Cubitus varus deformity following paediatric supracondylar humeral fracture remodelling predominantly in the sagittal direction: A three-dimensional analysis of eighty-six cases.

PURPOSE: Three-dimensional (3D) capacity for remodelling in cubitus varus deformity (CVD) after paediatric supracondylar humeral fractures (PSHFs) remains unelucidated. This study investigated remodelling patterns after PSHFs by examining 3D deformity distribution over time after injury. METHODS: Computed tomography (CT) data of 86 patients with CVD after PSHFs were analysed. The 3D deformity angles in the sagittal, coronal, and axial directions were assessed and correlated with the duration between the age at injury and CT evaluation. For the subgroup analysis, we performed the same correlation analysis in a younger (< 8 years old) and an older group (≥ 8 years old); we categorized the duration into early (< 2 years), middle (≥ 2 to < 5 years), and late periods (≥ 5 years) and compared the deformity angles of each direction among the three groups. RESULTS: Sagittal deformity showed a moderate correlation with the duration of deformity (r = -0.54; P < 0.001), while coronal and axial deformities showed a negligible correlation. Sagittal deformity showed moderate correlations with the duration in the younger group (r = -0.62; P < 0.001) and weak correlations in the older group (r = -0.37; P = 0.091). In the sagittal direction, the deformity angle in the early period was significantly larger than those in the mid and late periods (P < 0.001). However, there were no significant differences among the three groups in the coronal and axial directions. CONCLUSION: Sagittal deformities in CVDs are capable of remodelling, especially in the early period and at a younger age, whereas coronal and axial deformities are less likely to undergo remodelling.

Posttraumatic Cubitus Varus: Respect the Columns.

Posttraumatic cubitus varus is a multiplanar deformity that results from an improperly reduced supracondylar humerus fracture. The prevention of posttraumatic cubitus varus hinges on the stable restoration of all 3 columns of the distal humerus while avoiding malrotation. The collapse of any column leads to varying degrees of deformity in the coronal, sagittal, and/or axial plane. The purpose of this article is to explain the pattern of the deformity and use this to summarize preventative tactics for avoiding its described sequelae. We also summarize, illustrate, and present case examples for the various osteotomies used to correct the deformity, and speculate future directions.

[Computer-simulated osteotomy based on health-side combined with guide plate technique in treatment of cubitus varus deformity in adolescents].

Objective: To explore the feasibility and early effectiveness of computer-simulated osteotomy based on the health-side combined with guide plate technique in the treatment of cubitus varus deformity in adolescents. Methods: The clinical data of 23 patients with cubitus varus deformity who met the selection criteria between June 2019 and February 2023 were retrospectively analyzed. There were 17 males and 6 females, ranging in age from 4 to 16 years with an average of 8.5 years. The time from injury to operation was 1-4 years. The angle of distal humerus rotation was defined by humeral head posterior inclination angle using low radiation dose CT to scan the patient's upper extremity data at one time, and the preoperative rotation of the distal humerus on the affected side was (33.82±4.39)°. The CT plain scan data were imported into 9yuan3D digital orthopaedic system (V3.34 software) to reconstruct three-dimensional images of both upper extremities. The simulated operation was performed with the healthy upper extremity as the reference, the best osteotomy scheme was planned, overlapped and compared, and the osteotomy guide plate was prepared. The patients were followed up regularly after operation, and the formation of callus in the osteotomy area was observed by X-ray examination. Before and after operation, the carrying angle of both upper extremities (the angle of cubitus valgus was positive, and the angle of cubitus varus was negative) and anteversion angle were measured on X-ray and CT images. At the same time, the flexion and extension range of motion of elbow joint and the external rotation range of motion of upper extremity were measured, and Mayo score was used to evaluate the function of elbow joint. Results: The operation time ranged from 34 to 46 minutes, with an average of 39 minutes. All patients were followed up 5-26 months, with a mean of 14.9 months. All the incisions healed by first intention after the operation; 2 patients had nail path irritation symptoms after Kirschner wire fixation, which improved after dressing change; no complication such as breakage and loosening of internal fixators occurred after regular X-ray review. Continuous callus formed at the osteotomy end at 4 weeks after operation, and the osteotomy end healed at 8-12 weeks after operation. At last follow-up, the carrying angle, anteversion angle, external rotation range of motion, and extension and flexion range of motion of the elbow joint of the affected side significantly improved when compared with preoperative ones ( P<0.05). Except for the extension range of motion of the healthy elbow joint ( P<0.05), there was no significant difference in other indicators between the two sides ( P>0.05). At last follow-up, the Mayo elbow score was 85-100, with an average of 99.3; 22 cases were excellent, 1 case was good, and the excellent and good rate was 100%. Conclusion: Computer-simulated osteotomy based on health-side combined with guide plate technique for treating cubitus varus deformity in adolescents can achieve precise osteotomy, which has the advantages of short operation time and easy operation, and the short-term effectiveness is satisfactory.

A Modified Reverse Right-angled Triangle Osteotomy Using the Lateral Approach for the Treatment of Posttraumatic Cubitus Varus Deformity in Children.

BACKGROUND: Cubitus varus deformity is a complex 3-dimensional deformity. Various osteotomies have been introduced to correct this deformity, however, there is no consensus on the best procedure to correct the deformity while avoiding complications. In this retrospective study, we used a modified inverse right-angled triangle osteotomy to treat 22 children with posttraumatic cubitus varus deformity. The primary objective was to evaluate this technique by presenting its clinical and radiologic results. METHODS: Twenty-two consecutive patients with a cubitus varus deformity underwent a modified reverse right-angled triangle osteotomy between October 2017 and May 2020 and were then followed for a minimum of 24 months. We evaluated its clinical and radiologic results. Functional outcomes were assessed using Oppenheim criteria. RESULTS: The average follow-up period was 34.6 months (range, 24.0 to 58.1 months). The mean range of motion was 4.32 degrees (range, 0 degrees to 15 degrees)/122.73 degrees (range, 115 degrees to 130 degrees) (hyperextension/flexion) before surgery and 2.05 degrees (range, 0 degrees to 10 degrees)/127.27 degrees (range, 120 degrees to 145 degrees) at the final follow-up. There were significant ( P < 0.05) differences between the flexion and hyperextension angles before surgery and at the final follow-up. Based on Oppenheim criteria, results were excellent for 20, good for 2, and none of the patients had poor results. The mean humerus-elbow-wrist angle improved from 18.23 degrees (range, 10 degrees to 25 degrees) varus preoperatively to 8.45 degrees (range, 5 degrees to 15 degrees) valgus postoperatively ( P < 0.05). The mean of the preoperative lateral condylar prominence index was 3.52 (range, 2.5 to 5.2) and the average postoperative lateral condylar prominence index was -3.28 (range, -1.3 to -6.0). All patients were pleased with the overall appearance of their elbows. CONCLUSIONS: The modified reverse right-angled triangle osteotomy can precisely and stably correct the deformity in the coronal and sagittal planes, we recommend this technique as a simple, safe, and reliable correction of cubitus varus deformity. LEVEL OF EVIDENCE: Level IV; case series; therapeutic studies-investigating the results of treatment.

A novel method of lateral closing wedge osteotomy for cubitus varus deformity in children.

BACKGROUND: Humeral osteotomy is the best method for treatment of severe cubitus varus in children. Many osteotomy methods have been developed in the past. In this study, we describe a novel corrective technique by applying the principles described by Paley involving lateral osteotomy using Kirschner wires (K-wires). Vertices of the osteotomy should be located at the center of rotation of angulation. The anatomical and mechanical axes can be corrected with precision. PATIENTS AND METHODS: In this retrospective study, 21 patients (17 male, 4 female) who fulfilled the study criteria and underwent lateral closing osteotomy for cubitus varus deformity from July 2015 to October 2017 were included into the study. The osteotomy line of all patients was designed according to Paley's principles. An isosceles triangle template was made according to the design preoperatively. The lateral osteotomy was made with the assistance of C-arm radiographs. The osteotomy was fixed by K-wires laterally. Patients were followed up, and elbows were evaluated by radiography and using the Mayo Elbow Performance Index (MEPI) score. RESULTS: The mean correction angle obtained was 32.33°±2.83°. According to the MEPI score assessment, 19 of the 21 patients had an excellent outcome and two had a good outcome. Two patients complained of conspicuous scars; however, no further cosmetic surgery was performed. The range of motion was 135.0° preoperatively and 133.7° postoperatively, showing no significant difference (p = 0.326). None showed evidence of neurovascular injury or complained of prominence of the lateral humerus. CONCLUSION: Paley's principles for correcting cubitus varus deformity in children are effective and reliable for treating such a condition. LEVEL OF EVIDENCE: Therapeutic IV.

Neural wedge osteotomy method of correction for cubitus varus deformity in children.

In this study, we evaluated the clinical outcome of neutral wedge osteotomy assisted with the center of rotation of angulation (CORA) method of distal humerus anatomical axis for the treatment of cubitus varus deformity in children. From 2016 to 2019, 20 children with cubitus varus deformity after supracondylar fracture of the humerus were enrolled. Standard anteroposterior radiograph of the humerus was taken preoperatively. The CORA point and angulation angles were obtained by measuring the proximal and distal humerus anatomical axis. During the operation, neutral wedge osteotomy was performed to correct the varus deformity. The Baumann angle and the carrying angle were used to evaluate the correction effect of the distal humeral varus deformity. The average age of the patients was 7.8 years. Patients were followed up for an average of 29.3 months (range, 24-36 months). The average interval between surgery and injury was 12 months. The mean preoperative Baumann angle and carrying angle were 99° (90°-115°) and -14° (range, -10° to -30°), respectively. At the last follow-up, the mean Baumann angle and carrying angle was 76° (70°-80°) and 13.6° (10°-18°), respectively, with 16 cases showing excellent outcome and 4 cases showing good outcome. Our results indicated that the neutral wedge osteotomy assisted with CORA method of distal humerus anatomical axis showed good clinical outcomes in the treatment of cubitus varus deformity in children and is worthy of clinical application. The level of evidence is IV.

[Three-dimensional printing combined with distal humeral osteotomy for cubital varus deformity in children].

OBJECTIVE: To explore clinical effect of three-dimensional(3D) printing combined with distal humerus osteotomy for children with cubital varus deformity. METHODS: From January 2017 to January 2020, 17 cubital varus deformity children treated with distal humerus osteotomy were retrospective analysis, included 11 boys and 6 girls, aged from 5 to 11 years old with an average of (7.8±1.7) years old. A model of affected side elbow joint was made by 3D printing technique before operation, pre-operation was performed on the model. Three-dimensional model was successfully used for distal humeral osteotomy during operation. Carrying angle, flexion and extension angle of elbow joint were compared before and six months after operation, and Flynn scoring criteria was used to evaluate clinical effect. RESULTS: All children were followed up for 6 to 12 months with an avergae of (9.6±1.7) months. One child occurred wound infection and healed completely after dressing change. No complications such as nonunion, internal fixation and nerve injury occurred. Carrying angle of affected limb was improved from (-20.8±2.4)°before operation to (7.2±2.3)°at 6 months after operation (P<0.01). Angle of affected elbow joint extension improved from (-5.6±3.9)° before opeation to(-2.6±2.1)°at 6 months after operation (P<0.01). There was no significant difference in extension angle of elbow joint between preopertaion and postopertaion at 6 months (P>0.05). While there was no difference in elbow joint function on the healthy side and affected side at 6 months after opertaion (P>0.05). According to Flynn scoring criteria, 13 patients got excllent results and 4 moderate. CONCLUSION: Three-dimensional printing combined with distal humerus osteotomy in treating elbow varus deformity could receive satisfactory clinical effect, which could accurately assist correction of cubital varus deformity, restore physiological structure and function of elbow joint.

Is modified reverse step-cut osteotomy better than Yun's reverse V osteotomy in paediatric cubitus varus deformity correction? A prospective, double-blinded, randomized controlled trial.

BACKGROUND: Various corrective osteotomy techniques have been described in the literature for correcting paediatric cubitus varus. But we are still in search of the perfect technique that gives maximum possible deformity correction and cosmetic appearance that satisfies parents with minimal complications. We compared the outcomes of two technically sound osteotomy techniques having minimal postoperative lateral condyle prominence described in the literature. RESEARCH QUESTION: Is modified reverse step-cut osteotomy (MRSO) better in terms of clinical, radiological, and cosmetic outcomes than Yun's reverse V osteotomy (RVO) in pediatric cubitus varus deformity correction? METHODS: In total, 20 children with unilateral cubitus varus resulting from malunited supracondylar humerus fractures were included. Randomization was done by computer-generated random slips. A total of ten cases each were operated by MRSO and RVO techniques, respectively. Clinical, radiological, and cosmetic appearance assessments were done at the final two year follow-up and compared between the two groups. RESULTS: The mean age of children in the MRSO and RVO groups is 9.9 years (3-16) and 8.6 years (3-16), respectively. The mean pre-operative carrying angle in the deformed elbow of MRSO and RVO group was - 20.5° and - 19.5°, respectively, and the mean pos-toperative carrying angle in the corrected elbow of MRSO and RVO group was + 6.8° and + 6.5°, respectively. Regarding the lateral prominence index (LPI), a positive correlation was noted between pre-operative and post-operative periods with a value of 0.855 and 0.844 (p value: 0.001 and 0.03, respectively) in both MRSO and RVO groups, respectively. However, the change was statistically not significant when compared between the two groups (p = 0.63). There was no statistically significant difference (p > 0.05) when the clinical, radiological, and cosmetic outcomes were compared between the groups at final follow-up. CONCLUSION: The surgeon can choose either one of these techniques based on their expertise since the results of both the techniques are comparable in terms of clinical, radiological, and cosmetic outcomes.

3D-printed model and osteotomy template technique compared with conventional closing-wedge osteotomy in cubitus varus deformity.

Cubitus varus deformity is the most common late complication of malunited supracondylar fracture that requires corrective osteotomy and fixation. From 2009 to 2017, 40 consecutive patients with cubitus varus deformity were included. Twenty patients underwent the conventional closing-wedge osteotomy (conventional group), while the other twenty patients underwent the 3D-printed model and osteotomy template osteotomy (3D-printed template group). The functional outcome was evaluated using the Mayo Elbow Performance Index (MEPI) Score and Flynn criteria. There were no statistically significant differences were observed regarding the humerus-elbow-wrist angle and tilting angle between the two groups, both preoperatively and postoperatively at 24 months. No statistically significant differences were observed regarding the elbow ROM (127.0 ± 4.7° VS 128.9 ± 3.8°) and MEPI score (93.5 ± 3.3 VS 94.3 ± 4.1) between the groups. All patients were satisfied both cosmetically and functionally as per the Flynn criteria and MEPI score. The conventional osteotomy and 3D-printed model and osteotomy template techniques both met the treatment requirements of cubitus varus deformity. The 3D-printed template technique showed better osteotomy accuracy, but no significant advantage regarding the functional and cosmetic results than conventional osteotomy.

Treatment outcome of tardy ulnar nerve palsy associated with traumatic cubitus valgus by supracondylar shortening wedge rotary osteotomy and ulnar nerve in situ tension release.

BACKGROUND: Tardy ulnar nerve palsy is a common late complication of traumatic cubitus valgus. At present, the treatment of tardy ulnar nerve palsy associated with traumatic cubitus valgus is still controversial, whether these two problems can be corrected safely and effectively in one operation is still unclear. To investigate the supracondylar shortening wedge rotary osteotomy combined with in situ tension release of the ulnar nerve in the treatment of tardy ulnar nerve palsy associated with traumatic cubitus valgus. METHODS: Between 2012 and 2019, 16 patients who had traumatic cubitus valgus deformities with tardy ulnar nerve palsy were treated with simultaneous supracondylar shortening wedge rotary osteotomy and ulnar nerve in situ tension release. we compared a series of indicators of preoperative and postoperative follow-up for at least 24 months, (1) elbow range of motion; (2) the radiographic correction of the preoperative and postoperative humerus-elbow-wrist angles; (3) the static two-point discrimination and grip strength; and (4) the preoperative and postoperative DASH scores of upper limb function. The minimum follow-up was 24 months postoperative (mean, 33 months; range, 24 ~ 44 months). RESULTS: The mean ROM was improved from 107 ° preoperatively to 122 ° postoperatively (P = 0.001). The mean preoperative elbow wrist angle was 24.6 °, and the mean postoperative humerus-elbow wrist angle was 12.1 ° (P < 0.001). The average grip strength and static two-point discrimination improved from 21 kgf and 8 mm to 28 kgf and 4.0 mm (P < 0.001 and P < 0.001, respectively). The ulnar nerve symptoms were improved in all patients except one. The mean HASH score improved from 29 to 16 (P < 0.001). CONCLUSION: Supracondylar shortening wedge rotary osteotomy combined with in situ tension release of ulnar nerve is an effective method for the treatment of traumatic cubitus valgus with tardy ulnar nerve palsy, which restored the normal biomechanical characteristics of the affected limb and improved the elbow joint function.

Unsuccessful mid-term results for distal humeral hemiepiphysiodesis to treat cubitus varus deformity in young children.

Cubitus varus is the most common complication following a pediatric humeral supracondylar fracture. No reports are available on the result of hemiepiphysiodesis to correct this deformity. We report the use of a transphyseal crossed cannulated screw (Metaizeau technique) in five very young children (mean 3 years and 7 months). No correction was observed after a mean of 3 years and 10 months of follow-up. The low growing capacity of the distal humeral physis makes corrective osteotomy the procedure of choice for cubitus varus deformity correction in children.

Post-traumatic cubitus varus: long-term follow-up of corrective osteotomy using the Ilizarov method of compression distraction osteogenesis.

The term cubitus varus describes the inward inclination of the supinated forearm on the extended elbow. The deformity manifests clinically as a decreased carrying angle, decreased range of motion (ROM) along with a cosmetically unsightly appearance. The aim of the present study was to evaluate the technique of compression-distraction osteogenesis using the Ilizarov apparatus in the management of patients with post-traumatic cubitus varus deformity. The objectives were to study the impact of this method on the ROM, the Humerus Elbow Wrist (HEW) angle as well as the Lateral Prominence Index. A total of 32 patients who presented with a cubitus varus deformity of ≥10° at the elbow were retrospectively analyzed using data retrieved from a computerized hospital database. All patients had undergone a mini-incision subperiosteal osteotomy followed by application of an Ilizarov frame. Cinico-radiological follow-up was carried out at regular intervals until union was achieved and yearly thereafter. The mean time to union was 11 weeks. The mean follow-up period ranged from 2 to 12 years (mean 4.0 years). Results were graded as excellent in 25 cases (78.1%), good in 2 (6.3%) and poor in 5 case (15.6%) using the grading system of Oppenheim. The mean HEW angle at final follow-up improved from 20° of varus to 6° of valgus. The mean flexion/extension improved from 121°/-3° preoperatively to 125°/-4° at final follow-up. The Mayo Elbow Performance scores at final follow-up were excellent in 23 cases, good in 7 and fair in 2. Complications encountered included superficial pintract infections in three cases, lateral condylar prominence in one case, loss of terminal flexion in three cases and valgus over-correction in one case.

Comparative evaluation of pinning and cast fixation vs. external fixation after lateral closing-wedge osteotomy for cubitus varus in children.

BACKGROUND: Cubitus varus has been regarded as a poor functional and cosmetic consequence of supracondylar humerus fracture in children. The aim of this study was to assess the clinical and radiologic outcomes of cubitus varus treatments based on fixation methods: Kirschner (K)-wire and cast fixation or external fixation. METHODS: Forty consecutive patients with cubitus varus secondary to supracondylar fractures were retrospectively enrolled between October 2015 and December 2018. Following lateral closing-wedge osteotomy, those undergoing K-wire and cast fixation were included in group A (n = 21) and those who were treated with external fixation comprised group B (n = 19). We measured the bony union, elbow joint range of motion, and carrying angle. The clinical and radiographic results were assessed according to the Bellemore criteria. RESULTS: No significant difference was found between the 2 groups in terms of age, gender, operation duration, union time, and postoperative elbow range of motion (P > .05). A significant difference was noted, however, in postoperative carrying angle and results according to Bellemore criteria in group B (P < .05). No nonunion, myositis ossificans, or neurovascular injury was found at follow-up in the 2 groups. In group A, revision surgery was needed for residual varus in 1 patient and lateral condylar prominence was found in 2 patients. In group B, a superficial pin-site infection occurred in 2 patients, who were treated successfully with oral antibiotics. CONCLUSIONS: Both K-wire and external fixation after lateral closing-wedge osteotomy are reliable and effective for the treatment of cubitus varus in children. Compared with the K-wire method, external fixation achieves better functional and cosmetic results with a shorter learning curve.

[Application of picture archiving and communication systems in lateral wedge osteotomy for cubitus varus deformity in teenagers].

OBJECTIVE: To investigate effectiveness of picture archiving and communication systems (PACS) in lateral wedge osteotomy for cubitus varus deformity in teenagers. METHODS: A clinical data of 16 teenagers with cubitus varus deformity between July 2014 and July 2016 was retrospectively analyzed. All patients were treated with lateral wedge osteotomy and fixed with plate. Before operation, the osteotomy design (the osteotomy angle and length) was done in the PACS, including the carrying angle of healthy limb and the varus angle of affected side. There were 10 males and 6 females, with an average age of 11.4 years (range, 10-17 years). The disease duration ranged from 2 to 10 years (mean, 5.6 years). The preoperative X-ray film showed that the supracondylar fractures of the humerus had all healed, and 9 cases had internal rotation deformity; the varus angle of the affected side was 19.5°-33.5°. After operation, the fracture healing and cubitus varus deformity correction were observed by X-ray films, the elbow function was evaluated by Mayo scoring, and the elbow range of motion was detected. RESULTS: There was no significant difference between the actual intraoperative osteotomy angle and length and the preoperative design ( P>0.05). The hospital stay was 2-8 days, with an average of 4.5 days. No complication such as incision infection or ulnar nerve injury occurred. All 16 cases were followed up 12-18 months, with an average of 14 months. X-ray films showed that the osteotomy healed at 2-7 months after operation, with an average of 2.5 months. The internal fixators were removed within 8-14 months after operation (mean, 12.0 months). X-ray films measurement showed that the carrying angle of the affected side recovered to (10.3±2.0)° at 1 day after operation, which was not significantly different from that of the healthy side [(10.6±1.5)°] before operation ( t=0.480, P=0.637). The carrying angle of the affected side was (9.8±2.6)° at 1 year after operation, which was not significantly different from that of the healthy side [(10.4±1.6)°] at the same time point ( t=0.789, P=0.438). At 1 year after operation, the ranges of flexion and extension of affected side were (131.6±8.4)° and (6.4±2.6)°, respectively; and the ranges of flexion and extension of healthy side were (134.2±6.3)° and (5.9±2.2)°, respectively. There was no significant difference between the healthy and affected sides ( t=1.143, P=0.262; t=0.587, P=0.561). The elbow joint function at 1 year after operation evaluated by Mayo scoring standard rated as excellent in 9 cases, good in 6 cases, and fair in 1 case, and the excellent and good rate was 93.7%. CONCLUSION: Before lateral wedge osteotomy, the PACS is used to design the osteotomy angle and length, which can guide the operation and make the osteotomy more accurate and simple.

A double-closed wedge broken-line osteotomy for cubitus varus deformity.

ABSTRACT: Various osteotomy methods have been proposed in the treatment of cubitus varus. We designed an improved stepped osteotomy to achieve improved deformity correction. We refer to this new approach as double-closed wedge broken-line osteotomy and report a series of clinical and imaging results (deformity correction, range of motion [ROM], function, osteotomy healing, and complications) of patients with cubitus varus treated with this technique.Between July 2014 and July 2019, we treated 9 cases of cubitus varus using the new technique. The study was conducted in accordance with the principles of the Declaration of Helsinki, and the study protocol was approved by the ethics committee of Shenzhen Children's Hospital. We obtained written parental consent for the minors before the study was begun. We compared preoperative and postoperative clinical and imaging parameters (humeral elbow-wrist angle, elbow ROM) in all patients. Postoperative evaluation was performed by telephone interview and outpatient review. The median follow-up was 23.2 months (range, 3-63 months).The median humeral elbow-wrist angle modified from -14.27 to 15.15. The median clinical and imaging parameters after correction of deformity were not different from that of the normal side. Using our rehabilitation program, all patients recovered preoperative elbow ROM at the last follow-up.Our double-closed wedge broken-line osteotomy has a larger cancellous bone contact surface. The deformity correction is satisfactory, the osteotomy healing is reliable, and the incidence of complications is low.Level of Evidence: Level IV.

Aponeurotic release of semimembranosus: A technical note to increase correction gained with hamstring lengthening surgery in cerebral palsy.

OBJECTIVE: The aim of this study was to determine the intraoperative corrective effect of the aponeurotic release of semimembranosus (SM) as a single procedure or an adjunct procedure to distal myotendinous release of semitendinosus (ST) and myofascial release of SM lengthening in the correction of knee flexion deformity in cerebral palsy (CP). METHODS: In this prospective study, 46 knees of 23 consecutive ambulatory patients (15 boys and 8 girls; mean age=8.33 years; age range=5-12 years) with spastic diplegic CP with a gross motor function classification system level (GMFCS) II or III were included. The patients were then divided into 2 groups. In group I, there were 10 patients (4 boys, 6 girls; mean age=8.6±2), and combined release of ST in the myotendinous junction and SM in the myofascial junction, followed by aponeurotic release of SM were carried out. In group II, there were 13 patients (2 girls, 11 boys; mean age=8±2.35), and aponeurotic release of SM was done first and followed by the combined release of ST in the distal myotendinous junction and the myofascial release of SM. Intraoperative popliteal angle (PA) measurements were recorded in each group. RESULTS: PA was reduced from 58.1°±7.6° (range=46°-75°) to 41.2°±8.8° (range=20°-54°) in group 1 and from 59.1°±11.3° (range=40°-87°) to 42.7°±10.8° (range=24°-64°) in group 2. No significant difference was observed between the groups in terms of reduction in PA (p=0.867). In group 1, adding the aponeurotic release of SM further reduced the PA to 31.7°± 8.5° (range=14°-47°) (p=0.002). In group 2, adding the myotendinous release of ST and myofascial release of SM further reduced the PA to 32.9°±7.2° (range=16°-44°) (p=0.004). There was no significant difference between the final PA values in the 2 groups (p=0.662). There was no difference in terms of early complications. CONCLUSION: Aponeurotic release of SM is equally effective to reduce the intraoperative PA with combined myotendinous release of ST and myofascial release of SM. Combining all the 3 procedures provides a better correction without forceful manipulation or lengthening of the lateral hamstrings during the correction of knee flexion deformity in CP.

Effect of denosumab switched from bisphosphonates in preventing joint destruction in postmenopausal rheumatoid arthritis patients with anti-cyclic citrullinated peptide antibodies.

INTRODUCTION: This study aimed to determine the effects of denosumab treatment on the joint destruction of Japanese females with rheumatoid arthritis (RA) and anti-cyclic citrullinated peptide (CCP) antibodies. MATERIALS AND METHODS: This retrospective longitudinal study included 56 patients treated with denosumab and 50 patients treated with bisphosphonate. All participants were positive for anti-CCP antibodies. All patients also had a history of osteoporosis treatment with bisphosphonate, which was either continued or switched to 60 mg of subcutaneous denosumab injection every 6 months. To assess the progression of joint destruction, hand and foot radiographs were taken, and changes in modified total Sharp score (mTSS), erosion score (ERO), and joint space narrowing score (JSN) were evaluated at 12 months and 24 months. The changes in BMD of the lumbar spine and hip were also assessed at 12 months. RESULTS: At 12 months, there were significant differences in the change of ERO (p = 0.015) and mTSS (p = 0.01). Similarly, there were significant differences in the change of ERO (p = 0.013) and mTSS (p = 0.003) at 24 months. In contrast, no significant difference was observed in the changes of JSN and clinical parameters. There were significant differences in the changes in BMD in the femoral neck (p = 0.011) and total hip (p = 0.012). CONCLUSION: Denosumab treatment might be effective for the inhibition of bone erosion progression in the patients with RA, and it potentially contributes to the treatment of osteoporosis and prevention of destructive arthritis in patients with switching treatment from bisphosphonate.

Arthrodesis of the digital joint using intraosseous wiring in patients with rheumatoid arthritis.

OBJECTIVE: Digital joints affected by rheumatoid arthritis often have severe deformity and/or dislocation, and arthrodesis in a functional position is required. METHODS: Arthrodesis was performed using intraosseous wiring (modified Lister's method) from January 2011 to December 2015, and we investigated the union rate, postoperative complications, and patient satisfaction with the operation at the final follow-up. The DASH score, grip power, and pinch power were also investigated before the operation and at the final follow-up. RESULTS: Arthrodesis was performed for 90 digital joints in 56 patients. Bone union was obtained in 85 of 89 joints (96%). Wire removal was needed due to subcutaneous protrusion in 20 joints and superficial infection in five joints. The mean preoperative DASH score of 50.5 improved to 45.2 at the final follow-up. The pulp pinch power of the index fingers through the little fingers changed significantly. In the questionnaire regarding the operated digit using a visual analogue scale (VAS, 0 [worst] to 100 [best]), the overall satisfaction was 70. CONCLUSION: With this approach, we achieved painless stability as well as deformity correction. A restored prehensile pattern and improvement in the activities of daily life can thus be expected after surgery.