Defining shoulder function and dysplasia in patients with longitudinal deficiencies of the upper limb.

BACKGROUND: Phenotypic differences and functional limitations in children with congenital radial and ulnar longitudinal deficiencies (RLD/ULD) are well understood for the forearm and hand. However, anatomical features of shoulder elements in these pathologies have only been scarcely reported. Moreover, shoulder function has not been assessed in this patient population. Therefore, we aimed to define radiologic features and shoulder function of these patients at a large tertiary referral center. METHODS: We prospectively enrolled all patients with RLD and ULD (minimum age: 7 years) for this study. Eighteen patients (12 RLD, 6 ULD) with a mean age of 17.9 years (range, 8.5-32.5) were evaluated using clinical examination (shoulder motion and stability), patient-reported outcome measures (Visual Analog Scale, Pediatric/Adolescent Shoulder Survey, Pediatric Outcomes Data Collection Instrument), and radiologic grading of shoulder dysplasia (including length and width discrepancy of the humerus, glenoid dysplasia in the anteroposterior and axial view [Waters classification], and scapular and acromioclavicular dysplasia assessment). Descriptive statistics and Spearman correlation analyses were performed. RESULTS: Despite five (28%) cases having anterioposterior shoulder instability and five (28%) cases with decreased motion, outcome scores indicated an overall excellent function of the shoulder girdle, with mean Visual Analog Scale of 0.3 (range, 0-5), mean Pediatric/Adolescent Shoulder Survey of 97 (range, 75-100), and mean Pediatric Outcomes Data Collection Instrument Global Functioning Scale of 93 (range, 76-100). The humerus was, on average, 15 mm shorter (range, 0-75), and metaphyseal and diaphyseal diameters both reached 94% of the contralateral side. Glenoid dysplasia was detected in nine (50%) cases, with increased retroversion evident in 10 (56%) cases. However, scapular (n = 2) and acromioclavicular (n = 1) dysplasia were rare. Based on radiographic findings, a radiologic classification system for dysplasia types IA, IB, and II was developed. CONCLUSIONS: Adolescent and adult patients with longitudinal deficiencies exhibit various mild-to-severe radiologic abnormalities around the shoulder girdle. Nevertheless, these findings did not seem to negatively affect shoulder function as the overall outcome scores were excellent.

Outcomes and complications of surgical treatment modalities for simple bone cysts of the humerus in children and adolescents.

PURPOSE: The aim of this study was to evaluate and compare different surgical treatment modalities for simple bone cysts (SBC) of the humerus regarding their effectiveness and recurrence rate. METHODS: In this retrospective study, patients who received surgical treatment for previously untreated primary SBCs of the humerus were analyzed. Demographic data, cyst-specific as well as treatment-specific parameters, complications, treatment failures, and recurrence rates were collected and correlated with different treatment modalities. Observed procedures were categorized as open procedure (n=20) or osteosynthesis alone (n=3). For the open procedure group, four subgroups could be defined. RESULTS: Twenty-three patients were included. The mean age at diagnosis was 11.6 ± 2.5 years, and the mean postoperative follow-up was 3.9 ± 2.6 years (range 1.0-10.3). After surgical intervention, a total of five (21.7%) patients showed at least one recurrence. Fracture occurred in three (13.0%) cases. The incidence of treatment failure was significantly higher in the curettage, allograft, adjuvants group, with five (83.3%) of six cases showing recurrence, than in the other subgroups (≤ 25.0%) including the osteosynthesis alone group (p=.024). For the open procedure group, the failure-free survival rates were 80.0% after two years and 50.4% after five years. For the three cases treated by osteosynthesis alone, no failures were observed. CONCLUSION: Open procedures showed similar failure rates except for the subgroup using curettage, allograft, and adjuvants which showed significantly higher treatment failure. Promising results were observed in the group which received solely osteosynthesis without cyst excision or filling, as no treatment failure was observed here.

Autologous replacement of the head of the radius-proximal fibula versus second metatarsal base: an anatomic feasibility study.

INTRODUCTION: This study investigated the anatomic feasibility of a new surgical therapy option for radial head arthrosis using an autologous vascularized bone graft of the second metatarsal and proximal fibula to recreate the proximal radiohumeral joint. MATERIALS AND METHODS: Upper and lower extremities of eleven body donors were evaluated using CT prior to anatomic dissection. Several distinct anatomic parameters were measured on the ipsi- and contralateral radial and fibular head and the second metatarsal base: bone diameter, articular surface diameter, head height, metaphyseal (neck) diameter, articular surface radius, total articular surface area, and angulation of the articular surfaces (facet). Each dissection phase was photographed in a standardized fashion and all measurements were repeated by direct caliper-measurements. RESULTS: When comparing the proximal radius and fibula to search for anatomic similarities, similar values were found in the maximum articular surface diameter and minimum and maximum measures of the neck diameter. Comparing the proximal radius and the second metatarsal, statistically similar values were found in the maximum neck diameter performing direct measurements and CT evaluation, the maximum head diameter in CT evaluation and the articular facet angulation. CONCLUSIONS: Neither the proximal fibula nor the base of the second metatarsal are ideal bone grafts for replacement of the head of the radius. The base of the second metatarsal might be a bit more suitable as a potential donor since the angulation of the proximal articular facet is similar to that of the radius. LEVEL OF EVIDENCE: Level IV, anatomic study.

Ethical Conflicts in Healthcare Chaplaincy: Results of an Exploratory Survey Among Protestant Chaplains in Switzerland, Germany, and Austria.

The paper reports the results of an exploratory online survey among German, Austrian, and Swiss hospital chaplains (n = 158, response rate 17%) to identify the ethical conflicts they encounter in their work. Respondents indicated that questions surrounding end-of-life care are predominant among the conflicts faced. Chaplains get involved with these conflicts most often through the patients themselves or through nursing staff. Most encounters occur during pastoral care visits rather than in structured forms of ethics consultation such as clinical ethics committees. The results add to the ongoing discussion of chaplains as agents in ethics consultation within healthcare systems as well as their specific role and contribution.

The Hand in Distal Arthrogryposis.

Distal arthrogryposis is the second most common type of arthrogryposis after amyoplasia and is defined as arthrogryposis that affects hands and feet; it is mostly inherited in an autosomal-dominant fashion. This review discusses up-to-date background information, clinical features, and treatment of distal arthrogryposis in hands concentrating on camptodactyly, thumb-in-palm deformity, and windblown hand deformity, which are the most common and functionally limiting deformities. Treating these deformities should be individualized and follow a multidisciplinary approach. Most deformities can be initially treated nonoperatively, and if not responsive, operative treatment may be pursued to improve function. Surgery primarily aims to release soft-tissue contractures, rebalance muscle forces, and may need bony correction based on the deficits of each case. Current literature suggests that early treatment leads to better outcomes. However, reported cases are scarce, and no consensus or gold standard for treatment exists. Therefore, long-term (multicenter) studies are needed to assess outcomes and standardize the treatment of such deformities whenever possible.

Age-related Outcomes and Complications of Osteodistraction in the Pediatric Upper Extremity: A Large Retrospective Single-center Study of 61 Cases.

BACKGROUND: The study purpose was to assess: (1) the complication rate of osteodistraction in the pediatric upper extremity, its severity and relation to patient-specific and treatment-specific parameters, and (2) dedicated patient-reported outcome scores after these procedures. METHODS: This retrospective study analyzed a chart of patients undergoing osteodistraction of the upper limb between 2003 and 2020. Demographics, distraction-specific parameters, healing index, and any complications graded according to the Sink grading scale (grades 1 to 5) were extracted. An additional phone interview was performed to assess patient satisfaction and functionality of the elongated limb using the Quick-DASH (Disabilities of Arm, Shoulder, and Hand) score. RESULTS: This study included 61 cases from 48 individual patients. The mean age at the start of distraction was 11.5±3.6 years. The ulna was the most frequently lengthened bone, with 21 (34.4%) cases. Ninety-four complications were observed, with an average complication rate of 77.0%. Based on the Sink grading scale (1 to 5), grade 3 complications were most common (n=29; 47.5%) followed by grade 1 (n=14; 23.0%), 2 (n=14; 23.0%), and 4 (n=4; 6.6%). A significantly lower and thus better bone healing index was observed for the age category less than 10 years compared with the 14 to 18 years group (P=0.006). The average satisfaction was 4.2±1.0 points of 5. The mean Quick-DASH score was 14.1±12.5, indicating very good clinical outcomes. CONCLUSIONS: Despite the occurrence of numerous complications, high patient satisfaction and good daily life functionality of the treated limb was observed. An age of more than 14 years at the beginning of therapy had a negative prognostic effect on bone healing during distraction. Thus, osteodistraction in the upper extremity may preferably be performed less than 10 years of age because of enhanced bone regeneration. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Splinting for the treatment of pediatric trigger thumbs: a pilot study.

Controversy still exists whether conservative treatment may be a useful option for the treatment of pediatric trigger thumbs. We reviewed a random sample patient cohort with regard to success rates depending on whether flexible or fixed trigger thumbs were present. We performed a pilot study of 13 children (15 thumbs), who received a standardized treatment protocol including a custom-made thermoplastic splint for use during sleeping hours for a minimum of 3 months. Splinting was of only minor value for moderate and severe cases was but was beneficial for the majority of patients showing triggering symptoms only. It may thus be a reasonable option to delay surgery in infants with mild/flexible cases.

Surgical treatment of atraumatic osteochondrosis dissecans of the immature talus-Clinical results and prevalence of radiographic joint degeneration after a median follow-up of 72.5 months.

BACKGROUND: This study aimed to assess the clinical and radiographic outcomes of different surgical procedures in atraumatic osteochondrosis dissecans (OCD) of the talus in youth and adolescence. METHODS: 32 joints in 30 patients (mean age 14.7 ± 2.2 years) were evaluated. Numeric Rating Scale (NRS), Foot and Functional Index (FFI), American Orthopedic Foot and Ankle Society ankle-hindfoot score (AOFAS), Pediatric Outcome Data Collection Instrument (PODCI), and sport participation were recorded. We compared preoperative and follow-up ankle radiographs to identify specific features in the OCD morphology and any signs of joint degeneration. RESULTS: After a median follow-up period of 72.5 months the drilling group showed significantly better scores than the combined fixation and reconstruction groups (AOFAS, p = 0.024; PODCI, p = 0.003; NRS, p = 0.027). Signs of joint degeneration were observed in 50% of all ankles, especially in those treated by OCD-fixation and reconstruction. CONCLUSIONS: Advanced fixation and reconstruction procedures in unstable and non-salvageable atraumatic talar OCD resulted in inferior clinical scores and a higher prevalence of joint degeneration than drilling procedures in stable OCD in young patients.

Editorial Commentary: The Hook Test Is More Accurate for Detecting Foveal Triangular Fibrocartilage Complex Tears but Not More Important Than the Trampoline Test.

Wrist arthroscopy is a successful tool to diagnose and treat several intra-articular wrist pathologies. To assess the stability and integrity of the triangular fibrocartilage complex (TFCC), the most commonly injured structure in the ulnocarpal compartment, the trampoline and hook tests are frequently used in daily practice. However, their arthroscopic performance measures have not been well elucidated to date. While the hook test may primarily be seen as a sensitive tool to detect foveal TFCC tears, the trampoline test is of equal importance for the clinician because it can detect frequently occurring superficial (distal) tears in the peripheral TFCC area. As opposed to the hook test, however, the trampoline test might more easily lead to interrater disagreement since the rebound after probing is rather a continuum than a binary measure and might be related to a different severity of peripheral TFCC disruption. The combination of both tests should thus be pursued since they complement each other very well. Proper interpretation of the tests needs sufficient experience and should be done in concordance with the clinical evaluation (ie, fovea sign, distal radioulnar joint ballottement test). Hence, the hook test may be more accurate to detect foveal TFCC tears but all together not more important than the trampoline test to establish the correct diagnosis. For once, Captain Hook has won!

Treatment of advanced stage osteochondrosis dissecans in the adolescent elbow using a hyaloronic acid-based scaffold: a case series of 5 patients.

INTRODUCTION: Osteochondrosis dissecans (OCD) is considered to be one of the main causes for pain, discomfort and morbidity in the pediatric elbow joint. Few treatment options, such as microfracture or autologous transplantation, of osteochondral bone grafts have been described to address advanced OCD. The aim of this retrospective case series is to present preliminary clinical and radiologic findings following advanced stage OCD repair using a novel combination of a hyaluronic acid-based scaffold with autologous iliac crest bone grafting. MATERIALS AND METHODS: Five adolescents, who underwent treatment of OCD (grade 3 or 4 according to Nelson) using a combination technique of defect debridement, transplantation of cancellous iliac crest bone and application of a HYALOFAST® membrane (Anika Therapeutics S.r.L., Italy), were re-assessed using clinical and radiologic examinations (defect diameter, depth, sclerosis, congruency, fragmentation, dissection, radiolucency, growth plate status; MRI) after a minimum of 2 years (mean, 34 months; range, 24-45) postoperatively. Dedicated outcome scores (Numeric Rating Scale [NRS], Pediatric Outcome Data Collection Instrument [PODCI], Mayo Elbow Performance Score [MEPS], and Timmerman-Andrews Score [TIMM] were collected. RESULTS: All patients reported a NRS score of 0. The mean total TIMM, MEPS and PODCI (Global Functioning Scale) scores were 189 (range 165-200), 94 (range, 70-100), and 92 (range 83-98; normative score 47; range 35-55), respectively, indicating good to excellent clinical outcomes. The radiographic analysis showed overall improvements with regard to OCD width and depth reduction (35%, - 27-100%; 52%, 4-100%), but full resolution in only 2 of 5 cases. Elbow motion improved slightly after surgery. No complications were noted. CONCLUSION: This study showed promising clinical short- to mid-term results in adolescent patients with advanced OCD using a novel surgical treatment combination. Radiographic results showed partial healing; hence, residual changes should be monitored over a longer period.

Perinatal outcomes of infants with congenital limb malformations: an observational study from a tertiary referral center in Central Europe.

BACKGROUND: Congenital limb malformations are rare, and their perinatal outcomes are not well described. This study analyzed the perinatal outcomes of infants with congenital limb malformations. METHODS: All infants with congenital limb malformations who underwent prenatal assessment and delivery at our tertiary referral center from 2004 through 2017 were retrospectively identified. Neonatal outcome parameters were assessed, and the predictors of worse perinatal outcomes were determined. RESULTS: One hundred twenty-four cases of congenital limb malformations were identified, of which 104 (83.9%) were analyzed. The upper limb was affected in 15 patients (14.4%), the lower limb in 49 (47.1%), and both limbs in 40 (38.5%) patients. A fetal syndrome was identified in 66 patients (63.5%); clubfoot and longitudinal reduction defects were the most frequent malformations. In total, 38 patients (36.5%) underwent termination, seven (6.7%) had stillbirth, and 59 (56.7%) had live-born delivery. Rates of preterm delivery and transfer to the Neonatal Intensive Care Unit were 42.4 and 25.4%, respectively. Localization of the malformation was a determinant of perinatal outcome (P = .006) and preterm delivery (P = .046). CONCLUSIONS: Congenital limb malformations frequently occur bilaterally and are associated with poor perinatal outcomes, including high rates of stillbirth and preterm delivery. Multidisciplinary care and referral to a perinatal center are warranted.

Is the Apert foot an overlooked aspect of this rare genetic disease? Clinical findings and treatment options for foot deformities in Apert syndrome.

BACKGROUND: Apert syndrome is characterised by the presence of craniosynostosis, midface retrusion and syndactyly of hands and feet, thus, synonymously referred to as acrocephalosyndactyly type I. Considering these multidisciplinary issues, frequently requiring surgical interventions at an early age, deformities of the feet have often been neglected and seem to be underestimated in the management of Apert syndrome. Typical Apert foot features range from complete fusion of the toes and a central nail mass to syndactyly of the second to fifth toe with a medially deviated great toe; however, no clear treatment algorithms were presented so far. This article reviews the current existing literature regarding the treatment approach of foot deformities in Apert syndrome. STATE-OF-THE-ART TOPIC REVIEW: Overall, the main focus in the literature seems to be on the surgical approach to syndactyly separation of the toes and the management of the great toe deformity (hallux varus). Although the functional benefit of syndactyly separation in the foot has yet to be determined, some authors perform syndactyly separation usually in a staged procedure. Realignment of the great toe and first ray can be performed by multiple means including but not limited to second ray deletion, resection of the proximal phalanx delta bone on one side, corrective open wedge osteotomy, osteotomy of the osseous fusion between metatarsals I and II, and metatarsal I lengthening using gradual osteodistraction. Tarsal fusions and other anatomical variants may be present and have to be corrected on an individual basis. Shoe fitting problems are frequently mentioned as indication for surgery while insole support may be helpful to alleviate abnormal plantar pressures. CONCLUSION: There is a particular need for multicenter studies to better elaborate surgical indications and treatment plans for this rare entity. Plantar pressure measurements using pedobarography should be enforced in order to document the biomechanical foot development and abnormalities during growth, and to help with indication setting. Treatment options may include conservative means (i.e. insoles, orthopedic shoes) or surgery to improve biomechanics and normalize plantar pressures. LEVEL OF EVIDENCE: Level V.

Peripheral Nerve Compression Syndromes in Children.

Nontraumatic neuropathies of the upper limb are rare in children. In this paper, we present the latest updates in this field and also critically review the diagnosis and treatment of nerve compression syndromes in children. This review describes the most common manifestations including idiopathic carpal tunnel syndrome (CTS), CTS occurring as a component of lysosomal storage diseases (mucopolysaccharidosis) and hereditary neuropathies, ulnar nerve neuropathy, and atraumatic radial nerve neuropathies.

Current Trends and Variations in the Treatment of Unicameral Bone Cysts of the Humerus: A Survey of EPOS and POSNA Members.

BACKGROUND: A variety of treatment methods have so far been described for unicameral bone cysts (UBC). However, to the best of our knowledge, no particular consensus has yet been reached on when to operatively treat a patient with a humeral UBC. Therefore, members of the European Pediatric Orthopedic Society (EPOS) and Pediatric Orthopedic Society of North America (POSNA) were surveyed to characterize current treatment preferences. METHODS: An online electronic questionnaire was sent out to all registered EPOS and POSNA members. The survey comprised 45 questions related to the diagnosis, treatment, and follow-up characteristics of patients with UBCs of the humerus. Particular questions related to the nonoperative or surgical treatment of pathologic proximal humerus and humeral shaft fractures were also included. RESULTS: In total, 444 participants (132 EPOS and 292 POSNA members) responded, of whom 400 were actively involved in UBC treatment. The preferred diagnostic modalities to confirm the diagnosis of a UBC in the humerus were radiographs (88%), MRI in cases of questionable diagnosis (58%) or CT scan (8%). For painless UBCs 67% prefer no treatment at all except when the fracture risk is deemed high (then 53% recommend surgery); 71% of respondents would treat painful UBCs with surgery. Most common surgical techniques comprise curettage (45%), artificial bone substitutes (37%), corticosteroid injection (29%), or intramedullary stabilization (eg, rodding; 24%).Fractured, nondisplaced and mildly displaced proximal humerus UBCs and mildly displaced pathologic humerus shaft fractures are all preferably treated nonoperatively (94%, 91%, 83%, respectively). Severely displaced pathologic proximal humerus fractures are treated less often conservatively (36%) than surgically (40%), and severely displaced humerus shaft fractures are preferably treated surgically (63%) by intramedullary stabilization (60%). CONCLUSIONS: There is great variation among EPOS and POSNA members with regards to the diagnosis and treatment of UBCs in the humerus. Although some consensus on general treatment principles is seen, specific surgical treatment indications vary.Prospective randomized-controlled studies are needed to evaluate the outcomes of the different surgical approaches compared with nonoperative strategies. LEVEL OF EVIDENCE: Level V-expert opinion.

Evaluation of radiological instability signs in the distal radioulnar joint in children and adolescents with arthroscopically-verified TFCC tears.

INTRODUCTION: Recent reports in the adult literature reported the use of standardized radiographic measurement techniques to determine distal radioulnar joint (DRUJ) instability. The aim of this study was to evaluate the efficacy and accuracy of (1) the MRI-based modified radioulnar ratio technique and (2) the pisoscaphoid (PiSca) and radioulnar (RaUl) distances in true lateral radiographs in children and adolescents with arthroscopically-verified TFCC tears. MATERIALS AND METHODS: We retrospectively assessed lateral wrist radiographs and axial MRI sequences of 18 adolescent patients (22 wrists) who had arthroscopically-confirmed TFCC tears and compared them to similar imaging of a control group of 28 healthy patients (28 wrists). Three raters assessed the images twice in a 2-week interval. Intraclass correlation coefficients (ICCs), unifactorial ANOVA, and ROC analysis were performed with regards to the different radiographic variables. RESULTS: The interrater ICCs were almost perfect for all measurements except RaUl1, which showed a substantial agreement (0.751) among the three observers. The intrarater ICCs were almost perfect when measuring PiSca and MRI, and substantial to almost perfect for RaUl. Pearson's correlation showed a moderate, positive correlation between PiSca and RaUl distances (r = 0.608; p < 0.001), and a moderate, negative correlation between RaUl distance and MRI shift (r = - 0.486; p = 0.010). When the three core groups (peripheral, central tear, controls) were compared to each other regarding the radiographic instability parameters, only the MRI shift revealed a statistically significant difference (p = 0.003). Comparisons revealed significant differences between patients and controls (p = 0.004) and peripheral tears vs. controls (p = 0.001 and p = 0.010). The ROC analysis revealed a significant AUC only for the MRI (AuC 0.787 and p = 0.002). CONCLUSIONS: Children and adolescents with peripheral TFCC tears showed significantly increased instability parameters in MRI compared to controls. These measurement techniques are no replacement for a thorough clinical examination but may be helpful for indicating diagnostic wrist arthroscopy in ambiguous cases. LEVEL OF EVIDENCE: Level III; Diagnostic.

Outcomes after thumb carpometacarpal joint stabilization with an abductor pollicis longus tendon strip for the treatment of chronic instability.

INTRODUCTION: Instabilities of the thumb carpometacarpal (CMC) joint, caused by idiopathic ligamentous hyperlaxity, trauma or other conditions may lead to pain, functional impairment and eventually osteoarthritis. Several techniques have been described to enhance stability of the CMC 1. The aim of this study was to evaluate postoperative outcomes after CMC 1 joint stabilization using a soft-tissue procedure in patients with chronic instability. MATERIALS AND METHODS: This study was designed as a retrospective study with a single follow-up visit after a minimum of 1 year postoperatively. All patients who underwent stabilization of the CMC 1 with an abductor pollicis longus (APL) tendon strip for chronic, habitual instability were re-assessed using clinical examination, dedicated outcome scores [Visual Analogue Scale (VAS); The Disability of the Arm, Shoulder and Hand (DASH) score; Nelson score; Kapandji opposition score], grip and pinch strength measurements, and radiographic examination. RESULTS: 12 patients (15 operated thumbs) with a mean age at surgery of 23.2 (± 9.3) years were included after a mean follow-up period of 3.5 (± 1.3) years. The postoperative outcomes indicated excellent results, with a mean DASH score of 13.3 (± 11.3), VAS 1.1 at rest (and 2.8 during stress) and Nelson score of 87.7 (± 11.3). Postoperative grip, pinch strength and passive stability were not significantly different between operated and non-operated sides (p = 0.852; p = 0.923 and p = 0.428, respectively). We observed one case of recurrent instability besides no other complications. However, patients with trapezium hypoplasia (5 of 12) were more prone to signs of radiographic instability during stress testing. CONCLUSIONS: Thumb carpometacarpal stabilization with an APL tendon strip yielded excellent clinical outcomes and low morbidity in the mid-term. However, long-term follow-up is needed to assess specifically whether patients with trapezium hypoplasia may be more prone to clinical symptom recurrence than those with normal anatomy. LEVEL OF EVIDENCE: Level IV.

Rebound of Frontal Plane Malalignment After Tension Band Plating.

BACKGROUND: Despite the popularity of tension band plating (TBP) current literature lacks clinical data concerning recurrence ("rebound") of frontal plane malalignment. This study investigated the rebound phenomenon after TBP in idiopathic genu varum/valgum deformities. We analyzed factors that may contribute to the development of rebound after removal of TBP. METHODS: Patients who had correction of idiopathic valgus or varus deformities by TBP at the distal femoral and/or proximal tibial growth plate were selected from a prospective consecutive database. Only patients who had plates removed for at least 1 year and had a long standing radiograph of the lower limbs before plate removal were included. Patients who had presumably not yet reached skeletal maturity (age under 14 y for girls and under 16 y for boys) were excluded. The change of the mechanical axis from plate removal to follow-up after skeletal maturity was evaluated and a statistical analysis was performed. RESULTS: Twenty-nine patients (64 extremities) were eligible. The mean follow-up was 39.1 months (range, 12.3 to 67.3 mo). The mean mechanical axis deviation (MAD) was +0.8 mm (range, -26 to +22 mm) after plate removal and -2.4 mm (range, -29 to +27 mm) at follow-up, accounting for a significant change of MAD (P=0.046). We observed a mean, relative recurrence of frontal plate malalignment into valgus direction of -3.2 mm (range, -48 to +23 mm). Twenty extremities (31%) showed <3 mm of MAD change; 27 extremities (42%) showed >3 mm of MAD change into valgus, and 17 extremities (27%) >3 mm of MAD change into varus direction. Patients with <3 mm MAD change had only 0.8 years, and those >3 mm a mean of 2.0 years of remaining growth until skeletal maturity. Each additional m/kg of body mass index increased the risk of valgus recurrence by 12.1%. The 3 genua vara patients revealed to have an even higher rate of malalignment recurrence (4 of 6 limbs) at final follow-up. CONCLUSIONS: Given our strict criteria, there is a high rate of radiologic recurrence of frontal plane malalignment after TBP. Children who are more than 1 year before skeletal maturity at TBP removal, and those with increased body mass index are at higher risk for rebound growth. LEVEL OF EVIDENCE: Level IV-consecutive therapeutic case series.

Radiographic Criteria for Undergoing an Ulnar Shortening Osteotomy in Madelung Deformity: A Long-term Experience From a Single Institution.

BACKGROUND: There are no established guidelines on the age or the severity of deformity for which an ulna shortening osteotomy or ulna epiphysiodesis should be performed in children and adolescents with Madelung deformity. The purpose of this study was to identify radiographic criteria associated with the eventual performance for an ulna shortening procedure in this patient population. METHODS: We retrospectively identified 41 wrists in 31 Madelung patients (mean±SD age 13.8±3.2 y) subjected to surgical correction of their deformity between 1999 and 2013. We assessed established radiographic criteria (ulnar tilt, lunate subsidence, palmar carpal displacement, ulnar variance) at preoperative and postoperative visits. Univariate and multivariate analyses were carried out to determine which radiographic criteria were associated with the performance of an "ulnar shortening procedure" at the first (index) surgical procedure. RESULTS: Eleven wrists were subjected to an ulna shortening osteotomy at the index and 5 at subsequent procedures; 10 cases received an ulnar epiphysiodesis (mean age 13.4±1.5 y). Ulnar shortening at the index procedure was associated with significantly higher preoperative lunate subsidence, ulnar variance, and palmar carpal displacement. Ulnar variance of >5 mm and lunate subsidence >4 mm resulted in a respective 67% and a 53% likelihood of undergoing ulnar shortening osteotomy; palmar carpal displacement over 22 mm resulted in a 50% likelihood for ulnar shortening. Patients who required a subsequent procedure (n=8) showed a significant increase in palmar displacement between surgeries. None of the 10 cases with a primary ulnar epiphysiodesis received a subsequent ulnar shortening; none of those undergoing late ulnar shortenings had an ulna epiphysiodesis at their index procedure (at 10.3±4.3 y). CONCLUSIONS: Lunate subsidence, ulnar variance, and palmar carpal displacement were significant radiographic criteria for undergoing an ulnar shortening osteotomy at our institution. A shortening osteotomy may be prevented by early ulna epiphysiodesis in skeletally immature children older than 10 years of age. LEVEL OF EVIDENCE: Therapeutic level IV-case series.

Inter- and intrarater reliability of ulna variance versus lunate subsidence measurements in Madelung deformity.

PURPOSE: To assess inter- and intrarater reliability of both ulna variance and lunate subsidence measurement methods in a large consecutive series of children with Madelung deformity. METHODS: Ulnar variance and lunate subsidence were measured on 41 standard anteroposterior wrist radiographs from 31 patients with Madelung deformity. The patients had a mean age of 13 years (range, 5-25) at the time of presentation. Two pediatric orthopedic hand/upper limb surgeons evaluated all radiographs twice in a 4-week interval using standard digital imaging software. Intraclass correlation coefficients (ICCs) were calculated for inter- and intrarater reliability, and results were reported using the Landis and Koch criteria. RESULTS: The interrater ICC for the ulna variance measurements was substantial, and for the lunate subsidence almost perfect. The intrarater ICC for ulna variance was substantial for both raters. In contrast, the intrarater ICC for lunate subsidence was almost perfect for both raters. CONCLUSIONS: Measurement of lunate subsidence showed both superior interrater and intrarater reliability compared with the ulnar variance method. Whenever relative ulna length is assessed in children and adolescents with Madelung deformity, the lunate subsidence should be the preferred method to characterize deformity.