Angular Malalignment Research Articles

What is the early fate of adjacent segmental lordosis compensation at L3-4 and L5-S1 following a lateral versus transforaminal lumbar Interbody Fusion at L4-5?

Degenerative spondylolisthesis causes translational and angular malalignment, resulting in a loss of segmental lordosis. This leads to compensatory adjustments in adjacent levels to maintain balance. Lateral lumbar interbody fusion (LLIF) and transforaminal lumbar interbody fusion (TLIF) are common techniques at L4-5. This study compares compensatory changes at adjacent L3-4 and L5-S1 levels six months post LLIF versus TLIF for grade 1 degenerative spondylolisthesis at L4-5. A retrospective study included patients undergoing L4-5 LLIF or TLIF with posterior pedicle screw instrumentation (no posterior osteotomy) for grade 1 spondylolisthesis. Pre-op and 6-month post-op radiographs measured segmental lordosis (L3-L4, L4-L5, L5-S1), lumbar lordosis (LL), and pelvic incidence (PI), along with PI-LL mismatch. Multiple regressions were used for hypothesis testing. 113 patients (61 LLIF, 52 TLIF) were studied. TLIF showed less change in L4-5 lordosis (mean = 1.04°, SD = 4.34) compared to LLIF (mean = 4.99°, SD = 5.53) (p = 0.003). L4-5 angle changes didn't correlate with L3-4 changes, and no disparity between LLIF and TLIF was found (all p > 0.16). In LLIF, greater L4-5 lordosis change predicted reduced compensatory L5-S1 lordosis (p = 0.04), while no significant relationship was observed in TLIF patients (p = 0.12). LLIF at L4-5 increases lordosis at the operated level, with compensatory decrease at L5-S1 but not L3-4. This reciprocal loss at adjacent L5-S1 may explain inconsistent improvement in lumbar lordosis (PI-LL) post L4-5 fusion.

The value of fibular fixation in patients with stabilized distal tibia fractures.

There is currently no consensus regarding the need for fixation of concomitant fibula fractures in patients with surgically treated distal tibia fracture. Although studies have shown it to be beneficial for fractures involving the syndesmosis, it remains unclear for suprasyndesmotic fractures. This study evaluates what effect the fixation of such suprasyndesmotic fibula fractures had on patients who underwent fixation of distal tibia fractures. This retrospective cohort study included all consecutive adult patients who received surgical treatment for an extra-articular or simple intraarticular distal tibia fracture between 2012 and 2020 and had a concomitant fibula fracture proximal to the syndesmosis. Two groups were formed depending on whether the fibula was stabilized. The need for revision surgery, the occurrence of complications, fracture healing, rotational and angular malalignment were evaluated for both groups. This study included 120 patients, of which 40 (33.3%) had operative treatment of the fibula fracture. Of those with stabilized fibula fractures, 28 (70%) were treated with a plate and 12 (30%) with a titanium elastic nail. The group of patients with surgically treated fibula fractures had significantly more angular malalignments (10% vs 1.2%, p = 0.042), while there was no difference regarding rotational malalignment or fracture healing. Further, infections of the fibular surgical site occurred in 15% of surgically treated patients leading to significantly more revision surgeries in this group (40% vs 20%, p = 0.03). All infections occurred when a plate was used. This study was unable to show any benefit from stabilizing concomitant, suprasyndesmotic fibula fractures in surgically treated distal tibia fractures. On the contrary, infection, revision surgery and angular malalignment were more frequent when the fibula was fixed. Therefore, such concomitant fibula fractures should not routinely be fixed and if stabilization is deemed necessary, the implant should be chosen carefully.

MIPO vs. intra-medullary nailing for extra-articular distal tibia fractures and the efficacy of intra-operative alignment control: a retrospective cohort of 135 patients.

Definitive treatment of distal extra-articular fractures of the tibia is challenging and both minimal invasive plate osteosynthesis (MIPO) and intramedullary nailing (IMN) are considered to be feasible surgical modalities with their own implant-specific merits and demerits. This retrospective study was designed to compare MIPO versus IMN in terms of fracture healing, complications, functional and radiological outcomes and to assess the efficacy of intra-operative alignment control to reduce the rate of malalignment after definitive fixation of distal extra-articular fractures of the tibia. All consecutive adult patients with extra-articular distal meta- or diaphyseal tibia fractures that were treated between January 2012 and September 2019 either with MIPO or IMN were included. Outcome measures included fracture healing, complications (infection, malalignment, subsequent surgeries), functional and radiological outcomes. Intra-operative alignment control encompassed bilateral draping of the lower extremities. A total of 135 patients were included out of which 72 patients (53%) were treated with MIPO and 63 patients (47%) underwent IMN. There was a significantly higher incidence of non-union for fractures treated with IMN (13 (22%) vs. 4 (6%), p = 0.04). There was no significant difference between both groups in terms of rotational malalignment (3% vs. 10%) and angular malalignment (4% vs. 5%). A significantly higher rate of infection was found after MIPO after correction of significant differences in baseline characteristics. No differences were found in subsequent surgeries or functional outcomes. Both MIPO and IMN are reliable surgical techniques. IMN is associated with higher rates of non-union, whereas MIPO results in a higher risk for infection. The incidence of malalignment was surprisingly low endorsing the utility of the intra-operative alignment control.

A prospective study of retrograde nailing for distal third femoral shaft fractures

<p><strong>Background: </strong>To evaluate the postoperative knee range of motion and results of unreamed retrograde nailing for distal third femoral shaft fractures.</p><p><strong>Methods: </strong>Between June 2019 and June 2021 inclusive, a consecutive series of 20 patients who underwent retrograde nailing were prospectively evaluated. Outcome measures were union time, initiation of weight bearing, deformity and shortening, functional length of the nail, knee function assessed using a modified knee society knee score. Correlations between union time and other variables were also studied.</p><p><strong>Results: </strong>In these patients 18 (90%) of the 20 fractures achieved union, of which 4 underwent dynamisation; the mean union time for the other 18 fractures was 3.1 months. Angular malalignment was present in 2 patients and shortening in 3 others. There was negligible correlation between union time and variables of nail-canal diameter mismatch, functional length of nail, fracture geometry, or initiation of partial weight bearing ambulation. Knee flexion of more than 100 degrees was achieved in 19 patients. 14 patients had anterior knee pain and 7 had instability in early phases of ambulation. By the end of one year, excellent or good scores for pain and function were recorded in 95% and 86% respectively of the 20 patients.</p><p><strong>Conclusions: </strong>In view of such favourable union rates and no significant deterioration in overall knee joint function, at best retrograde nailing is a reliable alternative in the management of selected complicated fractures of the distal femoral shaft.</p>

An Adaptable Computed Tomography-Derived Three-Dimensional-Printed Alignment Fixture Minimizes Errors in Radius Biomechanical Testing.

Biomechanical testing of long bones can be susceptible to errors and uncertainty due to malalignment of specimens with respect to the mechanical axis of the test frame. To solve this problem, we designed a novel, customizable alignment and potting fixture for long bone testing. The fixture consists of three-dimensional-printed components modeled from specimen-specific computed tomography (CT) scans to achieve a predetermined specimen alignment. We demonstrated the functionality of this fixture by comparing benchtop torsional test results to specimen-matched finite element models and found a strong correlation (R2 = 0.95, p < 0.001). Additional computational models were used to estimate the impact of malalignment on mechanical behavior in both torsion and axial compression. Results confirmed that torsion testing is relatively robust to alignment artifacts, with absolute percent errors less than 8% in all malalignment scenarios. In contrast, axial testing was highly sensitive to setup errors, experiencing absolute percent errors up to 50% with off-center malalignment and up to 170% with angular malalignment. This suggests that whenever appropriate, torsion tests should be used preferentially as a summary mechanical measure. When more challenging modes of loading are required, pretest clinical-resolution CT scanning can be effectively used to create potting fixtures that allow for precise preplanned specimen alignment. This may be particularly important for more sensitive biomechanical tests (e.g., axial compressive tests) that may be needed for industrial applications, such as orthopedic implant design.

Intramedullary nail versus bridge plate in open tibial fractures - randomized clinical trial

IntroductionOpen tibial shaft fractures present a challenge to the orthopedic surgeon, because they are common, have a high rate of complications and still have a controversial treatment. As a result of the high incidence of these fractures, the need of a definitive treatment and the unavailability of the intramedullary nail or a well-trained team, we developed this study to compare the effectiveness of the bridge-plating (BP) with the unreamed intramedullary nail (UIMN) in the treatment of open tibial shaft fractures. Materials and methodsEighty patients were included in a prospective, consecutive and random way and then randomized in two groups of treatment: unreamed intramedullary nail and bridge-plating.The primary outcomes were the reoperation rate and the Johner-Wruhs functional criteria. Secondary outcomes were complication rates, partial and total weight bearing time and bone consolidation time. We verified the existence of normality in the quantitative variables for the outcomes using the Kolmogorov-Smirnov test. The Chi-Square test was utilized to compare the methods according to the relative frequencies and the comparison between the methods regarding the average of the quantitative variables was done through the T-Student test. ResultsBoth the reoperation rates and the functional criteria of Johner-Wruhs showed no difference between the two groups. The exposure time and the total surgical time were longer in the UIMN group, however the consolidation time, partial weight bearing time and total weight bearing time did not show significant difference. A significant difference was found between the groups in the implant failure rate, in favor of UIMN, the angular malalignment was another secundary outcome that showed a non significant difference in favor of UIMN. ConclusionsWe concluded that both methods were effective for the treatment of open tibia shaft fractures, however, the implant failure rate was higher in the bridge plate group.

MIPO vs. nail for extra-articular distal tibia fractures and the effect of intra-operative alignment control

Abstract Objective Definitive treatment of distal extra-articular fractures of the tibia is challenging and both minimal invasive plate osteosynthesis (MIPO) and intramedullary nailing (IMN) are considered feasible surgical modalities with their own implant-specific merits and demerits. This retrospective study was designed to compare MIPO versus IMN in terms of fracture healing, complications, functional and radiological outcomes and to assess the efficacy of intra-operative alignment control in order to reduce the rate of malalignment after definitive fixation of distal extra-articular fractures of the tibia. Methods All consecutive adult patients with extra-articular distal meta- or diaphyseal tibia fractures that were treated in a level 1 trauma center in Switzerland between January 2012 and September 2019 either with plating or IMN were included. Outcome measures included fracture healing, complications (infection, malalignment, subsequent sur-geries), functional and radiological outcomes. Intra-operative alignment control encompassed bilateral draping of the lower extremities. Results A total of 135 patients were included out of which seventy-two patients (53%) were treated with MIPO and 63 patients (47%) underwent IMN. There was a significantly higher incidence of non-union for fractures treated with an IMN (13 (22%) vs. 4 (6%), p = 0.037). There was no significant difference between both groups in terms of rotational malalignment (4% vs. 9%) and angular malalignment (4% vs. 5%). The incidence of malalignment in both groups was lower than reported in literature. A significantly higher rate of infection was found after MIPO (13% vs. 6%, p = 0.028). No differences were found in subsequent surgeries or functional outcomes. Conclusion Both MIPO and IMN are reliable surgical techniques. IMN is associated with higher rates of non-union whereas MIPO results in a higher risk for infection. The incidence of malalignment was surprisingly low endorsing the utility of the intra-operative alignment control.

Femoral malalignment after gamma nail insertion in the lateral decubitus position.

Introduction: Insertion of gamma nail with the patient in lateral decubitus position have the advantages of easier access to the entry point, easier fracture reduction and easier implant positioning. Our study described the incidence of femoral angular and rotational deformity following gamma nail insertion in lateral decubitus position.Methods: In a prospective clinical case series, 31 patients (26 males and 5 females; the average age of 42.6 years) with 31 proximal femoral shaft fractures that were treated with gamma IMN were included in our study. Postoperatively, computerized tomography scans of the pelvis and both knees (injured and uninjured sides) were examined to measure anteversion angles on both sides. A scout film of the pelvis and upper both femurs was taken to compare the neck shaft angles on both sides.Results: No angular malalignment was detected in our series; the mean angular malalignment angle was 1.6 ± 1.5°. There was a high incidence of true rotational malalignment of ≥10° in 16 out of 31 patients (51.6%); most of them were external rotational malalignment. Younger age group (≤40 years) had significantly more incidence of rotational malalignment (≥10°) than older age group (>40 years) (P-value 0.019).Discussion: Gamma nail fixation in lateral decubitus position without the fracture table gives an accurate and easier access to the entry point, good implant positioning with no or minimal angular malalignment (varus −valgus) but poses high incidence of true rotational malalignment. Great care and awareness of rotation should be exercised during fixing proximal femoral fractures in lateral decubitus position.

Orthopedic complications of linear morphea: Implications for early interdisciplinary care.

Linear morphea of the limb primarily affects children, and extracutaneous manifestations are common. Orthopedic surgeons are often essential in the care of patients with linear morphea, yet there are few reports outlining specific orthopedic complications in this population. We sought to improve the understanding of orthopedic complications in linear morphea of the limb. Between 1999 and 2014, 51 children were evaluated for linear morphea of an extremity. Twenty-six (51%) had documented orthopedic manifestations. Outcome measures included limb length discrepancy, angular malalignment, limb atrophy, and orthopedic surgical intervention. Joint contractures were most common, affecting 88% of patients, followed by limb atrophy, angular deformity, and limb length discrepancy; 14% required surgical intervention. Despite the use of systemic immunosuppressive therapy in many patients, approximately half of patients with linear morphea of an extremity have orthopedic disease. Early orthopedist involvement is crucial to improve limb alignment and preserve function.

Waders (Scolopacidae) surviving despite malaligned leg fractures in the wild: kinematics of bipedal locomotion

BackgroundBone fracture frequencies and survival rates are essential parameters in skeleton evolution, but information on the functional consequences of naturally healed fractures is scarce. No leg bone fracture healing in the wild has been reported so far from long-legged Charadriiformes (waders), which depend on bipedal locomotion for feeding.MethodsWe documented a healed but malaligned tarsometatarsus fracture in a wild Willet (Tringa [Catoptrophorus] semipalmata), and a malaligned tibiotarsus fracture in a Curlew (Numenius arquata) skeleton from a museum collection. Functional consequences of the malalignments were evaluated by kinematic analyses of videos (Willet) and in silico 3D modeling (Curlew).ResultsThe Willet’s left tarsometatarsus exhibited an angular malalignment of 70°, resulting in a limping gait that was less pronounced at high than at low walking speed. The bird seemed unable to club the toes of the left foot together, apparently a secondary effect of the deformity. The Curlew’s tibiotarsus showed an angular and an axial malalignment, causing the foot to rotate outwards when the intertarsal joint was flexed. Despite the severe effects of their injuries, the birds had survived at least long enough for the fractures to heal completely.ConclusionsSomewhat unexpectedly, leg fractures are not necessarily fatal in long-legged waders, even if deformities occur in the healing process. Bipedal locomotion on vegetated grounds must have been impeded due to the bone malalignments in both analyzed cases. The birds probably alleviated the impact of their handicaps by shifting a larger proportion of their activities to vegetation-free habitats.

Modified dome shaped proximal tibial osteotomy for treatment of infantile tibia vara

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Tibial deformity in childhood is not always one plane deformity, but often combines torsional and angular malalignment.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; In this prospective study, dome shaped osteotomy was performed in 36 tibiae in 24 patients. The osteotomy was held with K-wires and a plaster cast. The mean age at surgery was 5.5 years and the mean follow-up time was 30 months, range (24-42) months.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; All osteotomies united and no compartment syndrome occurred. Postoperatively, one leg (2.7%) had temporary weakness of external hallucis longus muscle. Thirty five of thirty six legs had good clinical and radiological correction of alignment. Recurrent deformity was seen in one leg. ‎ &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Dome shaped osteotomy of the tibia is a simple, safe and effective method for correction of uni-planar varus deformity. For bi-planar deformities in childhood with infantile tibia vara we may need to step cut the lateral cortex to allow good bone contact to help in union with minimum morbidity.&lt;/p&gt;&lt;p class="abstract"&gt; &lt;/p&gt;

Suprapatellar Intramedullary Nail Technique Lowers Rate of Malalignment of Distal Tibia Fractures.

To report on the immediate postoperative alignment of distal tibia fractures (within 5 cm of the tibial plafond) treated with suprapatellar intramedullary nail (IMN) insertion compared with the infrapatellar technique. Primary outcomes include alignment on both the anteroposterior and lateral radiographic views. Retrospective cohort study. Two urban level I trauma centers. A total of 266 skeletally mature patients with a distal tibia fracture were treated with an IMN. One hundred thirty-two patients underwent this procedure through a suprapatellar technique. Intramedullary nail placement. Alignment. The 2 treatment groups were evenly matched with respect to age, gender, fracture grade, and the presence of open fracture. Within the suprapatellar group, the fibula was intact, fixed, and remained fractured in 6 (4.5%), 22 (16.7%), and 104 (78.8%) cases, respectively. The fibula was intact, repaired, and remained fractured in 9 (6.7%), 32 (23.9%), and 93 (69.4%) cases, respectively, in the infrapatellar group. There was no difference in the rate of fibular fixation between the groups (P = 0.2). Primary angular malalignment of ≥5 degrees occurred in 35 (26.1%) patients with infrapatellar IMN insertion and in 5 (3.8%) patients who underwent suprapatellar IMN insertion (P < 0.0001). This is the largest patient series directly comparing the suprapatellar with infrapatellar IMN insertion technique in the treatment of distal tibia fractures. In the treatment of distal tibia fractures, suprapatellar IMN technique results in a significantly lower rate of malalignment compared with the infrapatellar IMN technique. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Intramedullary nailing versus minimally invasive plate osteosynthesis for distal extra-articular tibial fractures: a prospective randomized clinical trial

PurposeThe purpose of this randomized clinical trial is to compare intramedullary nailing (IMN) versus minimally invasive plate osteosynthesis (MIPO) for the treatment of extra-articular distal tibial shaft fractures. Materials and methodsTwenty-five consecutive patients with distal extra-articular tibial fractures which were located between 4 and 12cm from the tibial plafond (AO 42A1 and 43A1) were randomly assigned into IMN (n:10) or MIPO (n: 15) treatment groups. All patients were followed for at least 1 year. Foot function index, time to weight bearing, union time, duration of operation, length of incision, intra-operative blood loss, intra-operative fluoroscopy time, rotational and angular malalignment, rate of infection, secondary interventions and complications were compared between groups. ResultsAll patients completed the trial and were followed with a mean of 23.1±9.4 months (range 12–52). Foot function index, weight bearing time, union time, rate of malunion, rate of infection and rate of secondary interventions were all similar between groups (p=0.807, p=0.177, p=0.402, p=0.358, p=0.404, p=0.404, respectively). Intra-operative blood loss, length of surgical incision, radiation time and rotational malalignment were higher in the IMN group (p=0.012, p=0.019, p=0.004 and p=0.027, respectively). ConclusionsResults of our study showed that both treatment methods have similar therapeutic efficacy regarding functional outcomes and can be used safely for extra-articular distal tibial shaft fractures, and none of the techniques had a major advantage over the other.

The CT-Based Patient Specific Hip Joint 3D-Modeling; Potential to Correct the Alignment

Background: The salvage proximal femoral osteotomy is performed in mild or moderate osteoarthritis when the articulating surfaces are normal and relieves the subject’s pain. Because the importance of angular mal-alignment of the femur bone at the hip junction accurate pre-op planning based on patient specific anatomy is required to prevent any lower limb misalignment and joint problem pre-operative. Methods: In this study a CT-Based modeling technique was used to generate a 3D model of the patient’s hip and proximal femur. The registration stage using angio-fluoroscopy was performed to calculate the proximal femur kinematic and input it into a finite element model to achieve the stress distribution pattern of femuroacetabular joint. Results: From finite element model the stress distribution on the articulating surface at the contact zone was analyzed. The result was showing the maximum stress of 1.1 MPa at the contact surface where femur contact the acetabulum. The maximum stress is found in line with mechanical loading of the lower limb. Conclusion: Use of a non-invasive 3D modeling method will remediate the surgical approach in pre-op stage. The in-vivo modeling and assessment of the patient femoroacetabular contact has performed. It has been shown that the accuracy of the proposed model is comparable with the existing surgical pre-op planning.

Radial Head Subluxation After Malalignment of the Proximal Ulna

Understanding the anatomy of proximal ulna is important when treating complex injuries, since nonanatomic reconstruction may lead to malunion, arthrosis, and instability. The proximal ulna has a sagittal bow, termed the proximal ulna dorsal angulation (PUDA). The purpose of this study was to evaluate the magnitude of angular malalignment at the PUDA that would lead to radial head subluxation. This biomechanical study was conducted on 6 fresh frozen upper extremities with an elbow movement simulator. An osteotomy was performed at the PUDA and stabilized with internal fixation at 5 angles. Lateral elbow fluoroscopic images were taken in 4 elbow and 3 forearm positions, with the annular ligament intact and then released. The displacement of the radial head was quantified with the radiocapitellar ratio measurement. A significant interaction exists between elbow positions, angles of malalignment, and annular ligament integrity (P < 0.001). The greatest magnitudes of radial head subluxation were with annular ligament tear, ranging from -4% to 88% (P < 0.001). Significant differences were found between the different internal fixation angles (P = 0.002) and elbow positions (P < 0.001). Anterior subluxation increased as malalignment was fixed into extension and with progressive elbow flexion. Posterior subluxation increased as malalignment advanced into flexion and decreased with elbow flexion. Proximal ulna malalignment combined with an annular ligament tear affect the biomechanics of the elbow and can lead to radial head subluxation. This study demonstrates the importance of an anatomic reconstruction, specifically recreation of each individual's unique PUDA. Thus, in the setting of a comminuted proximal ulna fracture with associated annular ligament insufficiency, radiographs of the contralateral elbow may assist with the restoration of the normal anatomy to limit radial head instability.

Modification of the Weil/Maceira Metatarsal Osteotomy for Coronal Plane Malalignment During Crossover Toe Correction

Metatarsophalangeal joint (MPJ) instability, which often involves the second ray, may result in dorsal translation and coronal drift of the proximal phalanx, with subsequent crossover of the first and second toe. After traditionally described soft tissue and osteotomy procedures are used to treat this deformity, coronal plane malalignment may persist, but few additional surgical options have been described to address this problem. We present a retrospective series of 5 patients who underwent a supplemental technique to augment coronal plane MPJ realignment. All patients underwent preplanned concomitant procedures. Crossover angulation of the second MPJ, amount of coronal translation required, and overall first-second ray alignment were compared pre- and postoperatively. Depending on the severity of refractory deformity after soft tissue release and decompressive metatarsal osteotomy, 1.5 to 4.5 mm of coronal plane metatarsal head translation was required to achieve 3 to 20 degrees of overall valgus correction at the MPJ and complete correction of the crossover toe deformity. All patients were satisfied and had good function at last follow-up, a mean of 10.2 months, although 3 patients exhibited some level of second MPJ stiffness. One patient ended up with a component of residual floating toe deformity that was considered more of an incomplete correction of dorsal MPJ subluxation rather than any technical complication of this translational osteotomy modification designed to primarily correct coronal plane malalignment. A second patient had asymptomatic angular malalignment through partial (coronal plane) malrotation of the metatarsal osteotomy before it had healed. We have found this technique modification to be a very effective and simple means of treating recalcitrant lesser MPJ coronal plane malalignment when traditional soft tissue and bony techniques fail to fully restore anatomic MPJ position. Level IV, retrospective case series.

The CT-Based Patient Specific Hip Joint 3D-Modeling; Potential to Create a Virtual Alignment

Background: The salvage proximal femoral osteotomy is performed in mild to moderate forms of osteoarthritis when the articulating surfaces are normal and relieves the subjects pain. Because of the importance of angular mal-alignment of the femur bone at the hip junction, accurate pre-op planning based on patient specific anatomy is required to prevent any lower misalignment and joint problem. Patients and Methods: In this study, a virtual CT-Based modeling technique was used to a 3D-Model of the patients pelvis and proximal femur. The registration stage using angio-fluoroscopy was performed to calculate the proximal femur kinematic and input it into a finite element model to achieve the stress distribution pattern of femoroacetabular joint. Results: To assess the biomechanics of the joint contact surface, it is necessary to have the stress distribution in the articulating surfaces of the hip joint. The decision about the salvage surgical approach and the appropriate plan for wedge excision will be made based on the biomechanical results at the joint. FE model also provides additional information on the stress profile of the contact surface when the joint moves from full extension to full flexion. Conclusions: Use of a non-invasive 3D modeling method will remediate the surgical approach in pre-op stage. Here, the in-vivo modeling and assessment of the patient femuroacetabular contact is approved. It has been shown that the accuracy of the proposed model is comparable with the existing surgical pre-op planning.

Angular malalignment as cause of limitation of forearm rotation: An analysis of prospectively collected data of both-bone forearm fractures in children

IntroductionAlthough limitation of pronation/supination following both-bone forearm fractures in children is often attributed to an angular malunion, no clinical study has compared pronation/supination and angular malalignment of the same child by analysis of prospectively collected clinical data. AimThe purpose of this trial is to explore whether limitation of pronation/supination can be predicted by the degree of angular malalignment in children who sustained a both-bone forearm fracture. MethodsIn four Dutch hospitals, children aged ≤16 years with a both-bone forearm fracture were prospectively followed up consecutive children for 6–9 months. At the final follow-up, pronation/supination and angular malunion on radiographs were determined. ResultsBetween January 2006 and August 2010, a total of 410 children were prospectively followed up, of which 393 children were included for analysis in this study. The mean age of the children was 8.0 (±3.5) years, of which 63% were male and 40% fractured their dominant arm. The mean time to final examination was 219 (±51) days. Children with a metaphyseal both-bone fracture of the distal forearm with an angular malalignment of ≤15° had a 9–13% chance of developing a clinically relevant limitation (i.e., <50° of pronation and/or supination), while children with an angular malalignment of ≥16° had a 60% chance. Children with diaphyseal both-bone forearm fractures with ≤5° of angular malalignment had a 13% chance of developing a clinically relevant limitation, which showed no significant increase with a further increase of angular malalignment. ConclusionsChildren who sustained a both-bone forearm fracture localised in the distal metaphysis have a higher chance of developing a clinically relevant limitation of forearm rotation in case of a more severe angular malalignment, while children with a diaphyseal both-bone forearm fracture had a moderate chance of limitation, irrespective of the severity of the angular malalignment.

Management of diaphysealtibial fracture in pediatrics by elastic stable intramedullary nails

Objectives The objectives of this study were to investigate the safety and the efficacy of elastic stable intramedullary nailing in the treatment of pediatric tibial shaft fractures. Background Use of the intramedullary nailing technique in the treatment of one of the common injuries involving the lower extremities in children and adolescents. Patients and methods A prospective study of 20 children with tibial shaft fracture, who had been admitted to the Menoufia University Hospital and the Nasr City Medical Insurance Hospital between March 2012 and June 2013; all patients had diaphysealtibial fracture. The average age of the patients in this series was 11.3 years (range 5-15 years), and the mean follow-up was 8.1 months (range 6-15 months). Patient charts and radiographs were reviewed prospectively. Outcomes were classified as excellent, satisfactory, or poor according to Flynn's classification for flexible nail fixation; functional assessment and radiological assessment using the Radiographic Union Scale of the Tibial Fracture scoring system was carried out in the 4th and the 12th weeks. Results All patients achieved full weight bearing at a mean of 9.7 weeks (range 8-16 weeks). The results were excellent in 15 (75%) patients and satisfactory in five (25%) patients; two cases showed 5-10΀ of angular malalignment, and the other three cases were complicated with nail-end protrusion and a limb-length discrepancy of 2 cm of less. No patient was with poor result. Conclusion On the basis of these results, elastic stable intramedullary nailing with titanium elastic nails is an effective surgical technique that allows rapid healing of tibial shaft fractures with an acceptable rate of complications.

Does proximal femoral varus osteotomy in Legg–Calvé–Perthes disease predispose to angular mal-alignment of the knee? A clinical and radiographic study at skeletal maturity

Though there is an impression that proximal femoral varus osteotomy (FVO) can result in a valgus deformity at the knee there is no agreement on this issue. This study was undertaken to ascertain whether a FVO predisposes to the development of genu valgum in children with Legg-Calvé-Perthes disease (LCPD). One hundred and one children with unilateral LCPD who underwent a FVO during the active stage of the disease and 32 children who were treated non-operatively were followed till skeletal maturity. The FVO was performed with a 20° varus angulation in all the patients and weight-bearing was not permitted till the stage of reconstitution. The alignment of the knee was assessed clinically at skeletal maturity. A subset of 33 operated children also had full length standing radiographs of the limbs. The mechanical axis deviation, femur-tibial angle, lateral distal femoral angle and the medial proximal tibial angle of both limbs were measured on these radiographs. The frequency of clinically appreciable mal-alignment of the knee was not greater on the affected side in patients who had undergone FVO when compared to the unaffected limb and also when compared to the affected limb in non-operated patients. The mechanical axis of the lower limb of operated children was relatively in more valgus than that of normal limbs but they fell within the normal range. This study does not support the impression that a proximal femoral osteotomy for LCPD predisposes to clinically discernable degrees of genu valgum in children who have had 20° of varus angulation at the osteotomy site and who have avoided weight-bearing for a prolonged period following surgery. Further studies are needed to clarify if genu valgum would develop if early post-operative weight-bearing is permitted. III.