Proximal Junctional Degeneration and Failure Modes: A Novel Classification and Clinical Implications.

STUDY DESIGN: Case-control study. OBJECTIVE: To introduce a classification system that will include the major types of degenerative changes and failures related to the proximal junction, and to determine the clinical course and characteristics for the different types of proximal junctional degeneration (PJD). SUMMARY OF BACKGROUND DATA: Proximal junctional kyphosis (PJK) and failures are well recognized after adult spinal fusion, however, a standardized classification is lacking. METHODS: The proposed system identified four different patterns of PJD: Type 1 (multi-level symmetrical collapse), Type 2 (Single adjacent level collapse), Type 3 (fracture) and Type 4 (spondylolisthesis). A single center database was reviewed from 2018 to 2021. Patients ≥18 years of age, who underwent posterior spinal fusion of ≥3 levels with an upper instrumented vertebral level between T8-L2, and a follow-up of ≥2 years were included. Radiographic measurements, revision surgery and time to revision were the primary outcomes. RESULTS: 150 patients were included with a mean age of 65.1 (±9.8) years and a mean follow-up of 3.2 (±1) years. 69 patients (46%) developed significant degenerative changes in the proximal junction, and were classified accordingly. 20 (13%) were Type 1, 17 (11%) were Type 2, 22 (15%) were Type 3 and 10 (7%) were Type 4. Type 3 had a significantly shorter time to revision with a mean of 0.9 (±0.9) years. Types 3 and 4 had greater preoperative sagittal vertical axis, and Types 1 and 3 had greater final follow-up lumbar lordosis. Bone density measured by Hounsfield units showed lower measurements for Type 3. Types 1 and 4 had lower rates of developing PJK. Type 1 had the lowest revision rate with 40% (types 2, 3 and 4 were 77%, 73% and 80%, respectively, P=0.045). CONCLUSION: This novel classification system defines different modes of degeneration and failures at the proximal junction, and future studies with larger sample sizes are needed for validation. LEVEL OF EVIDENCE: 3.

Immediate Postoperative Change in the Upper Instrumented Screw-Vertebra Angle Is a Predictor for Proximal Junctional Kyphosis and Failure.

STUDY DESIGN: Retrospective review. OBJECTIVES: To determine if change in position of upper instrumented vertebral (UIV) screw between intraoperative prone and immediate postoperative standing radiographs is a predictor for proximal junctional kyphosis or failure (PJK/PJF). SUMMARY OF BACKGROUND DATA: Cranially directed UIV screws on post-operative radiographs have been found to be associated with PJK. Change in the screw position between intraoperative and immediate postoperative radiographs has not been studied. METHODS: Patients with posterior fusion ≥3 levels and UIV at or distal to T8, and minimum 2-year follow-up were identified from a single center database. Primary outcomes were radiographic PJK/PJF or revision for PJK/PJF. Demographic, surgical and radiographic variables, including intraoperative screw-vertebra (S-V) angle, change in S-V angle, direction of UIV screw (cranial-neutral-caudal) and rod-vertebra (R-V) angle were collected. RESULTS: 143 cases from 110 patients were included with a mean age of 62.9 years and a follow-up of 3.5 years. 54 (38%) cases developed PJK/PJF, of whom 30 required a revision. Mean S-V angle was -0.9°±5.5° intraoperative and -2.8°±5.5° postoperative. The group with PJK/PJF had a mean S-V angle change of -2.5°±2.4 while the rest had a change of -1.0°±1.6 (P=0.010). When the change in S-V angle was <5°, 33% developed PJK, this increased to 80% when it was ≥5° (P=0.001). Revision for PJK/PJF increased from 16% to 60% when S-V angle changed ≥5° (P=0.001). Regression analysis showed S-V angle change as a significant risk factor for PJK/PJF (P=0.047, OR=1.58) and for revision due to PJK/PJF (P=0.009, OR=2.21). CONCLUSIONS: Change in the S-V angle from intraop prone to immediate postop standing radiograph is a strong predictor for PJK/PJF and for revision. For each degree of S-V angle change, odds of revision for PJK/PJF increases by 2.2x. A change of 5° should alert the surgeon to the likely development of PJK/PJF requiring revision.

Safety and efficacy of growth-friendly instrumentation for early-onset scoliosis in patients with spinal muscular atrophy type 1 in the disease-modifying treatment era.

Purpose: To evaluate the safety of growth-friendly instrumentation for early-onset scoliosis (EOS) in patients with spinal muscular atrophy (SMA) type 1 who received disease-modifying treatment (DMT) and analyze short-term efficacy. Methods: Retrospective search was conducted between 2017 and 2023. Patients with genetically confirmed SMA type 1 who were surgically treated for spinal deformity and receiving DMTs (nusinersen, risdiplam, or onasemnogene abeparvovec) were included. SMA types 2 and 3 and patients who do not receive DMTs were excluded. Clinical and radiographic data were collected at preoperative, postoperative, and latest follow-up visits. Results: Twenty-eight patients (mean follow-up: 16 months (range 2-41)) were included. The mean age at surgery was 60 months (range 29-96). Fifteen were treated with dual magnetically controlled growing rods (MCGR), four with unilateral MCGR and a contralateral guided growth system, three with Vertical Expandable Prosthetic Titanium Rib (VEPTR®) implants, five with self-distracting systems, and one with traditional dual growing rods. The mean amount of correction was 57% (44°± 17) for scoliosis and 83% (13°± 11) for pelvic obliquity. The mean T1-12 height gain during surgery was 31 mm (±16 mm), while the mean T1 S1 height gain was 51 mm (±24 mm), and instrumented growth was observed during follow-up. Five patients (18%) developed six serious adverse events: three surgical site infections, two anchor failures, and one rod fracture, and all required unplanned reoperations. No neurologic complication, difficulty during nusinersen injections, or respiratory decline was recorded. Conclusion: We report that spinal deformity in this population can be safely treated with growth-friendly instrumentation, with similar complication rates when compared with SMA type 2.

Management of low back pain accompanying sagittal plane pathologies in children: Spondylolysis/spondylolisthesis and Scheuermann's disease.

Background: Low back pain in childhood was underappreciated for a long time, but recent studies report higher prevalences, up to 70%. Two of the common causes are spondylolyis/spondylolisthesis and Scheuermann's disease. These disorders are relevant in a way they both cause significant back pain, and may disrupt the sagittal spinal balance. Purpose: To present the current evidence on the diagnosis, natural history and treatment of these disorders with a special focus on sagittal spinal alignment. Methods: This study is conducted as a literature review. Results and Conclusions: Spondylolysis and low-grade spondylolisthesis have a benign course and are typically treated conservatively. When pars repair is indicated, pedicle screw-based techniques achieve more than 90% fusion with acceptable complication rates. High-grade spondylolisthesis, however, is frequently progressive. Surgical treatment involves fusion, which can be done in situ or after reduction. Reduction is useful for "unbalanced" patients to acquire sagittal spinopelvic balance, and it is important to distinguish these patients. Despite lowering the risk for pseudoarthrosis, reduction brings a risk for neurologic complications. With re-operation rates as high as 40%, these patients definitely require careful preoperative planning. Scheuermann's disease generally causes back pain in addition to cosmetic discomfort during adolescence. If the kyphosis is lower than 60°, symptoms typically resolve into adulthood with conservative measures only. However, it must be kept in mind that these patients may experience problems with physical performance and have a lower quality of life even when the problem seems to have "resolved". Severe kyphosis and intractable back pain are the most frequently referred surgical indications, and surgery typically involves fusion. Proper utilization of osteotomies and proper selection of the upper and lower fusion levels are of utmost importance to prevent complications in these patients.

Predictive value of different glycemic control markers in total hip or knee arthroplasty: A prospective study.

OBJECTIVE: The optimal glycemic control marker before total hip or knee arthroplasty remains inconclusive. Hemoglobin A1c (HbA1c) is widely used, while fructosamine may be valuable for predicting periprosthetic joint infection (PJI). Fructosamine levels can be affected by serum albumin levels; albumin-corrected fructosamine (AlbF) can be calculated to overcome this issue. The objective of this study was to evaluate the predictive value of different markers for complications after primary total hip or knee arthroplasty. METHODS: This prospective cohort study included 304 patients (mean age: 65 years [range, 16-85), mean follow-up: 32 months (range, 12-49)] who underwent primary total hip or knee arthroplasty between 2018 and 2021. Of them, 156 patients had diabetes. Mean HbA1c was 6.5% (range, 4.8%-13%), fructosamine 244 µmol/L (range, 98-566 µmol/L), and AlbF 632 (range, 238-2308). Patients who did and did not have diabetes were matched 1 : 1. Hemoglobin A1c 7% and fructosamine 292 µmol/L were used as cutoff. Complications were documented. Glycemic markers were compared using logistic regression analyses, with a special focus on PJI. RESULTS: In the logistic regression analyses, HbA1c was strongly associated with total complications [adjusted odds ratio (OR): 3.61; 95% CI, 1.65-7.91, P = .001], while fructosamine was associated with PJI (adjusted OR: 13.68; 95% CI, 1.39-134.89, P = .025). Albumin-corrected fructosamine did not show any additional benefits. CONCLUSION: Preoperative assessment before total hip or knee arthroplasty must not focus on a single marker; HbA1c is a good predictor of total complications, while fructosamine is a better predictor of PJI. To the best of our knowledge, in its first orthopedic study, AlbF did not show any advantages. LEVEL OF EVIDENCE: Level II, Prognostic Study.

Intraoperative medial wall disruption in Dega pelvic osteotomy: Does it effect the radiographic outcome at medium-term?

OBJECTIVES: To compare the radiographic outcomes of our patients who encountered medial wall disruption, with those who did not while undergoing Dega osteotomy. METHODS: We retrospectively reviewed the records of 95 hips with developmental dysplasia of the hip who were treated with Dega pelvic osteotomy. Hips were divided into 2 groups according to medial wall disruption: group A included the hips with medial wall disruption, while group B included the hips without disruption. Preoperative, immediate postoperative, 12 weeks and last follow-up anteroposterior radiographs of the pelvis were reviewed for changes in the acetabular index (AI) between groups. RESULTS: There were 22 hips in group A and 73 hips in the group B. Preoperative (34.6 versus [vs] 37.2, p=0.231), postoperative (17.9 vs 18.4, p=0.682), 12th week (18 vs 18, p=0.504) and last follow-up (13.3 vs 15.1, p=0.097). The acetabular index measurements were comparable between the groups. Corrections achieved during surgery, and during the follow-up period were also comparable between the two groups, indicating no loss of radiographic correction caused by medial wall disruption. Ninety one percent of the patients in group A and 90% of group B achieved good or excellent results according to the Severin classification (p=0.944). CONCLUSION: Our study shows that disruption of the medial wall did not have a significant detrimental effect on radiographic correction when performing Dega osteotomy.

Closed versus medial open reduction in the treatment of developmental dysplasia of the hip under age 1: A retrospective comparative study.

OBJECTIVE: This study aimed to compare the mid-term results of closed reduction (CR) versus medial open reduction (MOR) in the treatment of children with developmental dysplasia of the hip (DDH) under age 1. METHODS: Thirty-four patients with DDH (41 hips) were included in this retrospective study with a mean follow-up of 4.2 years (range: 2-6.9 years). All hips were then divided into 2 groups based on the treatment type: the CR group (20 hips) and the MOR group (21 hips). All hips from both groups were assessed with post-spica magnetic resonance imaging (MRI) in the first 24 hours, and reinterventions were recorded. Medial dye pool width was also measured. RESULTS: Age at the time of reduction was similar between the CR and MOR groups (6.6 ± 1.3 months vs. 6.7 ± 1.6 months). There was no significant difference between groups regarding avascular necrosis rate and further corrective surgery (FCS) requirement (P=.454, .697). The appropriate reduction was seen at 38/41 hips. Three hips in the CR group had revealed dislocation in post-spica MRIs and required re-intervention, and none of the hips in the MOR group required re-intervention (P=.107). Medial dye pool width in 3 planes showed no significant difference between MOR and CR. CONCLUSION: There is no difference in the avascular necrosis rate and FCS requirements between CR and MOR under age 1. Post-spica MRI is a favorable tool for evaluating reduction after CR, but its efficacy after MOR is questionable.

Evaluation of the Effects of Transforming Growth Factor-Beta 3 (TGF-ß3) Loaded Nanoparticles on Healing in a Rat Achilles Tendon Injury Model.

BACKGROUND: Achilles tendon (AT) midsubstance injuries may heal suboptimally, especially in athletes. Transforming growth factor-beta 3 (TGF-ß3) shows promise because of its recently discovered tendinogenic effects. Using poly(lactic-co-glycolic acid)-b-poly(ethylene glycol) (PLGA-b-PEG) nanoparticles (NPs) may enhance the results by a sustained-release effect. HYPOTHESIS: The application of TGF-ß3 will enhance AT midsubstance healing, and the NP form will achieve better outcomes. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 80 rats underwent unilateral AT transection and were divided into 4 groups: (1) control (C); (2) empty chitosan film (Ch); (3) chitosan film containing free TGF-ß3 (ChT); and (4) chitosan film containing TGF-ß3-loaded NPs (ChN). The animals were sacrificed at 3 and 6 weeks. Tendons were evaluated for morphology (length and cross-sectional area [CSA]), biomechanics (maximum load, stress, stiffness, and elastic modulus), histology, immunohistochemical quantification (types I and III collagen [COL1 and COL3]), and gene expression (COL1A1, COL3A1, scleraxis, and tenomodulin). RESULTS: Morphologically, at 3 weeks, ChT (15 ± 2.7 mm) and ChN (15.6 ± 1.6 mm) were shorter than C (17.6 ± 1.8 mm) (P = .019 and = .004, respectively). At 6 weeks, the mean CSA of ChN (10.4 ± 1.9 mm2) was similar to that of intact tendons (6.4 ± 1.1 mm2) (P = .230), while the other groups were larger. Biomechanically, at 3 weeks, ChT (42.8 ± 4.9 N) had a higher maximum load than C (27 ± 9.1 N; P = .004) and Ch (29.2 ± 5.7 N; P = .005). At 6 weeks, ChN (26.9 ± 3.9 MPa) had similar maximum stress when compared with intact tendons (34.1 ± 7.8 MPa) (P = .121); the other groups were significantly lower. Histologically, at 6 weeks, the mean Movin score of ChN (4.5 ± 1.5) was lower than that of ChT (6.3 ± 1.8). Immunohistochemically, ChN had higher COL3 (1.469 ± 0.514) at 3 weeks and lower COL1 (1.129 ± 0.368) at 6 weeks. COL1A1 gene expression was higher in ChT and ChN at 3 weeks, but COL3A1 gene expression was higher in ChN. CONCLUSION: The application of TGF-ß3 had a positive effect on AT midsubstance healing, and the sustained-release NP form improved the outcomes, more specifically accelerating the remodeling process. CLINICAL RELEVANCE: This study demonstrated the effectiveness of TGF-ß3 on tendon healing on a rat model, which is an important step toward clinical use. The novel method of using PLGA-b-PEG NPs as a drug-delivery system with sustained-release properties had promising results.

Osseous Ilio-Trochanteric Bars as an Etiology of Hip Contracture in a Child with Congenital Contractures: A Case Report.

CASE: A 5-month-old female patient presented with bilateral lower-limb deformities. Hips were fixed at 100° abduction, 15° flexion and 45° external rotation, flexion contracture in the knees, and bilateral teratologic equinovarus deformities. Radiographs revealed ilio-trochanteric osseous bars as the etiology of hip contractures. Staged surgeries were undertaken. At 4 years of age, she could stand upright with orthoses and sit without support. CONCLUSION: This is the first study to report bilateral congenital ilio-trochanteric osseous bars, which were resected without recurrence. Even with a very low potential of walking, release of the contractures allows for better function and possible wheelchair-dependent mobility in the future.

The efficacy of two-hole tension band plates in the treatment of lower extremity limb length discrepancy.

The main purpose of our study was to investigate the efficacy of dual two-hole tension band plates in the treatment of lower extremity limb length discrepancy (LLD). We retrospectively reviewed patients who underwent epiphysiodesis utilizing dual two-hole tension band plates due to lower extremity LLD between January 2012 and June 2018. The efficacy of epiphysiodesis was defined as the inhibited percentage of the expected growth of the physis between two time intervals and was calculated between 0-6 months and 6-18 months as the primary outcome. The relationship of efficacy of epiphysiodesis with time intervals, bone segments, physeal coverage percentage by the screws, age and interscrew angle and physeal health was also assessed. A total of 11 patients' 17 bone segments (9 femurs and 8 tibias) with a mean age of 8.7 ± 2.3 were included. The mean efficacy of the epiphysiodesis in the first 6 months for femurs was 23 ± 20 % (range, 0-53%) and for tibias was 21 ± 19 % (range, 0-53%); between 6 and 18 months it was 27 ± 19 % (range, 0-56%) for femurs and 15 ± 19 % (range, 0-50%) for tibias. In the first 6 months, physeal coverage percentage by the screws (r = 0.503, P = 0.04) and age (r = -0.534, P = 0.027) had a strong correlation with the epiphysiodesis efficacy. Dual two-hole tension band plating has variable efficacy in the treatment of LLD. Age and physeal coverage percentage by the screws could be related to epiphysiodesis efficacy.

Scapular body fractures: Short-term results of surgical management with extended indications.

INTRODUCTION: Scapular body fractures represent less than 1% of all skeletal fractures. Operative criteria and risk factors for scapular fracture instability are well defined. Non-operative management of scapular body fractures show satisfactory results but with shortening and medialization of the scapular body. The aim of this study is to evaluate if surgical treatment will result in an improved quality of life and shoulder function compared to non-operative treatment on patients suffering from a scapular body fracture. MATERIALS AND METHODS: From a total of 381 retrospectively identified scapular body fractures, we included 45 patients. The enrolled patients were divided into two groups: the surgical treatment (ST, n = 20) group and the non-operative treatment (NOT, n = 25) group. The Non-Union Scoring System (NUSS) was used to assess bone healing on radiographs. The functional evaluation of the two groups during the follow-up were performed using the Constant Shoulder Score (CSS) and the Quick Disabilities of the Arm, Shoulder and Hand Score (QuickDASH). Complications, reoperation rates, and time until bony union were also documented. The minimum follow-up for this study was designated as 12 months. RESULTS: The ST group had better mean CSS and QuickDASH scores compared to the NOT group at 1, 3 and 6 months of follow-up. No statistically significant difference was detected at 12 months follow-up. ST group also demonstrated improved results in time until bone union, reduction of rehabilitation time, complications and return to work rates. CONCLUSION: This study suggests that surgical treatment for extraarticular scapular fractures can achieve better short-term functional outcomes (3 to 6 months) compared to conservative treatment.

Biceps Tenodesis versus Tenotomy with Fast Rehabilitation Protocol-A Functional Perspective in Chronic Tendinopathy.

The study aimed to evaluate the results after arthroscopic tenodesis and tenotomy of the biceps tendon (LHBT), coupled in tenotomy modality with a personalized postoperative rehabilitation protocol. The study included patients who underwent arthroscopic biceps tenotomy or tenodesis due to chronic biceps tendinopathy. Postoperatively, a standard rehabilitation program was prescribed to the tenodesis group and personalized was introduced in the tenotomy group, respectively. The outcomes were assessed using the American Shoulder and Elbow Surgeons scale (ASES), clinical tests that are dedicated to biceps tendinopathy, the occurrence of a Popeye deformity, night pain, and return to previous sporting activities. A cohort of 67 patients was enrolled in the final follow-up examination (mean 27 months) of which 40 patients underwent tenotomy (60%), and 27 patients (40%) underwent tenodesis. The mean ASES score improved from 48.1 to 87.8 in the tenotomy group and from 44 to 72.7 in the tenodesis group during the follow-up (p < 0.0001). The tenotomy group had better mean postoperative ASES scores than the tenodesis group (p < 0.0001). Positive clinical tests for biceps pathology were noticed more often in patients after LHB tenodesis (p = 0.0541). The Popeye deformity occurred more often in the tenotomy group; however, no patient complained of the visual appearance of the arm contour (p = 0.0128). Moreover, the frequency of night pain decreased in the tenotomy group (p = 0.0059). Return to previous sporting activities was more frequent in the tenotomy group (p = 0.0090). Arthroscopic biceps tenotomy is a reproducible, simple procedure, and augmented by a rapid rehabilitation protocol that provides promising clinical outcomes, reduces shoulder pain, and allows the patient to return to previous sporting activities, even in population older than 50 years.

Proximal Humerus Tumors: Higher-than-Expected Risk of Revision With Constrained Reverse Shoulder Arthroplasty.

BACKGROUND: The treatment of proximal humerus tumors with endoprostheses is associated with a high risk of implant-related surgical complications. Because of extensive soft-tissue resection and muscular detachment during surgery, instability is the most common serious complication. A reverse total shoulder arthroplasty with a highly constrained design is one option to mitigate instability, but few studies have reported the results of this prosthesis for proximal humerus tumor resections. QUESTIONS/PURPOSES: (1) What are the short-term functional results of the constrained reverse total shoulder prosthesis in terms of Musculoskeletal Tumor Society (MSTS), DASH, and Constant-Murley scores and ROM values? (2) What is the frequency of revision, using a competing-risks estimator to assess implant survival, and what were the causes of the revisions that occurred? (3) What proportion of patients experienced dislocations at short-term follow-up? METHODS: Between January 2014 and June 2017, we treated 55 patients with proximal humeral resections and reconstructions for malignant tumors. Of those, 33% (18) of patients were treated with the constrained, reverse total shoulder arthroplasty implant under study here. During that period, no other constrained reverse total shoulder implant was used; however, 13% (seven) of patients were treated with conventional (unconstrained) reverse total shoulder implants, 27% (15) had hemiarthroplasties, 15% (eight) of patients had biologic reconstructions with auto- or allografts and 13% (seven) underwent amputation. During the period in question, our general indications for use of the constrained device under study here were resection of the deltoid muscle/axillary nerve or the deltoid insertion on the humerus due to tumor invasion, or extensive rotator cuff and surrounding soft tissue resection that might result in shoulder instability. During this period, these indications were adhered to consistently. Four of 18 patients treated with the study implant died (three died with the implant intact) and none were lost to follow-up before 2 years, leaving 14 patients (seven women and seven men) for study at a median (range) follow-up of 35 months (25 to 65). Two authors evaluated the clinical and functional status of each patient with ROM (flexion, extension, internal and external rotation, abduction, and adduction) and MSTS, (range 0% to 100%), Constant-Murley (range 0% to 100%), and DASH (range 0 points to 100 points) scores. For the MSTS and Constant-Murley scores, higher percentage scores mean better functional outcome; and for the DASH score, a higher score means more severe disability. Radiographs were obtained at each visit and were used to look for signs of loosening, which we defined as progressive radiolucencies between visits, prosthetic component migration, and fragmentation/fracture of the cement. The Sirveaux classification was used to determine scapular notching. A competing risks analysis with 95% confidence intervals was performed to estimate the cumulative incidence of revision surgery, which we defined as any reoperation in which the implant was removed or changed for any reason, with patient mortality as a competing event. RESULTS: At the most recent follow-up, the median (range) MSTS score was 78% (50 to 90), the DASH score was 20 (8 to 65), and the Constant-Murley score was 53% (26 to 83). The median ROM was 75° in forward flexion (40 to 160), 78° in abduction (30 to 150), 35° in internal rotation (10 to 80), and 33° in external rotation (0 to 55). Postoperatively, two of 14 patients underwent or were supposed to undergo revision surgery, and the cumulative incidence of revision surgery was 18% for both 30 and 48 months (95% CI 2 to 45). During the study period, no patients reported instability, and no dislocations occurred. CONCLUSIONS: Our findings are concerning because the revision risk with this constrained reverse total shoulder implant was higher than has been reported by others for other proximal humerus prostheses. The highly constrained design that helps prevent instability might also transmit increased stresses to the humeral component-bone interface, therefore making it susceptible to loosening. We believe that any other implant with a similar degree of constraint will have the same problem, and changing the indications for patient selection may not solve this issue. These theories need to be tested biomechanically, but our desire is to warn surgeons that while trying to prevent instability, one might trade one complication (instability) for another: aseptic loosening. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Synovial Non-langerhans Cell Histiocytosis of the Shoulder: A Case Report and Review of the Literature.

INTRODUCTION: Histiocytoses are rare disorders and most orthopedic surgeons are unfamiliar with this diagnosis. We report a case of synovial non-Langerhans cell histiocytosis (LCH) located in the shoulder, which has not been reported in the literature previously. CASE REPORT: A 24-year-old female patient presented to our clinic with shoulder pain and decreased range of motion. MRI results suggested pigmented villonodular synovitis. Arthroscopic synovial debridement and biopsy were performed. Histologic examination came back as non-LCH of the shoulder. Hematology/oncology evaluation indicated localized disease and no further treatment was necessary. At the 6th month follow-up, the patient gained full shoulder motion and is symptom free. CONCLUSION: This case represents a rare diagnosis of synovial non-LCH which should be considered in the differential diagnosis of synovial diseases. A misdiagnosis could result in inadequate treatment, and coordination with the hematology/oncology department is of utmost importance in the treatment of this neoplastic disease.

Effectiveness of abduction orthosis for the treatment of acetabular dysplasia.

OBJECTIVES: This study aims to evaluate the effectiveness of full-time bracing in residual acetabular dysplasia (RAD) and the effect of previous Pavlik harness usage on the results of treatment with abduction orthosis. PATIENTS AND METHODS: We retrospectively reviewed 80 patients (9 males, 71 females; mean age 6±0.8 months; range, 5 to 7 months) with developmental dysplasia of the hip (119 dysplastic hips) treated with hip abduction orthosis. Patients with an acetabular index (AI) measurement of 30° and over who used full-time hip abduction brace for six months were included in the study. Acetabular index values were measured at the initiation, third, and sixth months of treatment and the effectiveness of abduction orthosis was evaluated. The patients were analyzed for the effect of prior Pavlik harness application on abduction orthosis treatment. RESULTS: Mean AI value of the dysplastic hips (n=119) was 33.4°±2.6°, which decreased to 28.5°±2.6° after treatment (p<0.001). The AI improvement in the first three-month period was significantly faster than the second three-month period (2.9°±1.9° vs. 1.9°±1°; p=0.013). No difference was observed in AI development between patients with or without prior Pavlik treatment (p=0.1). In patients with unilateral dysplasia, dysplastic hips improved significantly faster than normal hips (p<0.001). As a result of a mean follow-up duration of 20.2±9.8 months from the onset of brace treatment, 32 (32%) hips were grouped as normal, 49 (48%) as mildly dysplastic, and 22 (20%) as severely dysplastic based on Tönnis criteria. CONCLUSION: Hip abduction orthosis may be used in patients with RAD between 6 to 12 months of age. Acetabular index improvement was faster in the first three months of brace treatment. Dysplastic hips improved faster than normal hips, and prior Pavlik harness treatment did not alter the effectiveness of orthosis.