Inestabilidad patelofemoral en niños y adolescentes: revisión de conceptos actuales / Patellofemoral instability in children and adolescents. Current concepts review

La inestabilidad patelofemoral es un trastorno frecuente de la rodilla en el paciente esqueléticamente inmaduro. Este cuadro plantea diversos desafíos en esta población que requieren una comprensión de la anatomía y la biomecánica para formular un plan de tratamiento que prevenga la reluxación y permita el regreso a las actividades. En esta revisión, se analizan las distintas formas de presentación y las alternativas terapéuticas, y se ofrece una guía práctica para el manejo integral de esta compleja condición clínica. Nivel de Evidencia: V

Patellofemoral instability (PFI) is a common knee disorder in the skeletally immature patient. PFI presents challenges in this patient population that require an understanding of anatomy and biomechanics to formulate a treatment plan aimed at preventing redislocation and facilitating return to activity. In this review, the different presentations and therapeutic alternatives will be analyzed, providing a practical guide for the comprehensive management of this complex clinical condition. Level of Evidence: V

Conceptos actuales sobre el tratamiento ortésico en el método Ponseti / Current concepts on bracing in the Ponseti method

El método Ponseti se ha convertido en el patrón de referencia para el tratamiento del pie bot, con excelentes resultados funcionales en el seguimiento a largo plazo. El cumplimiento del protocolo de férula es fundamental para mantener la corrección obtenida y el éxito terapéutico a largo plazo. Existen múltiples férulas para mantener la corrección y prevenir la recurrencia. En este artículo, proporcionamos una revisión de las férulas utilizadas para el pie bot, y analizamos sus ventajas y desventajas, así como la evi-dencia sobre cada una. Nivel de evidencia: V

The Ponseti method has become the gold standard for the treatment of clubfoot, with excellent long-term functional outcomes. Adherence to the bracing protocol is essential for the long-term success of the treatment. Currently, there are multiple braces that can be used to prevent relapse. In this article, we provide a review of clubfoot braces, discussing their advantages and disadvantages, as well as the current evidence on each of them. Level of Evidence: V

Puntajes VII Ortopedia infantil / Scores VII Pediatric orthopedics

El Comité Editorial quiere brindar a sus lectores una actualización de las escalas de uso corriente. El empleo de tablas y escalas es una práctica muy extendida en la Ortopedia y Traumatología. La medición y la cuantificación de los aspectos clínicos, funcionales y radiográficos se convirtieron en una herramienta imprescindible para la toma de decisiones en diferentes aspectos de la actividad asistencial. Llevamos a cabo una revisión de las escalas más utilizadas, definiendo su uso e incluyendo bibliografía original y actualizada. Nivel de Evidencia: V

The Editorial Committee wants to provide its readers with an update on the commonly used scales. The use of tables and scales is a widespread practice in Orthopedics and Traumatology. The measurement and quantification of clinical, functional, and radiographic aspects has become an essential tool for decision-making in different aspects of healthcare activity. We carry out a review of the most used scales, defining their use and including original and updated literature. Level of Evidence: V

Síndrome del torniquete capilar en la población pediátrica: reporte de un caso / Hair tourniquet syndrome in the pediatric population. A case report

El síndrome del torniquete es un cuadro poco frecuente que ocurre, por lo general, en la población pediátrica. Consiste en la disminución del aporte sanguíneo por estrangulación circunferencial de algunas partes del cuerpo y suele comprometer dedos de los miembros superiores o inferiores, genitales externos u otros apéndices. En la mayoría de los casos, el agente causal suele ser una hebra de cabello, aunque se han descrito otros elementos, como fibras sintéticas de la indumentaria del paciente. El objetivo de este artículo es presentar el caso de una paciente con síndrome del torniquete y analizar la bibliografía disponible. Se trata de una lactante de 3 meses de edad con síndrome del torniquete por cabello, con compromiso del cuarto dedo del pie derecho, que fue traída al servicio de urgencia por un importante edema de partes blandas. La paciente evolucionó favorablemente luego de la extracción del agente causal (hebra de cabello) de la base del cuarto dígito y la recuperación de la irrigación fue completa. Si bien es un cuadro poco frecuente, es imprescindible tener un alto índice de sospecha y realizar un diagnóstico precoz para indicar un tratamiento oportuno y evitar complicaciones potencialmente graves para el paciente. Nivel de Evidencia: IV

Tourniquet syndrome is a rare condition that usually affects the pediatric population. It consists of a decrease in blood supply due to circumferential strangulation of some parts of the body, mainly fingers or toes, external genitalia or other appendages.In most cases, the causative agent is usually a strand of hair, although other elements have been described, such as synthetic fibers from the patient's clothing. The aim of this study is to report a case of a patient with hair tourniquet syndrome and to review the available literature. The patient is a 3-month-old female with hair tourniquet syndrome, with involvement of the fourth toe of the right foot, who was brought to the emergency department for significant soft tissue edema. The patient evolved favorably after removal of the causative agent (hair strand) from the base of the fourth toe and recovery of irrigation was complete. Although tourniquet syndrome is a rare entity, early diagnosis and treatment is essential to avoid potentially severe complications. Level of Evidence: IV

Sinovitis transitoria de cadera en un niño como probable manifestación inicial atípica de COVID-19 / Transient synovitis of the hip in a pediatric patient as an atypical initial manifestation of COVID-19

Comunicamos el caso de un niño con sinovitis de cadera como manifestación inicial atípica de una infección por SARS-CoV-2. Varón de 7 años que consultó por dificultad en la marcha e impotencia funcional con dolor localizado en la cadera derecha. El diagnóstico presuntivo fue sinovitis transitoria de cadera, por lo que recibió tratamiento conservador. A los 12 días, continuaba con impotencia funcional y presentó decaimiento y fiebre. Ante la evolución atípica del cuadro, se decidió su internación para punción articular/drenaje. Se obtuvo un líquido articular claro de aspecto inflamatorio que no presentó desarrollo en los cultivos bacterianos. Durante la internación, se confirmó el resultado positivo de la reacción en cadena de la polimerasa para SARS-CoV-2. El paciente evolucionó favorablemente una vez resuelto el cuadro viral. En el último seguimiento, no tenía síntomas y el rango de movilidad era completo. La sinovitis transitoria de cadera puede ser una manifestación clínica inicial atípica de COVID-19. En el contexto de la pandemia, es indispensable sospechar una posible artropatía reactiva como consecuencia del virus, principalmente cuando la presentación es atípica, hay contactos familiares estrechos, fiebre u otros síntomas respiratorios asociados. Nivel de Evidencia: IV

We report the case of a pediatric patient with transient synovitis of the hip as an initial atypical manifestation of a COVID-19 infection. A 7-year-old boy presented with gait disturbance, limping, and pain in his right hip. After 12 days, the patient continued with functional limitations and had associated symptoms such as fatigue and fever. Because of the atypical course, he was admitted to the hospital for joint aspiration. Due to institutional protocols, the preoperative evaluation included a COVID-19 PCR test. The joint aspiration sample showed clear synovial fluid with inflammatory characteristics and negative bacterial culture. COVID-19 PCR test results came out positive during the patient's hospital stay. Clinical symptoms improved after the viral condition resolved. In the last follow-up, he was asymptomatic with a full hip range of motion. Transient synovitis of the hip could be an atypical initial symptom of a COVID-19 infection. Given the pandemic context of this disease, it is important to consider reactive arthritis as a consequence of this infection, especially in cases of atypical presentation, close family contact, fever, or other associated respiratory symptoms. Level of Evidence: IV

Condroblastoma de astrágalo. Reporte de un caso y revisión de la bibliografía / Chondroblastoma of the talus. Case report and literature review

El condroblastoma es un tumor óseo benigno infrecuente que representa el 1-2% de todos los tumores óseos primarios. Como aproximadamente solo el 4% se localiza en el astrágalo, la bibliografía es escasa. Se presenta a un varón de 18 años con un condroblastoma localizado en el astrágalo derecho. El paciente tuvo una buena evolución, sin complicaciones a los 15 meses de la cirugía. Revisamos los casos ya publicados para analizar la forma de presentación y la evolución luego del tratamiento quirúrgico. Nivel de Evidencia: IV

Chondroblastoma (CB) is a rare benign bone tumor that represents between 1% to 2% of all primary bone tumors. Because only abouy 4% of them are located in the talus, the literature is scarce. We present a case of an 18-year-old male patient who presents with a chondroblastoma located in the right talus. He had an uneventful recovery; with no complications at his last follow-up at 15 months. We also reviewed the published literature to discuss the diagnosis and treatment of chondroblastoma in the talus. Level of evidence: IV

Growth modulation with tension-band plates for the correction of paediatric lower limb angular deformity: current concepts and indications for a rational use.

Growth modulation (GM) with tension-band plates (TBPs) by tethering part of the growth plate is an established technique for the correction of angular deformities in children, and it has increasingly supplanted more invasive osteotomies.Growth modulation with TBPs is a safe and effective method to correct a variety of deformities in skeletally immature patients with idiopathic and pathological physes. The most common indication is a persistent deformity in the coronal plane of the knee exceeding 10°, with anterior and/or lateral joint pain, patellofemoral instability, gait disturbance, or cosmetic concerns. GM has also shown good results in patients with fixed flexion deformity of the knee and ankle valgus.This paper reviews the history of the procedure, current indications, and recent advances underlying physeal manipulation with TBPs. Cite this article: EFORT Open Rev 2021;6:658-668. DOI: 10.1302/2058-5241.6.200098.

Ankle Morphology and Juvenile Osteochondritis Dissecans (JOCD) of the Talus: Is There an Association? An MRI Study.

PURPOSE: Factors that contribute to the development of juvenile osteochondritis dissecans (JOCD) of the talus are poorly understood. Some authors suggest that a higher loading of the affected zone may be a cofactor in osteochondral lesions. Therefore, the purpose of the study is to evaluate any association between ankle morphology and talus JOCD using morphologic parameters from magnetic resonance images. Our hypothesis is that ankles with JOCD lesions would have differences in the anatomy compared with age and sex-matched unaffected ankles. METHODS: We evaluated a total of 75 extremities. There were 22 patients (25 ankles) with talus JOCD lesions, and 50 patients (50 ankles) sex and age-matched individuals with healthy ankles served as controls. Two examiners conducted independent measurements of 8 magnetic resonance images parameters: tibial anterior surface angle, tibial shaft both malleoli angle (TBM), tibial axis-medial malleolus angle, anterior opening angle of the talus, malleolar width, tibial lateral surface angle, Maximal tibial thickness, length of trochlea tali arc, and height of trochlea tali arc. Measurement reliability was assessed using intraclass correlation coefficients. Differences in parameters between JOCD patients and controls were evaluated using independent t test. The level of significance was taken to be P<0.05. RESULTS: Intraclass correlation coefficients demonstrated good to excellent consistency for all measurements. Sagittal parameters demonstrated a significant length of trochlea tali arc increase in ankles with JOCD lesions compared with normal ankles (P=0.015). There was no statistical difference in any of the axial or coronal parameters. CONCLUSIONS: Ankle morphology may have a relationship with JOCD lesions. Future larger studies will be useful for further clarifying our findings, and detecting other potential predisposing factors with clinical relevance and how they can be modified. STUDY DESIGN: Cross-sectional study (Level of evidence III).

Transferencia subperióstica del tendón rotuliano en pacientes esqueléticamente inmaduros con inestabilidad patelofemoral / Patellofemoral instability in skeletally immature patients. Subperiosteal transfer of the patellar tendon

El objetivo de este artículo es describir un procedimiento que puede ser aplicado en pacientes esqueléticamente inmaduros con el objetivo de realinear el aparato extensor a nivel distal. Se describe en detalle la técnica y se analizan otras alternativas terapéuticas para este escenario. Diseño del estudio: Técnica quirúrgica. Nivel de Evidencia: V

The aim of this article is to describe a procedure that can be applied in skeletally immature patients for distal realignment of the extensor mechanism. The author makes a detailed description of the technique and analyzes therapeutic alternatives for this scenario. Study design: Surgical technique. Level of Evidence: V

Medición intraoperatoria con una aplicación para teléfono inteligente que mejorar la precisión de las osteotomías desrotadoras / Intraoperative measurement with a smartphone App that improves the accuracy of derotational osteotomies

El desarrollo de teléfonos inteligentes ha creado nuevas oportunidades para incorporar la tecnología médica en la práctica clínica diaria. La medición intraoperatoria exacta de los grados necesarios de corrección es un desafío frecuente para el cirujano cuando realiza osteotomías desrotadoras. Por lo general, se utilizan clavijas divergentes colocadas proximal y distal a la osteotomía que, luego de la desrotación, deben quedar paralelas. Sin embargo, la medición de estos grados, en general, se hace por estimación visual, lo que suele ser poco preciso. El objetivo de este estudio es describir un detalle técnico que combina la aplicación de clavijas divergentes con la medición intraoperatoria mediante telefonía móvil para mejorar la precisión de las osteotomías desrotadoras. Nivel de Evidencia: V

Smartphone technology has created new opportunities to incorporate medical technology into daily clinical practice. Accurate intraoperative measurement of the desired derotation angle is a frequent challenge for the surgeon when performing derotational osteotomies. Divergent pins are commonly used proximal and distal to the osteotomy, which after derotation should remain parallel. However, the measurement of the derotation angle is usually performed by visual estimation, which could be unreliable. The aim of this study is to describe a technical detail that combines the application of divergent pins with intraoperative measurement by mobile phone to improve the accuracy of derotational osteotomies. Level of Evidence: V

Resultados funcionales de las fracturas desplazadas del cuello del radio en niños: correlación entre las medidas de resultado informadas por el paciente (PROMIS y QuickDASH) / Functional outcomes of displaced radial neck fractures in children: Correlation between patient-reported outcomes (PROMIS and QuickDASH)

Introducción: Nuestros objetivos fueron: 1) evaluar los resultados subjetivos en pacientes esqueléticamente inmaduros que habían sido sometidos a una cirugía por fracturas desplazadas del cuello del radio, 2) comparar el desempeño del PROMIS y QuickDASH y 3) evaluar los efectos de piso y techo de las medidas de resultado. Materiales y métodos: Se evaluaron los datos demográficos, las lesiones asociadas, el tipo de fractura, la técnica quirúrgica y las complicaciones. La evaluación funcional se realizó con la escala QuickDASH y el instrumento PROMIS (Upper Extremity/Strength/Pain Interference). Las correlaciones de las escalas se efectuaron con el coeficiente rho de Spearman. El valor alfa se estableció en 0,05. Resultados: Se incluyó a 26 pacientes (13 varones) con una edad promedio de 7.5 años. El seguimiento promedio fue de 31 meses. Hubo correlaciones significativas entre las métricas QuickDASH y PROMIS Upper Extremity posoperatorias (rs = -0,64; p = 0,003). No se halló una correlación entre PROMIS Pain Interference y PROMIS Strength con el QuickDASH (rs = 0,001; p = 0,966 y rs = -0,39; p = 0,101, respectivamente). Se observaron efectos de techo o piso en todas las escalas. Conclusiones: Hubo una marcada correlación entre el PROMIS Upper Extremity y el QuickDASH para evaluar los resultados después de la cirugía de fracturas del cuello del radio en niños. Sin embargo, todas las medidas tuvieron marcados efectos de piso y techo, probablemente debido al tamaño de la cohorte y a que un alto porcentaje de estas fracturas suelen tener resultados clínicos favorables. Nivel de Evidencia: IV

Introduction: Objectives: 1) to evaluate the subjective outcomes in skeletally immature patients undergoing surgical treatment of displaced radial neck fractures, 2) to compare the performance between PROMIS and QuickDash, 3) to evaluate the floor/ceiling effects of the outcome measurements. We hypothesized that the PROMIS scale would correlate favorably with QuickDash and would demonstrate lower floor or ceiling effects. Materials and methods: Demographic data, associated lesions, fracture type, surgical technique, and complications were evaluated. QuickDash and PROMIS scales (PROMIS Upper Extremity (UE), PROMIS Strength and PROMIS Pain interference) were used for functional assessment. The Shapiro-Wilk test was used to analyze the normal distribution of the data. Metrics correlations were made with Spearman's rho coefficient. Ceiling and floor effects were further assessed. The alpha value was set at 0.05. Results: 26 patients were evaluated. Average age: 7.5 years; average follow-up: 31 months. There were significant correlations between the postoperative QuickDash and PROMIS UE metrics (rs = -0.64, p = 0.003). We found no correlation between PROMIS Pain and PROMIS Strength with QuickDash (rs = 0.001, p = 0.966 and rs = -0.39, p = 0.101 respectively). Ceiling or floor effects were observed at all scales. Conclusion: We observed a strong correlation between PROMIS UE and QuickDash assessing the results after surgical treatment of radial neck fractures in children. However, all the measures had evident floor/ceiling effects, probably due to the size of the cohort and the fact that a high percentage of these fractures usually present favorable clinical outcomes. Level of Evidence: IV

Tenodermodesis para el tratamiento del dedo en martillo tendinoso de presentación tardía en niños y adolescentes / Tenodermodesis for the treatment of late-presenting tendinous mallet finger deformities in children and adolescents

Introducción: El diagnóstico del dedo en martillo tendinoso puede pasar desapercibido inicialmente en niños y adolescentes, esto limita las posibilidades del tratamiento conservador. El objetivo fue evaluar los resultados del tratamiento quirúrgico con la técnica de tenodermodesis en lesiones de presentación tardía.materiales y métodos: Se evaluó retrospectivamente a 9 pacientes (8 niños) con una edad promedio de 8.6 ± 6 años (rango 1-15). Los días promedio de evolución de la lesión eran 27±11.4 (rango 15-45). El mecanismo de lesión fue una herida cortante (4 casos) y un traumatismo indirecto (5 casos). El tratamiento consistió en tenodermodesis e inmovilización transitoria con clavija transarticular. El seguimiento promedio fue de 61 ± 34.7 meses (rango 12-106). Se evaluaron la movilidad activa y pasiva de la articulación interfalángica distal, la presencia de dolor o deformidad, la limitación de actividades de la vida diaria y la necesidad de tratamientos adicionales. Se clasificaron los resultados con los criterios de evaluación de Crawford. Resultados: En 8 pacientes, el resultado fue excelente y, en uno, regular según Crawford. Un paciente poco colaborador requirió una segunda intervención por re-rotura. En dos casos, hubo una complicación (granuloma) y requirió resección. Ningún paciente refirió dolor al final del seguimiento, ni limitaciones para las actividades de la vida diaria. Ocho presentaron extensión activa completa y uno, una deformidad residual de 20°. Conclusión: La tenodermodesis permite la reconstrucción anatómica del mecanismo extensor en niños y adolescentes. Los resultados clínicos de este estudio son alentadores en lesiones no diagnosticadas en forma temprana. Nivel de Evidencia: IV

Introduction: Tendinous mallet finger may go initially unnoticed in children and adolescents, limiting the possibilities of conservative treatment. The aim of this study was to evaluate the outcomes of surgical treatment with the tenodermodesis technique in late-presentig injuries. Materials and Methods: Nine patients (8 males) with an average age of 8.6±6 years (1-15 range) were retrospectively evaluated. The injury manifested at an average of 27±11.4 days after trauma (15-45 range). In 4 patients the mechanism was a laceration and, in 5, indirect trauma. Patients were treated by tenodermodesis and transitory fixation of the distal interphalangeal joint with a Kirschner wire. The average follow-up was 61±34.7 months (12-106 range). Active and passive range of motion of the distal interphalangeal joint (DIPJ), pain, deformity, limitations in everyday life activities, and need for further treatment were evaluated. Crawford criteria was used to evaluate the outcomes. Results: The results were excellent in eight patients, and fair in one according to the Crawford criteria. One case required reintervention for re-rupture in a poorly collaborating patient. Two cases presented granuloma as a complication and required resection. No patients presented pain at the last follow-up, nor limitations in everyday life activities. Eight patients had full active DIPJ extension, and one had a 20° residual deformity. Conclusion: Tenodermodesis allows anatomical reconstruction of the extensor mechanism in pediatric patients. The clinical results are encouraging in late-presenting lesions. Level of Evidence: IV

Distal Femoral Physeal Bar Resection Combined With Guided Growth for the Treatment of Angular Limb Deformity Associated With Growth Arrest: A Preliminary Report.

PURPOSE: Distal femoral growth arrest can result in progressive deformities and functional disability. The treatment is challenging given the significant growth potential of the distal femoral physis. This study addresses the short-term outcomes after distal femoral physeal bar resection combined with guided growth for the treatment of angular limb deformity. METHODS: We conducted a retrospective analysis of patients treated with distal femoral physeal bar resection, fat graft interposition, and growth modulation with a tension-band plate. Data recorded included patient demographics, growth arrest cause, physeal bar size, time-to-surgery, details of the operative procedure, and complications. The mechanical axis zones, tibiofemoral angle, and the anatomic lateral distal femoral angle were assessed on 51-inch anteroposterior standing radiographs. RESULTS: Five patients (3 male individuals) with valgus (n=4) and varus deformities (n=1) due to physeal arrests of the distal femur were analyzed. The cause of the physeal arrest was trauma (n=3) and infection (n=2). The average age at the time of surgery was 6.6 years (range: 2 to 11 y). Average size of the physeal bar was 413.4 mm, which represented 16.8% of the total distal femoral physis (range: 12% to 26%). Four of the 5 patients had a total correction of the deformity in 14.3 months (range: 9 to 22 mo). One patient required correction by osteotomy and external fixation. Postoperatively, 1 patient presented no improvement, and 4 had restoration of the longitudinal bone growth and alignment. Two patients had rebound valgus: one is being observed and another has undergone a repeat guided growth procedure. CONCLUSIONS: Distal femoral physeal bar resection combined with tension-band hemiepiphysiodesis provides a viable option for the correction of angular deformities associated with physeal arrest. Longer follow-up is required to evaluate future growth of the distal femoral physis after this combined procedure. LEVEL OF EVIDENCE: Level IV-therapeutic study.

Medial Epicondyle Fractures: Current Practices and Preferences Between SLAOTI Members (Sociedad Latinoamericana de Ortopedia y Traumatología Infantil).

BACKGROUND: Medial epicondyle fractures represent up to 20% of elbow fractures in children and adolescents. There is a growing body of literature to support surgical fixation for displaced fractures. However, controversy regarding imaging modality for displacement measurement and surgical indications remain controversial. The purpose of this survey was to gauge Latin American surgeons' practices and preferences for the evaluation and treatment of medial epicondyle fractures. METHODS: A web-based survey containing 19 questions was distributed to active members of SLAOTI (Sociedad Latinoamericana de Ortopedia y Traumatología Infantil) in November 2018. The survey elicited information regarding surgeon demographics, evaluation methods, the factors involved in the decision to perform surgery, and their experience in cases of symptomatic nonunion. Categorical variables were summarized using frequencies and proportions. Analysis of associations between surgeon demographics and treatment preferences were carried out. RESULTS: A total of 193 out of 354 completed questionnaires were returned (54% response rate). In total, 74% of the participants (142/193) favored radiographs for the evaluation of the fracture displacement, and 25.4% (49/193) added a computed tomography scan for a more detailed evaluation. The majority of respondents (48.2%) would consider a 5 mm displacement as the cutoff for surgical treatment, 21.8% 2 mm, 20.7% 10 mm, and 9.3% 15 mm. There were no differences between the experience of the participants, academic versus private setting, or training regarding surgical/nonsurgical management. CONCLUSIONS: There are significant differences in opinions between SLAOTI members as to the optimal management of medial epicondyle fractures. Implications of disagreement in evaluation and treatment support the need for multicenter prospective studies to develop evidence-based guidelines for the management of this fracture. LEVEL OF EVIDENCE: Level V-expert opinion. Cross-sectional electronic survey.

Lipoblastoma: una causa inusual de tumoración del pie en niños / Lipoblastoma: An unusual cause of foot lump in children

Los tumores óseos y de partes blandas localizados en el pie son muy poco frecuentes. El lipoblastoma es una neoplasia benigna de partes blandas rara que se presenta exclusivamente en la población pediátrica, con predilección por el sexo masculino. Su asiento preferente son las extremidades, pero raramente afecta el pie. Presentamos un caso de lipoblastoma de pie en un niño de 13 meses de edad y una revisión de la bibliografía. Nivel de Evidencia: IV

Bone and soft tissue tumors of the feet are uncommon. Lipoblastoma is a rare benign soft tissue tumor, exclusive to the pediatric population, with predilection for boys. Lipoblastomas most commonly occur in the extremities, but rarely affect the foot. We present a case of lipoblastoma occurring in the foot of a 13-month-old boy, as well as our literature review. Level of Evidence: IV

Complex Clubfoot Treatment With Ponseti Method: A Latin American Multicentric Study.

BACKGROUND: Complex clubfoot is a term used to describe those feet that present after treatment with a short first metatarsal, severe plantar flexion of all metatarsals, rigid equinus, and deep folds through the sole of the foot and above the heel. Ponseti has described a modification of his original technique for the treatment of the deformity. Few series have reported the treatment outcomes of this group of patients. The purpose of this study is to analyze mid-term results and complications of a large multicenter cohort. METHODS: Patients with complex clubfoot treated at 6 tertiary-care institutions with a minimum of 1-year follow-up were retrospectively analyzed. Demographic data, previous treatment, number of casts, Achilles tenotomy, recurrences, complications, and additional procedures were documented. The patients were clinically evaluated at the time of presentation, after treatment, and at the last follow-up according to the Pirani score. All variables had a nonparametric distribution and are thus described as median (interquartile range (IQR), minimum-maximum). A comparison between the variables was performed using a Mann-Whitney U test, the change within each group was performed with a Wilcoxon-designated range test. A P-value <0.05 was used to indicate statistical significance. RESULTS: One hundred twenty-four feet (79 patients) were evaluated. The median age at initial treatment was 7 months (IQR, 15; min-max, 1 to 53 mo). The mean follow-up was 49 months (IQR, 42; min-max, 12 to 132 mo). A median of 5 casts (IQR, 5; min-max, 3 to 13) was required for correction. Percutaneous tenotomy of the Achilles tendon was performed in 96% of the feet. One hundred twenty-two feet (98%) were initially corrected; 2 feet could not be corrected and required a posteromedial release. The Pirani score improved significantly from a pretreatment mean of 6 points (IQR, 1; min-max, 4.5 to 6) to 0.5 (IQR, 0.5; min-max, 0 to 2.5) at the last follow-up (P <0.001). Seven feet (6%) presented minor complications related to casting. Relapses occurred in 29.8% (37/124). In this subgroup, the number of casts required at initial treatment was higher (6; IQR, 5; min-max, 1 to 12 vs. 4 IQR, 4; min-max, 1 to 13; P<0.001), and follow-up was significantly longer (62 mo; IQR, 58; min-max, 28 to 132 vs. 37 mo; IQR, 48, min-max, 7 to 115; P<0.001). CONCLUSIONS: Ponseti method is safe and effective for the correction of complex clubfeet. Early diagnosis and strict adherence to the Ponseti principles are key to achieve deformity correction. Patients with complex clubfoot require frequent follow-up because of a higher recurrence rate. LEVEL OF EVIDENCE: Level III-therapeutic study.

Osteotomía de la tuberosidad anterior de la tibia en adolescentes y adultos jóvenes: resultados funcionales y complicaciones / Anterior tibial tubercle osteotomy in adolescents and young adults: functional results and complications

Introducción: La osteotomía de la tuberosidad anterior de la tibia (O-TAT) es una técnica quirúrgica que permite restablecer la alineación distal de la rótula en pacientes esqueléticamente maduros. Los objetivos de este estudio fueron evaluar los resultados funcionales y analizar factores que influyeron en el desarrollo de complicaciones. Materiales y Métodos: Se analizaron retrospectivamente pacientes con O-TAT tratados entre 2008 y 2016. Se documentaron datos demográficos y clínicos. Los resultados fueron evaluados según las escalas de Kujala y Tegner-Lysholm, y las complicaciones, con una adaptación de la clasificación de Clavien- Dindo. Resultados: Se analizaron 33 O-TAT en 29 pacientes (17 mujeres). Mediana de la edad: 18 años (RIC 2, mín.-máx. 14-39). Mediana de seguimiento: 49 meses (RIC 2, mín.-máx. 12-115). Mejoría en las escalas de Kujala y Tegner-Lysholm de 61 y 61,5 a 94 y 92,3, respectivamente (p = 0,001). La mediana de tiempo de consolidación fue de 8 semanas. Hubo 9 complicaciones (27%): 1 grado II (infección superficial) y 8 grado III (artrofibrosis, fracturas de tibia y fracturas de TAT, n = 2). La tasa de complicaciones fue más alta en los pacientes sometidos a desinserción de la TAT (51,5% vs. 11,1%, p = 0,029). Conclusiones: La O-TAT representa una técnica eficaz para tratar diversas patologías de la articulación patelofemoral en adolescentes y adultos jóvenes. Hubo complicaciones en un alto porcentaje de los procedimientos, sin que esto afectara el resultado final. El riesgo de complicaciones fue mayor en las osteotomías que requirieron desinserción de la TAT y la reconstrucción ligamentaria. Nivel de Evidencia: IV

Introduction: Tibial tubercle osteotomy (TTO) is a surgical approach that allows for the restoration of distal patellar alignment in skeletally mature patients. The objectives of this study were to evaluate functional results and to analyze the risk factors associated with complications. Methods: We carried out a retrospective analysis of patients subjected to a TTO between 2008 and 2016 and documented demographic and clinical data. Results were evaluated according to Kujala Anterior Knee Pain Scale and Tegner-Lysholm Knee Scoring Scale. Complications were evaluated with a modified Clavien-Dindo classification of Surgical Complications. Results: We evaluated 33 TTOs in 29 patients (17 women) with a median age of 18 years (IQR 2, range 14-39) and a median follow-up time of 49 months (IQR 2, range 12-115). The Kujala and the Tegner-Lysholm scoring improved from 61 and 61.5 to 94 and 92.3, respectively (p=0.001). Union was achieved at a median of 8 weeks. There were 9 complications (27%): a grade II complication (superficial infection) and 8 grade III complications (arthrofibrosis, tibial fractures, and anterior tibial tubercle fractures). Osteotomies in which tibial tubercle was completely detached had a significantly higher rate of complications (51.5% vs. 11.1%, p=0.029). Conclusions: TTO represents an effective approach for the treatment of several conditions of the patellofemoral joint in adolescents and young adults. In our series, a high percentage of the procedures presented complications, although they did not affect the final result. Osteotomies that involve complete detachment of the tubercle and those associated with ligament reconstruction have an increased risk of complications. Level of Evidence: IV

Utilidad de la artrografía intraoperatoria para el tratamiento de fracturas en niños / Usefulness of intraoperative arthrogram in the treatment of pediatric fractures

Introducción: El objetivo de este estudio fue evaluar las indicaciones y las complicaciones de una serie consecutiva de niños con fracturas a quienes se les realizó artrografía intraoperatoria. Materiales y Métodos: Se evaluó retrospectivamente a pacientes pediátricos con fracturas de codo o tobillo sometidos a una artrografía intraoperatoria, entre enero de 2009 y julio de 2014. Se analizaron los datos demográficos, la evolución clínica posoperatoria (criterios de la Clínica Mayo y puntaje de la AOFAS), la evolución radiográfica y las complicaciones derivadas del uso de material de contraste intrarticular. Resultados: Se evaluaron 25 pacientes (16 niños, 9 niñas) con una edad promedio de 7.6 años (rango 4-15). El seguimiento promedio fue de 30.1 meses. Quince tenían fracturas de codo y 10, de tobillo. Según el puntaje de la Clínica Mayo, 14 pacientes tuvieron resultados excelentes y uno fue bueno (promedio 99; rango 85-100). Los 10 pacientes con fracturas de tobillo obtuvieron resultados excelentes según el puntaje de la AOFAS (promedio 98,5; rango 95-100). No ocurrieron infecciones ni reacciones adversas relacionadas con el uso del medio de contraste. Tres pacientes tuvieron complicaciones no relacionadas con el uso del medio de contraste. Conclusión: La artrografía es un procedimiento simple, de bajo costo, que agrega poco tiempo quirúrgico y permite una mejor evaluación de estructuras intrarticulares para la toma de decisiones intraoperatorias. Es una herramienta útil que debe ser tenida en cuenta en el tratamiento de algunas fracturas en pediatría. Nivel de Evidencia: IV

Introduction: The objective of this study is to assess the indications and complications of a consecutive series of children with fractures where intraoperative arthrogram was performed. Methods: We retrospectively evaluated children with elbow or ankle fractures who underwent intraoperative arthrogram between January 2009 and July 2014. We assessed demographic data, postoperative clinical outcomes (Mayo Clinic and AOFAS scores), radiographic outcome and complications arising from the use of intra-articular contrast material. Results: Twenty-five patients (16 boys, 9 girls) with an average age of 7.6 years (range 4-15) were evaluated. The average follow-up was 30.1 months. There were 15 patients with elbow fractures and 10 with ankle fractures. According to Mayo Clinic score, results were excellent in 14 patients and good in one patient (average 99; range 85-100). Ten patients with ankle fractures presented excellent results according to AOFAS score (average 98.5; range 95-100). There were no in fections or adverse reactions related to the use of contrast. Three patients presented complications unrelated to the use of contrast. Conclusion: Arthrogram is a simple, low-cost procedure, adds short surgical time and allows better assessment of intraarticular structures for intraoperative decision-making. It is a useful tool that should be taken into account in the treatment of some pediatric fractures. Level of Evidence: IV

Fracturas fisarias Salter-Harris VI de tobillo y pie

Introducción: Las fracturas Salter-Harris VI son lesiones cuya característica es la ablación del anillo pericondral. Son infrecuentes, pero potencialmente devastadoras. El objetivo de este estudio fue evaluar el mecanismo, el tratamiento y los resultados funcionales de estas lesiones en pie y tobillo. Materiales y Métodos: Se analizaron retrospectivamente todos los pacientes con lesiones Salter-Harris VI de tobillo y pie, tratadas entre enero de 2010 y enero de 2013. Se documentaron datos demográficos, clasificación, mecanismo de lesión, tipo de lesiones asociadas y número de cirugías necesarias. La evaluación funcional se realizó con el puntaje de la AOFAS y se tomaron radiografías para determinar viabilidad de la fisis, acortamiento o deformidad angular. Resultados: Se analizaron 5 fracturas (4 pacientes). La edad promedio fue de 7.5 años (rango 6-10 años). El seguimiento promedio fue de 26.2 meses. Tres lesiones se produjeron por accidentes de moto y 2, por auto versus peatón. Todos los casos se acompañaron de pérdida de sustancia, el 75% tenía lesiones en más de un hueso y el 50%, lesiones tendinosas asociadas. Cada paciente requirió un promedio de 3,2 cirugías. El puntaje de la AOFAS promedio fue de 79.8 (rango 62- 100). Sólo el 40% de las fisis afectadas permanecían viables al último control. Conclusiones: Las fracturas Salter-Harris VI se acompañan de una gran variedad de lesiones asociadas, requieren múltiples cirugías, suelen producir un cierre precoz de la fisis y algún grado de discapacidad. Se requieren medidas preventivas para evitar la exposición de los niños a este tipo de lesiones.(AU)

Background: Salter-Harris VI fractures (SHVI) are injuries in which part of the physis is missing. They are rare in children but potentially devastating. The aim of this study was to evaluate the mechanism of production, treatment, and functional outcomes of these injuries in the foot and ankle. Methods: All patients with foot and ankle SHVI injuries treated between January 2010 and January 2013 were retrospectively analyzed. Demographics, classification, mechanism of injury, type and number of associated injuries that required surgery were documented. Patients were assessed functionally with the AOFAS score and a radiological evaluation was performed to determine the viability of the physis, limb length discrepancies or angular deformities. Results: Five fractures in 4 patients were analyzed. The average age at injury was 7.5 years (range 6-10 years). Mean follow-up was 26.2 months (range 12-37 months). Three injuries occurred as a result of motorcycle accidents, and 2 in a car accident. All were associated with soft-tissue injuries, 75% had more than one injured bone and 50% had tendon lesions. Each patient required an average of 3.2 surgeries (range 2-5). The average AOFAS was 79.8 points (range 62-100). Radiographically, only 40% of the affected physis remained viable at last follow-up. Conclusions: SHVI fractures are associated with several injuries, require multiple surgeries and often result in premature growth arrest and some degree of disability. Prevention measures are required to avoid the exposure of children to this type of injury.(AU)