Pubo-femoral distance in selective ultrasound screening of developmental dysplasia of the hip.

BACKGROUND: Developmental dysplasia of the hip (DDH) incidence is already debated due to different types of screening techniques. Despite of that, timely treatment of this pathology is necessary to reduce complications on the hip joint. METHODS: A retrospective study has been performed on the incidence of DDH in Marche region (Italy) in 2017. Epidemiological data have been collected and evaluated. 302 ultrasound images stored in the hospital archives were selected to measure pubo-femoral distance (PFD) and bony rim percentage (BRP). PFD and BRP values were compared with α and ß angles measured by Graf method. RESULTS: DDH incidence was 12%. Girls were more affected than males (ratio 3:1). Right side was more involved, 20% of patient had familiarity with DDH, 7% were breech babies and 15% suffered from other congenital orthopedic diseases. PFD in pathological hips was 3.21 mm (0.60-7 mm) and 2.47 mm (0.80-5.30 mm) in normal hips (P<0.005). Dispersion of PFD with respect to α and ß angles showed that PFD grows with increasing ß angle values and decreasing α angles. BRP in pathological hips was 47.29%, while in normal hips was 49.53% (<3 months). BRP was 49.71% in normal hips and 45.83% in pathological ones (>3 months). BRP measurement did not match the expected results, requiring more studies before its adoption in clinical practice. CONCLUSIONS: Our study evidenced the DDH incidence in Marche region and helped to validate a new screening technique consisting in measuring of PFD. For a full BRP validation, future studies will still be required.

Resorbable magnesium screws for fixation of medial epicondyle avulsion fractures in skeletally immature patients: A comparison with Kirschner wires.

Background: Displaced medial epicondyle fractures are treated with open reduction and internal fixation with K-wires or screws. Rates of implant prominence, failure, or non-union reported are considerable. Magnesium screws have demonstrated biocompatibility, osteoconductivity, and high pull-out strength. The aim of this study was to compare surgical fixation of medial epicondyle fracture using resorbable magnesium Herbert screws to K-wires, in skeletally immature patients. Methods: A retrospective analysis was performed from January 2015 to April 2020. Inclusion criteria were as follows displaced medial epicondyle fracture, <15 years, and absence of concomitant ipsilateral upper limb fractures. Two consecutive cohorts based on fixation device were made: Group A (wires) and Group B (magnesium screws). Alignment, pain, range of motion, Mayo Elbow Performance Score, and radiological healing were assessed. Results: A total of 27 patients were included: 15 in Group A and 12 in Group B. Groups were comparable for age and sex. Mean follow-up was higher in Group A (38.73 ± 3.15 vs 26.18 ± 4.85 months; p < 0.001). No significant differences were observed regarding range of motion, alignment, pain, and Mayo Elbow Performance Score, with excellent results in both groups. Two patients in Group A developed a deep wound pin site infection requiring antibiotics. X-rays revealed three cases of non-union in Group A and one in Group B, all of them asymptomatic. No patient required a second surgical procedure. Conclusion: Open reduction and internal fixation of medial epicondyle fractures with magnesium screws showed comparable results to a widely accepted procedure such as the use of K-wires, potentially with a lower incidence of non-union and infection. No adverse reactions were recorded. Level of evidence: level III.

Relapse in surgically treated clubfoot: treatment approach and midterm results of revision surgery.

BACKGROUND AND AIM: The rate of recurrence of surgically early treated clubfoot is around 25% and the treatment of clubfoot recurrence remains debated. The aim of the study is to report a case series of 15 patients (16 feet) surgically treated for relapse of surgically treated clubfoot. METHODS: A careful clinical and radiological evaluation of each deformity was made. The treatment algorithm was based on the pathological anatomy of the relapse, on the patient's age and on the use of a combination of surgical steps involving bones, soft tissue or both. RESULTS: The average age of patients at the time of relapse treatment was 8 years and 6 months, with an average follow-up of 2 years. The average Avatar score was 77 (good result). The 16 feet submitted to evaluation obtained the following scores: 6 excellent, 4 good, 4 mediocre and 2 poor. CONCLUSIONS: The number of previous interventions does not seem to be related to the outcome. The clinical and radiological evaluation of the deformity is the most important step for the right application of the algorithm. The use of a treatment approach based on age and on the systematic treatment of bony and soft tissues leads to reproducible clinical results with functional improvement.

Coronal plane deformity around the knee in the skeletally immature population: A review of principles of evaluation and treatment.

Coronal plane deformity around the knee, also known as genu varum or genu valgum, is a common finding in clinical practice for pediatricians and orthopedists. These deformities can be physiological or pathological. If untreated, pathological deformities can lead to abnormal joint loading and a consequent risk of premature osteoarthritis. The aim of this review is to provide a framework for the diagnosis and management of genu varum and genu valgum in skeletally immature patients.

The use of 3D printed models for the pre-operative planning of surgical correction of pediatric hip deformities: a case series and concise review of the literature.

BACKGROUND AND AIM: Three-dimensional (3D) printing is prevailing in surgical planning of complex cases. The aim of this study is to describe the use of 3D printed models during the surgical planning for the treatment of four pediatric hip deformity cases. Moreover, pediatric pelvic deformities analyzed by 3D printed models have been object of a concise review. METHODS: All treated patients were females, with an average age of 5 years old. Patients' dysplastic pelvises were 3D-printed in real scale using processed files from Computed Tomography (CT) or Magnetic Resonance Imaging (MRI). Data about 3D printing, surgery time, blood loss and fluoroscopy have been recorded. RESULTS: The Zanoli-Pemberton or Ganz-Paley osteotomies were performed on the four 3D printed models, then the real surgery was performed in the operating room. Time and costs to produce 3D printed models were respectively on average 17:26 h and 34.66 €. The surgical duration took about 87.5 min while the blood loss average was 1.9 ml/dl. Fluoroscopy time was 21 sec. MRI model resulted inaccurate and more difficult to produce. 10 papers have been selected for the concise literature review. CONCLUSIONS: 3D printed models have proved themselves useful in the reduction of surgery time, blood loss and ionizing radiation, as well as they have improved surgical outcomes. 3D printed model is a valid tool to deepen the complex anatomy and orientate surgical choices by allowing surgeons to carefully plan the surgery.

Remodeling of distal radius fractures in children: preliminary retrospective cost/analysis in level II pediatric trauma center.

BACKGROUND AND AIM: Children displaced distal radius fractures (DRFs) are commonly treated by reduction. Yet, their excellent remodeling ability provides good clinical-radiographic outcomes even in case of non-anatomical reduction. The reduction under analgesia or sedation involves hospitalizations, greater risks, and higher hospital costs. The aim of this preliminary study is to demonstrate the accountability and conveniency of non-anatomical reduction. METHODS: The study involved all 0-8 years-old children who were affected by a closed overriding DRF from February 2017 to December 2018 and were managed non-operatively by a long arm cast without reduction, analgesia, or sedation treatments. We retrospectively evaluated their clinical-radiographic outcomes and healing time. The costs of no-reduction treatments were compared with those of the two main approaches to DRFs, that is: closed reduction under sedation and application of a long arm cast; closed reduction under anesthesia, percutaneous pinning, and application of a long arm cast. The comparison was based on the Diagnosis Related Group system. RESULTS: We treated 11 children with an average initial radial shortening of 5±3 mm and average initial sagittal and coronal angulations of 4.0° and 3.5°, respectively. Average casting duration was 40 days. All patients achieved a full range of wrist motion without deformities. The procedure was respectively 7 times less expensive than closed reduction in emergency room under sedation and application of a long arm cast, and 64 times less expensive than closed reduction in the operating room under anesthesia, percutaneous pinning, and application of a long arm cast. CONCLUSIONS: In children aged 0-8 years, non-operative treatment of closed overriding DRFs with a long arm cast without reduction is a simple and cost-effective procedure with both clinical and radiographic medium-term excellent outcomes.

Use of resorbable magnesium screws in children: systematic review of the literature and short-term follow-up from our series.

PURPOSE: Biodegradable implants are of major interest in orthopaedics, especially in the skeletally immature population. Magnesium (Mg) implants are promising for selected surgical procedure in adults, but evidence is lacking. Thus, the aim of this study is to analyze the safety and efficacy of resorbable Mg screw in different orthopaedic procedures in skeletally immature patients. In addition, we present a systematic review of the current literature on the clinical use of Mg implants. METHODS: From 2018 until the writing of this manuscript, consecutive orthopaedic surgical procedures involving the use of Mg screws performed at our centre in patients < 15 years of age were retrospectively reviewed. In addition, a systematic review of the literature was performed in the main databases. We included clinical studies conducted on humans, using Mg-alloy implants for orthopaedic procedures. RESULTS: A total of 14 patients were included in this retrospective analysis. Mean age at surgery was 10.8 years (sd 2.4), mean follow-up was 13.8 months (sd 7.5). Healing was achieved in all the procedures, with no implant-related adverse reaction. No patients required any second surgical procedure. The systematic review evidenced 20 clinical studies, 19 of which conducted on an adult and one including paediatric patients. CONCLUSION: Evidence on resorbable Mg implants is low but promising in adults and nearly absent in children. Our series included apophyseal avulsion, epiphyseal fractures, osteochondritis dissecans, displaced osteochondral fragment and tendon-to-bone fixation. Mg screws guaranteed stable fixation, without implant failure, with good clinical and radiological results and no adverse events. LEVEL OF EVIDENCE: IV - Single cohort retrospective analysis with systematic review.

Pediatric trans-olecranon fracture dislocation of the elbow associated with fracture of the radial head and with medial collateral ligament lesion: A case report and review of the literature.

INTRODUCTION: We report what is, to the best of our knowledge, the first case of pediatric trans-olecranon fracture dislocation of the elbow associated with a radial head fracture and with a medial collateral ligament disruption. CASE PRESENTATION: A 7-year-old girl presented to the emergency department after a fell on his right elbow while playful activity at home. The elbow X-ray showed acute trans-olecranon fracture dislocation of the elbow associated with a radial head fracture. A pre-operative 3D TC scans confirmed and clarified the injury pattern. However, stress radiographs performed in the operating room under anesthesia revealed an associated severe valgus instability caused by medial collateral ligament disruption. The olecranon fracture was fixed with two crossing 1.5 mm K-wires and the angulated radial neck fracture was fixed with a retrograde 1.5 mm K-wire by S.E.R.I. technique. CONCLUSION: Although trans-olecranon fracture dislocation of the elbow is well recognized and clearly described in adults, it is uncommon in children. A pre-operative 3D TC scans are recommended to enable a more accurate diagnosis and surgical planning. Medial collateral ligament has a central role in elbow stability and is very important to repair it during surgery.

Percutaneous k-wire leverage reduction and retrograde transphyseal k-wire fixation of angulated radial neck fractures in children.

PURPOSE: To describe clinical and radiographic outcomes after surgical management of angulated radial neck fracture in children. METHODS: Twenty children (aged 2-11 years) with angulated radial neck fracture with more than 30° angulations (Judet type III and IV fractures) were retrospectively reviewed. All the enrolled patients were surgically treated with percutaneous k-wire leverage reduction and retrograde transphyseal k-wire fixation. Clinical outcomes were evaluated using Tibone and Stoltz score and the Mayo Elbow Performance Score (MEPS). Radiographic outcomes were evaluated with Métaizeau score. Complications were also evaluated. RESULTS: At a mean follow-up of 20 months, no patients showed axial deformity of the upper limb or instability of the elbow. The mean value of the MEPS was 99.2, and excellent clinical results were achieved in 14 patients (73.7%) at Tibone and Stoltz score. The final X-rays showed fracture healing in all patients; furthermore, 75% of patients showed excellent reduction at Métaizeau score. No patient developed complication. There were no iatrogenic nerve injuries or pin infections. CONCLUSIONS: The results demonstrate that percutaneous k-wire leverage reduction and retrograde transphyseal k-wire fixation of angulated radial neck fracture treatment is a simple, effective, rapid and inexpensive procedure. LEVEL OF EVIDENCE: IV (case series and systematic review of level IV studies).

Pediatric intervertebral disc calcification: case series and systematic review of the literature.

Pediatric intervertebral disc calcification (PIDC) is an uncommon disease with an unclear etiology. The clinical picture may suggest a severe spinal disease, thus involving an extensive differential diagnosis. The aim of this study was to find a diagnostic and treatment approach for PIDC on the basis of the literature. The Medline, Embase, Web of Science, and Cochrane Systematic Review databases were searched for relevant studies, whose reference lists were checked manually for additional articles. For each study, year of publication, study design, demographics, onset type, history of trauma, clinical and neurological signs and symptoms, imaging studies performed, blood test results, treatment strategies, and outcomes were recorded. The charts of eight patients with symptomatic PIDC treated at our institution from 2000 to 2016 were reviewed. Of 1522 articles identified by the search, 51 level IV studies involving 91 patients fulfilled the inclusion criteria. Most patients were treated conservatively and achieved complete recovery. Of the 13 patients who were treated surgically, one had a persistent myelopathy at the final follow-up. All the patients of our case series were treated conservatively and achieved complete symptom resolution at the final follow-up. PIDC is predominantly a benign and self-limiting condition. Surgery should be considered only in case of failure of conservative treatment in the presence of severe neurological impairment and myelopathy. Level of Evidence: IV (case series and systematic review of level IV studies).

Unilateral uniplanar modular external fixator for percutaneous proximal femoral osteotomy in children: surgical technique.

Varus derotation femoral osteotomy (VDFO) is a commonly used surgical procedure in association with pelvic osteotomy for dislocated hip in developmental hip dysplasia. Several types of internal fixation devices were described in the literature, but none of them showed a superiority or a lower rate of complication over the others. Different types of external fixator were also described for proximal osteotomy fixation with good results. We describe the surgical technique of the VDFO using a modular external fixator with an illustrative case.

Midshaft clavicle fractures treatment: threaded Kirschner wire versus conservative approach.

Clavicle fractures are common, accounting for 2.6 to 10% of all fractures. Treatment of these fractures is usually non-surgical. Recent evidence, however, reveals that the final result of non-surgically midshaft clavicular fractures, particularly those with quite large displacements or shortening, is not like that which was previously thought. This study evaluated retrospectively all patients presented with a clavicle fracture at Emergency Department of our Institution, between January 2006 and December 2011. Fractures were classified according to Allman's radiographic classification system, modified by Nordqvist and Petersson. Patients were distinguished into two groups: one that underwent conservative treatment with a "figure-of-8" orthosis and one that underwent surgery with reduction in fracture and fixation with intramedullary threaded Kirschner wire. Pin removal was performed after 4 weeks of rest in Gilchrist bandage, after clinical and radiographic evaluation demonstrating the bone healing. The QuickDASH score and the Constant Murley Shoulder Score were used to evaluate the clinical outcomes. The radiographic outcome was evaluated at 1 and 6 months of follow-up. Database review provided a final cohort of 58 patients, with similar demographic features. There was no significant difference in qDASH and CS between the two groups. The results of qDASH and CS evaluated in function of the radiographic outcome show a statistically significant correlation between the worst qDASH and CS results and the grade of malunion in both groups. In particular, we have found unsatisfactory results when final shortening of the clavicle was 20 mm or more. On radiographic evaluation, surgical treatment demonstrated a greater efficacy in reducing initial shortening of the fractured bone; this is in opposition to conservative treatment that results very often in malunion, shortening, anatomic alterations and loss of functionality. The use of intramedullary threaded Kirschner wire for fixation of midshaft clavicle fractures is a safe procedure and is recommended in case of shortening greater than 2 cm in high-function-demand patients.

Intramedullary nailing versus external fixation in Gustilo type III open tibial shaft fractures: a meta-analysis of randomised controlled trials.

Open tibial shaft fractures are the most common of long-bone open fractures. Management of the fracture is either by intramedullary nailing (IMN) or by external fixation (EF). Since the literature does not indicate clearly which is more effective, a meta-analysis was conducted to establish which approach is more suitable to treat Gustilo type III fractures. MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE and CINAHL databases were searched for randomised controlled trials (RCT) describing IMN and EF treatment of Gustilo type III fractures. As of 15 November 2012, five RCT involving 239 patients had been published; the outcomes examined in this study are their surgical complications. Data analysis led complications to be grouped into infection, fracture healing problems (non-union, malunion) and "other complications" (vascular injury, revision surgery, soft tissue damage, mechanical failure and tibial malalignment). IMN was associated with lower rates of infection and fracture healing problems; the differences between the two approaches for "other complications" were not significant. The data indicate that IMN is the treatment of choice for Gustilo type III fractures.

Treatment of pseudoarthrosis after minimally invasive hallux valgus correction.

OBJECTIVE: Treatment of mild and moderate hallux valgus deformities. DISCUSSION: Minimally invasive technique enables surgeons to treat mild and moderate hallux valgus deformities with excellent and good results in the majority of patients. Nonunion of first metatarsal, moreover, has only rarely been reported. SUMMARY: We describe the essential steps of a surgical technique for the treatment of nonunions after miniinvasive subcapital first metatarsal osteotomy reconstructed using a tricortical iliac crest bone graft.

Chopart arthrodesis with graft bone from the iliac crest after a traumatic subamputation of the forefoot: surgical technique.

We present a 49-year-old man with a traumatic subamputation of the forefoot, associated with lacerated wound in correspondence of the dorsal surface of the right foot, with injuries of tendinous, ligamentous and vascular structures and with the loss of talus head. The patient underwent salvage arthrodesis of the talonavicular and calcanealcuboid joints with graft bone harvested from the iliac crest. The patient was re-evaluated during a clinical and radiographic follow-up. The arthrodesis was consolidated in ∼3 months. There were no infectious problems and the patient has resumed normal work activities. At a sixth month follow-up, the patient had returned to work and remained pain free while walking. Early anatomic reduction, stable fixation and ligament reconstruction are essential for a good outcome. Primary arthrodesis is a viable option for severe midfoot fracture dislocations, because it facilitates rehabilitation and functional recovery and obviates the need for a secondary arthrodesis should arthritis arise.

Operative delay and mortality in elderly patients with hip fracture: an observational study.

BACKGROUND: Hip fracture is the third cause of death among the elderly and appears to be increasingly frequent. We analysed the influence of the major variables in hip fracture management in relation to 30-day mortality. MATERIALS AND METHODS: The records of all patients with isolated hip fracture treated at a regional trauma centre from January 1995 to September 2008 were reviewed. Data on demographics, comorbidities, operative delay, complications, functional status at discharge and mortality were collected and subjected to univariate and multivariate analysis. RESULTS: The cohort included 1,199 patients; the mortality rate was 11.7%. Surgery was performed within 48 h of injury in 17.7% and after more than 48 h in 82.3%; the mortality rate was 9.27% in the former and 10.4% in the latter patients; however, at variance with previous reports, operative delay was not associated with a worse outcome in patients with comorbidities. CONCLUSIONS: Our data support the policy envisaging fracture repair within 48 h in stable patients and delayed surgery (>48 h) in those with comorbidity conditions requiring stabilization.

Treatment of osteoid osteoma with CT-guided percutaneous radiofrequency thermoablation.

Osteoid osteoma is a benign bone tumor with a male predominance occurring mainly in children and young adults. The most common symptom is intermittent pain that worsens at night and is at least partially relieved by nonsteroidal anti-inflammatory drugs. The purpose of this study was to assess the long-term effectiveness of computed tomography-guided percutaneous radiofrequency thermoablation in patients with a minimum follow-up of 2 years. Twenty patients with osteoid osteoma (15 men and 5 women) with a mean age of 20.7 years (range, 4-61 years; 12 patients aged 20 years or younger) underwent computed tomography-guided percutaneous radiofrequency thermoablation. Lesion sites were the femur (n=9), tibia (n=7), pelvis (n=1), talus (n=1), cuneiform bone (n=1), and humerus (n=1). Mean follow-up was 44 months (range, 3-106 months). Pain relief was significant in 95% of patients; it disappeared within 24 hours in 14 patients, within 3 days in 4, and within 7 days in 1. The patient with persistent symptoms underwent another percutaneous radiofrequency thermoablation procedure that was successful. The difference between pre- and postoperative pain was significant (P ≤ .01). No recurrences occurred. Computed tomography-guided percutaneous radiofrequency thermoablation is a safe, minimally invasive, and economical procedure with high technical and clinical success rates, and it effectively and durably enhances quality of life.

Hospital cost of treating early dislocation following hip arthroplasty.

Dislocation is a frequent and costly complication of hip arthroplasty. The purpose of this study was to assess the financial impact on the treating institution of this complication in patients with primary hemiarthroplasty (HA), total hip arthroplasty (THA) and revision surgery (RTHA). Between October 2001 and August 2009, 2014 consecutive hip arthroplasties were performed at our institution, of which 87 (18 HA, 44 THA and 25 RTHA) dislocated within 6 weeks of the primary operation. The average cost of treating implant dislocation by closed reduction, open reduction or revision was assessed and expressed as a percentage cost increase compared to an uncomplicated procedure. Of the 87 dislocated implants all needed one or more closed reductions and 52 eventually required revision surgery. An early dislocation increased the cost of HA, THA and RTHA by 472%, 342% and 352%, respectively.