Diagnosis and Treatment of Varus Posteromedial Rotational Instability of the Elbow Joint in Children: Re-Understanding of the Injury Mechanism Associated With Coronoid Process Fractures.

PURPOSE: To investigate the injury mechanism, diagnosis, and treatment of varus-posteromedial rotational instability of the elbow joint in children. METHODS: According to the diagnostic criteria of varus posteromedial rotational instability of elbow joint, 16 children with coronoid process fractures treated in our department from July 2013 to July 2017 were re-evaluated. There were 14 males and 2 females, aged 7 to 14 years, with an average age of 11.6 years. Eight cases on left and 8 cases on right side. An associated elbow dislocation occurred in 8 of 16 cases. Nine patients were treated with a lateral soft tissue repair only. In 7 other patients in addition to the lateral soft tissue repair, the coronoid process fractures were treated with open reduction and fixation. At the last clinical follow-up, each elbow joint range of motion was recorded, radiographs were obtained, and functional performance was evaluated by the Mayo elbow performance score (MEPS). RESULTS: The average follow-up time was 81.9 months for the 9 patients treated with lateral elbow soft tissue repair. At the last follow-up, 2 of the patients had MEPS scores as excellent, 1 was good, and 6 were rated as moderate or poor. Four patients had a cubitus varus deformity. The average follow-up time was 30.3 months for the 7 patients treated with both soft tissue repair and coronoid fracture stabilization. The elbow joint MEPS scores for each of these 7 patients was excellent at the last follow-up, and no complications such as cubitus varus occurred. CONCLUSION: The results of the study suggest that children could also develop elbow varus-posterior medial rotational instability injuries under the same mechanism. Although the morbidity rate is low, due to insufficient understanding of the injury mechanism, it is prone to missed diagnosis, misdiagnosis, and delayed treatment, resulting in severe complications such as elbow instability, dislocation, traumatic arthritis, and elbow stiffness. On the contrary, according to the treatment principle of the posterior medial rotational instability of the elbow joint in adult, while the lateral repair is carried out, strong and effective reduction and fixation of the coronoid process fractures are adopted, it is expected that such children with rare elbow injuries can obtain excellent treatment outcomes.

Repositioning of the Annular Ligament in the Management of Missed Monteggia Fracture.

BACKGROUND: Successful treatment of missed Monteggia fractures usually requires ulnar osteotomy and open reduction of the radial head with reconstruction of the annular ligament. We have observed cases in which the annular ligament was displaced into the joint but remained intact. Here we report our experience with repositioning of the annular ligament at the time of the open reduction rather than reconstruction in the management of missed Monteggia fractures. METHODS: We retrospectively reviewed 23 patients with missed Monteggia fractures treated by repositioning of the annular. There were 16 males and 7 females with an average age of 6 years (range, 4 to 9 y). The average time from injury to definitive treatment was 7 months (range, 6 wk to 16 mo). The average follow-up was 18 months (range, 8 to 36 mo). We evaluated the patients by clinical examination, Kim score, and radiographs. RESULTS: All patients had no pain and full elbow function at the latest follow-up. There were no significant differences between the preoperative and postoperative Kim scores. Radiographs at the latest follow-up demonstrated maintenance of radial head reduction in all cases. CONCLUSIONS: Repositioning of an intact annular ligament in cases of missed Monteggia fractures is a viable alternative to reconstruction of the ligament and provides long-term stability. LEVEL OF EVIDENCE: Level IV-therapeutic.

[Results of following-up for 5-10 years of periacetabular osteotomy for acetabular dysplasia in adolescence].

OBJECTIVE: To investigate the effects of periacetabular osteotomy (PAO) for developmental dysplasia of the hip in adolescent. METHODS: Twelve hips in 9 adolescent patients who underwent a Bernese periacetabular osteotomy for symptomatic or asymptomatic developmental dysplasia of the hip were analyzed. The average age of the patients at the time of surgery was 12.9 years(11-14 years). The Harris hip score and overall patient satisfaction with surgery were used to assess hip function and clinical results. Plain radiographs were used to assess the correction of the deformity and to observe progression of degenerative changes. RESULTS: The average duration of clinical follow-up was 88.5 (60-136) months. The mean Harris hip score increased from 89 ± 6 preoperatively to 97 ± 3 at the time of the most recent follow-up (t = -6.754, P = 0.000). All patients (12 hips) had an excellent clinical result. The lateral center-edge angle of Wiberg increased from 4° ± 13° preoperatively to 36° ± 7° at the time of the most recent follow-up (t = -11.677, P = 0.000). The acetabular roof obliquity decreased from 28° ± 10° preoperatively to 2° ± 8° at the time of the most recent follow-up (t = 9.038, P = 0.000). The acetabular-head index increased from 54% ± 11% preoperatively to 89% ± 13% at the time of the most recent follow-up (t = -11.137, P = 0.000). The hip center was translated medially. Improvement of cystic degeneration of the acetabulum were found in 4 hips. Remodeling of aspherical uncongruence were found in 5 cases. Crossing sign were found in 2 hips postoperatively without symptoms of impingement. CONCLUSIONS: PAO can provide comprehensive deformity correction and improve hip function in treatment of developmental dysplasia of the hip in adolescence. Some of the patients have improvement of cystic degeneration and remodeling of the hip.

Multi-segment osteotomy with interlocking intramedullary nail fixation in the treatment of lower limb deformity in older children with hypophosphatemic rickets.

Objective: Malformations of the lower limbs caused by hypophosphatemic rickets in older children are mostly complex, occurring on multiple planes without a single apex and showing arcuate bending of the diaphysis combined with torsion deformity, and are difficult to correct. This study retrospectively investigated the effect of and indicators for multi-segment osteotomy with interlocking intramedullary nail fixation in the treatment of bony deformity caused by hypophosphatemic rickets. Methods: The clinical data of 21 hypophosphatemic rickets patients seen between August 2007 and March 2022 were collected. The age range of the patients at the first surgery was 11 years and 1 month old to 15 years and 3 months old, with an average age of 12 years and 8 months. There were 6 males and 15 females. All patients had abnormal alignment of their lower limbs, with 32 limbs having varus deformity and 10 limbs having valgus deformity. Results: A total of 67 surgeries were performed across the 21 patients, including 24 cases of femoral osteotomy with antegrade intramedullary nail fixation, 6 cases of femoral osteotomy with retrograde intramedullary nail fixation, and 20 cases of tibial osteotomy with interlocking intramedullary nail fixation. A total of 34 limbs eventually underwent interlocking intramedullary nail fixation, 9 with genu valgum and 25 with genu varus. All 21 patients were followed up for a period of 14∼96 months, with an average of 42.6 months. The ends of the osteotomies achieved bony union in 4-9 months (average 6.8 months), after which normal weight-bearing walking could be resumed. No infection, vascular or neurological complications, or nonunion occurred. During postoperative follow-up, the alignment the lower limbs passed through zone 1 in 13 limbs, zone 2 in 12 limbs, and zone 3 in 5 limbs. The overall rate of an excellent effect was 83.3%. Conclusion: For lower limb deformity caused by hypophosphatemic rickets in older children, multi-segment osteotomy and strong fixation with interlocking intramedullary nails can achieve good correction outcomes.