Can immediate postoperative radiographs predict outcomes in pediatric clubfoot?

BACKGROUND: The goal of treatment for pediatric idiopathic clubfoot is to enable the patient to comfortably walk on his or her soles without pain. However, currently accepted treatment protocols are not always successful. Based on the abnormal bone alignment reported in this disease, some studies have noted a correlation between radiographic characteristics and outcome, but this correlation remains debated. AIM: To assess the correlation between immediately postoperative radiographic parameters and functional outcomes and to identify which best predicts functional outcome. METHODS: To predict the outcome and prevent early failure of the Ponseti's method, we used a simple radiographic method to predict outcome. Our study included newborns with idiopathic clubfoot treated with Ponseti's protocol from November 2018 to August 2022. After Achilles tenotomy and a long leg cast were applied, the surgeon obtained a single lateral radiograph. Radiographic parameters included the tibiocalcaneal angle (TiCal), talocalcaneal angle (TaCal), talofirst metatarsal angle (Ta1st) and tibiotalar angle (TiTa). During the follow-up period, the Dimeglio score and functional score were examined 1 year after surgery. Additionally, recurring events were reported. The correlation between functional score and radiographic characteristics was analyzed using sample and multiple logistic regression, and the optimal predictor was also identified. RESULTS: In total, 54 feet received approximately 8 manipulations of casting and Achilles tenotomy at a mean age of 149 days. The average TiCal, TaCal, Ta1st, and TiTa angles were 75.24, 28.96, 7.61, and 107.31 degrees, respectively. After 12 mo of follow up, we found 66% excellent-to-good and 33.3% fair-to-poor functional outcomes. The Dimeglio score significantly worsened in the poor outcome group (P value < 0.001). Tical and TaCal showed significant differences between each functional outcome (P value < 0.05), and the TiCal strongly correlated with outcome, with a smaller angle indicating a better outcome, each 1 degree decrease improved the functional outcome by 10 percent. The diagnostic test revealed that a TiCal angle of 70 degrees predicts an inferior functional outcome. CONCLUSION: The TiCal, derived from lateral radiographs immediately after Achilles tenotomy, can predict functional outcome at 1 year postoperatively, justifying its use for screening patients who need very close follow-up.

Risk factors for loss of fixation in pediatric supracondylar humeral fractures.

OBJECTIVE: The aim of this study was to determine the risk factors for loss of fixation in pediatric supracondylar humeral fractures. MATERIAL AND METHOD: The data were analyzed regarding assessed loss of fixation in 256 supracondylar fractures from January 2010 to December 2012, all of which were treated by closed or open reduction and Kirschner wire fixation. The confounding factors that were thought to cause loss of reduction were collected. Multivariate logistic regression analysis was performed to predict risk factors. RESULTS: Reduction was lost in 14.8% of the patients. Poor surgical technique was significantly higher in the cases with lost reduction (odds ratio: 15.21). Additionally, cases with only lateral pins placement (odds ratio: 2.57), Gartland type 3 fractures (odds ratio: 2.38), and, obesity with a BMI ≥ 25 (odds ratio: 14.35) had a significantly higher risk of losing reduction and fixation. Other factors including age, energy type of injury, time of surgery, and time to surgery were not associated with risk. CONCLUSION: The loss of reduction following fracture fixation is associated with poor surgical technique,fixation with lateral pinning only, Gartland type 3 fractures, and pediatric obesity (BMI > 25). The stability of fracture fixation in pediatric supracondylar fractures is largely dependent on the use of effective fixation techniques. Cross pinning provides a more stabile fixation than lateral pinning.

Four-point molding: a new cast molding technique for closed reduction treatment of developmental dysplasia of the hip.

BACKGROUND: In order to achieve added stability in a hip spica cast and decrease unnecessary open reduction, the authors have devised a new hip spica cast molding technique that has been named, "Four-point molding technique". Our aim was to evaluate the efficacy of this technique, in terms of its ability to deliver a stable, concentric reduction of the hip. MATERIAL AND METHOD: The authors retrospectively reviewed the patients, aged 6-24 months, that were diagnosed with DDH and who had undergone closed reduction with a hip spica cast. The authors used the four-point molding technique on all patients. The authors evaluated radiographs for redislocation during the 12 weeks of cast treatment and followed-up to 1 year after hip spica cast removal. 15 children (15 hips) who were treated over a 14-year period were included in the present study to determine the success rate ofthis procedure. RESULTS: From 1996-2010, there were 15 unilateral DDH patients who were treated with the four-point molding technique. The average age of the patients at the time of the reduction was 17 months (age range: 8-23 months). The treatment was 86.6% successful in 13 children (95% CI 0.62-0.96). The average duration in the hip spica cast was 12.5 weeks. Mean follow-up was 23.1 months. Two children were unable to be concentrically reduced with sufficient stability with closed reduction and therefore required open reduction and osteotomy. CONCLUSION: Four-point molding is simple, gives good result, and with low complications. The authors propose this technique for use in closed reduction treatmentfor DDH.

Results of surgical treatment of coxa vara in children: valgus osteotomy with angle blade plate fixation.

BACKGROUND: Coxa vara is a rare condition. Surgical correction of coxa vara has been challenging. A few reports present correction coxa vara in multiple causes. In this retrospective study, the authors reported the results of surgical treatment of coxa vara by valgus osteotomy with angle blade plate fixation in 11 children with 12 hips. MATERIAL AND METHOD: Since 2002-2011, 11 children with 12 hips with coxa vara were reviewed retrospectively by medical chart and radiographic data after surgical treatment. All of them were operated by valgus osteotomy and fixation with angle blade plate. All of them had been hip spica cast between 8-12 weeks after surgery. Neck-shaft angle, Hilgenreiner-epiphyseal angle, leg-length discrepancy and Harris hip score were evaluated at preoperative, postoperative, and final follow-up. RESULTS: Twelve coxa vara; 4 malunion femeral neck fracture, 4 congenital coxa vara, 2 spondyloepiphyseal dysplasia and 1 multiple epiphyseal dysplasia were operated on in 11 patients. One spondyloepiphyseal dysplasia had bilateral coxa vara. The average age at surgery was 9.5 years (range, 7-12 years). The average time of follow-up was 4.2 years (range, 3-7years). The average neck-shaft angle was changed significantly from 79.8 to 123.7 degrees, the Hilgenreiner-epiphyseal angle was changed significantly from 70 to 39.3 degrees and leg-length discrepancy was changed significantly from 2.2 to 1.7 centimeters at final follow-up. The average Harris Hip score was improved significantly from 68 at preoperative to 96 atfinalfollow-up. No complication or recurrence was found. CONCLUSION: Surgical treatment of coxa vara is uncommon treatment. The aims of treatment were to change the stress in the neck femur from shearing force to compression force and also improving shortening that could reduce incidence of further fracture and osteoarthritis. The Hilgenreiner-epiphyseal angle should be closed to 38-40 degree or less after surgery.