Management of post-traumatic ankle deformities in children.

The objective of this clinical appraisal was to assess the clinical-radiological results of ankle deformity correction secondary to physeal injury, utilizing the methods based on the age of the child, site & severity of the deformity, remaining growth potential, condition of the soft tissue envelop and integrity of neurovascular status. Fifteen subjects ≤ 16 years of age, with angular deformities of the ankle secondary to physeal injury, were included. Deformities secondary to infection and pathological fractures were excluded. Demographic data, type of injury, treatment method, and follow-up were recorded from the case files. Treatment categories included osteotomies for acute correction (> 10 years) and growth modulation (≤ 10 years). Male to female ratio was 7:8, with an average age of 11.8 ± 2.31 years (range 9-16 years). The right and left ratio was 7:8. Mean duration of follow-up was 1 year and 4 months. Gradual deformity correction was done in 2 cases utilizing the principle of growth modulation, while acute correction by osteotomy was done in 13 cases. The average pre-operative ankle deformity was 20.8 ± 3.11 degrees (Range -25 to 24 degrees). Radiological union was attained at a mean of 11 weeks (8-24). Nine patients achieved neutral ankle alignment. The mean residual varus was 2.3°, and the valgus was 4°. There was a statistically significant improvement of the AOFAS score by 17 points from a mean pre-operative score of 57 (44-84) to 74 (56-100) points at the final follow-up (p-value < 0.001). The average pre-operative shortening was 2.36 ± 0.21 cm, which was completely corrected in 9 individuals. Management of angular deformities around the ankle calls attention to correcting the resultant angular deformity and/or limb length disparity, utilizing acute or gradual correction. A successful outcome depends on early recognition and patient-specific treatment of paediatric ankle fracture patterns. Correlating the results of our study with the available literature, we feel that both acute or gradual correction for angular deformities around the ankle is a feasible solution as long as principles of deformity correction are adhered to. Techniques for salvaging and restoring the viability of injured physeal plate warrant additional research.

Does early stable fixation reduce complications in paediatric femoral neck fractures?

The primary objective of this study was to juxtapose the union rate and incidence of complications in paediatric patients presenting early (≤ 7 days) following injury with children presenting later (> 7 days) with femoral neck fractures. This critical appraisal evaluated 15 patients according to their timing of presentation and surgery from the initial day of injury (Group A: operated ≤ 7 days or Group B: > 7 days of injury). Patients with traumatic femoral neck fractures with Delbet 1 to 4 subtypes who were skeletally immature (age ≤ 16 years) were included in the study. Pathological fractures and post-infective fractures were not included. Each patient's secondary loss of reduction was calculated by measuring the Neck shaft angle (NSA) on the immediate post-operative radiograph and at the union. A change in NSA of ≥ 5 degrees was considered a significant loss of reduction. Ratliff's Criteria was used to analyze the final result, and a thorough record of complications was kept. There were no significant variations in the two groups' with respect to distributions of age, sex, injury mechanism, or fracture pattern. The most frequent injury culprit in both groups was falling from a height. Type II fracture pattern (54.54%) was more common in group A, while Type III and Type II fracture pattern was equally distributed in group B. In group A, the mean operation time was 55 ± 8.25 minutes, whereas in group B, it was 65 ± 15 minutes (p-value > 0.05). In group A, 90.9% of patients underwent CCS fixation, and in group B, 75% underwent fixation by CCS. The quality of reduction in post-operative radiographs was anatomical in 10 (90.9%) patients and unacceptable in 1 (9.1%) patient. In group B, 2 (50%) patients had an anatomical reduction, while 2 (50%) patients had an unacceptable reduction. Timing of reduction and its association with complications showed that early stable reduction and fixation decrease the occurrence of complications in femoral neck fractures (p-value = 0.033). Fracture union was seen in all our patients in both groups and none of our patients underwent non-union. The mean union time was 11.11 ± 7.06 weeks in group A and 16.5 ± 2.59 weeks in group B (p-value = 0.0189). In group A, only 1 (9.1%) patient developed coxa vara. In group B, out of 4 patients, the femoral head of one patient underwent avascular necrosis, one patient exhibited coxa vara, and 1 patient developed premature physeal closure with limb length inequality. Management of femoral neck fractures in children is challenging because of the paediatric bone's peculiar anatomic and physiological considerations. In our study, patients operated within 7 days developed fewer complications as compared to patients who were operated after 7 days, which was statistically significant. Although AVN is a frequent adverse consequence of pediatric femoral neck fractures, early reduction and stable fixation lowers AVN rates, as observed in our study. Our short-term functional and radiological results using the Ratliff scoring system were comparable to previous studies owing to stable anatomic reduction. Based on our findings and the existing literature, we emphasize long-term follow-up and recommend an early stable anatomic reduction in the treatment of paediatric femoral neck fractures.

Medial swivel dislocation of talonavicular joint: a case report and literature review.

Midtarsal dislocations of the foot are rare injuries. Most descriptions of these injuries state that they develop due to high-energy trauma. We present a case of low-energy trauma leading to a medial swivel dislocation of the talonavicular joint, which was reduced by a closed method and immobilized in a cast. A 48-year-old non-diabetic male with no rheumatoid symptoms or any steroid injection suffered low-energy trauma to his right foot and presented to the emergency department with pain, tenderness and with his foot adducted. On X-rays and NCCT, it was found to be medial type swivel dislocation of the Talonavicular joint with a fractured base of the fifth metatarsal and talar head impaction fracture with talocalcaneal joint subluxation. Closed reduction under sedation was done successfully, which was stable on stressing under fluoroscopy, so the foot was immobilized in a cast without internal fixation. Talonavicular dislocations are rare injuries, with most of them requiring open reduction and internal fixation. Low-energy trauma can also lead to talonavicular dislocations, which, if stable after reduction, can be immobilized in a cast without internal fixation.

Arthroscopic debridement of the ankle in synovitis.

Inflammation and hypertrophy of the ankle joint's synovial lining can occur due to various causes. Chronic pain and degenerative changes may be due to synovitis causing clinical manifestations through traction on the joint capsule. The failure of conservative treatment for at least six months indicates arthroscopic debridement, which can provide significant pain relief without the morbidity of extensive surgical exposures. This study was therefore conducted to establish the functional results of arthroscopic debridement of the ankle joint in synovitis. Fifteen patients with chronic ankle pain who had not responded to conservative treatment for approximately six months were included in the study. Arthroscopic debridement was performed using a shaver blade, followed by a postoperative ankle physiotherapy regimen. Patients were assessed preoperatively and postoperatively using the AOFAS, FADI, and VAS scores, with a mean follow-up period of 26 months. There was a significant improvement in the final clinical outcomes of the patients. The post-operative VAS score improved to 2.20±0.56 (2-4) (p-value=0.001), the AOFAS score was 86±8.25 (65-98) (p-value-0.001), and the FADI Score was 86.93±7.35(70-96) (p-value=0.001). Thirteen patients (86.67%) achieved outstanding or good results, while two had fair results, according to Meislin's criterion. One patient reported a superficial wound infection, which subsided with antibiotic therapy. The study findings indicate that arthroscopic ankle debridement is an efficient method to treat persistent ankle discomfort induced by synovitis, and it has a low postsurgical complications rate, quicker recovery, and less joint stiffness.

Haemophilic arthropathy of the knee: a surgeon's nightmare.

Surgical management of knee synovitis secondary to mild haemophilia, without any significant previous medical history and an adverse family history of haematological disorders, is arduous. Due to its rare occurrence, the diagnosis is often delayed or sometimes missed, leading to the grave and often lethal consequences in intraoperative and postoperative periods. Hardly isolated knee arthropathy due to mild haemophilia has been reported in the available literature. In this report, we present the management of a case of a 16-year-old male with isolated knee synovitis with undiagnosed mild haemophilia, who came to us with the first episode of knee bleeding. We elucidate the signs and symptoms, investigations, surgical management, and difficulties faced, especially during the postoperative period. This case report is presented to enhance awareness of the existence of this disorder and its management to prevent postoperative complications.

Pantalar dislocation: a rare presentation with review of treatment methods.

Pantalar dislocation means the simultaneous dislocation of the talocalcaneal, talonavicular, and tibiotalar joint. It is a rare injury comprising only 3.4% of major talar injuries. Treatment of closed Pantalar dislocation is controversial. However, the aim should be to attain a stable anatomic reduction of the Talus in the ankle joint. To prevent further damage to the skin and neurovascular structures, closed reduction of these dislocations should be performed as soon as possible. We report a case of Pantalar dislocation where we tried to reduce the talus both by closed and open methods but it was not possible to reduce the dislocation until the talonavicular joint was reduced first. Intending to improve the clinical knowledge of Pantalar dislocation, we want to convey our clinical experience and results from this rare dislocation.

Does an Adjustable-Loop Device Loosen following ACL Reconstruction with a Hamstring Graft? A Retrospective Study with a Follow-Up of Two Years.

Arthroscopic anatomic anterior cruciate ligament reconstruction (ACLR) is the gold standard treatment for an ACL tear and requires the use of fixed or adjustable-loop devices to fix a femoral-side graft. Although the adjustable mechanism is designed to provide one-way tensioning, there is a concern that the adjustable loop will loosen and lengthen during cyclic loads, creating graft laxity. The present paper is a retrospective study of patients who underwent ACLR with the fixation of a hamstring graft with an adjustable loop on the femoral side from November 2016 to October 2018. The knee's functional outcome was evaluated using an International Knee Documentation Committee (IKDC) score, Lysholm score, Lachman test, and pivot shift test. The patients were assessed preoperatively and finally postoperatively after two years of surgery. Thirty-two patients were analyzed. Significant improvement was obtained in the final clinical outcome of the patients. Twenty-seven patients (84.4%) were Lachman negative, and twenty-eight patients (87.5%) were pivot shift test negative, the mean Lysholm score was 96.91, and the IKDC score was 91.47 (p < 0.001). There was no infection, graft failure, or flexion restriction. Arthroscopic ACLR with an adjustable-loop suspensory device is a successful fixation method for femoral-side graft fixation and offers a similar functional outcome as with fixed-loop devices.