Is subclassification of Gartland extension-type pediatric supracondylar fracture into types IIA and IIB necessary for treatment decision? A result of pediatric orthopedist's survey and review of literature.

Extension-type pediatric supracondylar humeral fractures are very common. The Gartland classification is typically used to guide treatment. However, there is still no consensus on what factors should be used to subclassify the type II fractures and whether subclassification is needed to guide treatment. Therefore, we aim to explore the opinions of pediatric orthopedists on the treatment method of the Gartland type II supracondylar fracture. Specifically, we ask what factors are considered for their treatment decisions and whether subclassification is needed to guide treatment. An online questionnaire was developed and sent to the Thai Paediatric Orthopedics Society and Asia-Pacific Paediatric Orthopaedic Society members. The results were analyzed to explore the relationship between respondents' demographic factors and treatment decisions. Out of 113 participants reached, 57 (50.4%) responded to the questionnaire. Factors chosen by respondents are stability testing intraoperatively (73.7%), the relationship of the anterior humeral line and capitellum (66.7%), the presence of rotation (50.9%), the presence of translation (47.4%), the presence of medial comminution 42.1%), soft tissue condition(38.6%), the shaft - condylar angle (31.6%), and the Bauman angle (21.1%). Thirty-three of 57 respondents (57.9%) deemed subclassification for Gartland type II necessary for guiding treatment. About half of respondents in our study deemed the current Gartland type II subclassification necessary to guide treatment, which may indicate that the subclassification might not be sufficiently comprehensive and reliable. Therefore, better criteria for a subclassification and a prospective evaluating study might be needed.

Comparative effectiveness of treatment modalities in severe Legg­Calvé­Perthes disease: Systematic review and network meta­analysis of observational studies.

PURPOSE: There are several treatment modalities for Legg-Calvé-Perthes disease (LCPD), self-limiting, avascular osteonecrosis of the femoral head in children. Most treatments focus on containment of the weakened femoral head, but there is no consensus on the best modality for severe LCPD. Therefore, we compared the effectiveness of all treatment modalities for severe LCPD. MATERIALS AND METHODS: We searched the PubMed, Embase, and Scopus up until July 2021 for studies that investigated LCPD treatment effectiveness. A network meta-analysis was performed to examine the comparative effectiveness in terms of the ability to achieve radiographic spherical congruity of the hip joint after skeletal maturity. The risk ratio (RR) and 95% confidence interval (CI) of each treatment modality were estimated from both direct and indirect evidence. Treatment ranking was based on Surface Under the Cumulative Ranking curve (SUCRA). RESULTS: A total of 857 studies were identified and 34 comparative studies with 3718 affected hips comparing seven different LCPD treatment modalities were included. Compared with symptomatic treatment, combined osteotomy was the most effective modality (RR = 1.47, 95% CI 0.90 to 2.42, SUCRA = 0.8), followed by femoral varus osteotomy (RR = 1.31, 95% CI 1.06 to 1.60, SUCRA = 0.7), and Salter innominate osteotomy (RR = 1.25, 95% CI 0.95 to 1.65, SUCRA = 0.6). CONCLUSIONS: Combined osteotomy is the most effective procedure in terms of improving the spherical congruity of the hip joint in severe LCPD patients. However, the superiority of operative treatments seems to be limited to patients older than eight years old.

No Difference in the Incidence of Complications in Pediatric Patients with Moderate Anemia 30 Days after Pediatric Hip Surgery with and without Blood Transfusion.

This study investigated the association between postoperative blood transfusion and the incidence of postoperative complications 30 days after pediatric hip surgery as well as factors significantly associated with 30-day postoperative complications. Patients were divided into two groups: those with postoperative complications and those with no complications. Postoperative hematocrit (Hct) was categorized as <25%, 25-30%, and >30%. Comparison was made between all postoperative complications at the 30-day follow-up that were influenced by anemia in patients who received transfusion and those who did not. A multivariate logistic regression model was used to identify factors independently associated with postoperative complications. The overall 30-day postoperative complication rate for all patients was 17% (24/138). No significant difference between the transfusion and the non-transfusion patients was found. Preoperative hematocrit (Hct) was significantly lower in the complications group (p = 0.030), and both length of stay and 30-day readmission were significantly higher in patients with complications (p = 0.011 and p < 0.001, respectively). Multivariate analysis revealed female gender (OR: 3.50, 95% CI: 1.18-10.36; p = 0.026) and length of hospital stay (OR: 1.23, 95% CI: 1.08-1.41; p = 0.004) to be factors independently associated with 30-day postoperative complications. However, no statistically significant difference in the incidence of complications at 30 days following pediatric hip dysplasia surgery was found between patients who received blood transfusion to maintain a Hct level ≥25% and those not receiving transfusion.

Using Combinations of Both Clinical and Radiographic Parameters to Develop a Diagnostic Prediction Model Demonstrated an Excellent Performance in Early Detection of Patients with Blount's Disease.

Early identification of pathological causes for pediatric genu varum (bowlegs) is crucial for preventing a progressive, irreversible knee deformity of the child. This study aims to develop and validate a diagnostic clinical prediction algorithm for assisting physicians in distinguishing an early stage of Blount's disease from the physiologic bowlegs to provide an early treatment that could prevent the progressive, irreversible deformity. The diagnostic prediction model for differentiating an early stage of Blount's disease from the physiologic bowlegs was developed under a retrospective case-control study from 2000 to 2017. Stepwise backward elimination of multivariable logistic regression modeling was used to derive a diagnostic model. A total of 158 limbs from 79 patients were included. Of those, 84 limbs (53.2%) were diagnosed as Blount's disease. The final model that included age, BMI, MDA, and MMB showed excellent performance (area under the receiver operating characteristic (AuROC) curve: 0.85, 95% confidence interval 0.79 to 0.91) with good calibration. The proposed diagnostic prediction model for discriminating an early stage of Blount's disease from physiologic bowlegs showed high discriminative ability with minimal optimism.

Identifying children at high risk for recurrence child abuse.

PURPOSE: To evaluate the characteristics of abused children, families and abusive event and to identify risk factors associated with recurrence of child abuse. METHODS: Retrospective data from 133 children aged between 2 months to 15 years old who were diagnosed as abuse between year 2002 and 2017. Thirteen items related to characteristics of the child, families, abusive event were selected. These factors were analyzed by multivariate logistic regression model for association with repeated child abuse. RESULTS: Total of 133 subjects with average age of 5.25 ± 4.65 years old. There were 54 cases (40.60%) reported of repeated abuse. Majority of repeated abuse type in this study was physical abuse (73.68%). Most perpetrators were child's own parents (45.10%). Factors associated with increased risk of repeated abuse were child age 1-5 years old (AOR = 4.95/95%CI = 1.06-23.05), 6-10 years old (AOR = 6.80/95%CI = 1.22-37.91) and perpetrator was child's own parent (AOR = 21.34/95%CI = 3.51-129.72). Three cases of mortality were found with single-visit children and one case in recurrence. Most of death cases were children less than 1-year-old with average age of 7 months. Causes of death were subdural hematoma with skull and ribs fracture. CONCLUSIONS: Identifying risk factors for repeated child abuse help in recognizing child at risk to provide prompt intervention. This study found two factors associated with higher risk of abuse recurrence: child age 1-10 years old and abusive parents. Children who presented with these risk factors should be recognized and intensively monitored.

Medial Metaphyseal Beak Angle as a Predictor for Langenskiöld Stage II of Blount's Disease.

OBJECTIVE: To determine the medial metaphyseal beak (MMB) cut-off angle predicting Langenskiöld stage II of Blount's disease and to study the intra-observer and inter-observer reliabilities of angle measurements and the influence of the experience level of observers. METHODS: A retrospective study was conducted on children aged 2-4 years from January 2000 to December 2017. Children were identified through a computer-based search. Children with Langenskiöld stage II of Blount's disease who had been initially evaluated at our institution were categorized into Blount group and children who were diagnosed with physiologic bowing were categorized into control group. Data on the patients' ages, genders, and affected sides were collected. The MMB angles were measured on standing anteroposterior radiographs of the knees. The angle was formed between one line drawn parallel to the medial cortex of the proximal tibia, and a second line running from the intersection of the first line with the proximal tibial metaphysis through to the most distal point of the MMB. Measurements were independently performed by six observers. All observers repeated the measurements 2 weeks after they were first done. RESULTS: There were 148 legs from 79 children (48 males and 31 females) with an average age of 28.6 months. The average MMB angle of the Blount group was 128.52° ± 5.38° (P-value <0.001) and of the control group was 114.45° ± 4.89°. The average femorotibial angle of the Blount group was 15.48° ± 6.81° (P-value <0.001) and of the control group was 7.71° ± 7.94°. The receiver operating characteristic curve showed that an MMB angle >122° (sensitivity 92.7%; specificity 97.0%) was associated with Langenskiöld stage II. The intraclass correlation coefficient of the intra-observer reliability ranged from 0.93-0.97, and the inter-observer reliability was 0.93. CONCLUSIONS: By using anteroposterior (AP) radiographs of the knee, the MMB angle is a potential radiographic parameter to distinguish between Langenskiöld stage II of Blount's disease and physiologic bowed legs, with an MMB angle >122° predicting Langenskiöld stage II.

Pediatric elbow measurement parameters: Evaluation of the six angles in inter- and intra-observer reliability.

BACKGROUND: Several radiographic measurements of the humerus can be used to evaluate the treatment outcome of supracondylar fractures in children. Because of the cartilaginous nature of the immature elbow, interpretation of radiographs around this area is sometimes challenging and can be unreliable. This study was conducted to determine the inter-observer and intra-observer reliability of the six commonly used radiographic measurements of the distal humerus. METHOD: The Baumann angle, humero-ulna angle, metaphyseal-diaphyseal angle, radial epiphyseal angle, shaft-condylar angle and lateral capitellohumeral angle of the humerus were measured by two observers on the radiographs of uninjured elbows from 58 children. The values between each measurement were compared and correlated using a Pearson coefficient of correlation to determine the inter-observer and intra-observer reliability. RESULTS: All of the radiographic parameters showed excellent intra-observer reliability with the correlation coefficient values of the Baumann angle, humero-ulna angle, metaphyseal-diaphyseal angle, radial epiphyseal angle, shaft-condylar angle, lateral capitellohumeral angle as 0.945, 0.95, 0.909, 0.888, 0.961 and 0.975 (p < 0.001), respectively. The inter-observer reliability of the Baumann and humero-ulna angles were also found to be highly correlated at r = 0.843 (p < 0.001) and 0.878 (p < 0.001), respectively. The metaphyseal-diaphyseal angle had poor reliability with r = 0.136 (p = 0.291) while the radial epiphyseal angle, shaft-condylar angle, and lateral capitellohumeral angle demonstrated good reliability with r = 0.675 (p < 0.001), 0.747 (p < 0.001), and 0.686 (p < 0.001), respectively. CONCLUSION: The Baumann angle and humero-ulna angle measurements of distal humerus showed excellent inter- and intra-observer reliability. Both parameters represent repeatable and reliable methods for determining the outcome of supracondylar humeral fractures in pediatric population.

Medial Metaphyseal Slope as a Predictor of Recurrence in Blount Disease.

OBJECTIVE: This study was aimed to find the radiographic parameter predicting recurrence of stage 2 Blount's disease. METHOD: We retrospectively reviewed radiographs of 82 legs from 49 patients diagnosed with stage 2 Blount's disease by Langenskiöld classification who had failed brace treatment and underwent valgus osteotomy between 1998 to 2016. Age ranged from 26 to 47 months. The metaphyseal-diaphyseal angle was measured preoperatively. The medial metaphyseal slope of the proximal tibia and femorotibial angle were measured preoperatively and 3, 6, 12, and 24 months postoperatively in both non-recurrence (group 1) and recurrence (group 2) group. The receiver operating characteristic curve calculated using MedCalc software was used to determine the medial metaphyseal slope predicting risk for recurrence. Statistical analysis was performed using SPSS software. RESULTS: The mean follow-up time was 4.83 ± 0.38 years. The mean age was 34.57 ± 5.76 in group 1 and 33.2 ± 1.48 in group 2 (P = 0.258). The mean preoperative metaphyseal slope was 62.39° ± 9.75° in group 1 and 73.22° ± 6.59° in group 2 (P = 0.02). The mean preoperative femorotibial angle (FTA) was -14.31° ± 8.25° in group 1 and -18.89° ± 7.74° in group 2 (P = 0.1). The mean preoperative metaphyseal diaphyseal angle (MDA) was 14.75° ± 4.21° in group 1 and 20.11° ±5.16° in group 2 (P = 0.001). Demographic data including age, gender, weight, height, and body mass index showed no statistically significant difference between both groups. Out of 82 legs, 9 (10.97%) had recurrence. Preoperatively, the metaphyseal-diaphyseal angle showed statistical significance between both groups. The medial metaphyseal slope showed statistically significant difference between group 1 and group 2 at 3, 6, 12, and 24 months postoperatively. The receiver operating characteristic curve showed that a medial metaphyseal slope more than 70° at 12 months (sensitivity 88.89% and specificity 69.86%) and more than 62° at 24 months postoperatively (sensitivity 100%, specificity 52.3%) was a predictor for recurrence of stage 2 Blount's disease. CONCLUSION: Medial metaphyseal slope more than 62° over the 24-month follow-up was associated with recurrence of varus deformity.

Periarticular large bone defects treatment with ring external fixator.

BACKGROUND: Joint stiffness and limited bone stock for fixation were the main problems in management of periarticular bone defects. The present study aimed to report clinical and radiographic outcome of periarticular, large (≥8 cm) bone defects treated with ring external fixator. MATERIALS AND METHODS: Seventeen patients (10 males and 7 females) who had periarticular bone loss at the minimum of 8 cm were treated with ring external fixator. Acute shortening and subsequent lengthening at the corticotomy site were performed in 5 patients. Bone transport was performed in 12 patients. Clinical outcome and radiographic outcome were reviewed. RESULTS: Seventeen patients (10 males and 7 females). Mean age was 31.1 years (9-52 years). Mean bone gap was 9.17 cm (8-14 cm.). Mean follow-up period was 39.7 months (30-60 months). Fracture united primarily in 14 cases and after iliac bone graft in 2 cases. One patient had nonunion. Based on ASAMI evaluation;The bone result was excellent, good, and poor in 13, 3, and 1 patients, respectively. The functional results were excellent and good in 14 and 3 patients respectively. Ten patients had superficial pin tract infection. CONCLUSION: Periarticular large bone defects were successfully treated with ring external fixator by bone transport or acute shortening and subsequent lengthening at corticotomy site. Superficial pin tract infection and joint stiffness were common problems in management of periarticular large bone defects. Early convert to internal fixation after achieve the acceptable length or after successfully bony contact of bone transport fragment to allowed early motion of the joint was recommend. Good to excellent functional outcomes were achieve in majority of the patients.

Potential risk factors for birth fractures: a case-control study.

INTRODUCTION AND HYPOTHESIS: Birth fractures are uncommon but remain a concern among obstetricians. Although such fractures usually heal without long-term sequelae, some are associated with lifelong disabilities, such as brachial plexus injuries. The purpose of this study was primarily to investigate risk factors related to birth fractures. METHODS: This study comprised newborns delivered at our institute between 2003 and 2013. All 46 birth fractures were reviewed and compared with 223 randomly selected normal neonates. Demographic data of newborns and their mothers, as well as the details of delivery and fracture characteristics, were recorded. Univariate and multiple logistic regression analyses were applied to differentiate the risk factors. RESULTS: Forty-six babies had birth fractures, and 223 babies were without fracture. Forty-five cases were midclavicular fractures and one was a humeral-shaft fracture. Babies with a fracture had significantly higher birthweight and length and were larger for gestational age (p ≤ 0.001 for all factors). After multivariate analysis, parameters that remained significantly correlated with higher fracture risk included nurse attendant [odds ratio (OR) 34.8, p = 0.004], large for gestational age (OR 12.1, p < 0.001), instrumented delivery (OR 10.62, p < 0.001), and meconium stain (OR 3.10, p = 0.004). A high Apgar score at one minute and cesarean delivery were associated with decreased fracture risk (OR 0.39, p = 0.004 and OR 0.12, p = 0.001, respectively). CONCLUSIONS: Patient (including large for gestational age) and peripartum (including meconium stain, shoulder dystocia, instrumented delivery, and nurse attendant) factors were associated with a higher risk of birth fracture. Factors related to a decreased risk were a high Apgar score at one minute and cesarean delivery. Careful prenatal assessments are recommended to evaluate the risk of birth fracture and prompt cesarean section for patients at high risk.

Evertor muscle activity as a predictor for recurrence in idiopathic clubfoot.

BACKGROUND: Clubfoot is a complex three-dimensional deformity. Although brace compliance after initial correction was previously found to be significantly associated with recurrence in clubfoot, few previous studies have specifically examined evertor muscle function as a factor that contributes to recurrence in children with idiopathic and non-idiopathic clubfoot. The aim of this study was to investigate the relationship among brace compliance, evertor muscle grading, and recurrence rate in pediatric clubfoot patients. METHODS: Children with idiopathic clubfoot who were treated and followed for a minimum of 2 years were included. Patients who used their brace <20-23 h a day for the first 3 months and then <8-10 h per day during sleep and nap times thereafter were classified as group I. Patients who complied fully by using the brace 23 h a day for the first 3 months and then 8-10 h per day during sleep and nap times thereafter were classified as group II. Demographic and clinical data including age, gender, follow-up time, recurrence, evertor muscle grading, types of surgery, brace compliance, severity of initial deformity, age at onset, number of casts required for initial correction, and the need for Achilles tenotomy were collected and analyzed. RESULTS: Seventy-nine children with clubfoot were included. There were 47 males and 32 females, mean age was 3.2 years (range 2.1-6.3), and the mean follow-up time was 31.4 months. All patients had follow-up of at least 2 years. Primary correction was obtained in all children. There was no significant difference in mean age, mean follow-up time, or recurrence rate between groups. There was, however, a statistically significant difference in mean brace time between groups (p = 0.002). The recurrence rate was 26.2% in group I and 22.2% in group II. The recurrence rate in group a (Pirani score 0) was 3.9%, group b (Pirani score 0.5) 43.8%, and group c (Pirani score 1) 75% (p < 0.001). No significant association was found between severity of the initial deformity, age at the onset of treatment, number of casts required for correction, or reported brace compliance and recurrence or rates of surgery. Only poor or absent evertor muscle activity was found to be statistically significantly associated with risk of recurrence. CONCLUSION: Good evertor muscle grading was found to be a significant protective factor against recurrence of idiopathic clubfoot. Thus, improvement in muscle balance around the ankle, especially the evertor muscle, should be emphasized to parents after the casting regimen is completed and correction is achieved.

Free non-vascularized fibular graft for treatment of large bone defect around the elbow in pediatric patients.

BACKGROUND: Large bone defect is a challenging problem in orthopedics practice. Several methods are available for bridging of these bone defects, including cancellous bone graft, free vascularized fibula graft, and bone transport with external ring fixator. The aim of this study was to describe our experience in nine pediatric cases of free non-vascularized autogenous fibular strut bone graft in which large bone defect and bone loss of >7 cm was caused by open fracture and infective nonunion around the elbow joint. OBJECTIVE: To describe our experience in nine pediatric cases of free non-vascularized autogenous fibular strut bone graft in which large bone defect and bone loss of >7 cm was caused by open fracture and infective nonunion around the elbow joint. METHOD: This retrospective review was conducted in patients with large bone defect with bony gap >7 cm. Time to union, range of motion, complications, Mayo Elbow Performance Score, and Foot and Ankle Disability Index (FADI) were recorded. RESULT: The large bone defects included in this study were managed by free non-vascularized fibular strut bone grafts (FNVFG) that were harvested subperiosteally. Nine patients with a mean age of 11 years (range: 6-17) underwent this procedure. Nine grafts (100%) united at both ends within an average of 9 weeks (range: 8-14). Mean length of defect was 9.3 cm (range: 8-13 cm). Mean postoperative Mayo Elbow Performance Score was significantly higher than the mean preoperative score (98.33 vs. 64.44, respectively; p < 0.001). Three fibulae were observed for hypertrophy. Mean Foot and Ankle Disability Index score was 100 both preoperatively and postoperatively in all patients. CONCLUSION: Free non-vascularized fibular graft is a simple procedure and a reliable method for bridging large bone defect or loss caused by open fracture and/or infection around the elbow in pediatric patients.

Does the parental stretching programs improve metatarsus adductus in newborns?

BACKGROUND: Metatarsus adductus (MA) is a common pediatric foot deformity. Current recommendations suggest observation until 4-6 months, then casting if the deformity persists. Based on our review of the literatures, no randomized controlled trial has been conducted to study the effectiveness of parental stretching in the correction of MA in newborn. MATERIAL AND METHODS: Ninety-four newborn feet that were diagnosed as MA by clinical examination were enrolled. Feet were randomized into two groups: observation group and stretching group. Outcome measurements were performed to compare success rate between groups. RESULTS: According to Pearson's χ2 test, there were no statistically significant differences between groups with regard to the overall success of the parental stretching program ( p = 0.191). There was also no significant difference between groups for mild degree or moderate-to-severe degree ( p = 0.134, p = 0.274, respectively). A more rapid success rate was observed in the stretching group at the first month follow-up, but rate of improvement then decreased. The stretching group tended to have a lower success rate compared to the observation group in moderate-to-severe feet, but the difference was not statistically significant. CONCLUSIONS: Parental stretching program found no benefit over observation group in this study. Parental stretching program should not be applied for newborn babies with moderate-to-severe MA as the result from the study appeared to have lower success rate compared to observation group. Observe until 4-6 months, then corrective casting for the persisting deformity is recommended.

The necessity of fixation in Gartland type 2 supracondylar fracture of the distal humerus in children (modified Gartland type 2A and 2B).

In type 2 supracondylar fracture, closed pinning has been recommended in most patients. However, a stable, mildly displaced fracture can be treated with nonsurgical means. If stable, mildly displaced fractures are categorized as Gartland type 2A and unstable fractures as type 2B, orthopedic surgeons will be greatly benefited while selecting the most appropriate treatment. This study was conducted to evaluate the results of pinning versus conservative treatment in these two groups of patients. Patients with Gartland type 2 supracondylar fractures were categorized into two groups: the first group (type 2A) consisted of patients with Baumann angle (BA) differing from the uninjured side by less than 5°; the second group (type 2B) consisted of patients with BA difference greater than or equal to 5°. Statistical analysis was performed between the two groups. In type 2A, we also analyzed the data on loss alignment in patients who had undergone closed reduction without fixation to clarify the necessity of fixation. Type 2A fractures had a median BA difference from the uninjured side of 3°, a median lateral capitellohumeral angle (LCHA) difference from the uninjured side of 19.5°, and a shaft condylar angle (SCA) difference from the uninjured side of 18°. Type 2B fractures had a median BA difference of 8°, an LCHA difference of 27°, and an SCA difference of 28°. The BA, LCHA, and SCA differences were statistically significant (P<0.001, P=0.019, and 0.002 between the two types, respectively). Type 2A patients who were treated without fixation had improved SCA of 6° and improved LHCA of 11° from postreduced radiographs, with statistical significance (P=0.018 and P<0.001, respectively). The ROC curve in type 2A patients show that if the LCHA difference or the SCA difference from the uninjured side is less than 18°, it is stable enough to maintain reduction without fixation. Classification into modified type 2A and 2B is very helpful for orthopedic surgeons in determining the most suitable treatment strategy. In type 2A patients with LCHA difference or SCA difference from the uninjured side less than 18°, Kirschner-wire fixation is deemed inessential. In the case of type 2B fractures, fixation was recommended in all patients because of the unstable reduction from loss of BA, LCHA, and SCA.

Complications Associated with Ponseti Serial Casting and Surgical Correction via Soft Tissue Release in Congenital Idiopathic Clubfoot.

Background: The current standard treatment used worldwide for management of congenital idiopathic clubfoot is serial casting by Ponseti method. Prior to 2006, standard treatment for congenital idiopathic clubfoot at Siriraj Hospital involved major soft tissue release by any of the following release techniques, modified posteromedial release, complete subtalar release, and posterior release. Objective: To evaluate the complications and recurrence of deformity associated with treatment of congenital idiopathic clubfoot by Ponseti serial casting and major soft tissue release at Siriraj Hospital. Material and Method: This retrospective review of medical charts and records was conducted in congenital idiopathic clubfoot patients who underwent primary treatment by either Ponseti serial casting or major surgical soft tissue release between 2000 and 2012 at Siriraj Hospital. Patient demographic, clinical, diagnostic, and surgical procedure-related data were reviewed. All associated complications were recorded and analyzed. Results: One hundred sixty one patients were included, of which 46 had treatment by Ponseti method and 115 had treatment by major soft tissue release. In the Ponseti group, there were 26 males and 20 females (73 feet), with an average age at the beginning of treatment of 10.70 weeks (range 0.86 to 42.86). The complication rate was 17.8% (13 feet in 11 patients). The most common complications were cast loosening in four feet (5.48%) and cast-associated skin irritation in four feet (5.48%). In patients treated with Ponseti method, second surgery for recurrent deformity was performed in 26 feet (35.61%). In the soft tissue release surgical intervention group, there were 69 males and 46 females (171 feet), with an average age at the beginning of treatment at 52.05 weeks (range 9.86 to 248.71). The complication rate was 12.87% (22 feet in 18 patients). The most common complications were wound infection in nine feet (5.26%), followed by cast loosening in seven feet (4.09%). In soft tissue release patients, second surgery for recurrent deformity was performed in 26 feet (15.20%). Conclusion: In this study, complication rates relating to clubfoot treatment by Ponseti serial casting and major soft tissue release were 17.8% and 12.87%, respectively. The two most common complications of Ponseti serial casting were cast loosening (5.48%) and cast-associated skin irritation (5.48%). The most common complication of major soft tissue release was wound infection (5.26%), followed by cast loosening (4.09%).

The Comparison between Computer-Assisted Hexapods and Ilizarov Apparatus in Gradual Tibial Deformity Correction: A Preliminary Study.

Background: The Hexagonal external fixator (Hexapods) is known to have the ability to correct complex multi-planar deformities faster than the Ilizarov apparatus. However, the difficulty of achieving deformity correction by Hexapods seems to limit its popularity. Objective: This study aims to compare the advantages and disadvantages of Hexapods and Ilizarov in the gradual correction of complex tibial deformities. Material and Method: A retrospective review was performed in patients with complex tibial deformities treated with Hexapods or with Ilizarov apparatus from 2000 to 2014. Magnitude of deformity, length of time in Hexapods or Ilizarov apparatus, Lengthening Index, and complications were recorded. Statistical analysis was used to compare the two methods. Results: Six patients were treated with Ilizarov apparatus and seven patients were treated with Hexapods. Patients in Hexapods group had more coronal plane angulation before surgery than in the Ilizarov group with statistical significance (p = 0.02). The differences of the sagittal and the axial plane angulations were not statistically significant. The difference of leg length was also not statistically significant. After completion of treatment, no statistical significance of residual deformities was found between the two methods. Lengthening Index had trends toward significance in Hexapods group (p = 0.051). Conclusion: Computer-assisted Hexapods may reduce the Lengthening Index compared to the conventional Ilizarov method. The hexapods device could be beneficial for faster correction of complex deformity if the patients or family members understand how to manipulate the apparatus.

Results of Primary Talectomy for Clubfoot in Infants and Toddlers with Arthrogryposis Multiplex Congenita.

BACKGROUND: Equinovarus deformity in arthrogryposis multiplex congenita patients is rigid and difficult to treat. Radical soft tissue operations yielded good results though recurrence of deformity was high. Talectomy is a bony procedure recommended as either a salvage procedure or a primary operation. OBJECTIVE: To evaluate the results ofprimary talectomy in infant and toddler patients retrospectively. MATERIAL AND METHOD: Arthrogryposis multiplex congenita patients with rigid equinovarus deformity treated with talectomy initially were retrospectively reviewed. Pain score, residual foot deformity, shoe modification, and ambulatory status were assessed. RESULTS: Talectomy were performed in 19 arthrogrypotic feet in 10 infants and toddlers. There were 6 males and 4 females. The mean age at surgery was 1.3 years old and the mean age of the follow-up time was 4.9 years. All patients had plantigrade foot without pain. One arthrogrypotic foot required posteromedial release 2 years after index surgery due to recurrent deformity. CONCLUSION: Talectomy as theprimaryprocedure in arthrogrypotic infants and toddlers demonstrated good results withfew residual deformities and recurrence. Patients could achieve plantigrade position.

Should we repair nonunion of the lateral humeral condyle in children?

PURPOSE: Patients with nonunion of the lateral humeral condyle often present with pain, instability, progressive cubitus valgus and tardy ulnar nerve palsy. At present repairing of this nonunion is still controversial due to previous reported complications such as stiffness and avascular necrosis (AVN). This study reported the outcomes of treatment in nonunion of the lateral humeral condyle in children. METHODS: We evaluated 17 patients with nonunion of the lateral humeral condyle after repair. Corrective osteotomy was done in patients with valgus deformity of more than 30 degrees and anterior ulnar nerve transposition in patients with ulnar nerve symptoms. Evaluations were performed with the use of radiographic examination, clinical assessment and also evaluated using Mayo Elbow Performance score by interview and physical examination interpreted as excellent (≥ 90 points), good (75-89 points), fair (60-74 points), and poor (<60 points). RESULTS: Nine patients were male, and eight were female. The mean age at presentation was 6.5 years. The average interval from the injury to the presentation of the symptoms was 31.5 months. The average duration of follow-up was 48.6 months. The range of flexion was 130-145° (average 130°). The Mayo elbow performance score was excellent in 11 patients and good in six patients. Mean Mayo elbow performance score was 94. Osseous union was achieved after the initial operation in 16 patients. One patient had re-operation using local bone graft and healed nicely. Determination of correlation coefficients found good correlation between neglected time and Mayo performance score <89 (-0.741), age of patient was fairly well correlated with Mayo performance score <89 (-0.635) and ROC curve show that neglected lateral condyle fracture in children more than 28 months will reduce the Mayo score. CONCLUSION: (1) We support osteosynthesis for children, not only for those who have pain but also for those who are less symptomatic. Good and excellent results by Mayo elbow performance score were found in all patients, and all nonunions were united with good range of motion. (2) Neglecting lateral condyle fracture in children more than 28 months will reduce Mayo performance score to below 89 points. (3) Cases presenting with AVN pre-operatively can still have good results and remodeling potential with congruency of the joint.

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 release in pediatric trigger thumb.

OBJECTIVE: To observe and evaluate the treatment outcome of pediatric trigger thumb in patients who had undergone surgical release of the annular ligament with the oblique pulley partially released in patients who did not achieve full IP joint extension. MATERIAL AND METHOD: From 2003 to 2010, 21 surgically operated thumbs in 17 patients were reviewed. Bowstringing, range of motion (ROM) of thumb interphalangeal joint, Notta's node resolution and assessment of patient/parent satisfaction were used as outcome parameters. The pulley pathology system was observed intra-operatively. The annular ligament was completely released, and in patients who were notfully corrected, a further procedure in which 50% of the oblique pulley was released was undertaken. RESULTS: One thumb had recurrent triggering after 60 months of follow-up. No infection, neurovascular injury, excessive scarring, or bowstringing were detected. Notta's node was fully resolved in all operated thumbs. Mean follow-up was 64 months. Improved IP joint motion without flexion contracture was observed in all patients. The procedure was well tolerated by patients and both the patients and parents of patients expressed satisfaction with the results of the procedure. CONCLUSION: Surgical release is recommended for children aged more than one year that are afflicted with trigger thumb. This procedure delivers satisfactory results with minimal complications. To achieve full FPL excursion, some patients need to release 50% of the oblique pulley after the first procedure.