Simultaneous subtalar arthroeresis, midfoot soft tissue release, and talo-navicular arthrodesis in children with planovalgus neurologic foot.

PURPOSE: Planovalgus foot deformity (PVFD) is common in children with neuromuscular conditions and severe deformity may require surgical correction. This study aims to assess clinical and radiological outcomes of PVFD secondary to neuromuscular disease managed by subtalar arthroeresis (SuAE), midfoot soft tissue release and talo-navicular arthrodesis (TNA). METHODS: A retrospective analysis of children with neuromuscular disease and nonreducible PVFD who underwent SuAE, midfoot soft tissue release, and TNA and with a minimum follow-up of 5 years was performed. A total of 60 patients with neuromuscular disease (108 feet) including cerebral palsy were reviewed. Mean age at surgery was 12.7 ± 4.6 years (6-17). Mean follow-up was 7 ± 2.9 years (5-10). Clinical outcomes and radiologic correction at final follow-up were compared with preoperative values. Statistical analysis was performed and significance was set at P < 0.01. RESULTS: Statistically significant radiological improvements between pre- and postoperative values were found for all angle values. At final follow-up, there was a significant improvement in VAS score (4.8 vs. 2; P < 0.01). There was also a positive trend in the improvement of walking ability. No cases of pseudoarthrosis were reported at final follow-up. Screw removal was required in 5 out of 108 feet (4.6%) and 2 feet (3.3%) had delayed medial wound healing. CONCLUSIONS: SuAE combined with TNA and midfoot soft tissue is a safe and feasible procedure that can provide good clinical and radiologic results in patients with neuromuscular disease and nonreducible PVFD; the procedure can improve foot stability, and has a limited number of complications. LEVEL OF EVIDENCE: IV.

Diagnosis of periprosthetic hip infection: a clinical update.

Periprosthetic joint infection (PJI) is a serious complication following hip arthroplasty, which is associated with significant health cost, morbidity and mortality. There is currently no consensus in the optimal definition of PJI, and establishing diagnosis is challenging because of conflicting guidelines, numerous tests, and limited evidence, with no single test providing a sensitivity and specificity of 100%. Consequently, the diagnosis of PJI is based on a combination of clinical data, laboratory results from peripheral blood and synovial fluid, microbiological culture, histological evaluation of periprosthetic tissue, radiological investigations, and intraoperative findings. Usually, a sinus tract communicating with the prosthesis and two positive cultures for the same pathogen were regarded as major criteria for the diagnosis, but, in recent years, the availability of new serum and synovial biomarkers as well as molecular methods have shown encouraging results. Culture-negative PJI occurs in 5-12% of cases and is caused by low-grade infection as well as by previous or concomitant antibiotic therapy. Unfortunately, delay in diagnosis of PJI is associated with poorer outcomes. In this article, the current knowledge in epidemiology, pathogenesis, classification, and diagnosis of prosthetic hip infections is reviewed.

Neglected patellar tendon rupture in tibial tubercle avulsion fracture in an adolescent: A case report.

A rare childhood injury is a combined tibial tubercle fracture and patellar tendon rupture, and this condition necessitates an open surgical procedure to perform a stable fixation of the tubercle fragment and a successful patellar tendon repair. When a tibial tubercle fracture in the tibia is present alone, a high index of suspicion is required. In this article, we described a case of a male teen who suffered a neglected patellar tendon rupture following close reduction and fixation of a tibial tubercle fracture.

Acquired genu recurvatum in a skeletally immature patient treated by physeal distraction: A case report.

The proximal tibia physis' anterior growth arrest is the cause of the uncommon condition known as acquired genu recurvatum, which can also be congenital, idiopathic, or secondary to trauma, infections, cerebrovascular accidents, or neuromuscular diseases. In order to avoid the reported drawbacks that could complicate osteotomies-incomplete correction, patella infera, knee pain or stiffness, and the requirement to remove plate metalwork-physeal distraction and callotasis with external fixation has been suggested. We present the case of a 14-year-old boy who had a 5 cm difference in limb length, with the right leg being shorter, and a right knee that was 30° recurved with flexion restriction beyond 40°. The correction was made in 50 days, and the external fixator was removed in 92 days after we performed a physeal distraction with an axial EF (ST.A.R., Citieffe) through an anterior physeal osteotomy just proximal to the tuberosity in conjunction with simultaneous asymmetrical tibial and femoral contralateral epiphysiodesys. The patient returned to playing football within 8 months despite the persistence of a 3 cm leg length discrepancy and had a symmetric full range of motion of the knee without any complications or persistent pain. The correction of genu recurvatum in adolescents may be achieved safely and effectively through physeal distraction with an axial external fixator.

Avascular necrosis of the first metatarsal head in adolescence: A case report.

Avascular necrosis (AVN) of the first metatarsal (MTT) head is an uncommon condition and it occurs most often as a complication after capital osteotomy in correction of hallux valgus deformity. Idiopathic osteonecrosis of the first MTT head in adolescent are rare and treatment is challenging (1,2). Many conditions have been proposed as predisposing factors of AVN, including trauma, hemoglobinopathies such as sickle-cell disease, steroid therapy, Cushing's disease, alcoholism, Gaucher's disease, Caisson's disease, and irradiation (3,4). However, etiology remains elusive. We described a case of an idiopathic AVN of the 1st MTT in adolescent treated by dorsal closing-wedge osteotomy, which to the authors' knowledge has not been described before.

A vascular lesion in hip revision arthroplasty: a case report.

Vascular injuries during hip revision surgery can be life-threatening complications for patients. There are many aspects to consider when approaching this type of surgery for an optimal diagnostic and therapeutic strategy, as a careful planning with extensive preoperative investigations, a full attention during the surgical procedure and the use of suitable material for a proper treatment. This kind of surgery can require a dedicated and trained multidisciplinary team. We report a case of an acute intraoperative vascular lesion during an acetabular revision performed in a 55-years-old patient.

Direct anterior approach versus direct lateral approach in total hip arthroplasty and bipolar hemiarthroplasty for femoral neck fractures: a retrospective comparative study.

BACKGROUND: In the current literature, there is no consensus on the best surgical approach in hip replacement for femoral neck fractures (FNFs). AIM: The aim of this study is to compare the direct anterior approach (DAA) and the direct lateral approach (DLA) in patients treated with bipolar hemiarthroplasty (BHA) and total hip arthroplasty (THA) for FNFs. MATERIALS AND METHODS: Patients with displaced FNFs (Garden type III and IV) treated operatively using BHA and THA were enrolled. The surgical approach techniques DAA and DLA are compared. The analysed variables are: mean surgery time, number of blood units transfused perioperatively, percentage of patients transfused, perioperative complications, pain and functional outcomes at 1 and 6 months and mortality at 1, 3 and 12 months. RESULTS: Between 2015 and 2017, 37 patients underwent BHA by the DAA and 38 patients underwent BHA by the DLA, 69 patients underwent THA by the DAA and 60 patients underwent THA by the DLA. For THA, the DAA compared to the DLA had a higher mean surgery time (100.8 min vs. 97.7 min), a lower mean number of blood units transfused perioperatively (1.4 U vs. 1.9 U), a significantly lower percentage of patients transfused (53.6% vs. 71.7%), a higher rate of perioperative complications (10.1% vs. 1.6%), a lower pain referred and better functional outcomes in the first 6 postoperative months and a significantly lower mortality rate at 12 months (2.9% vs. 16.7%). For BHA, the advantages of the DAA over DLA are not as significant. CONCLUSIONS: The direct anterior approach in THA for FNFs provides significant benefits in the early post-operative period compared to the direct lateral approach in terms of functional recovery, residual pain, blood loss and mortality rate in the elderly active population. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Triradiate cartilage fracture of the acetabulum treated surgically.

Fractures of the acetabulum are rare in the pediatric age and may be complicated by the premature closure of the triradiate cartilage. We report a case of triradiate cartilage displaced fracture treated surgically. A 14 years old boy, following a high-energy road trauma, presented an hematoma in the right gluteal region with severe pain. According to radiographic Judet's projections was highlighted a diastasis of the right acetabular triradiate cartilage.  CT scan study with 2D-3D reconstructions confirmed as type 1 Salter-Harris epiphyseal fracture. Due to the huge diastasis of the triradiate cartilage, the patient was operated after 72 hours through a plating osteosynthesis. We decided during the preoperative study that the plates should not be removed. Two years after surgery, the patient is clinically asymptomatic; the radiographic evaluation shows a complete cartilage's fusion and the right acetabulum is perfectly symmetrical to the contralateral. For the treatment of acetabular fractures in pediatric age should be carefully evaluated fracture's pattern, patient's age, skeletal maturity's grade, acetabulum's volume and diameter.