Intra- and interobserver reliability analysis of pediatric lower limb parameters on digital long leg radiographs.

BACKGROUND: Malalignments of the lower extremity are common reasons for orthopedic consultation because it may lead to osteoarthritis in adulthood. An accurate and reliable radiological assessment of lower limb alignment in children and adolescents is essential for clinical decision-making on treatment of limb deformities and for regular control after a surgical intervention. OBJECTIVE: First, does the analysis of full-length standing anteroposterior radiographs show a good intra- and interobserver reliability? Second, which parameter is most susceptible to observer-dependent errors? Third, what is the Standard Error of Measurement (SEM95%) of the absolute femoral and tibial length? METHODS: Two observers evaluated digital radiographs of 144 legs from 36 children and adolescents with pathological valgus alignment before a temporary hemiepiphysiodesis and before implant removal. Parameters included Mechanical Femorotibial Angle (MFA), Mechanical Axis Deviation (MAD), mechanical Lateral Distal Femoral Angle (mLDFA), mechanical Medial Proximal Tibial Angle (mMPTA), mechanical Lateral Proximal Femoral Angle (mLPFA), mechanical Lateral Distal Tibial Angle (mLDTA), Joint Line Convergence Angle (JLCA), femur length, tibial length. Intra- and interobserver reliability (ICC2,1), SEM95% and proportional errors were calculated. RESULTS: The intra- and interobserver reliability for almost all measurements was found to be good to excellent (Intra-ICC2,1: 0.849-0.999; Inter-ICC2,1: 0.864-0.996). The SEM95% of both observers was found to be ± 1.39° (MFA), ± 3.31 mm (MAD), ± 1.06° (mLDFA) and ± 1.29° (mMPTA). The proportional error of MAD and MFA is comparable (47.29% vs. 46.33%). The relevant knee joint surface angles show a lower proportional error for mLDFA (42.40%) than for mMPTA (51.60%). JLCA has a proportional error of 138%. Furthermore, the SEM95% for the absolute values of the femoral and tibial length was 4.53 mm for the femur and 3.12 mm for the tibia. CONCLUSIONS: In conclusion, a precise malalignment measurement and the knowledge about SEM95% of the respective parameters are crucial for correct surgical or nonsurgical treatment. The susceptibility to error must be considered when interpreting malalignment analysis and must be considered when planning a surgical intervention. The results of the present study elucidate that MAD and MFA are equally susceptible to observer-dependent errors. This study shows good to excellent intra- and interobserver ICCs for all leg alignment parameters and joint surface angles, except for JLCA. TRIAL REGISTRATION: This study was registered with DRKS (German Clinical Trials Register) under the number DRKS00015053. LEVEL OF EVIDENCE: I, Diagnostic Study.

Hemimelia tibial: Presentación de un caso / Tibial Hemimelia

Introducción: La hemimelia tibial o hemimelia paraxial longitudinal tibial, es una deficiencia congénita de la tibia. Esta deficiencia de los miembros inferiores longitudinal tibial, es muy rara y su frecuencia está en el orden de 1: 1 000 000 de niños nacidos vivos. Objetivo: Presentar un caso de hemimelia tibial diagnosticado por medio del cuadro clínico y radiografías y tratado quirúrgicamente. Presentación del caso: Paciente masculino de dos horas de nacido, atendido por presentar malformación congénita a nivel de la pierna derecha que se presentaba acortada con una prominencia dura a nivel proximal y el pie con deformidad marcada en supinación, aducción y rotación interna. Se realizó examen físico exhaustivo de la extremidad afecta y se constató el acortamiento evidente de la misma. Se indicó radiografía anteroposterior y lateral de la pierna y se observó que el segmento proximal de la tibia y el peroné estaban bien, pero con implantación alta, por lo que se diagnosticó una hemimelia tibial tipo II de Jones. Luego del alta el niño recibió seguimiento por consulta de Genética y el servicio de Ortopedia donde se decidió someterlo a un primer tiempo quirúrgico a los 6 meses de edad, mediante tibialización del peroné. A los 10 meses se realizó un segundo tiempo quirúrgico para centrar el astrágalo al peroné. Conclusiones: La hemimelia tibial se considera un diagnóstico poco frecuente en nuestro medio. No existe prevención conocida. El tratamiento es complejo y altamente especializado, y en algunos casos requiere la amputación temprana del miembro afectado para adaptar al paciente al uso de prótesis(AU)

Introduction: Tibial hemimelia or tibial longitudinal paraxial hemimelia is a congenital deficiency of the tibia. This tibial longitudinal lower limb deficiency is very rare and its frequency is in the order of 1: 1,000,000 live births. Objective: To report a case of tibial hemimelia diagnosed through the clinical condition and radiographs and treated surgically. Case report: We report the case of a two-hour-old male patient, treated for a congenital malformation at the level of the right leg that was shortened with a hard prominence at the proximal level and the foot with marked deformity in supination, adduction and internal rotation. An exhaustive physical examination of the affected limb was carried out and its evident shortening was confirmed. Anteroposterior and lateral X-rays of the leg were indicated and it revealed that the proximal segment of the tibia and fibula were fine, but with high implantation, for which a Jones type II tibial hemimelia was diagnosed. After discharge, the child was followed up by the Genetics consultation and the Orthopedics service, where it was decided to undergo a first stage surgery at 6 months of age, by means of tibialization of the fibula. At 10 months, a second surgical time was performed to center the talus to the fibula. Conclusions: Tibial hemimelia is considered a rare diagnosis in our setting. There is no known prevention. Treatment is complex and highly specialized, and in some cases requires early amputation of the affected limb to adapt the patient to the use of a prosthesis(AU)

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.

An accessory muscle of the posterior compartment of leg of clinical significance: a cadaveric case report / Un músculo accesorio del compartimento posterior de la pierna de importancia clínica: reporte de un caso cadavérico

SUMMARY: Accessory and anomalous muscles are common in humans, although their unique morphologic characteristics can make accurate identification difficult. In this case report, we attempt to identify an anomalous accessory muscle of the posterior compartment of the leg [Compartimentum posterius cruris] detected during cadaveric dissection and discuss its clinical significance. The muscle was found on the right lower limb of an 81-year-old female cadaver and extended from the distal femur to attach to the gastrocnemius muscle at the point where the medial and lateral heads fuse. At its origin, the muscle was found lateral to the popliteal vessels and crossed posterior to these vessels and tibial nerve. It displayed characteristics similar to both an accessory plantaris muscle and gastrocnemius tertius, thus making its ultimate identification difficult. Though the muscle displayed a morphologically similar appearance to the plantaris, we suggest that its common insertion with the gastrocnemius best identifies it as a gastrocnemius tertius. In addition, due to its relationship with the popliteal neurovasculature, it is possible that this muscle could have resulted in neurovascular entrapment although it is unknown whether or not this cadaver exhibited symptoms.

RESUMEN: Los músculos accesorios y anómalos son comunes en los seres humanos, aunque sus características morfológicas pueden dificultar la identificación precisa. En este reporte de caso, intentamos identificar un músculo accesorio anómalo del compartimento posterior de la pierna [Compartimentum posterius cruris] detectado durante la disección cadavérica y discutir su importancia clínica. El músculo fue encontrado en el miembro inferior derecho de una mujer de 81 años de edad y se extendía desde la parte distal del fémur para unirse al músculo gastrocnemio en la fusión de sus cabezas medial y lateral. En su origen, el músculo se encontraba lateral a los vasos poplíteos y cruzaba posteriormente a estos vasos y al nervio tibial, presentando características similares tanto al músculo plantar accesorio como al gastrocnemio tercero, lo que dificultaba su identificación final. Similar al músculo plantar, sugerimos que debido a su inserción común con el gastrocnemio lo identifica mejor como un músculo gastrocnemio tercero. Además, debido a su relación con la neurovasculatura poplítea, es posible que este músculo haya dado lugar a un síndrome de compresión neurovascular aunque se desconoce si este individuó presentó síntomas o no en vivo.

What is the effect of larval therapy on the debridement of venous leg ulcers? A systematic review.

AIM: To determine the impact of larval therapy on the debridement of venous leg ulcers, in comparison to other debridement methods or no debridement. METHOD: Using systematic review methodology, published quantitative studies focusing on the effect of larval therapy on the debridement of venous leg ulcers were included. The search was conducted in January 2020 and updated in May 2021 using CINAHL, PubMed, Embase, and the Cochrane library, and returned 357 records, of which six studies met the inclusion criteria. Data were extracted using a predesigned extraction tool and all studies were quality appraised using the RevMan risk of bias assessment tool. RESULTS: Larval therapy was found to debride at a faster rate than hydrogel (p = 0.011, p < 0.001, p = 0.0039), have a similar effect to sharp debridement (p = 0.12, p = 0.62), and was a resource-effective method of debridement (p < 0.05, p < 0.001, p < 0.001). When larval therapy in combination with compression therapy was compared to compression alone, larvae had a greater effect on debridement (p < 0.05), however, it did not improve overall wound healing rates (p = 0.54, p = 0.664, p = 0.02). Pain levels increased during larval therapy and reduced after treatment, when compared to other standard debridement techniques. CONCLUSION: Larval therapy promotes rapid debridement of venous leg ulcers. However, further high quality randomised controlled trials, comparing larval therapy to other debridement methods for venous leg ulcers, incorporating the use of compression is required to determine the long term effects of larval therapy.

Homeopathic Treatment of a Lower Leg Edema-A Case Report.

BACKGROUND: Homeopathy is frequently and successfully used in daily clinical practice, so there is a need for well-documented case reports that illustrate its effectiveness. For this reason, we present a case in which homeopathy was used to treat an ankle and lower leg for spontaneous acute swelling and redness. CASE REPORT: A 54-year-old man presented with recurrence of a swollen left ankle and lower leg, which had previously been treated by conventional medicine. After case taking, a homeopathic treatment with Apis mellifica 200c led to a fast improvement. The patient was free of symptoms within 24 hours and has remained so for 3 years. CONCLUSION: Homeopathic treatment with Apis mellifica led to a fast and long-lasting improvement of an acute ankle swelling and reddening that had recurred after conventional medical therapy of similar symptoms.

A bilateral third head of the gastrocnemius which is morphologically similar to the plantaris.

PURPOSE: An extra muscle was observed on both sides of the popliteal fossa in the cadaver of a 78-year-old Japanese male during dissection. The aim of this case report was to identify whether this variant is a double plantaris or a third head of the gastrocnemius according to its morphological characteristics and innervation. METHODS: The muscles were displayed by careful dissection and delineation of surrounding structures. The size of each of the muscle bellies and tendons of those extra muscles were measured manually by the vernier caliper. RESULTS: The origin of each extra muscle was lateral to the tibial nerve and superior to the plantaris, and each extra muscle which transitioned to a descending tendon parallel to the plantaris had a cone-shaped belly. However, the tendon of the extra muscles was fused into the investing fascia of the gastrocnemius with a tendon length of 4.5 cm on the left and 4.6 cm on the right. The extra muscles were innervated by the branch of the tibial nerve to the medial head of the gastrocnemius on both sides. CONCLUSION: Although they had an origin and shape similar to that of the plantaris, we identified the extra muscles in this case as a third head of the gastrocnemius, because of innervation to the plantaris arises directly from the tibial nerve. This case highlighted that the innervation is essential to understanding the myogenesis of extra muscles, especially in cases which are difficult to categorize based on the morphological features of the muscle.

Better outcomes and reduced failures for arthroplasty over osteotomy for advanced compartmental knee osteoarthritis in patients older than 50 years.

BACKGROUND: Both compartmental knee arthroplasty (CKA) and open-wedge high tibial osteotomy (HTO) may be used to treat patients older than 50 years of age with advanced compartmental osteoarthritis (OA) secondary to leg axis deformities. A meta-analysis was conducted to clarify the role of open-wedge HTO versus CKA for patients older than 50 years with advanced compartmental knee OA. The present investigation aimed to analyse the clinical outcomes, implant failure and survivorship. METHODS: This meta-analysis was performed in accordance with the PRISMA guidelines. In September 2020, the main online databases were accessed. All clinical trials comparing the outcomes of open-wedge HTO versus CKA for compartmental knee OA were considered. Data analysis was performed through the Review Manager Software 5.3 (the Nordic Cochrane Collaboration, Copenhagen). Implant survivorship was analysed with a Kaplan-Meier (KM) curve that was performed using the STATA/MP software (StataCorp, College Station, TX). RESULTS: Data from 618 (HTO, 307; CKA, 311) patients were collected. Good baseline comparability among patient age, BMI and gender was detected. The Tegner Activity Scale was higher in the CKA group (P = 0.04), as were the Lysholm score (P = 0.001), the International Knee Documentation Committee (P = 0.0001) and the Knee injury and Osteoarthritis Outcome Score (P = 0.05). At a mean follow-up of 5 years, revisions were less in the CKA cohort (OR, 2.27; P = 0.004). The Kaplan-Meier curve evidenced longer implant survivorship in favour of the CKA group (P = 0.01). CONCLUSION: In patients older than 50 years of age with compartmental knee OA secondary to frontal axis leg deformities, CKA performed better than open-wedge HTO.

The safety and efficacy of Sclerosing foam on treating venous leg ulcers: Protocol for systematic review and meta-analysis.

BACKGROUND: Venous leg ulcers (VLUs) are common throughout the world, which seriously affects the patient's work and life. Relevant researches suggested that sclerosing foam (SF) has potential benefits for VLUs. However, there is no consistent conclusion. The purpose of our study is to assess whether SF is effective and safe for VLUs. METHODS: Relevant clinical randomized controlled trials will be obtained from a search of 8 databases (with no language restrictions) from their inception to May 2020: PubMed, the Cochrane Library, EMBASE, Web of Science, China National Knowledge Infrastructure Database, Wanfang Database, China Science and Technology Journal Database, and Chinese Biological Medicine. Data will be analyzed using RevMan 5.3 after literature screening and data extraction according to predefined inclusion and exclusion criteria. Cochrane Collaboration Risk of bias Tool will be applied in evaluating the quality of enrolled articles. The primary outcome is Closure of venous leg ulcers, ulcer healing rate, adverse events related to SF. The secondary outcomes include ulcer healing time, ulcer recurrence rate, pain. Risk ratio will be used for categorical data; mean differences will be used for measurement data. Where possible and appropriate, meta-analysis will be performed for each outcome. RESULTS: To clarify whether Sclerosing foam can be safe and efficient on treating venous leg ulcers. CONCLUSION: Our review will provide useful information to judge whether Sclerosing Foam is an effective and safe intervention for patients with venous leg ulcers.

Hyperpigmentation of the legs.

Was a drug or a comorbidity to blame for this patient's hyperpigmentation?

One-Step Lower Leg Reconstruction with Vascularized Functional Vastus Lateralis Muscle Flap in the Treatment of Embryonal Rhabdomyosarcoma for a Six-Month-Old Boy: A Case Report.

Rhabdomyosarcoma (RMS) is a common soft tissue sarcoma in childhood, however, it is very rare in the neonatal period (0.4-2% of cases). This case depicts a boy, who presented with RMS at two weeks of age, but officially diagnosed at the age of three months. MRI and scintigraphy determined a soft tissue tumor in the soleus muscle, while biopsy confirmed embryonal RMS with high mitotic activity (Ki67 (monoclonal antibodies) ~80%). CWS (Cooperative Weichteilsarkom Studiengruppe)-2012 with I2VA (ifosfamide, vincristine, actinomycin) chemotherapy regimen was administered per protocol. Surgical treatment was performed at age of six months and 18 days. The operation consisted of radical tumor resection and total triceps surae with partial fibula resection. Immediate reconstruction of triceps muscle was accomplished using a vascularized functional musculocutaneous vastus lateralis flap. Functional outcome was measured using the Lower Extremity Functional Scale (LEFS) and the Foot and Ankle Outcome Score (FAOS) with the results of 92.5% and 99% respectively.

Colgajos locorregionales para defectos complejos de pierna y pie: uso actual en hospitales públicos de Montevideo, Uruguay / Locoregional flaps for complex leg and foot defects: valid options in public hospitals of Montevideo, Uruguay

INTRODUCCIÓN Y OBJETIVO: Las heridas complejas de pierna y pie representan un desafío para la Cirugía Plástica, más aún cuando se asocian a fracturas expuestas dada la escasa disponibilidad de tejido local y regional. En estos casos suele plantearse la indicación de colgajos microquirúrgicos. En nuestro medio, donde la infraestructura aún está en desarrollo y no siempre se cuenta con equipamiento, horas de bloque quirúrgico para cirugías prolongadas, personal de enfermería capacitado, y hay poca colaboración de los pacientes para la recuperación, es frecuente optar por colgajos fasciocutaneos y musculares pediculados para la reconstrucción de estos defectos a pesar de que también esté indicado un colgajo libre. El objetivo de este trabajo es mostrar nuestra experiencia en hospitalespúblicos de Montevideo, Uruguay, en reconstrucción de pierna y pie utilizando colgajos locorregionales con buenos resultados y tiempo de recuperación aceptable. MATERIAL Y MÉTODO: Realizamos un estudio descriptivo retrospectivo de 7 casos de diferentes opciones terapéuticas de colgajos locorregionales fasciocutáneos y musculares para cobertura de diferentes defectos complejos de pierna y pie, en el Hospital de Clínicas y en el Instituto Nacional de Ortopedia y Traumatología de Montevideo. Seleccionamos los casos dentro de las etiologías más frecuentes de heridas en esta topografía que requieren reconstrucción por Cirugía Plástica y representan el modelo de colgajo realizado en cada tipo de herida descrito (topografía, tamaño y tejidos expuestos). RESULTADOS: Presentamos 7 pacientes de entre 21 y 80 años de edad, en los que se realizaron colgajos musculares de gemelo interno, externo, hemitríceps, hemitríceps con tibial anterior, hemisoleo, fasciocutáneo de transposición y fasciocutáneo en isla sural. Los resultados fueron aceptables en cuanto a ausencia de complicaciones de los colgajos, no necesidad de revisiones y tiempo de recuperación de 2 a 6 meses. CONCLUSIONES: Los colgajos locorregionales descritos proporcionan cobertura satisfactoria en defectos complejos de pierna y pie cuando los colgajos microquirúrgicos, aún estando indicados, no pueden realizarse por déficit de material, infraestructura o personal de la salud, así como por falta de colaboración del paciente para la recuperación. Las opciones planteadas pueden formar parte del algoritmo terapéutico en centros que comparten la misma epidemiología y recursos que los nuestros

BACKGROUND AND OBJECTIVE: Complex leg and foot wounds represent a challenge for Plastic Surgery, and even more so when they are associated with exposed fractures, given the limited availability of local and regional tissue. In these cases, the indication of microsurgical flaps is usually considered. In our environment, where the infrastructure is still under development and equipment is not always available, neither hours of surgical block for prolonged surgeries, trained nursing personnel, added to the little collaboration of patients for recovery, it is frequent to opt for fasciocutaneous flaps and pedicled muscle flaps for reconstruction, even though a free flap is also indicated. The objective of this paper is to show our experience in public hospitals in Montevideo, Uruguay, in leg and foot reconstruction using locoregional flaps, with good results and acceptable recovery time. METHODS: We performed a retrospective descriptive study, in which 7 cases of different therapeutic options were described within the fasciocutaneous and muscular locoregional flaps to cover different complex leg and foot defects, from the Hospital de Clínicas and Instituto Nacional de Ortopedia y Traumatología in Montevideo, Uruguay. The cases were selected within the most frequent etiologies of wounds in this topography that require reconstruction by Plastic Surgery, and represents the flap model performed in each type of wound described (topography, size, exposed tissues). RESULTS: We present 7 patients between 21 and 80 years of age, in whom internal, external twin muscle flaps, hemitriceps, hemitriceps with anterior tibial, hemisoleous, transpositional fasciocutaneous, fasciocutaneous in sural island flaps were performed. The results were acceptable in terms of the absence of flap complications, the lack of flap reviews and based on the recovery time from 2 to 6 months. CONCLUSIONS: The locoregional flaps described provide satisfactory coverage in complex leg and foot defects when the microsurgical flaps, even when indicated, cannot be performed due to deficits in material, infrastructure or health personnel, as well as due to patient's lack of collaboration in recovery. The options proposed may be part of the therapeutic algorithm in centers that share the same epidemiology and resources as ours

FOOTFIT Physical Activity mHealth Intervention for Minimally Ambulatory Individuals With Venous Leg Ulcers: A Randomized Controlled Trial.

PURPOSE: The purpose of this study was to investigate the use of an mHealth application (app), self-management physical activity intervention FOOTFIT with an added patient-provider connectivity feature (FOOTFIT+), that was designed to strengthen the lower extremities of minimally ambulatory individuals with venous leg ulcers (VLUs). DESIGN: Randomized controlled trial. SUBJECTS AND SETTING: Twenty-four adults 18 years and older with VLUs being treated in 2 wound clinics in the Southeastern United States participated in this study. METHODS: Preliminary estimates and 95% confidence intervals for the medians of short-term functional impacts on foot function, strength, ankle range of motion, walking capacity, depression, and physical functioning were obtained pre- and postassessment after the 6-week intervention trial. RESULTS: There were negligible changes in either group for foot function. It is noted that both groups experienced substantial foot and ankle impairment at baseline. The greatest improvement in range of motion was noted in the FOOTFIT group for dorsiflexion of the right ankle (4.6 ± 5.22 lb/in over baseline) whereas strength decreased in both ankles for dorsiflexion and plantar flexion in the FOOTFIT+ group. No improvements were noted in walking distance or physical health for FOOTFIT (slight decrease -2.9 ± 5.6) and FOOTFIT+ (slight increase 3.0 ± 6.6) during the 6-week study period. CONCLUSIONS: In a minimally ambulatory population with VLUs, our mHealth FOOTFIT intervention composed of progressive exercise "boosts" demonstrated minimal short-term effects. We recommend engagement with the app for a longer period to determine longer-term outcomes of lower extremity function.

The lived experience of recurrence prevention in patients with venous leg ulcers: An interpretative phenomenological study.

AIM OF THE STUDY: To explore patient understanding of why they develop a venous leg ulcer and how they can prevent recurrence. METHOD: The methodological framework of the hermeneutic phenomenological approach was used. Semi-structured interviews were conducted with seventeen participants living with a venous leg ulcer from May 2017 to November 2018. Data were analysed using Smith's interpretative hermeneutic analysis. RESULTS: The results are categorised into three main themes: "Trauma due to accident" (initial venous leg ulcer) and "Prevention of ulcer recurrence" (compression); "Trauma due to compression therapy" (venous leg ulcer recurrence). The findings demonstrate active venous leg ulcers are often caused by acute incidents while carrying out an activity in people with underlying chronic venous insufficiency. After a complete healing, preventive measures, such a compression stockings are initiated by the patient or health care provider. Trauma due to adherence to compression stockings caused skin breakdown beneath compression that caused subsequent ulcer recurrence. CONCLUSION: This study contributes to understanding the lived experience of patients with venous leg ulcers who develop a venous leg ulcer and their understanding of how they can prevent recurrence. Patients with VLUs would benefit from early preventive strategies, such as such a compression stockings fitting and application, integrated into daily care plan of primary care and community settings.