Preliminary Results of Calcaneal Lengthening Osteotomy Combined With Extra-articular Subtalar Arthrodesis for Severe Pes Planovalgus Deformity in Children With Cerebral Palsy: A New Surgical Technique.

OBJECTIVE: Pes planovalgus is the most common foot deformity seen in patients with cerebral palsy (CP). There are several different treatment modalities to treat this condition. Single or double calcaneal osteotomies, extra-articular arthrodesis, calcaneo-cuboido-cuneiform osteotomy, intraarticular arthrodesis, and arthroereisis are some of these modalities. Currently, there is insufficient information to determine the most effective treatment approach for pes planovalgus in children with CP. The aim of this study is to show the short to mid-term results of the new technique which combines calcaneus lengthening osteotomy, extra-articular subtalar arthrodesis, and soft tissue reconstruction that aims to decrease recurrence and complication rates of pes planovalgus surgery for patients with ambulatory CP. METHODS: Patients with CP who were treated with calcaneal lengthening surgery and extra-articular subtalar arthrodesis between 2018 and 2021 were investigated retrospectively. All patients were ambulatory and Gross Motor Function Classification System I-II-III. Functional levels of the patients were assessed with the American Orthopaedic Foot and Ankle Society, Ankle-Hindfoot Score, and the Foot and Ankle Ability Score (Foot and Ankle Ability Measure) in preoperative and postoperative periods. On anteroposterior x-rays, talus-first metatarsal, talocalcaneal, talonavicular coverage angle and on lateral x-rays talus-first metatarsal, talocalcaneal, calcaneal inclination angle and talar tilt angle were evaluated. RESULTS: The mean follow-up was 46 (range: 36 to 60) months. The mean American Orthopaedic Foot and Ankle Society increased from 41 (20 to 79) to 74 (38 to 93; P < 0.001). The mean Foot and Ankle Ability Measure increased significantly from 35 (7 to 73) to 54 (29 to 96; P <0.001). Clinical results were "satisfactory" for 32 feet, while they were "unsatisfactory" for 2 feet. Significant deformity correction was observed in all radiologic parameters. CONCLUSION: Our technique is found to be efficient for patients with Gross Motor Function Classification System I-II-III CP with pes planovalgus deformity. In short to mid-term follow-up, the technique achieved successful clinical and radiologic results with low complication rates. Superiority of this technique compared with the traditional ones can only be shown with randomized prospective studies. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Congenital Factor XIII Deficiency With the Presence of Inhibitor: A Case Study.

Coagulation factor XIII (FXIII) is a fibrin-stabilizing factor with additional roles in wound healing and interactions between the decidua and fetus. Congenital FXIII deficiency is rare bleeding disorder. Inhibitor development against FXIII in inherited FXIII deficency is also uncommon, but may cause severe, life-threatening bleeding. FXIII is the last step in the coagulation cascade with normal coagulation paramaters (PT, aPTT), the detection of inhibitor to FXIII is quite difficult. The treatment of inhibitor-positive congenital FXIII deficiency is challenging due to the lack of a role of by-pass agents such as FVII. The best known ways of treatment in these cases are the use of high-dose FXIII concentrates and immunosuppression. Herein, we report the management of postoperative bleeding diathesis in a patient with FXIII deficiency who developed inhibitors, and to follow the clinical course of the disease with FXIII concentrate and immunosuppression.

Which inflammatory marker is more reliable in diagnosing acute septic arthritis in the pediatric population?

BACKGROUND: The present study aimed to investigate diagnostic values of C-reactive protein (CRP), white blood cell (WBC), erythrocyte sedimentation rate (ESR), neutrophil to lymphocyte ratio (NLR), and the platelet to lymphocyte ratio as possible indirect inflammatory markers in children with septic arthritis (SA) for diagnosis process. METHODS: The medical records of pediatric patients with SA who underwent debridement surgery between February 2005 and November 2018 were obtained from the hospital records. A total of 59 children with SA and 60 age- and gender-matched healthy controls were enrolled in the study. Hemograms parameters including WBC count, neutrophil count, lymphocyte count, hemoglobin, platelet count, CRP, ESR, NLR, and platelet to lymphocyte ratio. Biochemical parameters including alanine transaminase, aspartate aminotransferase, blood urea nitrogen, creatinine, glucose, and albumin were investigated and compared between both groups. RESULTS: Fifty-nine patients, 30% female (n: 18) and 70% male (n: 41), who had received operations for SA were included in the study. The mean age of the patients was 7.1 (range 6 days to 15 years) years and mean follow up 56.6 (12-140) months. No significant differences were observed in any biochemical parameters between the groups. However, a significant difference was found between the septic arthritis and the control group in all hemogram parameters. CONCLUSIONS: Although the sensitivity and specificity of the NLR are lower than CRP, ESR, and WBC which are most commonly used inflammatory parameters in diagnosis process of septic arthritis, NLR may be useful in confirming the diagnosis in the clinical practise, with an optimum diagnostic cut-off value of 4.05.

Mid-term results of hindfoot arthrodesis with a retrograde intra-medullary nail in 24 patients with diabetic Charcot neuroarthropathy.

Background and purpose - Hindfoot arthrodesis using retrograde intramedullary nailing assumes a critical role in limb salvage for patients with diabetic Charcot neuro-arthropathy (CN). However, this procedure is compelling and fraught with complications in diabetic patients. We report the mid-term clinical and radiological outcomes of retrograde intramedullary nailing for severe foot and ankle deformity in patients with diabetic CN.Patients and methods - Hindfoot arthrodesis was performed using a retrograde intramedullary nail in 24 patients (15 females) with diabetic Charcot foot. The mean age of the patients was 62 years (33-82); the mean follow-up was 45 months (24-70). The primary outcomes were rates of fusion, limb salvage, and complications.Results - The overall fusion rate was 23/24, and none of the patients needed amputation. The rate of superficial wound infection was 4/24, and no deep infection or osteomyelitis was observed postoperatively.Interpretation - For selected cases of diabetic CN with severe foot and ankle deformity, hindfoot arthrodesis using a retrograde intramedullary nail seems to be a good technique in achieving fusion, limb salvage, and avoidance of complications.

The natural course of pain in patients with symptomatic tarsal coalitions: A retrospective clinical study.

BACKGROUND: This study aims to examine changes in pain intensity in the long course of symptomatic tarsal coalition. METHODS: Thirty consecutive patients who were treated for symptomatic tarsal coalition was retrospectively reviewed. The patients were divided into two groups: the nonsurgical group (14 patients) and the surgical group (16 patients). To assess pain intensity, the visual analogous scale (VAS) was utilized. RESULTS: On admission, the mean VAS was 4,9 ± 1,9 in the nonsurgical group and 7,7 ± 1,3 in the surgical group (p < 0,05). After 6 months of nonoperative treatment, the mean VAS was decreased from 4,9 ± 1,9 to 2,8 ± 1,0 in the nonsurgical group (p < 0,05) and from 7,7 ± 1,3 to 7,1 ± 0,8 in the surgical group (p > 0,05). At the final follow-up, the mean VAS was 2,3 ± 2,4 in the nonsurgical group and 3,1 ± 2,7 in the surgical group (p > 0,05). The decrease in the VAS after surgery was significant in the surgical group (p < 0,01). CONCLUSION: For patients with symptomatic tarsal coalitions who present with an initial VAS score of 6 and above, early surgery may be more effective than nonoperative treatment in relieving pain intensity.

High Rates of Psychiatric Disorders and Below Normal Mental Capacity Associated With Spastic Peroneal Flatfoot: A New Relationship.

Spastic peroneal flatfoot (SPFF) is a rare hindfoot pathology usually seen in the adolescent age group that is characterized by painful spasms in the peroneal muscles. We have clinically observed that patients with SPFF also have some behavioral and emotional difficulties and problems in their academic achievements. Because of these observations, we investigated the prevalence and patterns of psychiatric disorders and intellectual disability among young subjects with SPFF. Our cohort consisted of 16 patients with SPFF. Their mean age at presentation was 21 (range 13 to 31) years. Only 6 patients had a tarsal coalition as an underlying condition. The psychometric evaluation was conducted using validated instruments (Wechsler Intelligence Scale for Children-revised form, Stanford Binet intelligence quotient [IQ] test, and Cattell IQ test). Psychiatric disorders were assessed using a semistructured diagnostic instrument (Schedule for Affective Disorders and Schizophrenia for School Age Children Present and Lifetime Version). The testers and psychiatrists were unaware of the orthopedic condition and the preliminary psychiatric diagnoses. The ethical committee approved the study protocol. The mean follow-up period was 41 (range 12 to 97) months. The mean IQ score of the patients was 75.1 ± 17.9 (range 52 to 107). Compared with the general population, the rate of intellectual disability was significantly greater (p = .0001) and the rate of normal intelligence significantly lower (p = .0015) in our patient group. Furthermore, according to the community schooling ratio, our cohort also had lower junior high and secondary education rates compared with the general population. The rate of most psychiatric disorders diagnosed in the SPFF patients was greater than that in the normal population. The most commonly identified psychiatric disorders were social phobia and attention deficit and hyperactivity disorder (75%). Timely interventions of the psychosocial and academic problems of patients with SPFF might increase their compliance with orthopedic treatment and help with their psychological well-being and academic achievement. In addition, this relationship might be a clue for uncovering the etiology of this disease, which has not yet been clarified.

Reliability of Computer-Assisted and Manual Measurement Methods for Assessment of Graf Type 1 and Type 2 Hip Sonograms.

OBJECTIVES: The purpose of this study was to investigate the interobserver, intraobserver, and intermethod reliability of computer-assisted digital and manual measurements of hip sonograms. METHODS: Seventy-four hip sonograms were evaluated in this retrospective study. Five evaluators measured digital images and manual paper printouts according to the Graf method (Arch Orthop Trauma Surg 1984; 102:248-255). Interobserver and intraobserver reliability rates were calculated. Reliability criteria were graded on a numeric scale. RESULTS: The interobserver reliability of both computer-based and manual methods for alpha angle measurements was good to excellent, but the interobserver reliability was fair to poor for beta angle measurements. Intraobserver reliability was varied. Alpha angle measurements by both manual and computer-based methods had high concordance with each other, whereas beta angle measurements had low concordance. The intermethod variability did not differ between observers. CONCLUSIONS: The alpha angle measurements had high concordance with each other for both manual and computer-based methods, whereas the beta angle measurements had low concordance. This information should be taken into account in clinical practice. Overall, the two measurement methods were reliable and consistent with each other.

Can Normal Fracture Healing Be Achieved When the Implant Is Retained on the Basis of Infection? An Experimental Animal Model.

BACKGROUND: Infection after open fractures is a common complication. Treatment options for infections developed after intramedullary nailing surgery remain a topic of controversy. We therefore used a rat fracture model to evaluate the effects of infection on osseous union when the implant was maintained. QUESTIONS/PURPOSES: In a rat model, (1) does infection alter callus strength; (2) does infection alter the radiographic appearance of callus; and (3) does infection alter the histological properties of callus? METHODS: An open femoral fracture was created and fixed with an intramedullary Kirschner wire in 72 adult male Sprague-Dawley rats, which were divided into two study groups. In the infection group, the fracture site was contaminated with Staphylococcus aureus (36 animals), whereas in the control group, there was no bacterial contamination (36 animals). No antibiotics were used either for prophylaxis or for treatment. We performed biomechanical (maximum torque causing failure and stiffness), radiographic (Lane and Sandhu scoring for callus formation), and histologic (scoring for callus maturity) assessments at 3 and 6 weeks. The number of bacteria colonies on the femur, wire, and soft tissue inside knee were compared to validate that we successfully created an infection model. The number of bacteria colonies in the soft tissue inside the knee was higher in the infection group after 6 weeks than after the third week, demonstrating the presence of locally aggressive infection. RESULTS: Infection decreased callus strength at 6 weeks. Torque to failure (299.07 ± 65.53 Nmm versus 107.20 ± 88.81, mean difference with 95% confidence interval, 192 [43-340]; p = 0.007) and stiffness at 6 weeks (11.28 ± 2.67 Nmm versus 2.03 ± 1.68, mean difference with 95% confidence interval, 9 [3-16]; p = 0.004) both were greater in the control group than in the group with infection. Radiographic analysis at 6 weeks demonstrated the fracture line was less distinct (Lane and Sandhu score of 2-3) in the infection group and complete union was observed (Lane and Sandhu score of 3-4) in the control group (p = 0.001). Semiquantitative histology scores were not different between the noninfected controls and the rats with infection (score 10 versus 9). CONCLUSIONS: Retaining an implant in the presence of an underlying infection without antibiotic treatment leads to weaker callus and impedes callus maturation compared with noninfected controls in a rat model. Future studies might evaluate whether antibiotic treatment would modify this result. CLINICAL RELEVANCE: This model sets the stage for further investigations that might study the influence of different interventions on fracture healing in implant-associated osteomyelitis. Future observational studies might also evaluate the histological properties of callus in patients with osteomyelitis.

Arthroscopic excision of acetabular osteoid osteoma in a 7-year-old patient.

The purpose of this study was to present the case report of a 7-year-old patient who was treated with hip arthroscopy for an acetabular osteoid osteoma. A 7-year-old patient was referred to our clinic with hip pain. In the assessment of the patient, an acetabular osteoid osteoma was detected in his right hip; it was adjacent to his triradiate cartilage. An arthroscopic surgery was planned as an alternative to open safe hip dislocation. The osteoid osteoma was completely removed with hip arthroscopy. Postoperative CT scanning and histopathological analysis confirmed the diagnosis. Exposure of the acetabulum can be problematic in paediatric patients due to the potential risks of open safe dislocation. Hip arthroscopy can safely be used for benign hip lesions in paediatric patients. Level of evidence Case report, Level V.

A new configuration of lateral-pin fixation for pediatric supracondylar humeral fracture: A biomechanical analysis.

OBJECTIVE: The aim of this study was to biomechanically compare a new lateral-pinning technique, in which pins engage the medial and lateral columns of the distal humerus in a divergent configuration in both the axial and sagittal planes instead of the coronal plane, with the cross-pin, and with 2 and 3 coronally divergent lateral-pin techniques in a synthetic humerus model of supracondylar humerus fractures. METHODS: Thirty-six identical synthetic models of the humerus simulating a standardized supracondylar humerus fracture were included in this study. They were divided into 4 groups based on the pin configuration of fixation: the new 3-lateral pin-fixation technique (group A), 2 crossed pins (group B), 3 divergent lateral pins (group C), and 2 divergent lateral pins (group D). Each model was subjected to combined axial and torsional loading, and then torsional stability and torsional stiffness (Nmm/°) were recorded. RESULTS: Group A had greater rotational stability than groups C and D but had no statistically significant additional rotational stability compared with group B (P=.042, P=.008, P=.648, respectively), whereas group B had greater rotational stability than only group D (P=.020). Furthermore, group A demonstrated higher internal rotational stiffness compared with groups C and D (P=.038, P=.006, respectively). Group B had better internal rotational stiffness than group D (P=.015). There was no significant difference in internal rotational stiffness between groups A and B (P=. 542), groups B and C (P=.804), and groups D and C (P=.352). Although no statistically significant differences existed between groups A and B, the modified pin configuration exhibited the highest torsional stability and stiffness. Group D showed the lowest values in all biomechanical properties. CONCLUSION: This study has shown us that this new lateral-pinning technique may provide torsional resistance to internal rotational displacement as strong as the standard technique of crossed-pin configuration of fixation. Furthermore, with this new pin configuration, greater torsional resistance can be obtained than with either the standard 2- or the standard 3-lateral divergent pin configuration. Cite this article as: Bilgili F, Demirel M, Birisik F, Balci HI, Sunbuloglu E, Bozdag E. A new configuration of lateral-pin fixation for pediatric supracondylar humeral fracture: A biomechanical analysis. Acta Orthop Traumatol Turc., 2023 10.5152/j.aott.2024.21091 [Epub Ahead of Print].

CNT incorporation improves the resolution and stability of porous 3D printed PLGA/HA/CNT scaffolds for bone regeneration.

In this study, 3D printed porous poly(lactide-co-glycolide) (PLGA) and its nanocomposites with 5 wt. % hydroxyapatite (HA) and 0.5, 1 and 2 wt. % carboxyl-functionalized multi-walled carbon nanotube (CNT) scaffolds were fabricated by using extrusion-based printing. The printing parameters were optimized by rheological studies. The rheological studies demonstrated shear thinning properties for all compositions and an increase in storage modulus was observed after the addition of CNT. Porous PLGA/HA/CNT scaffolds were printed by applying a pressure of 4.76 bar at 125 °C. The addition of 0.5 wt. % of CNT reduced the strut size and increased the porosity from 42% to 60%. The increase in storage modulus and decrease in strut size were related to hydrogen bonding between CNT, HA and PLGA which ultimately improved shape fidelity. The scaffolds were characterized by analysis of their chemical structure, water contact angle measurement,in vitrobioactivity test, biodegradation test, mechanical analysis, andin vitrocell studies. The scaffolds were found to be more hydrophilic by the incorporation of CNTs. Also, degradation studies showed that the microstructure of the scaffold became more stable with the addition of HA and CNT. The compressive modulus of PLGA/HA/CNT2 scaffold was found to be 548.5 MPa, which is found suitable to replace cancellous bone. The scaffolds were found to be highly biocompatible which is possibly due to alignment of CNT and PLGA during 3D printing process. Alizarin red staining indicated improvement of mineralization of MC3T3-E1 cells on the CNT incorporated porous 3D scaffolds. The results suggest that the produced porous 3D printed PLGA/HA/CNT scaffolds are promising for bone regeneration applications.

An AI based classifier model for lateral pillar classification of Legg-Calve-Perthes.

We intended to compare the doctors with a convolutional neural network (CNN) that we had trained using our own unique method for the Lateral Pillar Classification (LPC) of Legg-Calve-Perthes Disease (LCPD). Thousands of training data sets are frequently required for artificial intelligence (AI) applications in medicine. Since we did not have enough real patient radiographs to train a CNN, we devised a novel method to obtain them. We trained the CNN model with the data we created by modifying the normal hip radiographs. No real patient radiographs were ever used during the training phase. We tested the CNN model on 81 hips with LCPD. Firstly, we detected the interobserver reliability of the whole system and then the reliability of CNN alone. Second, the consensus list was used to compare the results of 11 doctors and the CNN model. Percentage agreement and interobserver analysis revealed that CNN had good reliability (ICC = 0.868). CNN has achieved a 76.54% classification performance and outperformed 9 out of 11 doctors. The CNN, which we trained with the aforementioned method, can now provide better results than doctors. In the future, as training data evolves and improves, we anticipate that AI will perform significantly better than physicians.

Evaluation of a novel semicircular locking external fixator for treating fractures of long bones: Biomechanical comparison with a circular external fixator.

PURPOSE: This study aimed to investigate the biomechanical properties of a novel semicircular locking external fixator with locking screw mechanism, shape of trapezoidal corrugations, half- ring designed for greater stability. MATERIALS AND METHODS: The novel external fixator had a half-ring with the shape of trapezoidal corrugations and locking screws fixing the bone at different angles in all three planes (sagittal, axial, and coronal). The biomechanical properties of the semicircular locking external fixator (group 1) were compared with those of a standard Ilizarov-type circular external fixator (group 2) (TST, Istanbul, Turkey) in an experimental study design. Five frames were used in each group. Standard PE 1000 (polyethylene) rod models (n = 10) simulating the tibia bone model were used. Both systems were compared biomechanically by applying axial and torsional loads simultaneously. RESULT: Two samples in group 2 were damaged before the test ended during axial loading. All of the samples in group 1 completed the tests without damage after 150,000 cycles. The axial stiffness of the semicircular locking external fixator was found to be significantly higher than that of the Ilizarov-type circular external fixator (p < 0.05). No statistically significant difference was found between the two fixators in torsional loading. The application time of semicircular locking external fixator was significantly shorter than Ilizarov-type circular external fixator (p < 0.05). CONCLUSION: The novel semicircular locking external fixator was biomechanically stronger than the Ilizarov-type external fixator for treating fractures of long bones. It can be used as a permanent external fixator for the definitive treatment of long bone fractures with soft tissue damage in terms of stability and application time.

CORONAL PLANE GROWTH MODULATION FOR GENU VALGUM IN SKELETAL DYSPLASIA.

Objective: To investigate the efficiency and rates of correction by hemiepiphysiodesis using 8-plate to manage genu valgum deformity in children with skeletal dysplasia. Methods: Eleven children with skeletal dysplasia (three female, eight male; mean age = 10.5 years; age range = 7-13) who underwent temporary hemiepiphysiodesis using 8-plates for genu valgum deformity were retrospectively reviewed. There were nine bilateral cases and two unilateral cases. The mean follow-up time from the index surgery to the final follow-up was 45 (ranging from 24 to 72) months. Radiographical assessment including preoperative and final follow-up measurements of joint orientation angles and mechanical axis deviation (MAD) were conducted. Results: Deformities were completely corrected in nine lower extremities (45%) and partially corrected in seven extremities (35%). In four extremities of two children with Morquio syndrome, MAD worsened. The correction rate of MAD was 1.25 ± 1.62 mm/mo. Conclusion: Though hemiepiphysiodesis using 8-plate requires a longer treatment period, it seems to be an effective treatment for correction of genu valgum in children with skeletal dysplasia. Level of Evidence IV, Case Series.

Objetivo: Investigar a eficiência e as taxas de correção da hemiepifisiodese usando placa-8 no tratamento da deformidade de geno valgo em crianças com displasia esquelética. Métodos: Foram avaliadas retrospectivamente 11 crianças com displasia esquelética (três meninas e oito meninos; idade média = 10,5 anos; faixa etária = 7-13) que foram submetidas à hemiepifisiodese temporária com placa-8 devido à deformidade do geno valgo. Havia nove casos bilaterais e dois casos unilaterais. O acompanhamento médio desde a cirurgia de implante até o acompanhamento final foi de 45 (variação de 24 a 72) meses. Foi feita avaliação radiográfica incluindo medidas de acompanhamento pré e pós-operatórias dos ângulos de orientação da articulação e desvio mecânico do eixo (MAD). Resultados: As deformidades foram completamente corrigidas em nove extremidades inferiores (45%) e parcialmente corrigidas em sete (35%). Em quatro extremidades de duas crianças com síndrome de Morquio, o MAD piorou. A taxa de correção do MAD foi de 1,25 ± 1,62 mm/mês. Conclusão: Embora a hemiepifisiodese com placa-8 necessite de um período de tratamento mais longo, a técnica parece ser um tratamento eficaz para a correção do geno valgo em crianças com displasia esquelética. Nível de Evidência IV, Série de Casos.

The Relationship of One Leg Standing Duration to GMFM Scores and to Stance Phase of Walking in Children with Hemiplegic Cerebral Palsy.

BACKGROUND: Lack of stability during stance negatively impacts gait and motor function for children with unilateral cerebral palsy. Improving stability and balance are the focus for gait rehabilitation). The One-Leg-Standing-Test may give valuable information about motor function and stability of stance for patients with unilateral cerebral palsy. OBJECTIVE: This study aimed to investigate the relationship between the One-Leg-Standing-Test and the gross-motor-function-measurement and single-limb support time. METHODS: The study included 18 patients with unilateral cerebral palsy (age 11.08 [SD 2.84] years old). The One-Leg-Standing-Test and pedobarographic evaluation were performed. Sections D and E of the gross-motor-function-measurement were assessed, and in pedobarographic evaluation, the single-limb support time (the total duration of mid-stance and terminal-stance during walking) was calculated to describe stability during stance. RESULTS: For patients, the One-Leg-Standing-Test scores and single-limb support time values were lower on the affected side than on the unaffected side. The One-Leg-Standing-Test was correlated with single-limb support time (p = .02, r = 0.60) and section E (p < .01, r = 0.59) values. The One-Leg-Standing-Test was also correlated to total stance phase and section D. CONCLUSION: The One-Leg-Standing-Test gives valuable information about gross-motor-function but cannot be substituted for motor function tests. The single-limb support time value may be used to describe stability in stance during walking.

Temporary Epiphysiodesis Using the Eight-Plate in the Management of Children with Leg Length Discrepancy: A Retrospective Case Series.

Background: Although eight-plates have been shown to be effective in correcting angular deformities of the knee, the literature is scarce regarding the efficiency of this method in treatment of children with LLD. Objectives: The aim of this study was to determine the efficiency, rates of correction and complications of epiphysiodesis using eight-plate in the management of children with leg length discrepancy (LLD). Methods: Eleven consecutive patients with LLD (7 boys, median age = 9, age range 6-11 years) who were treated by temporary epiphysiodesis using eight-plates were retrospectively reviewed and included in the study. The main indication for temporary epiphysiodesis was an LLD between 2 and 5 cm in all patients. LLD and lower limb alignment were examined on lower extremity weight-bearing radiography preoperatively and at skeletal maturity. Longitudinal correction rate was calculated. The final LLD was categorized as ''good result'' (final LLD < 1.5 cm), ''fair result'' (1.5-2 cm), and ''poor result'' (> 2 cm). Results: The mean treatment period with the eight-plate was 44 (min to max = 32-72) months, and the mean follow-up from the index surgery to the final follow-up was 62 (min to max = 39-106) months. The mean LLD was significantly reduced from 39 (range 25-50) mm preoperatively to 22.40 (range 6-55) mm postoperatively (p = 0.006). The mean longitudinal correction rate was found to be 0.48 mm/mo. Radiographic evidence of lower limb deformity in frontal and sagittal planes was determined in neither preoperative nor postoperative deformity analysis. No major complications were recorded. Conclusion: For the management of children with LLD of 2-5 cm, temporary hemiepiphysiodesis using the eight-plate seems to be an effective treatment with low complication rates.

Relationship Between Recurrent Adductus Deformity of the Forefoot and Achilles Tendon Elongation Following Ponseti Treatment in Children with Idiopathic Clubfoot.

BACKGROUND: Many authors have highlighted the role of muscle strength imbalance around the ankle in the development of recurrent clubfoot following Ponseti treatment. However, this possible underlying mechanism behind recurrence has not been investigated sufficiently to date. This study aimed to explore whether there is a relationship between Achilles tendon elongation and recurrent metatarsus adductus deformity in children with unilateral clubfeet treated by the Ponseti method. METHODS: A retrospective chart review was performed on 20 children (14 boys and six girls; mean age, 7 years; age range, 5-9 years) with a recurrent metatarsus adductus deformity treated by the Ponseti method for unilateral idiopathic clubfoot. At the final follow-up, isometric muscle strength was measured using a portable, hand-held dynamometer in reciprocal muscle groups of the ankle. The length of the tendons around the ankle was measured ultrasonographically. RESULTS: The plantarflexion-to-dorsiflexion ratio was lower on the involved side (P = .001). No significant differences in the strength ratio of inversion to eversion were found (P = .4). No difference was observed in lengths of tibialis anterior and posterior tendons (P = .1), but the Achilles tendon was longer on the involved side (P = .001; P < .01). A significant negative correlation was discovered between involved-to-uninvolved Achilles tendon length ratios and involved-to-uninvolved plantarflexion strength ratios (r = -0.524; P = .02) Conclusions: Achilles tendon elongation may be a contributor to the muscle imbalance in clubfeet with relapsed forefoot adduction treated by the Ponseti technique.

Vitamin D level, body mass index and fracture risk in children: vitamin D deficiency and fracture risk.

The objective of this study was to determine the impacts of preventable causes of fracture, such as vitamin D deficiency, disturbed calcium homeostasis and obesity on fracture occurrence in minor traumas. In this way, the effects of relevant parameters on fracture may be further elucidated. A prospective case-control study in children aged 2-18 years children with and without fractures was performed. Participants with a pediatric trauma score higher than 10 presenting to minor trauma were included to exclude the significant impact of severe trauma on fracture. The effects of obesity, parameters associated with vitamin D and Ca homeostasis on fracture occurrence were evaluated. Univariate and multivariate analyses were used to test for associations between fracture status and the assessed variables. The relationships between the variables and the odds of fracture occurrence were examined using logistic regression models. The sample consisted of 76 patients and 50 controls. There were no significant differences between the patients and controls in terms of age, sex, trauma type and pubertal period. The patients had a significantly higher mean BMI percentile (61.2 ± 30.7, 36.7 ± 30.7; P < 0.001). Likewise, patients were more likely than controls to have a lower mean 25(OH)D level and mean phosphorus level (respectively, 13.4 ± 7.0, 17.3 ± 7.8; P = 0.004, and 4.6 ± 0.7, 5.1 ± 0.8; P < 0.001). Moreover, fractures were substantially more frequent in children with vitamin D deficiency (<20 ng/mL, χ2: 7.781, df: 1, P = 0.005). In the multivariate logistic model, BMI percentile and vitamin D levels remained significantly associated with increased odds of fracture [1.02 (1.01-1.04), P < 0.001 and 0.93 (0.89-0.98), P = 0.01]. The present study supports an association of high BMI and vitamin D deficiency with an increased odds of fracture occurrence in children. The findings may help physicians to reduce the risk factors of fracture by preventive efforts. Thus, unexpected health costs and morbidity may be minimized.

A novel approach for computerized quantitative image analysis of proximal femur bone shape deformities based on the hip joint symmetry.

As a result of most of the bone disorders seen in hip joints, shape deformities occur in the structural form of the hip joint components. Image-based quantitative analysis and assessment of these deformities in bone shapes are very important for the evaluation, treatment, and prognosis of the various hip joint bone disorders. In this article, a novel approach for the image-based computerized quantitative analysis of proximal femur shape deformities is presented. In the proposed approach, shape deformities of the pathological proximal femurs were quantified over the contralateral healthy proximal femur shape structure of the same patient in 2D by taking the hip joint symmetry property of human anatomy into consideration. It is based on the idea that if the right and left proximal femurs in bilateral hip joints are highly symmetrical and also if one of the proximal femurs is healthy and the contralateral one is pathological, the non-overlapping bone shape regions can represent the deformities in pathological proximal femurs when both proximal femurs are registered to overlap each other. In the methodological process of the proposed study, a set of image preprocessing operations was primarily performed on the raw magnetic resonance imaging (MRI) data. Then, the segmented proximal femurs in bilateral hip joint images were automatically aligned with the Iterative Closest Point (ICP) rigid registration method. Following the registration, a set of image postprocessing operations was performed on the images of proximal femurs aligned. In the quantification phase, the bone shape deformities in pathological proximal femurs were quantified simply in terms of the mismatching area in 2D by measuring a shape variation index representing the total bone shape deformity ratio. To evaluate the proposed quantitative shape analysis approach, bilateral hip joints in a total of 13 coronal MRI sections of 13 patients with Legg-Calve-Perthes disease (LCPD) were used. Experimental studies have shown that the proposed approach has quite promising results in the quantitative representation of the pathological proximal femur shape deformities. Furthermore, consistent results have been observed for the Waldenström classification stages of the disease. The shape deformity ratios in pathological proximal femurs were quantified as 9.44% (±1.40), 18.38% (±6.30), 24.73% (±12.42), and 27.66% (±10.41), respectively for the Initial, Fragmentation, Reossification, and Remodelling stages of LCPD with the quantification error rates of 0.29% (±0.16), 0.58% (±0.71), 1.12% (±0.82), and 0.80% (±0.98). Additionally, a mean error rate of 0.65% (±0.68) was observed for the quantified shape deformity ratios of all samples.

Determining the relationship between the impairment of selective voluntary motor control and gait deviations in children with cerebral palsy using simple video-based analyses.

BACKGROUND: The impairment of selective voluntary motor control (SVMC) in children with cerebral palsy (CP) has been shown to correlate with their gait characteristics using complex 3D gait analysis systems (3DGA); however, this relationship has not been investigated using simple video-based observational gait analysis (VBOGA). The aim of this study was to determine the relationship between VBOGA and SVMC of the lower extremities in children with CP. METHODS: Forty-two CP children 10.9 ± 5.7 years old with Gross Motor Function Classification System (GMFCS) levels I-III participated in the study. Their gait characteristics were assessed using the Edinburgh Visual Gait Score (EVGS), and selective voluntary motor control was tested using the Selective Control Assessment of the Lower Extremity (SCALE). Spearman's rho correlation test with Cohen's classification were used in the statistical analyses. RESULTS: The GMFCS levels (r = 0.604, p < 0.001), foot clearance (r = -0.584. p < 0.001), and maximum ankle dorsiflexion (r =-0.567, p < 0.001) during the swing phase had strong correlations with total SCALE scores. There was also a moderate correlation between total SCALE scores and total EVGS (r =-0.494, p < 0.001), knee extension in the terminal swing phase (r = -0.353, p < 0.001), peak sagittal trunk position (r = -0.316, p < 0.005), and maximum lateral shift (r = -0.37, p < 0.001). CONCLUSION: Impaired lower extremity SVMC was noticeably related to the foot and ankle movements in the swing phase and initial stance during walking as well as the total EVGS scores and sagittal and frontal trunk movements. The SCALE correlations with VBOGA were similar those observed in the complex 3DGA in the literature; therefore, we suggest that SVMC impairment of gait could be evaluated using simple VBOGA. These findings may help to tailor physical therapy programs for CP children to increase their motor control and walking quality.