Long-term outcome of nonunion of the lateral humeral condyle fracture in children: a multicentre retrospective study.

PURPOSE: Lateral humeral condyle nonunion in children is a rare condition. The treatment protocol for nonunion of lateral humeral condyle remains controversial due to the potential complication. This study reports long-term functional outcomes of the nonunion of the lateral humeral condyle fracture. In addition, we identified the prognostic factors for nonunion of the lateral humeral condyle fracture. METHODS: We conducted a multicentre retrospective cohort study of nonunion of lateral humeral condyle between January 1995 and December 2022. The patient's preoperative demographic information was reviewed. Potential risk factors of poor functional outcome, such as age, duration from initial injury, and fracture displacement, were retrieved. Functional outcomes at the latest follow-up visit were evaluated using the Mayo Elbow Performance Score (MEPS). Multivariable linear regression was deployed to evaluate the association of potential risk factors with the functional outcome. RESULTS: A total of 63 patients from eight medical centers were included, of which 60 were surgically treated. Patients' average age was 7.3 years old, with a mean follow-up duration of seven years. All nonunion cases were successfully treated, resulting in a normalized humeroulnar angle. The rate of AVN was 16.7%. All patients reported excellent range of motion and MEPS at the latest follow-up. Multivariable linear regression demonstrated that Fracture displacement (ß = -0.88, 95% CI -1.55 to -0.22, p = 0.010) and duration from initial injury (ß = -0.09, 95% CI -0.17 to -0.02, p = 0.010) were statistically significant factors influencing functional outcome of lateral humeral condyle nonunion. CONCLUSIONS: Initial fracture displacement and duration from the initial injury are statistically significantly associated with elbow function in lateral humeral condyle nonunion. However, the effect size for these factors is relatively small and does not reach clinical significance. Despite this, the functional outcome is excellent in all patients, with an average follow-up duration of seven years.

Perioperative blood loss reduction using a sterile exsanguination tourniquet for orthopedic femoral-related surgeries in children: a randomized controlled study.

OBJECTIVES: The sterile exsanguination tourniquet (SET) could be an alternative for providing bloodless surgeries in orthopedic femoral-related surgeries in pediatric patients where the standard pneumatic tourniquet would not be feasible. This randomized-controlled study aimed to evaluate the efficacy of SET in decreasing total perioperative blood loss and blood transfusion. METHODS: We conducted an unplanned interim analysis of data from a randomized-controlled trial. At the time of the analysis, 31 pediatric patients had been randomly assigned to undergo surgery with the SET application (the SET group, 15 patients) and without the SET application (the control group, 16 patients). An intention-to-treat analysis was performed to evaluate the total perioperative blood loss, postoperative blood transfusion, estimated intraoperative blood loss, total drainage volume, postoperative hemoglobin level, and operative time according to the significance level adjusted for multiplicity (p < 0.029). RESULTS: There was a borderline statistically significant lower body weight-adjusted TBL in the SET group (SET = 14.1 (7.7, 16.9) ml/kg vs. control 18.3 (14.8, 37.2) ml/kg, p-value = 0.027). The body weight-adjusted transfusion volume was statistically significantly greater in the control group (SET = 0.0 (0.0, 0.0) ml/kg vs. control = 2.1 (0.0, 9.7) ml/kg, p = 0.017). Body weight-adjusted estimated intraoperative blood loss was significantly lower in the SET group (SET = 0.8 (0.2, 3.5) ml/kg vs. control = 5.6 (3.4, 21.5) ml/kg, p < 0.001). In addition, the operative time was lower in the SET group with borderline statistical significance (SET = 105 (85.0, 125.0) vs. control = 130 (101.3, 167.5), p = 0.039). CONCLUSION: Utilization of a sterile exsanguination tourniquet (SET) significantly reduced an estimated intraoperative blood loss while preventing the need for blood transfusion after pediatric orthopedic femoral-related surgeries. Trial registration TCTR20220412003.

Predictive factors for recurrence after lower limb deformity correction in hypophosphatemic rickets.

BACKGROUND: Surgical treatment for severe lower limb deformities in patients with hypophosphatemic rickets has shown satisfactory outcomes. However, the rates of recurrence of deformities after surgical correction were high, and studies on predictive factors of recurrence were limited. This study aimed to determine the predictive factors for the recurrence of lower limb deformities after surgical correction in patients with hypophosphatemic rickets, and the effects of each predictor on the recurrence of deformities. METHODS: We retrospectively reviewed the medical records of 16 patients with hypophosphatemic rickets aged 5-20 years and who had undergone corrective osteotomies between January 2005 and March 2019. Demographic data from the patients, biochemical profiles, and radiographic parameters were collected. Univariable Cox proportional hazard analyses of recurrence were performed. Kaplan-Meier failure estimation curves for deformity recurrences of potential predictors were created. RESULTS: A total of 38 bone segments were divided into 2 groups: 8 segments with recurrent deformities and 30 segments without recurrent. The average follow-up time was 5.5 ± 4.6 years. Univariable Cox proportional hazard analyses of recurrence found that an age < 10 years (hazard ratio [HR], 5.5; 95% CI, 1.1-27.1; p = 0.04), and gradual correction by hemiepiphysiodesis (HR, 7.0; 95% CI, 1.2-42.7; p = 0.03) were associated with recurrence after surgery. The Kaplan-Meier failure estimation for deformity recurrences by age at the time of surgery also achieved a statistically significant difference between ages < 10 years and those > 10 years (p = 0.02). CONCLUSIONS: Identifying predictive factors for the recurrence of lower limb deformities after surgical correction in hypophosphatemic rickets can assist in early recognition, proper intervention, and prevention. We found that an age < 10 years at the time of surgery was associated with recurrence after deformity correction and gradual correction with hemiepiphysiodesis may also be a potential factor affecting the recurrence.

A long-term outcome (up to 29 years) of bilateral iliac wings "bayonet osteotomies" for closure of bladder exstrophy.

BACKGROUND: Several types of pelvic osteotomy techniques have been reported and employed by orthopedic surgeons to enhance the approximation of symphyseal diastasis in bladder exstrophy patients. However, there is limited evidence on a long-term follow-up to confirm which osteotomy techniques provide the most suitable and effective outcomes for correcting pelvic deformities. This study aimed to describe the surgical technique of bilateral iliac bayonet osteotomies for correcting pelvic bone without using fixation in bladder exstrophy and to report on the long-term clinical and radiographic outcomes following the bayonet osteotomies. METHODS: We retrospectively reviewed patients with bladder exstrophy who underwent bilateral iliac bayonet osteotomies with the closure of bladder exstrophy between 1993 and 2022. Clinical outcomes and radiographic pubic symphyseal diastasis measurements were evaluated. From a total of 28 operated cases, eleven were able to attend a special follow-up clinic or were interviewed by telephone by one of the authors with completed charts and recorded data. RESULTS: A total of 11 patients (9 female and 2 male) with an average age at operation of 9.14 ± 11.57 months. The average followed-up time was 14.67 ± 9.24 years (0.75-29), with the average modified Harris Hip score being 90.45 ± 1.21. All patients demonstrated decreased pubic symphyseal diastasis distance (2.05 ± 1.13 cm) compared to preoperative (4.58 ± 1.37 cm) without any evidence of nonunion. At the latest follow-up, the average foot progression angle was externally rotated 6.25° ± 4.79° with full hips ROM, and no patients reported abnormal gait, hip pain, limping, or leg length discrepancy. CONCLUSIONS: Bilateral iliac wings bayonet osteotomies technique demonstrated a safe and successful pubic symphyseal diastasis closure with an improvement both clinically and radiographically. Moreover, it showed good long-term results and excellent patient's reported outcome scores. Therefore, it would be another effective option for pelvic osteotomy in treating bladder exstrophy patients.

A Predictive Score for Infantile Blount Disease Recurrence After Tibial Osteotomy.

INTRODUCTION AND OBJECTIVE: Several predictive factors for infantile Blount disease recurrence after tibial osteotomy were discovered. This study aimed to examine and utilize various predictors to develop a prediction score for infantile Blount disease recurrence after tibial osteotomy. METHODS: We conducted a retrospective cohort study of infantile Blount disease patients who underwent tibial osteotomy between January 1998 and December 2020. Potential predictors, including clinical and radiographic parameters, were examined for their association with the disease recurrence after receiving tibial osteotomy. A predictive score was subsequently developed based on those potential predictors through multivariable logistic regression modeling. RESULTS: A total of 101 extremities diagnosed with infantile Blount disease from 58 patients who underwent tibial osteotomy were included. Of those, 15 extremities (14.9%) recurred. Univariable logistic regression analysis identified age older than 42 months [odds ratio (OR)=4.28; P =0.026], Langenskiöld classification stage III (OR=9.70; P <0.001), LaMont classification type C (OR=15.44; P <0.001), preoperative femorotibial angle <-14 degrees (OR=4.21, P =0.021), preoperative metaphyseal-diaphyseal angle >16 degrees (OR=8.61, P =0.006), preoperative medial metaphyseal slope angle >70 degrees (OR=7.56, P =0.001), and preoperative medial metaphyseal beak angle >128.5 degrees (OR=13.46, P =0.001) as potential predictors of infantile Blount disease recurrence after tibial osteotomy. A predictive score comprised of age younger than 42 months, LaMont classification type C, and medial metaphyseal beak angle >128 degrees demonstrated an excellent predictive performance (area under the receiver operating characteristic curve =0.87), good calibration, and high internal validity. CONCLUSIONS: Our developed predictive score accurately predicted infantile Blount disease recurrence after tibial osteotomy. The results from our developed prediction tool allow physicians to inform prognosis, increase awareness during the follow-up period, and consider additional interventions to prevent disease recurrence. LEVEL OF EVIDENCE: Level II.

Is subclassification of Gartland extension-type pediatric supracondylar fracture into types IIA and IIB necessary for treatment decision? A result of pediatric orthopedist's survey and review of literature.

Extension-type pediatric supracondylar humeral fractures are very common. The Gartland classification is typically used to guide treatment. However, there is still no consensus on what factors should be used to subclassify the type II fractures and whether subclassification is needed to guide treatment. Therefore, we aim to explore the opinions of pediatric orthopedists on the treatment method of the Gartland type II supracondylar fracture. Specifically, we ask what factors are considered for their treatment decisions and whether subclassification is needed to guide treatment. An online questionnaire was developed and sent to the Thai Paediatric Orthopedics Society and Asia-Pacific Paediatric Orthopaedic Society members. The results were analyzed to explore the relationship between respondents' demographic factors and treatment decisions. Out of 113 participants reached, 57 (50.4%) responded to the questionnaire. Factors chosen by respondents are stability testing intraoperatively (73.7%), the relationship of the anterior humeral line and capitellum (66.7%), the presence of rotation (50.9%), the presence of translation (47.4%), the presence of medial comminution 42.1%), soft tissue condition(38.6%), the shaft - condylar angle (31.6%), and the Bauman angle (21.1%). Thirty-three of 57 respondents (57.9%) deemed subclassification for Gartland type II necessary for guiding treatment. About half of respondents in our study deemed the current Gartland type II subclassification necessary to guide treatment, which may indicate that the subclassification might not be sufficiently comprehensive and reliable. Therefore, better criteria for a subclassification and a prospective evaluating study might be needed.

Comparative effectiveness of treatment modalities in severe Legg­Calvé­Perthes disease: Systematic review and network meta­analysis of observational studies.

PURPOSE: There are several treatment modalities for Legg-Calvé-Perthes disease (LCPD), self-limiting, avascular osteonecrosis of the femoral head in children. Most treatments focus on containment of the weakened femoral head, but there is no consensus on the best modality for severe LCPD. Therefore, we compared the effectiveness of all treatment modalities for severe LCPD. MATERIALS AND METHODS: We searched the PubMed, Embase, and Scopus up until July 2021 for studies that investigated LCPD treatment effectiveness. A network meta-analysis was performed to examine the comparative effectiveness in terms of the ability to achieve radiographic spherical congruity of the hip joint after skeletal maturity. The risk ratio (RR) and 95% confidence interval (CI) of each treatment modality were estimated from both direct and indirect evidence. Treatment ranking was based on Surface Under the Cumulative Ranking curve (SUCRA). RESULTS: A total of 857 studies were identified and 34 comparative studies with 3718 affected hips comparing seven different LCPD treatment modalities were included. Compared with symptomatic treatment, combined osteotomy was the most effective modality (RR = 1.47, 95% CI 0.90 to 2.42, SUCRA = 0.8), followed by femoral varus osteotomy (RR = 1.31, 95% CI 1.06 to 1.60, SUCRA = 0.7), and Salter innominate osteotomy (RR = 1.25, 95% CI 0.95 to 1.65, SUCRA = 0.6). CONCLUSIONS: Combined osteotomy is the most effective procedure in terms of improving the spherical congruity of the hip joint in severe LCPD patients. However, the superiority of operative treatments seems to be limited to patients older than eight years old.

Comparative Evaluation of the Radiographic Parameters for Screening Early Blount Disease.

BACKGROUND: Radiographic findings in young children with physiological bowing sometimes difficult to distinguish from early Blount disease. However, early diagnosis of the disease is critical because of the poor treatment outcomes for Blount disease. In this study, we aim to evaluate the accuracy of the metaphyseal-diaphyseal angle (MDA) compared with the medial metaphyseal beak (MMB) angle for differentiating between physiological bowing and early Blount disease and to determine which parameter to adequately screen for the subsequent development of Blount disease. METHODS: A retrospective study was conducted on children aged 1 to 3 years old who were brought to our outpatient clinic with bowed leg between 2000 and 2017. Data on the patients' age, sex, and affected sides were collected. Radiographic measurements of the femorotibial angle (FTA), MDA, and MMB angle were evaluated from the initial radiographs. An observer repeated the measurements on all the radiographs 2 weeks after they were first done. RESULTS: In total, 158 legs were considered from 79 children (48 males/31 females), whose average age was 26.0±6.1 months old. Eighty-seven legs were diagnosed with Blount disease and 71 legs had physiological bowing. Using single cutoff values of 16 degrees for the MDA showed low sensitivity (50.6%), very high specificity (100.0%), and a very high positive predictive value (PPV); while using MMB angle cutoff values ≥122 degrees showed very high sensitivity (92.0%), high specificity (80.3%), and a high PPV. Considering the MDA and MMB angle simultaneously showed very high sensitivity (93.1%), high specificity (80.3%), and a high PPV. The area under the receiver operating characteristic curve of the MDA and MMB showed excellent (0.89) and outstanding (0.93) discriminative ability, respectively. When combining the MDA and MMB angles, it was also considered outstanding performance (area under the receiver operating characteristic curve=0.95). CONCLUSIONS: The MMB angle represents a potential radiographic screening parameter for predicting early Blount disease in children 1 to 3 years old, offering high sensitivity and specificity. The MDA showed excellent specificity as a confirmation parameter for Blount disease patients. Applying both the MDA and MMB angles is another option to increase early recognition and confirm the diagnosis in early Blount disease patients. LEVEL OF EVIDENCE: Level II.

No Difference in the Incidence of Complications in Pediatric Patients with Moderate Anemia 30 Days after Pediatric Hip Surgery with and without Blood Transfusion.

This study investigated the association between postoperative blood transfusion and the incidence of postoperative complications 30 days after pediatric hip surgery as well as factors significantly associated with 30-day postoperative complications. Patients were divided into two groups: those with postoperative complications and those with no complications. Postoperative hematocrit (Hct) was categorized as <25%, 25-30%, and >30%. Comparison was made between all postoperative complications at the 30-day follow-up that were influenced by anemia in patients who received transfusion and those who did not. A multivariate logistic regression model was used to identify factors independently associated with postoperative complications. The overall 30-day postoperative complication rate for all patients was 17% (24/138). No significant difference between the transfusion and the non-transfusion patients was found. Preoperative hematocrit (Hct) was significantly lower in the complications group (p = 0.030), and both length of stay and 30-day readmission were significantly higher in patients with complications (p = 0.011 and p < 0.001, respectively). Multivariate analysis revealed female gender (OR: 3.50, 95% CI: 1.18-10.36; p = 0.026) and length of hospital stay (OR: 1.23, 95% CI: 1.08-1.41; p = 0.004) to be factors independently associated with 30-day postoperative complications. However, no statistically significant difference in the incidence of complications at 30 days following pediatric hip dysplasia surgery was found between patients who received blood transfusion to maintain a Hct level ≥25% and those not receiving transfusion.

Percutaneous hamstring lengthening in cerebral palsy and the risk of neurovascular transection.

PURPOSE: Percutaneous hamstring lengthening is increasingly popular due to its simplicity, fast recovery rate, and low morbidity. Neurovascular anatomy changes due to knee flexion contracture and the precise proximity of peroneal nerve and Biceps femoris tendon are not well established. This study examined (1) the coronal distance between the peroneal nerve and lateral hamstring tendon ("PLD"), and (2) the distance between the popliteal vessels and medial hamstring tendons ("VMD") to determine the safe distance for percutaneous hamstring lengthening. METHODS: This prospective study recruited cerebral palsy patients aged under 15 who needed hamstring lengthening. Ultrasonography was performed after the patients were anesthetized. PLDs and VMDs at popliteal angles (PAs) of 40°, 60°, and 80° knee flexions were collected. RESULTS: Sixteen patients (32 knees) were enrolled. The mean minimum PLDs at PAs of 40°, 60°, and 80° were 3.5, 4.1, and 3.1 mm, respectively. The peroneal nerve physically touched the lateral hamstring tendon in 5/32 knees (15.6%). The mean minimum VMDs at PAs of 40°, 60°, and 80° were 19, 18.3, and 16.4 mm, respectively. One spastic diplegic patient had a minimum VMD < 3 mm on both sides. Changing the PAs demonstrated no statistical significance for both PLD and VMD (P value = 0.105 and 0.779, respectively). CONCLUSIONS: Percutaneous medial hamstring lengthening should be done with caution. We recommend open biceps femoris surgery, with preoperative ultrasonography (to check the PLD) or peroneal nerve palpation to reduce the risk of peroneal nerve transection.

Does ultrasound-guided popliteal-sciatic nerve block have superior pain control in pediatric foot and ankle surgery? A randomized control trial.

BACKGROUND: Tendon surgery in the pediatric foot and ankle could cause severe postoperative pain, which may lead to psychologic distress and chronic pain. This study was aimed to compare the efficacy of a peripheral nerve block (PNB) and local surgical site infiltration (LSI) in pediatric foot and ankle tendon surgery. METHODS: Forty pediatric patients, who underwent foot and ankle tendon surgery were enrolled. Patients age 1-6 years old were allocated to group 1 and 7-15 years old were group 2. The popliteal-sciatic nerve block with 0.5% Bupivacaine (0.25 ml/kg) for group 1A and 2A. Group 1B and 2B received 0.5% Bupivacaine (0.25 ml/kg) local injection before wound closure. Pain score was recorded using CHEOPS in 1-6 years (Group1A, 1B), NRS in age 7-15 years (Group 2A, 2B). The post-operative morphine consumption and complications were recorded. RESULTS: For 7-15 years, pain score in group 2B was more than group 2A at postoperative 2 and 6 h [Mean difference (95% CI); -3.4 (-6.4 to -0.3), and -2 (-4.4 to 0.5), respectively], and reached MCID of 2. The number of morphine consumption was significantly higher in group 2 B at 0-6 and 6-12 h post-operatively [Mean difference (95% CI); -0.8 (-1.4 to -0.2), and -0.6 (-1.1 to -0.1), respectively, with p-value < 0.05]. For 1-6 years, there was no significant difference in pain score and number of postoperative morphine consumption. CONCLUSIONS: PNB and LSI provided effective pain management in patients aged 1-6 years old with no statistically significant difference. PNB showed significant superior pain control in patients aged 7-15 years old.

Using Combinations of Both Clinical and Radiographic Parameters to Develop a Diagnostic Prediction Model Demonstrated an Excellent Performance in Early Detection of Patients with Blount's Disease.

Early identification of pathological causes for pediatric genu varum (bowlegs) is crucial for preventing a progressive, irreversible knee deformity of the child. This study aims to develop and validate a diagnostic clinical prediction algorithm for assisting physicians in distinguishing an early stage of Blount's disease from the physiologic bowlegs to provide an early treatment that could prevent the progressive, irreversible deformity. The diagnostic prediction model for differentiating an early stage of Blount's disease from the physiologic bowlegs was developed under a retrospective case-control study from 2000 to 2017. Stepwise backward elimination of multivariable logistic regression modeling was used to derive a diagnostic model. A total of 158 limbs from 79 patients were included. Of those, 84 limbs (53.2%) were diagnosed as Blount's disease. The final model that included age, BMI, MDA, and MMB showed excellent performance (area under the receiver operating characteristic (AuROC) curve: 0.85, 95% confidence interval 0.79 to 0.91) with good calibration. The proposed diagnostic prediction model for discriminating an early stage of Blount's disease from physiologic bowlegs showed high discriminative ability with minimal optimism.

Identifying children at high risk for recurrence child abuse.

PURPOSE: To evaluate the characteristics of abused children, families and abusive event and to identify risk factors associated with recurrence of child abuse. METHODS: Retrospective data from 133 children aged between 2 months to 15 years old who were diagnosed as abuse between year 2002 and 2017. Thirteen items related to characteristics of the child, families, abusive event were selected. These factors were analyzed by multivariate logistic regression model for association with repeated child abuse. RESULTS: Total of 133 subjects with average age of 5.25 ± 4.65 years old. There were 54 cases (40.60%) reported of repeated abuse. Majority of repeated abuse type in this study was physical abuse (73.68%). Most perpetrators were child's own parents (45.10%). Factors associated with increased risk of repeated abuse were child age 1-5 years old (AOR = 4.95/95%CI = 1.06-23.05), 6-10 years old (AOR = 6.80/95%CI = 1.22-37.91) and perpetrator was child's own parent (AOR = 21.34/95%CI = 3.51-129.72). Three cases of mortality were found with single-visit children and one case in recurrence. Most of death cases were children less than 1-year-old with average age of 7 months. Causes of death were subdural hematoma with skull and ribs fracture. CONCLUSIONS: Identifying risk factors for repeated child abuse help in recognizing child at risk to provide prompt intervention. This study found two factors associated with higher risk of abuse recurrence: child age 1-10 years old and abusive parents. Children who presented with these risk factors should be recognized and intensively monitored.

Medial Metaphyseal Beak Angle as a Predictor for Langenskiöld Stage II of Blount's Disease.

OBJECTIVE: To determine the medial metaphyseal beak (MMB) cut-off angle predicting Langenskiöld stage II of Blount's disease and to study the intra-observer and inter-observer reliabilities of angle measurements and the influence of the experience level of observers. METHODS: A retrospective study was conducted on children aged 2-4 years from January 2000 to December 2017. Children were identified through a computer-based search. Children with Langenskiöld stage II of Blount's disease who had been initially evaluated at our institution were categorized into Blount group and children who were diagnosed with physiologic bowing were categorized into control group. Data on the patients' ages, genders, and affected sides were collected. The MMB angles were measured on standing anteroposterior radiographs of the knees. The angle was formed between one line drawn parallel to the medial cortex of the proximal tibia, and a second line running from the intersection of the first line with the proximal tibial metaphysis through to the most distal point of the MMB. Measurements were independently performed by six observers. All observers repeated the measurements 2 weeks after they were first done. RESULTS: There were 148 legs from 79 children (48 males and 31 females) with an average age of 28.6 months. The average MMB angle of the Blount group was 128.52° ± 5.38° (P-value <0.001) and of the control group was 114.45° ± 4.89°. The average femorotibial angle of the Blount group was 15.48° ± 6.81° (P-value <0.001) and of the control group was 7.71° ± 7.94°. The receiver operating characteristic curve showed that an MMB angle >122° (sensitivity 92.7%; specificity 97.0%) was associated with Langenskiöld stage II. The intraclass correlation coefficient of the intra-observer reliability ranged from 0.93-0.97, and the inter-observer reliability was 0.93. CONCLUSIONS: By using anteroposterior (AP) radiographs of the knee, the MMB angle is a potential radiographic parameter to distinguish between Langenskiöld stage II of Blount's disease and physiologic bowed legs, with an MMB angle >122° predicting Langenskiöld stage II.

Do Different Tibial Osteotomy Techniques Affect Sagittal Alignment in Children with Blount Disease?

OBJECTIVE: To determine the radiographic outcomes following dome or wedge-shaped proximal tibial osteotomy in the management of infantile Blount disease with a particular interest in sagittal alignment of the knee joint. METHOD: Medical records of patients with Langenskiöld stage 2 Blount disease (aged ≤5 years) who underwent surgical correction between January 2005 and November 2019 were retrospectively identified. Patients with metabolic bone disease, bone tumors, prior traumatic fractures, congenital anomalies, inadequate plain films, and incomplete medical documents were excluded. Patient characteristics (e.g. age, gender, and body mass index [BMI]) and surgical characteristics (e.g. side, type of surgery, and follow-up times) were recorded. Antero-posterior (AP) and lateral knee radiographs were analyzed. Data were categorized by surgical technique as dome-shaped proximal tibial osteotomy or wedge-shaped proximal tibial osteotomy. The femorotibial angle (FTA) was used to evaluate the correction angle in varus deformities. Sagittal alignment of the lower limbs using the posterior tibial slope (PTS) angle was measured postoperatively at 3, 6, 12, and 24 months, and at the final follow-up visit. RESULTS: The present study included 72 surgeries of 46 patients who had undergone proximal tibial osteotomy. Twenty-nine (63%) were male. The mean age of patients at the time of surgery was 34.50 months (range, 26-47). The mean weight was 23.11 ± 4.98 kg (mean ± SD); the mean height was 95.33 ± 6.36 cm, and the mean BMI was 25.32 ± 4.36 kg/m2 . The mean duration of follow up was 4.77 ± 2.78 years. Sixty-four patients (88.90%) received dome-shaped proximal osteotomy of the tibia, while 8 (11.10%) received wedge-shaped proximal osteotomy of the tibia. The average FTA of the total correction measured was 29.32° ± 7.98°. The demographic data of the two groups were not significantly different for gender, age, BMI, side follow-up times, and the total correction of varus deformities. In the dome-shaped osteotomy group, the mean correction of the FTA was 29.59° ± 7.45°. The mean degree of the PTS angle was 6.50° at 3 months, 6.38° at 6 months, 5.32° at 12 months, 5.17° at 24 months, and 5.53° at the final follow-up visit. In the wedge-shaped proximal tibial osteotomy group, the mean correction of the FTA was 27.25° ± 11.77°. The PTS was 6.00° at 3 months, 7.50° at 6 months, 7.00° at 12 months, 5.40° at 24 months, and 5.57° at the final follow-up visit. No significant difference was observed in the radiological outcome between surgical techniques. CONCLUSION: Dome and wedge-shaped proximal tibial osteotomies did not demonstrate significant differences in the PTS angle in children with Blount disease.

Does overcorrection cause any negative effect on pediatric missed Monteggia lesion?

PURPOSES: To evaluate the outcome of different types of ulna osteotomy in missed Monteggia fracture with a particular interest in anatomical correction and overcorrection techniques. The outcome between the two groups were compared on aspects of (1) clinical outcome (2) radiologic outcome. METHODS: Twenty-one patients with type 1 missed Monteggia fracture who underwent surgery between January 2005-2018 were retrospectively reviewed. The patients were divided into two groups according to the degrees of correction: group 1 anatomical correction (no ulnar dorsal angulation) and group 2 overcorrection (degrees of ulnar dorsal angulation ≥ 10°). Clinical outcomes were assessed using the Kim elbow performance score. Radiologic outcomes were categorized into four groups with regard to the radial head: excellent (complete reduction), good (slight subluxation), fair (moderate subluxation), and poor (dislocation). RESULTS: Eleven patients with anatomical ulna osteotomy and ten patients with overcorrection ulnar osteotomy were enrolled with a mean age of 7.95 (5-12) years at the time of operation. The mean duration from injury to surgery was 27.05 (3-120) months, and the mean period of follow-up was 29.90 ± 22.37 (12-84) months. The average angle of total correction measured in group 1 was 6.09° (3°-9°) and 28.37° (12°-40°), in group 2. Fair-to-poor radiological outcomes at the last follow-up were more frequently observed in overcorrection group (40% vs. 0%) (p = 0.035) as well as clinical outcome (20% vs. 0%) (p = 0.214). Among the patients in group 2, posterior dislocation was diagnosed in two patients at 18 months and 2 months after surgery. CONCLUSION: The postoperative result of overcorrection ulna osteotomy showed significant inferiority in radiologic outcome compared to anatomical correction. Overcorrection of ulna osteotomy could be associated with posterior dislocation of radial head.

Pediatric elbow measurement parameters: Evaluation of the six angles in inter- and intra-observer reliability.

BACKGROUND: Several radiographic measurements of the humerus can be used to evaluate the treatment outcome of supracondylar fractures in children. Because of the cartilaginous nature of the immature elbow, interpretation of radiographs around this area is sometimes challenging and can be unreliable. This study was conducted to determine the inter-observer and intra-observer reliability of the six commonly used radiographic measurements of the distal humerus. METHOD: The Baumann angle, humero-ulna angle, metaphyseal-diaphyseal angle, radial epiphyseal angle, shaft-condylar angle and lateral capitellohumeral angle of the humerus were measured by two observers on the radiographs of uninjured elbows from 58 children. The values between each measurement were compared and correlated using a Pearson coefficient of correlation to determine the inter-observer and intra-observer reliability. RESULTS: All of the radiographic parameters showed excellent intra-observer reliability with the correlation coefficient values of the Baumann angle, humero-ulna angle, metaphyseal-diaphyseal angle, radial epiphyseal angle, shaft-condylar angle, lateral capitellohumeral angle as 0.945, 0.95, 0.909, 0.888, 0.961 and 0.975 (p < 0.001), respectively. The inter-observer reliability of the Baumann and humero-ulna angles were also found to be highly correlated at r = 0.843 (p < 0.001) and 0.878 (p < 0.001), respectively. The metaphyseal-diaphyseal angle had poor reliability with r = 0.136 (p = 0.291) while the radial epiphyseal angle, shaft-condylar angle, and lateral capitellohumeral angle demonstrated good reliability with r = 0.675 (p < 0.001), 0.747 (p < 0.001), and 0.686 (p < 0.001), respectively. CONCLUSION: The Baumann angle and humero-ulna angle measurements of distal humerus showed excellent inter- and intra-observer reliability. Both parameters represent repeatable and reliable methods for determining the outcome of supracondylar humeral fractures in pediatric population.

Intra-Observer and Inter-Observer Reliability of Shaft Condylar Angle and Lateral Capitellohumeral Angle: Evaluation Based on Reliability in Different Ages and Levels of Experience.

OBJECTIVES: The aims of this paper were: (i) to examine the intra-observer and inter-observer reliability of the shaft-condylar angle (SCA) and the lateral capitellohumeral angle (LCHA); (ii) to study the influence of experience level on the inter-observer and intra-observer reliability; and (iii) to determine the influence of the the age of the patients on reliability. METHOD: A retrospective cohort study was conducted. The study reviewed 81 elbow radiographs. The patients were aged between 2 and 13 years. All the images taken between 2000 and 2017 were independently measured by a senior pediatric orthopaedic surgeon, a pediatric orthopaedic surgeon, a pediatric orthopaedic fellow, an orthopaedic chief resident, a general practitioner, and a pediatric orthopaedic research assistant. Measurement was performed two times within a 2-week interval. Inexperienced observers (general practitioner and research assistant) were supervised by senior pediatric orthopaedic surgeons for at least 30 radiographs before performing the measurement. Inclusion criteria were as follows: (i) age 2-13 years; and (ii) no previous elbow fracture. EXCLUSION CRITERIA: elbow radiographs do not show true lateral view. The intraclass correlation coefficient (ICC) was used to calculate the reliability. RESULTS: The mean values of SCA and LCHA were 43° and 48°, respectively. For SCA, intra-observer reliability was excellent (ICC = 0.85) for one observer, good (range = 0.73-0.76) for three observers, and moderate (0.59) for one observer. Inter-observer reliability was moderate (0.48, 0.58), whereas the reliability categorized by age group showed excellent agreement (0.88-0.94). For LCHA, intra-observer reliability was excellent (0.84-0.89) for three observers and good (0.66-0.80) for two observers. Inter-observer reliability was moderate (0.44-0.45). Conversely, the reliability classified by age group showed excellent agreement (0.83-0.91). CONCLUSION: Intra-observer reliability for LCHA and SCA were excellent to good for most observers. Inter-observer reliability was moderate for LCHA and SCA. Reliability classified by age group showed excellent to good agreement. Reliability was influenced by the level of experience, especially for non-medical staff.

Medial Metaphyseal Slope as a Predictor of Recurrence in Blount Disease.

OBJECTIVE: This study was aimed to find the radiographic parameter predicting recurrence of stage 2 Blount's disease. METHOD: We retrospectively reviewed radiographs of 82 legs from 49 patients diagnosed with stage 2 Blount's disease by Langenskiöld classification who had failed brace treatment and underwent valgus osteotomy between 1998 to 2016. Age ranged from 26 to 47 months. The metaphyseal-diaphyseal angle was measured preoperatively. The medial metaphyseal slope of the proximal tibia and femorotibial angle were measured preoperatively and 3, 6, 12, and 24 months postoperatively in both non-recurrence (group 1) and recurrence (group 2) group. The receiver operating characteristic curve calculated using MedCalc software was used to determine the medial metaphyseal slope predicting risk for recurrence. Statistical analysis was performed using SPSS software. RESULTS: The mean follow-up time was 4.83 ± 0.38 years. The mean age was 34.57 ± 5.76 in group 1 and 33.2 ± 1.48 in group 2 (P = 0.258). The mean preoperative metaphyseal slope was 62.39° ± 9.75° in group 1 and 73.22° ± 6.59° in group 2 (P = 0.02). The mean preoperative femorotibial angle (FTA) was -14.31° ± 8.25° in group 1 and -18.89° ± 7.74° in group 2 (P = 0.1). The mean preoperative metaphyseal diaphyseal angle (MDA) was 14.75° ± 4.21° in group 1 and 20.11° ±5.16° in group 2 (P = 0.001). Demographic data including age, gender, weight, height, and body mass index showed no statistically significant difference between both groups. Out of 82 legs, 9 (10.97%) had recurrence. Preoperatively, the metaphyseal-diaphyseal angle showed statistical significance between both groups. The medial metaphyseal slope showed statistically significant difference between group 1 and group 2 at 3, 6, 12, and 24 months postoperatively. The receiver operating characteristic curve showed that a medial metaphyseal slope more than 70° at 12 months (sensitivity 88.89% and specificity 69.86%) and more than 62° at 24 months postoperatively (sensitivity 100%, specificity 52.3%) was a predictor for recurrence of stage 2 Blount's disease. CONCLUSION: Medial metaphyseal slope more than 62° over the 24-month follow-up was associated with recurrence of varus deformity.

Surgical correction of coxa vara: Evaluation of neck shaft angle, Hilgenreiner-epiphyseal angle for indication of recurrence.

BACKGROUND: Coxa vara is a hip deformity in which the femoral neck-shaft angle decreases below its normal value. Standard surgical treatment for this condition is corrective valgus osteotomy. Appropriate correction of the Hilgenreiner-epiphyseal angle is important to prevent recurrence. The purpose of this study is to: 1) evaluate the recurrence of the deformity at the latest follow up; and 2) find the appropriate angle of correction associated with the lowest recurrence. METHODS: 34 hips in 31 patients who underwent surgery for treatment of coxa vara from 2005 to 2014 were included. Patient-reported outcomes, Hilgenreiner-epiphyseal angle, and neck-shaft angle were assessed preoperatively, postoperatively, and at latest follow-up. RESULTS: The mean age at surgery was 10.99, with a range of 5-30, years. Preoperative neck-shaft angle ranged from 60 to 100 degrees, and Hilgenreiner-epiphyseal angle ranged from 60 to 90 degrees. At the latest follow up, the neck-shaft angle ranged from 120 to 135 degrees and the Hilgenreiner-epiphyseal angle ranged from 22 to 35 degrees (p < 0.001). The Harris hip score improved from 47.20 (34-66) to 79.68 (60-100) (p < 0.001). There was no recurrence of deformities at the mean follow up of 37.87 months. CONCLUSION: Surgical correction of coxa vara in various pathologies can be done successfully with the Hilgenreiner-epiphyseal angle corrected to ≤ 35 degrees or the neck shaft angle corrected to > 120 degrees in order to prevent recurrence of the deformity. Majority of the patients were reported improvement of hip function. However, a longer-term follow up is required to determine further outcomes regarding to recurrence of the deformity.