Efficacy and Complications of Fixator-Assisted Correction with Internal Fixation in the Genu Valgum.

Background and Purpose: Two basic methods for genu valgum correction are osteotomy and internal fixation or external fixator assited correction. External fixators have the advantage of stabilizing fragments before osteotomy allowing better control of fragments and preventing secondary displacements. The purpose of this study was to evaluate the efficacy and complications of fixator assisted correction for genu valgum and internal fixation, using the AO distal femur pediatric osteotomy plate. Materials and Methods: Thirty-six limbs in 26 patients (age 10-16 years) underwent osteotomy in the distal femur at CORA. Open lateral wedge osteotomy was done; the desired position obtained was temporarily stabilized by connecting the pins with the AO external fixator and stabilized with 90 degrees AO distal femur pediatric locking plate and gap grafted with hydroxyapatite bone granules. Results: Translation of distal fragment was required in 17 osteotomies (53.12%). Osteotomies united within 12 weeks; no non-union was observed. The range of motion was full in all patients. The mean tibiofemoral angle was corrected by 12 degrees and the mean mechanical LDFA was corrected to 87 degrees. There was no secondary deformity, either in the rotational or sagittal plane. Conclusion: This method combines the modularity of external fixator and the advantages of internal fixation.

Reliability of Radiologic Classifications of Sequelae of Septic Arthritis of the Hip in Children.

OBJECTIVE: To the best of our knowledge, there is no study comparing the inter and intraobserver reliability of current classifications for postseptic hip sequelae in children. The current study aims to assess the interobserver and intraobserver reliability of four current classifications and identify hips that could not be classified in each classification system. METHODS: The hip radiographs of 148 consecutive children with sequelae of sepsis of the hip from 2 centers were assessed after a minimum of 2 years of follow-up after sepsis. All hips (affected and normal sides) were classified according to the 4 original descriptions of the authors of the respective classifications. If a hip did not fall into any subtype of the classification, the rater was asked to mark it as nonclassifiable and state the reason for being unable to classify the hip in the respective classification. The intraclass correlation coefficient was computed to assess the reproducibility of each classification. RESULTS: Interrater reliability and intrarater reliability were moderate (0.57 to 0.72) while including all hips. The reliability was poor (0.35 to 0.49) in all 4 classifications, with an evaluation of only affected 180 hips. A few sequelae of infection, including caput valgus (n = 7), acetabular dysplasia (4), joint space narrowing (2), and bony ankylosis (1), were not included in any of the 4 current existing classification systems. CONCLUSION: The reliability of all current classifications of sequelae of septic arthritis of the hip is moderate. A proportion of sequelae do not find a place in all current classifications. LEVEL OF EVIDENCE: Level III.

Post infective physeal bar sequelae around knee: Natural history and coronal plane deformities.

Background: and methodology: The presented retrospective study is a report of 17 children (18 limbs) with post infective physeal bars around the knee. Minimum 2 years follow up post sepsis follow up was available. Observations: The mean follow up post infection was 6.9 years. The bar formation manifested mean 22.6 months post sepsis. The angular deformity progressed at the mean monthly rate of 0.84, 0.1, 0.26° for peripheral, central and extensive bars respectively. Peripheral bars underwent early intervention. Balancing of physeal growth using contralateral '8' plate was useful for partial bars. For extensive bars and older patients, complete epiphyseodesis and limb length equalization was used. Articular abnormalities (cupping, flattening, small epiphysis) were associated in 80% bars. Neonatal infections were often multifocal and had articular abnormalities. Conclusions: The 3 bar types presented with different characteristics. Peripheral bars produced most angular deformities and required early intervention. Articular abnormalities were associated with physeal bars in large number of patients especially those with neonatal infections. Overall unhealthy physis beside bar, delayed manifestations, and limb length discrepancy should be accounted for while planning treatment.

Predisposing factors for migration of epiphyseal screws into physis in tension band plating.

The migration of epiphyseal screws into growing physis in tension band plating is a known complication. We investigated the screw migration into physis in 10 patients (18 plates) to study the various technical details, which may have contributed to this complication. The methodology involved retrospective review of radiological records. Among these 10 affected patients, in four patients, there were eight additional tension band plates, which had remained uncomplicated ('controls') at the time when implant failure was detected. We statistically compared the length of epiphyseal screw, proximity of screw start point to the physis, screw trajectory angle, interscrew angle and correction rate between the migrated and other uncomplicated plates. Majority patients were postrachitic ( n = 7). The mean time from primary procedure to detection of radiological complication was 15.1 months. The mean epiphyseal screw length proportion in migrated and uncomplicated plates matched. The starting point of epiphyseal screw was relatively closer to physis in migrated plates. The trajectory of epiphyseal screw with respect to physis was more divergent in the migrated plates ( P = 0.02). All implants were inserted in a divergent manner with mean interscrew angle being 22.3° for migrated and 13.8° for the uncomplicated plates ( P = 0.02). The correction rate of the implant reduced as it failed. Osteopenic bone and pathological physis predispose to migrated plates. Technically, a wider trajectory of epiphyseal screw and too divergent screws should be avoided. A migrated implant becomes less effective in its function.

Baksi procedure for habitual dislocation of patella in children - Revisiting the key surgical steps.

The pes anserinus transfer procedure for habitual dislocation of patella described by Baksi is a biomechanically sound technique with predictable long term results. The dynamic pes anserinus sling counteracts the lateral quadriceps contracture and keeps patella relocated till the vastus medialis activity is restored and takes over. The procedure is especially suitable for children with open physeal growth plates. Moreover, the surgery runs a low complication rate. In the present review, we recapitulated the steps of the procedure to illustrate its surgical basics. We also describe our experience and long term follow up results of 4 cases operated with same technique. The indigenous Baksi's procedure remains a viable option for managing habitual patellar dislocations in pediatric age group with immature skeleton.

Surgical delay for traumatic recurrent shoulder dislocations leads to inferior functional outcomes.

Background: The effect of time interval between injury and surgery on outcomes of Bankart repair surgery has not been published previously. The purpose of this study was to assess the effect of surgical delay on functional outcomes after arthroscopic Bankart repair. Method: One hundred and five athletes who underwent arthroscopic Bankart repair ± remplissage were enrolled in the study. Patients were divided into 2 groups depending upon the injury to surgery time- < 12 months (n = 19), and ≥12 months (n = 86). Depending upon the number of episodes of dislocation, patients were further categorized into 2 groups- <10 episodes (n = 66) and ≥10 episodes (n = 39). All patients were assessed post-operatively for functional outcomes (Modified Rowe's score, Constant Murley score) and return to sports at a minimum of 2 years of follow-up. Results: The mean injury to surgery time was 31.7 ± 23.1 months. The average number of episodes of dislocation before surgery were 10 (range 3-50). 49/105 (46.7%) patients returned to sports after a mean post-operative duration of 10.9 months. Athletes operated after a surgical delay of ≥12 months had inferior functional outcomes (Modified Rowe's score-89.5 ± 8.9 vs.77.4 ± 21.4; p = 0.02), lower rate of return to sports (14/19 vs. 35/86; p = 0.02) and higher mean time to return to sports (8.7 ± 1.9 vs. 11.5 ± 2.6; p < 0.05). Similarly, athletes who had ≥10 dislocations before surgery had inferior functional outcomes (Modified Rowe's score-84.5 ± 15.2 vs.72.9 ± 25.6; p = 0.004), lower rate of return to sports (37/66 vs. 12/39; p = 0.02) and higher mean time to return to sports (10.3 ± 2.4 vs. 12.6 ± 2.5; p < 0.05). Conclusion: A delay in surgery (≥12 months) or dislocation episodes of ≥10 are associated with inferior functional outcomes, lower rate of return to sports and higher surgical failure rate. Level of evidence: Level III; Prospective cohort study.