. Better outcomes have been reported after a combination of both, independently of the presence of knee extensor lag. In this study, we evaluated the clinical and kinematic outcomes of these procedures. PATIENTS AND METHODS: We reviewed a cohort of 52 limbs (28 patients) who were treated for crouch gait by DFEO/DFSO alone (group 1, n = 15) or DFEO/DFSO + PTA (group 2, n = 37) as a part of single event multilevel surgery (SEMLS). The mean age at surgery was 14 years, and the mean follow-up time was 18 months. The physical examination data and three-dimensional standardized gait analysis were collected and analyzed before the surgery and postoperatively. RESULTS: Overall knee range of motion improved in all limbs. The knee flexion decreased significantly in both groups at initial, mid, and terminal stance. Hip flexion significantly decreased in mid-stance for limbs in group 2. Both clinical and gait parameters were most improved in limbs who underwent DFEO/DFSO + PTA. Increased pelvic tilt was observed in both groups after surgery. CONCLUSION: Although DFEO/DFSO alone was successful in correcting knee flexion contractures, PTA has helped to improve knee extensor lag and knee extension during gait. LEVEL OF EVIDENCE: Therapeutic level IV.

An additively manufactured titanium tilting suture anchor: a biomechanical assessment on human and ovine bone specimens.

Introduction: A novel titanium tilting suture anchor was designed and fabricated using additive manufacturing. The anchor enjoyed a nonsymmetrical structure to facilitate its insertion procedure through a weight-induced tilt, a saw-teeth penetrating edge to provide a strong initial fixation into cancellous bones of various densities, and an appropriate surface texture to enhance the longterm fixation strength through bone ingrowth. Methods: Biomechanical tests were performed on 10 ovine and 10 human cadaveric humeri to examine the insertion procedure and assess the initial fixation strength of the anchor, in comparison with a standard screw-type anchor as control. Results: This study indicated a simple yet reliable insertion procedure for the tilting anchor. All anchors survived after 400 cycles of cyclic loadings and failed in the load-to-failure step. There were no significant differences between the displacements and fixation stiffnesses of the anchors in either group. The ultimate failure load was significantly smaller (p<0.05) for tilting anchors in ovine group (273.7 ± 129.72 N vs. 375.6 ± 106.36 N), but not different in human group (311.8 ± 82.55 N vs. 281.9 ± 88.35). Also, a larger number of tilting anchors were pulled out in ovine group (6 vs. 3) but a smaller number in human group (4 vs. 6). Conclusion: It was concluded that the biomechanical performance of the designed tilting anchor is comparable with that of the standard screw-type anchors.

Understanding the management of pediatric spondylodiscitis based on existing literature; a systematic review.

BACKGROUND: Spondylodiscitis (SD), a rare disease in children, poses diagnostic challenges due to non-specific presenting symptoms, scarcity in incidence, and difficulty expressing pain in non-verbal children. METHOD: A comprehensive search was conducted on three databases, including PubMed/Medline, Web of Science, and Scopus until March 2023. The inclusion criteria were studies that investigated the clinical characteristics, treatment, and complications of children's spondylodiscitis. Full text of cross-sectional and cohort studies were added. The quality assessment of cohort studies was conducted using the Newcastle-Ottawa Quality Assessment Scale. The search, screening, and data extraction were performed by two researchers independently. RESULT: Clinical manifestations of discitis in children are nonspecific, such as back pain, fever, reduced ability or inability to walk or sit, limping, and reduced range of movements. The mean delay in the time of diagnosis was 4.8 weeks. The most affected site of all the studies was the lumbar spine. 94% of studies reported increased inflammatory markers such as white blood cell count, C-reactive protein, and erythrocyte sedimentation rate. Less than 30% of patients had positive blood cultures and biopsy findings. The most common microbiological results (64%) were Staphylococcus Aureus and Kingella kingae. In radiographic evaluation, intervertebral disk narrowing, lumbar lordosis reduction, loss of disk height, and destruction of the vertebral body have been reported. In all studies, antibiotic therapy was initiated; in 52% immobilization was employed, and 29% of studies reported surgery was performed, and the follow-up period differed from 1.5 months to 156 months. 94% of studies reported complications such as vertebral body destruction, back pain, kyphosis, reduced range of movement, scoliosis, and neurological complications. CONCLUSION: Spondylodiscitis is an uncommon, heterogeneous, multifactorial disease with resulting difficult and delayed diagnosis. Due to its morbidity, it is essential to investigate children with refusal to walk, gait disturbances, or back pain, particularly when associated with elevated inflammatory markers.

Changes in gait pattern and quality of life of adolescents with flexible flat foot after Calcaneal Lengthening Osteotomy.

BACKGROUND: Calcaneal Lengthening Osteotomy is a surgical technique to correct flexible flat foot deformities in patients who did not show any change in their symptoms after conservative treatment. In this study, the effects of CLO on the kinematic and kinetic changes of gait was analyzed and the clinical and quality of life improvements in children treated by CLO for moderate to severe symptomatic flexible flat foot deformities were assessed. METHODS: Participants were seven adolescents (13 feet) with symptomatic FFF who underwent during 2019-2022 and seven (10 feet) healthy children as control group. Three items were evaluated in each foot before and after surgery including: 1. Clinical examination 2.quality of life (using Pediatric Quality of Life Inventory version 4 questionnaire) 3. Gait analysis (Vicon motion systems, Oxford metrics Inc., UK). Also, the kinetic and kinematic analysis between patients and healthy groups were compared. RESULTS: Kinematic results of control was significantly better than FFF group. Ankle range of motion(32.94 ± 13.39 compared to 32.94 ± 13.39,P-Value:0.01),foot progression angle (-9.26 ± 7.67 compared to -16.07 ± 9.00,P-Value:0.01),and internal rotation of ankle was higher in control group compared to FFF. FFF patients demonstrated improvement in kinematic results after CLO surgery. Foot progression angle was improved after surgery (-11.31 ± 6.07 compared to -16.19 ± 7.06, P-value:0.00), maximum plantar flexion decreased after CLO surgery due to achil tendon procedure during CLO surgery. Kinetic results of FFF patients showed significant increase in ankle Power in coronal and transverse plane, Also knee and hip power showed similar results.Quality of life parameters showed significant improve in all parameters (Physical,Social, emotional and school function), Also ADKE and ADKF improved after surgery. CONCLUSION: CLO surgery significantly improved patients' quality of life of patients with symptomatic FFF. Also, kinetic results showed improvement in some parameters of gait results after CLO surgery. Thus, our study suggested CLO surgery as an excellent surgical option for symptomatic FFF.

Outcomes of the Pin and Plate Technique in Complex Fractures and Nonunions of Distal Humerus.

Objectives: This study investigates outcomes and complications of the pin and plate fixation technique, which was suggested for distal humerus fractures. It also reports the results of its application in nonunions for the first time. Methods: Forty-nine fracture and 17 nonunion cases who underwent surgery using the technique and were followed for at least 18 months were assessed through the range of motion (ROM), Quick Disabilities of the Arm, Shoulder, and Hand Score (Quick-DASH), Mayo Elbow Performance Score (MEPS), four-category verbal rating scale (VRS-4), and complications. Results: At the last follow-up, the mean scores of flexion, extension deficit, supination, and pronation ranges in fracture cases were 116.7, 22.9, 90.0, and 90.0 degrees, respectively. These values in nonunion cases were 112.2, 26.4, 86.7, and 85.5 degrees, respectively. The average ROM in fracture cases was 93.8, while it was 85.8 degrees in nonunion cases. The mean Quick-DASH in fracture and nonunion patients were 25.2 and 31.1, respectively. According to the MEPS, 77.5% of fracture and 64.7% of nonunion patients had excellent and good results. In fracture cases, the mean scores of VRS-4 at rest, light activity, and hard activity were 1.3, 1.8, and 2.3, respectively. These values in nonunion cases were 1.8, 2.2, and 2.5, respectively. The most common complications were device prominence and ulnar neuropathy. Conclusion: An acceptable union rate and proper elbow function can be expected by using this technique. Owing to the promising results of this study, further high-quality studies are recommended. Hereby this technique is called Persian Fixation.

Dominant omodysplasia-A sporadic case-A new case report and review of the literature.

Omodysplasia is an extremely rare skeletal dysplasia. Since introducing this phenotype as a new syndrome, ten cases of the autosomal dominant type of this disease have been reported. Here, we present a new patient and review published articles in this field to provide a clinical diagnostic criterion.

Complications of single growing rod constructs in the treatment of severe early-onset scoliosis: a lesson relearned.

PURPOSE: Early-onset scoliosis (EOS) is one of the most challenging areas of orthopedic management. Previous studies have reported that EOS patients were associated with high risk of complications following growth-friendly surgery. This study was performed to evaluate the complications of single traditional growing rods (TGRs) in the treatment of EOS. METHODS: In a retrospective chart review study, medical records of all EOS patients treated with single TGRs between 2006 and 2018 were analyzed. Patients under the age of 10 at the time of surgery who had at least 24 months of follow-up were included. Intra- and post-operative complications included both device-related and disease-related complications. Statistical analysis was performed with SPSS. RESULTS: A total of 35 patients with a mean age of 5.7 ± 2.1 years with the mean follow-up duration of 33.3 ± 9.1 months were included in the final analysis. Of the 35 participants, 27 children (77.1%) experienced at least one complication. A total of 61 complications were observed, giving rise to 1.7 complications per patient. An unplanned surgical procedure was needed to manage 42 of the 61 complications (68.8%). Thirty-five cases of implant failure, 11 cases of deep infection, and 2 cases of junctional kyphosis were identified. CONCLUSION: It seems that even in the setting that the use of dual TGRs is not possible, the use of single TGRs as the only therapeutic modality should be minimized due to high rate of complications even as a bridge treatment. LEVEL OF EVIDENCE: Therapeutic level III.

Langenskiöld classification of tibia vara: a multicenter study on interrater reliability.

Since 1952, when Langenskiöld introduced his six-stage classification on roentgenographic morphologies of tibia vara, this method has been used extensively in Orthopaedic studies. Different studies have tried to determine the reliability of this method. Although there are scarce reports of major variability in using Langenskiöld classification, but the question still remains, as to whether using expert subspecialists and MRI would improve its reliability. The aim of this study is to evaluate inter-rater reliability of Langenskiöld classification using simple radiograph and MRI, by expert raters. This is a cross-sectional multicenter study, involving patients from 4 tertiary pediatric orthopedic centers in France and Iran. Radiograph and MRI (T1, T2, fat saturation) of the affected knees were independently classified by 12 academy members from France and Iran: six pediatric fellowship orthopedic surgeons and six musculoskeletal radiologists. All data were analyzed afterwards by an independent researcher. Mean weighted kappa for agreement based on radiograph and MRI was 0.47 and 0.45, respectively. Mean percent of total agreement was 46.6 and 40.8% in the same order. Kappa statistics for the new grouping were 0.53 and 0.46 for roentgenograms and MRIs, respectively. The new regrouping was proposed so that each group would need a different treatment strategy. Fleiss kappa statistics for group B (stages 2 and 3), rose from (0.33 and 0.09) to 0.44. These values for group C (stages 4 and 5) rose from (0.42 and 0.11) to 0.54. This study concludes that Langenskiöld's classification when used by experts, still has a moderate inter-rater reliability at best. This variability is most at stages 2, 3, and 4; and can cause different treatment approaches. Use of MRI does not have a significant effect on its reliability. Regrouping the stages improved the inter-rater reliability. Level of evidence: III.

Orthopedic management of myelomeningocele with a multidisciplinary approach: a systematic review of the literature.

BACKGROUND: Myelomeningocele (MMC) is the most common and severe form of spina bifida and imposes a significant burden on patients and the healthcare system. Recently, the multidisciplinary management of MMC has become popular. Herein, we aimed to review the orthopedic management, outcomes, and complications of the of patients with MMC eyeing a multidisciplinary approach. METHODS: We searched PubMed and EMBASE to find relevant studies published before August 2020. All studies that included clinical management of MMC patients and published earlier than 2000 were considered for review on the condition that they reported at least one orthopedic intervention and the rate of complications. We excluded review articles, case reports, case series, letters, commentaries, editorials, and conference abstracts. The primary and secondary goals of our review were to report the outcomes and complication rates of multidisciplinary management for MMC patients. RESULTS: Twenty-six studies included data for the management of 229,791 patients with MMC and were selected. Sixteen studies reported multidisciplinary management in addition to orthopedic management. From those, 11 (42.31%) included urologic management, 13 (50%) neurosurgical management, 11 (42.31%) neurologic management, and 5 (19.23%) gastrointestinal management. All studies included postnatal operations and related management. No randomized clinical trial was found in our search. CONCLUSION: Orthopedic approaches play a key role in MMC management by alleviating spinal deformities, particularly scoliosis, and hip, foot, and ankle complications. However, the most appropriate management, whether surgical or non-surgical, may vary for different patients, given disease severity and the age of patients.

Bone in the Time of Corona: Suggestions for Managing Pediatric Orthopaedics Conditions in a Resource-limited Environment during the COVID-19 Pandemic.

The outbreak of a novel coronavirus, referred to as coronavirus disease-19 (COVID-19), with its sentinel case in Wuhan, China, in December 2019, has spread rapidly around the globe. On March 11, 2020, the World Health Organization (WHO) declared COVID-19 a worldwide pandemic, which led to most countries implementing social distancing protocols. Most non-essential medical practices have been halted to direct resources to the facilities caring for patients with COVID infection. The pediatric orthopaedic practice is in a unique position, with the treatment of many conditions being treated by pediatric orthopedists being non-emergent, but time-sensitive. We hereby review the current literature and guidelines surrounding the practice change around the world and give recommendations regarding the practice of pediatric orthopaedics during the COVID pandemic.

Orthopedic Trauma Surgeries in COVID-19 Pandemic; A Trauma Management Algorithm.

After the COVID-19 outbreak worldwide, we will sooner or later encounter trauma patients with COVID-19 in the developing countries. It is a challenging decision-making process for an orthopedic surgeon to provide the patients with the best practice in the crisis. Here we discuss the issue in terms of clinical severity of COVID-19 pneumonia, priority of orthopedic surgical trauma procedures and standard of care for the treatment of trauma injuries. We finally propose an algorithm for better management of trauma patients in the setting of COVID-19 mass spread.

Novel Coronavirus Infection in Orthopedic Patients ; Report of Seven Cases.

During the course of novel coronavirus pandemic ,Shariati hospital in Tehran , as a tertiary center in both orthopedic trauma and COVID-19 , we detected 7 cases with definite diagnosis of COVID-19 and concomitant emergent orthopedic problem.This paper represents considerations and special issues in managing and decision making in these patients.

How to Continue Essential Orthopedic Services during COVID-19 Crisis?

The first pandemic of the coronavirus family was caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in late 2019. As a result of the pandemic critical condition, specialized orthopedic services were obviously affected. To respond properly, we initiated a series of strategic measures, aiming at the safety of staff, minimizing the exposure, and prevention of possible disruption in providing services.

Is bipolar latissimus dorsi transfer a reliable option to restore elbow flexion in children with arthrogryposis? A review of 13 tendon transfers.

BACKGROUND: Scant data are published about different available therapeutic options for restoration of active elbow flexion in arthrogryposis with varying degrees of improvement. In this retrospective study we evaluated medium-term effects of bipolar latissimus dorsi transfer in patients with arthrogryposis. METHODS: Pedicled latissimus dorsi bipolar muscle transfer was used to restore elbow flexion in 11 patients (13 limbs) with arthrogryposis. Elbow and shoulder range of motions and strength of elbow flexion were measured preoperatively and at the last follow-up. The functional use of the upper limb was examined by observation of activities of daily living and presence of adaptive mechanisms. General satisfaction was assessed at the final follow-up. RESULTS: The patients were a mean age of 5.69 ± 2.49 years. The follow-up period was 27.31 ± 17.8 months. At the last examination, according to transferred muscle function and elbow range of motion, function of 12 limbs was graded as excellent and good, and 1 was graded poor. The active postoperative elbow range of motion was 97.7° ± 34.5°. The general satisfaction of the patients with the surgical results was 92.3%. Activities of daily living were improved in 10 of 13 limbs, but adaptive mechanisms were detected in all patients except 2 at the last follow-up. CONCLUSIONS: We suggest pedicled bipolar latissimus dorsi transfer as a reliable therapeutic option to restore active elbow flexion in arthrogryposis with acceptable results regarding regaining range of motion and patient satisfaction. Functional passive elbow range of motion and good quality of latissimus dorsi muscle preoperatively is mandatory.

Comparison of Pediatric and General Orthopedic Surgeons' Approaches in Management of Developmental Dysplasia of the Hip and Flexible Flatfoot: the Road to Clinical Consensus.

Developmental dysplasia of the hip (DDH) and flatfoot are common pediatric orthopedic disorders, being referred to and managed by both general and pediatric orthopedic surgeons, through various modalities. Our study aimed to evaluate their consensus and perspective disagreements in terms of diagnostic and therapeutic approaches of the mentioned deformities. Forty participants in two groups of general orthopedic surgeons (GOS) (n=20) and pediatric orthopedic surgeons (POS) (n=20), were asked to answer an 8-item questionnaire on DDH and flexible flatfoot. The questions were provided with two- or multiple choices and a single choice was accepted for each one. Chi-square and Fisher's exact tests was performed to compare the responses. For a neonate with limited hip abduction, hip ultrasonography was the agreed-upon approach in both groups (100% POS vs 71% GOS), and for its interpretation 79% of POS relied on their own whereas 73% of GOS relied on radiologist's report (P=0.002). In failure of a 3-week application of the Pavlik harness, ending it and closed reduction (57% POS vs. 41% GOS) followed by surgery quality assessment with CT scan (64% POS vs. 47% GOS) and without the necessity for avascular necrosis evaluation (79% POS vs. 73% GOS) were the choice measures. In case of closed reduction failure, open reduction via medial approach was the favorite next step in both groups (62% POS and 80% GOS). For the patient with flexible flat foot, reassurance was the choice plan of 79% of pediatric orthopedists. Our findings demonstrated significant disagreements among the orthopedic surgeons. This proposes insufficiency of high-level evidence.

Arthroscopic ablation of an osteoid osteoma of the elbow: a case series with a minimum of 18 months' follow-up.

BACKGROUND: Arthroscopic excision of an osteoid osteoma was first reported in the knee joint; since then, there have been several reports of arthroscopic excisions in the knee, shoulder, and elbow, with inconclusive outcomes because of a limited number of cases. The aim of this prospective study was to evaluate the medium-term functional effects of arthroscopic ablation in cases of an osteoid osteoma around the elbow. METHODS: We treated osteoid osteoma of the elbow through arthroscopic ablation in 10 patients. The arthroscopic resection procedure was performed 23 ± 9 months (range, 12-36 months) after initial symptoms. At the preoperative examination and last follow-up examination, the elbow flexion-extension and forearm supination-pronation ranges of motion were measured. The patients were assessed by the Mayo Elbow Performance Score, the visual analog scale for the elbow and wrist, and the Quick Disabilities of the Arm, Shoulder, and Hand score. Finally, the patients' general satisfaction was assessed. RESULTS: The postoperative elbow flexion-extension range of motion was significantly higher compared with range of motion before surgery (P = .001; r = 0.86). According to the Mayo Elbow Performance Score, the average score increased significantly at the final follow-up examination. The mean preoperative and final Quick Disabilities of the Arm, Shoulder, and Hand scores were 47 ± 14 and 1.6 ± 2.8, respectively (P < .001). All patients were satisfied with the operation result. CONCLUSION: According to the results of our study, arthroscopic ablation is a safe and efficient method of treatment for osteoid osteoma of the elbow, with a fast rehabilitation time.