Effect of the Pavlik harness used in the treatment of developmental dysplasia of the hip on unaided sitting and independent walking age.

Background: Pavlik harness is the most widely used orthosis in the treatment of developmental dysplasia of the hip. The aim of this study was to evaluate the effect of the Pavlik harness on the development of "unaided sitting" and "independent walking" in infants with developmental dysplasia of the hip. Methods: This prospective study, conducted from 2017 to 2020, included infants undergoing Pavlik harness therapy. Inclusion criteria comprised gestational age > 37 weeks, treatment initiation before 6 months of age, and no prior treatment for developmental dysplasia of the hip. We assessed treatment initiation age, treatment duration, and the age of achieving unaided sitting and independent walking. Results: In the patient group, unaided sitting commenced at a mean age of 6.8 ± 1.6 (range: 4-11) months, while independent walking began at a mean age of 12.7 ± 1.8 (range: 9-18) months. By 15 months, 92% of the patients achieved independent walking. In the control group, unaided sitting occurred at a mean age of 6.1 ± 1.1 (range: 4-8) months, and independent walking at 11.8 ± 1.6 (range: 9-18) months. A significant positive correlation was observed between the duration of Pavlik harness usage and the age of unaided sitting (p < 0.001) and independent walking (p < 0.001). Conclusion: Our study indicates that Pavlik harness treatment for developmental dysplasia of the hip is generally safe and does not lead to clinically significant delays in unaided sitting and independent walking. However, some minor delays may occur due to extended orthosis use. Level of evidence: level III-prospective cohort study.

Which factor is more reliable considering prophylactic pinning of contralateral hip of unilateral SCFE patients?

BACKGROUND: This study evaluates the radiological parameters of developing subsequent contralateral slips in unilateral slipped capital femoral epiphysis (SCFE) patients at the time of initial presentation. METHODS: The study group included the review of unilateral SCFE patients treated between June 2007 and August 2018. Age, gen-der, side, stability, posterior slope angle, grade of slip, modified Oxford bone age score (mOBAS), the Risser classification, and the ap-pearance of the triradiate cartilage were evaluated retrospectively. Data were analyzed between two groups: subsequent contralateral SCFE (SCFESC) patients that developed contralateral slip during follow-up and unilateral SCFE (SCFEU) patients that did not develop contralateral slip up to skeletal maturity. Descriptive statistics were used to compare risk factors between groups. RESULTS: This study included 48 patients and 6 patients (12.5%) developed a SCFESC. Only mOBAS was significantly different be-tween groups. The mOBAS scores in SCFESC were 18 in 2 patients (33.3%), 19 in 4 patients (66.7%). The mOBAS scores in SCFEU were 18 in 1 patient (2.4%), 19 in 24 patients (57.1%), and >20 in 17 patients (40.5%). In the SCFESC group, all patients had a Risser score of 0 and all had open triradiate cartilage. CONCLUSION: Patients with unilateral SCFE are at risk for SCFESC, and the mOBAS is the best predictor of risk assessment. We agree that mOBAS score of 16,17 or 18 patients' contralateral hips can be prophylactically pinned. We also suggest pinning or close screening of mOBAS 19 patients that some carry relatively high risk of subsequent contralateral slip.

Salter osteotomy has lower fluoroscopy exposure time compared to Tonnis lateral acetabuloplasty.

Salter osteotomy and Tonnis lateral acetabuloplasty (TLA) are pelvic osteotomies with similar indications and clinical results used in the treatment of developmental dysplasia of the hip (DDH). The aim of our study was to compare the intraoperative fluoroscopy exposure time (FET) in patients with DDH treated with the Salter osteotomy and TLA. In this study, data were collected prospectively and compared after the study was completed. The patients were evaluated in three groups: pelvic osteotomy (group 1), open reduction with pelvic osteotomy (group 2) and open reduction + pelvic osteotomy + femoral shortening (group 3). Pelvic osteotomy techniques in each group were further analyzed in two subgroups as Salter osteotomy and TLA. Age, sex, surgery side, degree of dysplasia according to the Tönnis classification, duration of anesthesia and intraoperative FET (seconds) were recorded. A total of 109 patients (93 girls and 16 boys) were included in the study; 29 patients in group 1, 50 in group 2 and 30 in group 3. Although the patients who underwent Salter osteotomy and TLA were similar in all three groups in terms of age, sex, surgery side, Tönnis classification and duration of anesthesia, FET was longer in the patients who underwent TLA (group 1, P < 0.001; group 2, P < 0.001; group 3, P = 0.005). The use of the Salter osteotomy technique in the treatment of acetabular dysplasia in patients with DDH seems to be more advantageous in terms of FET than TLA osteotomy. It would be beneficial to consider this result in terms of radiation safety. Level of Evidence: II.

Isokinetic Analysis of Flexible Flatfoot: Is It a Weakness of Proprioception and Muscle Strength?

BACKGROUND: Although flexible flatfoot (FF) in children is a foot deformity that is frequently encountered in daily orthopedics practice, its etiology is still controversial. The aim of this study was to determine whether there is a weakness in muscle strength and proprioception in patients with FF. METHODS: The study group consisted of 16 cases with FF, and the control group consisted of 25 volunteers with normal feet. An isokinetic dynamometer was used to assess muscle strength and proprioception of movement directions of plantarflexion, dorsiflexion, eversion (EV), and inversion (INV) in both groups. RESULTS: There was no statistically significant difference between the groups in strength of plantarflexion and dorsiflexion muscles, whereas in the control group, proprioception of all four movement directions and strengths of the EV and INV muscles were found to be statistically significantly higher (P < .05). CONCLUSIONS: There is weakness in EV and INV muscle strength and proprioception disorder in patients with FF. We recommend conducting further studies that validate muscle weakness and proprioception disorders with different study designs and evaluate the effectiveness of improving muscle strength and proprioception weakness in FF.

Evolution of the angular deformity and limb length discrepancy of congenital posteromedial bowing of the tibia over time.

OBJECTIVES: This study aims to assess the natural history of congenital posteromedial bowing of the tibia (CPMBT) deformity during growth and to evaluate the outcomes of lengthening by an Ilizarov frame in CPMBT patients with limb length discrepancy (LLD). PATIENTS AND METHODS: Between January 2000 and December 2019, a total of 22 patients (12 males, 10 females; mean age: 10.5±4.4 years; range, 6 to 19 years) with the diagnosis of CPMBT and followed closely from birth until skeletal maturity were retrospectively analyzed. The radiographic evaluation included the anteroposterior and lateral interphyseal angle and full leg standing radiographs. Limb lengthening by an Ilizarov frame was performed for an estimated LLD over 40 mm. RESULTS: The age of the patients ranged from six days to 10 months at the time of presentation, while the mean age at the final follow-up was 10.5±4.4 years. Posterior medial bowing was satisfactorily remodeled in 13 (59%) patients those were not operated either for deformity or LLD. The mean LLD was 21±4.1 mm in 13 nonoperated CPMBT patients. Nine of 22 (41%) patients underwent lengthening for LLD. Five of the nine CPMBT patients were operated under the age of 10 years, while four were operated over the age of 10 years. CONCLUSION: According to the results of the current study, CPMBT was satisfactorily remodeled in more than half of the patients, and the majority of patients did not undergo surgery for angular deformity and LLD within 10 years of their lives. Based on these findings, although most of the patients' deformities remodeled, it should be kept in mind that some may require lengthening surgery.

Disability and Quality of Life After Talectomy for Arthrogryposis Multiplex Congenita.

BACKGROUND: Arthrogryposis multiplex congenita (AMC) is one of the causes of rigid and resistant clubfoot. Talectomy is considered as a primary or salvage procedure for recurrent equinovarus deformity in these patients. We conducted this study to assess patients with AMC who underwent talectomy for the correction of foot and ankle deformities in terms of health-related quality of life and disability. METHODS: Patients under 10 years of age with a primary diagnosis of AMC who underwent talectomy and attended follow-up for at least 5 years were included in this study. We also formed an age- and gender-matched control group consisting of 20 individuals without any foot-ankle problem in order to compare the measurements between the AMC and healthy groups. Oxford Ankle Foot Questionnaire (OxAFQ) was administered as a health-related quality of life instrument to objectively measure the disability of the pediatric patients. RESULTS: Twenty patients (10 girls, 10 boys) who underwent a total of 35 talectomy operations with an average follow-up of 7.2 years and a control group of 20 similarly aged unaffected children were included in the study. The mean OxAFQ scores were significantly lower in the AMC group than in the controls for all domains (physical, emotional, and school and play), especially for the one concerning satisfaction with footwear The presence of plantigrade foot and absence of forefoot supination were significantly associated with the physical and footwear domains of the OxAFQ scores. The presence of hindfoot varus, midfoot adductus, dorsal bunion, and having less than 10 degrees of dorsiflexion had no effect on the OxAFQ scores. CONCLUSION: In this study, we found that the major driving factors for satisfaction after talectomy for AMC were plantigrade foot and absence of forefoot supination. The mean OxAFQ scores were universally lower in the AMC group than controls. Finding comfortable footwear is a major concern for the AMC patients. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Multivariate analysis of the predictive value of asymmetric skin creases in diagnosis of decentralized developmental dysplasia of the hip.

The aim of this study was to investigate the relationship of developmental dysplasia of the hip (DDH) with asymmetrical skin crease (ASC) in the inguinal, gluteal and thigh regions and to determine which ASC has the most predictive value for the diagnosis of hip dislocation in infants. This study was planned as a prospective, observational study and conducted between 1 October 2020 and 1 June 2021. Asymmetric distribution of skin creases was evaluated separately in three regions (inguinal, gluteal and thigh). Then, hip ultrasonography (USG) was performed and the Graf method was used to classify the cases as 'centralized' [Graf types I, IIa (-), IIb and IIc] and 'decentralized' (Graf types IId, III and IV). The relationship between the groups was evaluated using univariate and then multivariate analyses. A total of 241 patients were included in the study. The number of patients with ASC was 49 (21%). While 36 of these 49 patients had centralized hips, 13 had decentralized hips ( P < 0.001). Sixty-five percent (13/20) of 20 infants with decentralized hips had ASC in at least one of the inguinal, gluteal or thigh regions. The presence of ASC in the inguinal ( P < 0.001) and gluteal ( P < 0.014) regions increased the risk of the decentralized hip in the child, whereas the presence of ASC in the isolated thigh region did not increase the risk of the dislocated hip ( P = 0.534). Inguinal ASC and gluteal ASC are reliable findings in DDH screening, but the relationship of isolated thigh ASC with DDH could not be demonstrated statistically. Level of Evidence: Level II - diagnostic study.

Foot abduction increases after achilles tenotomy in clubfoot patients.

BACKGROUND: Although Achilles tenotomy is performed to increase the ankle dorsiflexion in clubfoot patients, it may also increase the amount of the foot abduction due to the unique oval field of motion property of the ankle and subtalar joint complex. This study investigated the effect of Achilles tenotomy on foot abduction in patients with clubfoot. METHODS: Equinus deformity before tenotomy (EBT), equinus deformity after tenotomy (EAT), abduction before tenotomy (ABT), and abduction after tenotomy (AAT) were measured. The decrease in the amount of equinus after tenotomy (Δ equinus) and the increase in the amount of abduction (Δ abduction) after tenotomy were then calculated. RESULTS: The Achilles tenotomy was performed on 22 feet of 16 patients. The results (Mean ± standard deviation) were as follows: EBT: 28° ± 19 (range, 8-76), EAT: -27° ± 7 (-36- -11), ABT: 54° ± 16 (21-72), AAT: 77° ± 5 (66-85), Δ equinus: 55° ± 15 (38-87), Δ abduction: 23° ± 15 (5-51). The change between EBT-EAT and ABT-AAT was statistically significant (both p < 0.001). EBT was correlated negatively with ABT (r = -0.648; p = 0.001) and Δ equinus was correlated positively with Δ abduction (r = 0.522; p = 0.013). CONCLUSION: The Achilles tenotomy in clubfoot patients not only increases ankle dorsiflexion but also increases the foot abduction due to oval field of motion of the ankle and subtalar joint complex. It should be considered that an increase of the foot abduction may be achieved after the Achilles tenotomy. Therefore, the maximum foot abduction may be achieved after the Achilles tenotomy, not before the Achilles tenotomy.

Effects of Long-Term Pamidronate Treatment on Bone Density and Fracture Rate in 65 Osteogenesis Imperfecta Patients.

OBJECTIVE: Osteogenesis imperfecta (OI) is a clinically and genetically heterogeneous disease characterized by recurrent fractures, blue sclera, and hearing loss. Bisphosphonate treatment has been reported to decrease the annual number of fractures and improve the quality of life in patients with OI. The aim of this study is to evaluate the effect of bisphosphonate treatment in the Turkish OI cohort. METHODS: Sixty-five patients with OI, who were treated with pamidronate, were included in this study. The mean treatment duration was 47.1 ± 40 months (range:12-168 months). Bone mineral densitometry (BMD) and the mean number of annual fractures were compared before and after the treatment within groups, and the difference after treatment compared between the OI types. RESULTS: After pamidronate treatment, a significant decrease in the mean annual fracture, along with an increase in BMD Z-score was detected in all patients. Treatment duration did not affect BMD Z-score. However, there was a significant decrease in the mean annual number of fractures after 5 years of treatment (P = .048). After treatment, the decrease in the number of fractures was significant in OI type 3, and the increase in BMD Z-score was significant in OI type 4 when compared with OI type 1. Besides, pamidronate treatment relieved pain, and also corrected the platyspondyly radiologically in all OI groups. CONCLUSION: We demonstrated that pamidronate treatment improves the quality of life by reducing the number of fractures, relieving pain, and also protecting from deformities in all patients with OI.

The effect of soft tissue interposition of the Endobutton on clinical results and on its postoperative migration after single-bundle anterior cruciate ligament reconstruction.

BACKGROUND: This study aimed to investigate the possible consequences of soft tissue interposition of Endobutton on clinical outcomes and reoperation rates after anterior cruciate ligament reconstruction. METHODS: We measured the distance between the centre of the Endobutton and the lateral femoral cortex on the postoperative first day anteroposterior X-rays of the 156 knees that underwent anterior cruciate ligament reconstruction. Those with a distance less than 1 mm were regarded as Group 1 (118 patients), the ones between 1 mm and 2 mm were regarded as Group 2 (30 patients) and the ones more than 2 mm were regarded as Group 3 (8 patients). The movement of the Endobutton of more than 1 mm along the femoral tunnel axis on anteroposterior X-rays or its rotation by more than 5° on lateral X-rays during follow-up were considered migration. Clinical assessment scores (Lysholm, Tegner Activity Scale), clinical examination tests, and rates of Endobutton migration in the groups were analysed. RESULTS: Eleven Endobuttons (9.3%) in Group 1, 26 Endobuttons (86.7%) in Group 2 and all of the 8 Endobuttons (100%) in Group 3 were observed to have migrated. Clinical results and examination tests showed no significant difference between Groups 1 and 2, whereas a significant difference was detected in Group 3 compared to Groups 1 and 2 (p < 0.05). CONCLUSION: Soft tissue interposition is a major cause of Endobutton migration, and an interposition over 2 mm between the Endobutton and the lateral femoral cortex can negatively affect the outcomes after an anterior cruciate ligament surgery.

Increased femoral anteversion related to infratrochanteric femoral torsion is associated with ACL rupture.

PURPOSE: To determine the association between femoral torsion and anterior cruciate ligament (ACL) rupture and determine the level of torsion using magnetic resonance imaging (MRI). METHODS: The medical records of patients who were diagnosed with ACL injury were reviewed retrospectively. This descriptive epidemiological study included 2344 patients. MRI scans were examined and patients with femur and knee MRI scans obtained at the same time were identified (ACL-deficient group). Twenty-eight of them had femur and knee MRI scans because of an incidental benign lesion in the distal femur. Patients who were diagnosed with enchondroma were followed up by MRI evaluation of the femur and were randomly selected as controls. Supratrochanteric torsion (STT), infratrochanteric torsion (ITT), and femoral anteversion (FA) were measured by orthopedic surgeons with at least 5 years of experience. RESULTS: Age, sex, and side properties were similar in both groups. The mean FA values were 19.4 ± 3.0 degrees and 11.9 ± 2.0 degrees in the ACL-deficient and control groups, respectively (p < 0.001). STT was similar in the ACL-deficient and control groups [mean: 38.2 ± 4.3 and 37.7 ± 3.3, respectively, (n.s.)]. ITT was increased in the ACL-deficient group compared with the control group (mean - 18.8 ± 4.3 and - 25.8 ± 3.8, respectively; p < 0.001). CONCLUSIONS: According to our results, increased FA was associated with ACL rupture. Further, the torsional abnormality was developed from the ITT. We concluded that each ACL-deficient patient should be assessed by a clinician for torsional abnormality using physical examination. LEVEL OF EVIDENCE: III.

A Formula to Predict the Magnitude of Achilles Tendon Lengthening Required to Correct Equinus Deformity.

OBJECTIVES: Achilles tendon lengthening (ATL) is one of the most commonly performed procedures in paediatric orthopaedic surgery. An appropriate adjustment of the amount of ATL is crucial to avoid insufficient or excessive lengthening. However, there is currently no effective method to preoperatively calculate the tendon length needed for equinus deformity correction. Thus, in this study we evaluated the accuracy of a calculation using a mathematical model based on the law of cosines. METHODS: A total of 16 feet of 14 patients who were scheduled for ATL surgery due to equinus deformity were included in the study. ATL surgery was performed using a standard Z-plasty technique. Calculation of the amount of ATL using the law of cosines, and assessments of intraoperative lengthening of the tendon, were performed in a double-blind manner. The extent of lengthening resulting from the two methods was then compared. RESULTS: The mean ATL determined intraoperatively was 23.67 ± 8.7 mm, and that obtained using the cosine-based method was 22.49 ± 8.6 mm. Thus, the new method showed excellent statistical agreement with the actual lengthening performed during surgery. CONCLUSIONS: The required dimension of ATL can be calculated preoperatively using the mathematical formula presented here. The advantages of this approach are that it allows accurate tendon lengthening and reduces the size of the surgical incision.

Comparison of two different methods in preoperative planning of the amount of lengthening in Z achilloplasty technique.

Achilles tendon lengthening (ATL) surgery is a technique that is frequently used in the surgical treatment of contracture of the Achilles tendon seen in many pediatric orthopedic problems such as cerebral palsy, clubfoot, pes planovalgus and myelomeningocele. It is important to appropriately adjust the amount of ATL. However, the literature on the preoperative calculation of the required amount of tendon lengthening is limited. The aim of the study was to compare the reliability of the two different methods of predicting the amount of ATL. Eighteen feet of 16 patients who underwent ATL with Z-plasty technique were included in the study. The required amount of ATL was calculated as double blind according to the Cosine theorem and a method that was described by Garbarino et al. in 1985 and compared with the amounts of ATL applied during the operation. The mean amount of lengthening was 25.24 mm during surgery. The required amount of lengthening was 41.55 ± 11.0 mm, according to the Garbarino's method. The required amount of lengthening was 23.93 ± 9.03 mm, according to the Cosine theorem. The quantities calculated according to the Cosine theorem showed excellent agreement with the amount of lengthening during surgery. The quantities calculated according to the Garbarino's method showed poor agreement with the amount of lengthening during surgery. The calculation of the amount of ATL required in the treatment of the equinus deformity before surgery is possible by Cosine Theorem. The method of Cosine theorem is more reliable than the previous method described by Garbarino et al.

Comparison of the Effects of Magnetically Controlled Growing Rod and Tradiotinal Growing Rod Techniques on the Sagittal Plane in the Treatment of Early-Onset Scoliosis.

OBJECTIVE: Comparing the effects of magnetically controlled growing rod (MCGR) and traditional growing rod (TGR) techniques on the sagittal plane in the treatment of early-onset scoliosis (EOS). METHODS: Twelve patients were operated using dual MCGR technique in one center, while 15 patients were operated using dual TGR technique for EOS in another center. Patients' demographic characteristics, complications and radiological measurements such as cobb angle, thoracic kyphosis, lumbar lordosis, T1-S1 range (mm), proximal junctional angle, distal junctional angle, sagittal balance, coronal balance, pelvic incidence, sacral slope and pelvic tilt were assessed and compared in preoperative, postoperative and last follow-up period. RESULTS: Age and sex distributions were similar in both groups. The mean number of lengthening in the MCGR group was 12 (8-15) and 4.8 (3-7) in the TGR group. Two techniques were shown to be effective in controlling the curvature and in the increase of T1-S1 distance. In TGR group, four patients had rod fractures, six patients had screw pull-out and four patients had an infection, whereas three patients had screw pull-out and one patient had infection complications in the MCGR group. CONCLUSION: There was no significant difference between the two groups in terms of cobb angle, coronal and sagittal balance and sagittal pelvic parameters. MCGR can cause hypokyphosis and proximal junctional kyphosis in a minimum 2-year follow-up period. The implant-related complications were less in the MCGR group. However, larger case groups and longer follow-up periods are required for the better understanding of the superiority of one method on other in terms of complications.

Greater Trochanter Apophysiodesis in Legg-Calve-Perthes Disease: Which Implant to Choose?

BACKGROUND: Greater trochanter apophysiodesis (GTA) is relatively minimal invasive technique for the treatment of trochanteric overgrowth. Various types of implants can be used in each procedure. The purpose of this study was to compare outcomes of three different types of implants that were used in treatment of trochanteric overgrowth in Legg-Calve-Perthes disease. MATERIALS AND METHODS: We retrospectively studied radiological results of three implants (screw, screw washer, and EP) on inhibiting trochanteric growth in 32 patients. Articulo-trochanteric and trochanter-trochanter distances (TTDs) were measured on radiographs. Embedding of implant evaluated on final radiographs. RESULTS: The mean of age at the surgery was 10 ± 2.3 years, and the mean of follow up period was 50.0 ± 16.7 months. In all groups, articulo-trochanteric distance was decreased on final radiographs. In screw and screw washer group, increase of TTD was not statistically significant (P < 0.05). Twelve, one, and two implants were embedded, respectively, in screw, screw washer, and EP groups. Two patients in EP group had revision surgery due to loosening. CONCLUSIONS: In this study group, GTA using screw and screw washer methods could slow down but did not restore trochanteric overgrowth. We suggest using washer to reduce embedding of the screw.

Radiological and functional outcomes of ultrasound-guided PRP injections in intrasubstance meniscal degenerations.

AIM: This retrospective study is aimed to analyze the effect of ultrasound-guided platelet-rich plasma (PRP) injections on grade 2 intrasubstance meniscal degenerations (IMDs). MATERIALS AND METHODS: Fifteen patients who underwent PRP injections for symptomatic grade 2 meniscal lesions were included in the study. All injections were performed with ultrasound in the degenerated menisci. Patients were evaluated with Lysholm score and magnetic resonance imaging (MRI) before the injection and after a mean of 32-month follow-up. T2-weighted MRI images were evaluated on sagittal by two authors as double-blind. RESULTS: Lysholm score was found to be statistically significantly increased, and in 67% of the patients, grade 2 degenerations were improved to grade 1. CONCLUSION: Intra-meniscal PRP injection under ultrasonography guidance provides good functional scores and radiological improvement in the patients with IMD.

A comparison of the open reduction-internal fixation and resection arthroplasty techniques in treatment of Mason Type 3 radial head fractures.

OBJECTIVE: The aim of this study was to retrospectively compare a series of patients surgically treated with ORIF or early resection arthroplasty due to isolated comminuted radial head fractures. METHODS: Between the years 2009 and 2013, 34 patients with isolated comminuted fractures of the radial head (Mason Type 3) had been operated (ORIF in 19 patients, resection arthroplasty in 15 patients). The mean age of the patients in the ORIF group was 38.5 years and 54 years in the resection group. The carrying angle (CA) and ulnar variance were measured bilaterally, and radiographs were reviewed for degenerative elbow arthritis. The Mayo elbow performance score, Turkish version of the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH-T) and visual analog scale (VAS) were used to evaluate the clinical results. RESULTS: The mean follow-up period in the ORIF group was 40.2 months and 44.4 months in the resection group. In the ORIF group, 11 patients were clinically rated excellent, six good, and two fair. In the resection group, seven patients had excellent, five had good, and two had fair scores. We did not find a statistically significant difference between the ORIF and resection groups regarding the clinical and radiological outcomes. CONCLUSION: With these short-term results, resection arthroplasty may be considered an effective method in the treatment of isolated comminuted radial head fractures, as it is less technically demanding and it also allows for early postoperative motion. However, the patients should be evaluated in detail, regarding ligamentous injuries prior to resection arthroplasty. LEVEL OF EVIDENCE: Level III, Therapeutic study.