Residual Deformity Research Articles

Outcomes of Eight-Plate Epiphysiodesis for Residual Clubfoot Deformities.

The outcome of congenital clubfoot treatment is still challenging if the feet deformities are not completely corrected. Here we explore a minimal invasive procedure with an eight-plate implant to correct the residual forefoot adduction deformity after treatment of neglected or relapsed clubfoot. We retrospectively reviewed patients with residual forefoot adduction deformity after clubfoot treatment between January 2013 and June 2016. The patients underwent temporary epiphysiodesis of the lateral column of the mid-foot, which in detail, an eight-plate was placed on each side of the calcaneocuboid joint. The foot deformities were recorded according to the weight-bearing radiographic measurements including talo-first metatarsal angle, calcaneo-fifth metatarsal angle and medial-to-lateral column length. A total of 13 patients (20 feet) with an average age of 7.8 years old were located with an average duration of 40.8 months follow-up (range, 28 to 54months). The average talo-first metatarsal angle improved from 28.3° (range, 19° to 47°) preoperatively to 8.3° (range, 3° to 18°) and the calcaneo-fifth metatarsal angle improved from 29.1° (range, 19° to 40°) preoperatively to 8.4° (range, 0° to 21°) at final follow-up. The mean ratio of the medial-to-lateral column length improved from 1.14 ± 0.06 to 1.55 ± 0.09 with statistical significance (t=3.566; P < 0.001). Eight-plate epiphysiodesis is an easy and effective method for the correction of residual forefoot adduction deformity after clubfoot treatment in growing children without the need of osteotomy.

The radiographic quality of conservatively managed distal radius fractures in adults using haematoma block versus intravenous sedation.

We compared the radiographic quality of initial reduction of distal radius fractures reduced using haematoma block to those reduced with intravenous sedation. The overall rate of re-manipulation and complications were noted. A prospective study carried out at the emergency unit of our hospital between 1st September, 2017 and 31st December, 2018. Patients were consecutively recruited into Haematoma Block (HB) and Sedation(S) groups using the simple balloting method. After 5-10min of administering anaesthesia, the fracture was reduced and immobilized in a below-to-elbow Plaster of Paris (P.O.P) cast for 6weeks. The pre- and post-reduction radiographs were reviewed for volar tilt, radial angulation, radial deviation and radial shortening. Sixty-seven patients completed the study with 33 patients in HB group and 34 patients in S group. There was no significant difference in the radiographic quality of initial reduction between the two groups using the Sarmiento's modification of Lindström criteria (p = 0.49). Five out of 34 patients among the sedated group had gastrointestinal symptoms. The overall rate of re-manipulation was low and the complications recorded were wrist stiffness and residual wrist deformity. Our study revealed that there was no significant difference in the radiographic quality of initial reduction between the groups. Excellent to good reduction was achieved with both anaesthetic options. The choice of anaesthesia should be individualized and based on surgeons' preference.

A Medical-Grade Polycaprolactone and Tricalcium Phosphate Scaffold System With Corticoperiosteal Tissue Transfer for the Reconstruction of Acquired Calvarial Defects in Adults: Protocol for a Single-Arm Feasibility Trial.

BackgroundLarge skull defects present a reconstructive challenge. Conventional cranioplasty options include autologous bone grafts, vascularized bone, metals, synthetic ceramics, and polymers. Autologous options are affected by resorption and residual contour deformities. Synthetic materials may be customized via digital planning and 3D printing, but they all carry a risk of implant exposure, failure, and infection, which increases when the defect is large. These complications can be a threat to life. Without reconstruction, patients with cranial defects may experience headaches and stigmatization. The protection of the brain necessitates lifelong helmet use, which is also stigmatizing.ObjectiveOur clinical trial will formally study a hybridized technique's capacity to reconstruct large calvarial defects.MethodsA hybridized technique that draws on the benefits of autologous and synthetic materials has been developed by the research team. This involves wrapping a biodegradable, ultrastructured, 3D-printed scaffold made of medical-grade polycaprolactone and tricalcium phosphate in a vascularized, autotransplanted periosteum to exploit the capacity of vascularized periostea to regenerate bone. In vitro, the scaffold system supports cell attachment, migration, and proliferation with slow but sustained degradation to permit host tissue regeneration and the replacement of the scaffold. The in vivo compatibility of this scaffold system is robust—the base material has been used clinically as a resorbable suture material for decades. The importance of scaffold vascularization, which is inextricably linked to bone regeneration, is underappreciated. A variety of methods have been described to address this, including scaffold prelamination and axial vascularization via arteriovenous loops and autotransplanted flaps. However, none of these directly promote bone regeneration.ResultsWe expect to have results before the end of 2023. As of December 2020, we have enrolled 3 participants for the study.ConclusionsThe regenerative matching axial vascularization technique may be an alternative method of reconstruction for large calvarial defects. It involves performing a vascularized free tissue transfer and using a bioresorbable, 3D-printed scaffold to promote and support bone regeneration (termed the regenerative matching axial vascularization technique). This technique may be used to reconstruct skull bone defects that were previously thought to be unreconstructable, reduce the risk of implant-related complications, and achieve consistent outcomes in cranioplasty. This must now be tested in prospective clinical trials.Trial RegistrationAustralian New Zealand Clinical Trials Registry ACTRN12620001171909; https://tinyurl.com/4rakccb3International Registered Report Identifier (IRRID)DERR1-10.2196/36111

Does Revision Surgery Peak after Extensive Joint Surgical Correction of Congenital Talipes Equinovarus?

Category: Other; Ankle; Hindfoot; Midfoot/Forefoot Introduction/Purpose: Severe congenital talipes equinovarus (also known as clubfoot) that resists conservative treatments is managed with extensive surgical soft-tissue release and bony procedures. Residual clubfoot deformity, or relapse after a primary intervention may also warrant an open surgery. While the high relapse rate of primary and secondary invasive surgical methods has been widely reported in the literature, the question if this curve will reach a peak in time remains open. This systematic review examines the tendency of required revision surgery in management of talipes equinovarus and statistically extrapolates the result to locate a pivot point. Methods: A comprehensive search was conducted of PubMed, CINAHL, Web of Science, and Cochrane from inception to December 2020 to identify literature on clubfoot. Using PRISMA guidelines, the search terms clubfoot OR clubfeet OR clubbed foot OR clubbed feet OR talipes equinovarus were used. Articles containing more than three human subjects were included. The database was searched for longitudinal studies of clubfoot management by extensive surgical procedures for pediatric, idiopathic, resistant, residual, or relapsed deformity. Retrospective studies of primary and revision surgery performed on children up to ten years old with reported mean follow up of at least one year were included. Outcomes were evaluated according to scoring systems Laaveg-Ponseti, Dimeglio-Bensahel, and Magone based on clinical examination of foot function, radiographic studies, or patient satisfaction questionnaires. Relapse was defined as revision surgery needed to manage residual deformities, mobility, pain, or other complications. Probability of less than 0.05 is considered statistically significant. Results: The initial search yielded 2907 articles, of which 23 relevant articles, were included. The number of treated clubfeet was 1646, and the average age at operation was 13.1 (1 - 120) months. The most common surgical procedures included posterior medial and lateral soft tissue release such as Turco's posteromedial release (PMR), subtalar release, and tibialis anterior tendon transfer. Initial correction outcome was commonly evaluated clinically by physical examination with high satisfaction, evidenced by often long lapses to first revision surgery when needed. The mean follow-up period was 17.2 years (1 - 47). For very long follow- up periods, relapse rate was as high as 89% (mean 37%). There was a strong positive correlation between mean follow-up and rate of relapse (R = 0.5023, p = 0.0073). Conclusion: The high rate of complications that warranted revision surgery (37%) was consistent with the literature, but of more concern was the consistent statistically positive slope that continued to climb even with follow-up periods as long as five decades. The absence of a peak in relapse is most consistent with the postulations that relapse was due to muscle-bone balancing dynamics evolving with growth and activities, damage from repeated surgeries, or severity of deformity at birth that is permanently incurable. Since clinical evidence and statistical assessment indicated persistent high rate of relapse, revision surgery should be limited in managing relapsed clubfoot.

Early Results and Complication Rate of the Lapidus Bone Block Fusion in the Treatment of Medial Longitudinal Arch Collapse: A Prospective Cohort Study

Category: Midfoot/Forefoot; Bunion; Hindfoot Introduction/Purpose: An unstable medial column lever arm may be associated with many conditions, particularly progressive collapsing foot deformity (PCFD), hallux valgus (HV), and midfoot arthritis (MA). Restauration of the first metatarsal length and its lever in the tripod is essential when surgically treating these deformities. Fusion of the first tarsometatarsal joint (TMT) using a structural graft aims to correct the first metatarsal malalignment and create a firm construct on the medial arch. This study aimed to assess early results, healing, and complication rate of a distraction dorsal opening plantarflexion wedge allograft first tarsometatarsal joint fusion in patients with collapse/instability of the medial column. Our main hypothesis is that using a structural allograft on a TMT fusion might present a considerable rate of nonunion. Methods: In this IRB-approved prospective cohort study, patients with a clinical diagnosis of PCFD, HV, MA that underwent a TMT distraction arthrodesis at our institution were evaluated. Adults undergoing the procedure and had performed a weight- bearing computed tomography (WBCT) at 12 weeks postoperatively were included. The technique was carried using a pre-shaped anatomically specific structural allograft and specific implants. Fusion was defined by two fellowship-trained orthopedic foot and ankle surgeons and one fellowship-trained musculoskeletal radiologist, unrelated to the study. A percentage higher than 50% of crossing trabeculae over the entire proximal and distal allograft surfaces had to be noticed. Complications were established as minor (superficial dehiscence, superficial infection, and neuropraxia) and major (deep dehiscence, deep infection, nerve damage, residual deformity, sesamoiditis, limited motion, lateral overload, and reoperation). Collapse correction was assessed by the talus- first metatarsal angle (TFMA). Results: A total of 22 patients (22 feet) were included (11 PCFD, 6 MA, and 5 HV patients) with a mean age of 52.6 years (range, 19-75 years; SD, 14.4), and a mean body mass index (BMI) of 32.9kg/m2 (95% CI, 29.2 to 36.5). Mean follow-up was 5.9 months (range, 3-12), and median allograft size was 8mm (range 5-19mm). Bone healing was observed on 91% of cases, and two patients (one PCFD and one MA) presented a non-union. Two minor complications (9%, both superficial dehiscence) and one major complication (4.5%, deep infection on a MA patient) were observed. Inter-observer reliability for TFMA measurements was excellent, with an ICC of 0.86. Statistically significant improvement of the sagittal plane TFMA was observed, with a mean enhancement of 9.4 degrees (95% CI, 6.7 to 12.1 degrees; p&lt;.0001). Conclusion: In this prospective cohort study of 22 patients treated with the TMT distraction arthrodesis for medial longitudinal arch collapse/instability, we observed a low complication rate (9% minor, 4.5% major). A high healing rate after 3 months (91%), one clinically stable radiographic non-union (4.5%), and one unstable non-union (4.5%) needing reoperation were noted, despite the use of a structural allograft requiring healing at two surfaces. Our results demonstrate promising initial outcomes for this technique in treating collapse of the medial longitudinal arch in patients with PCFD, MA, and HV deformities. Long-term results are needed to confirm these promising results.

Clinical and Radiographic Outcomes after Total Ankle Arthroplasty and Suture Tape Augmentation for Ankle Arthritis Combined with Ankle Instability

Category: Ankle Arthritis; Ankle; Sports Introduction/Purpose: End-stage ankle arthritis is commonly seen in combination with various forms of ligamentous instability. Correction of the ankle arthritis and meticulous ligament balancing is key to a successful outcome after a total ankle replacement. In particular, with varus or multidirectional instability, ligament repair or reconstruction can be performed with a combination of suture and/or suture anchors if there is adequate biologic tissue remaining for repair. To date there has been no study to report on the isolated use of suture tape to correct residual intraoperative lateral ankle instability and talar tilt after total ankle replacement. The purpose of this study is to evaluate the clinical and radiographic outcomes after this combined surgical procedure. Methods: This was a single institution, retrospective study involving 36 patients that underwent a primary total ankle arthroplasty surgery in combination with a lateral ankle ligament reconstruction using a suture tape construct (InternalBraceTM, Arthrex, Naples, FL). Retrospective review of prospectively collected information from patient charts of three foot and ankle fellowship trained surgeons were evaluated at preoperative, 6-months, 1-year and 2-years postoperative for various demographics as well as VAS pain and FAAM scores. Postoperative complications including revision surgery, hardware failure, or persistent instability were also recorded. In addition, preoperative radiographs were compared to 1-year and final follow up (mean, 26 months; range, 13-90 months) radiographs for correction of the coronal deformity. Analysis involved a 1-way repeated Friedman test with post hoc Wilcoxon signed-rank tests. P values are adjusted using the Bonferroni multiple testing correction method. Assumptions for normality were checked through normal quantile-quantile (QQ) plots. Results: At two years postoperative, VAS pain (p&lt;0.001) and FAAM functional scores (p&lt;0.001) were significantly improved from preoperative. Additionally, both VAS pain (p=0.026, p-0.043) and FAAM scores (p=0.00142, p&lt;0.001) significantly improved at each time point (6-months, 1-year) compared to preoperative. On weight bearing mortise view radiographs, the mean preoperative talar tilt angle was 11.9 (range, 1.4-25.7) degrees of varus. At 1-year and 2-years postoperative the mean talar tilt angles were significantly improved from preoperative at 1.1 and 0.7 degrees, respectively (p&lt;0.001, p&lt;0.001)). The correction was significantly improved and maintained at final follow up of at least 2 years. There were no significant differences between 1-year and 2-year talar tilt measurements (p=1.00). There were three complications requiring revision surgery. Two were for component loosening and the third was for a deep infection. Conclusion: Combined ankle arthritis and instability can be a challenging problem for foot and ankle surgeons. This study demonstrated that the use of suture tape to reconstruct the lateral ankle ligament complex after total ankle replacement provides and maintains adequate correction of any residual coronal deformity at a final follow up of at least two years.

Residual flexion deformity after scaphoid nonunion surgery: 7-year follow-up study.

The clinical implication of a residual flexion deformity following surgery for scaphoid nonunion is unclear. Sixty-three patients who underwent scaphoid nonunion surgery were assessed after a mean of 7 years (range 5-10) to analyse the outcomes based on the presence of residual scaphoid deformity. Primary outcome was Disabilities of the Arm, Shoulder and Hand score. Secondary outcomes were Patient-Rated Wrist Evaluation score, wrist range of motion and strength. Patients were dichotomized to residual deformity or no deformity. Scaphoid deformity was calculated from CT scans based on the median difference between the height-length ratio of the operated versus the uninjured scaphoid. There were no differences between residual deformity (n = 33) and no deformity (n = 30) in any outcome variables, except for wrist extension which was slightly worse in the deformity group. The deformity group had a greater number of radiographic osteoarthritis, but all cases were mild, and osteoarthritis did not correlate to a worse outcome. We conclude that residual scaphoid deformity has no relevant negative impact on mid-term wrist function.Level of evidence: IV.

Functional and radiological outcomes after treatment of congenital pseudarthrosis of the tibia using the Ilizarov technique: a retrospective single-center study

BackgroundCongenital pseudarthrosis of the tibia (CPT) is a challenging problem in orthopedic practice, with high rates of non-union, refracture, and residual deformities. After union, long-term follow-up is required to manage late post-union complications. This study aimed to assess the outcomes of the Ilizarov technique in the management of CPT.Materials and methodsThis retrospective study included patients with CPT treated with the Ilizarov method between 2005 and 2018. Intramedullary rods were used in 9 cases and iliac bone graft was used in 12 cases. An orthosis was applied till the end of follow-up in all cases. The American Orthopaedic Foot and Ankle Society (AOFAS) scale was used for the evaluation of the functional outcomes.ResultsThis study included 16 patients, 11 males and 5 females, with an average age of 5.4 ± 2.8 years. Seven cases had multiple previous surgeries. Six patients had neurofibromatosis. The mean follow-up period was 5.8 ± 3.4 years. The average AOFAS score improved significantly from 47.5 ± 7.6 preoperatively to 78.9 ± 8.9 at the latest follow-up.Union was achieved in 15 cases, and persistent non-union occurred in one case. The clinical results were excellent in one patient, good in seven cases, fair in 6, and poor in 2 cases. The radiological results were excellent in one patient, good in seven cases, fair in seven, and poor in one case.ConclusionsThe Ilizarov technique combined with intramedullary rod and primary or secondary bone graft provides a high union rate of CPT and can achieve simultaneous effective management of problems related to pseudarthrosis, including non-union, deformity, limb shortening, and adjacent joint contracture and subluxation.Level of evidence Level IV.

Effect of a functional brace in combination with physical therapy for early correction of cubitus varus in young children

BackgroundThis study aimed to assess the clinical and radiologic outcomes of a functional brace in combination with physical therapy (FBPT) for early correction of cubitus varus in young children.MethodsEighteen consecutive patients with cubitus varus secondary to supracondylar fractures were enrolled between July 2017 and March 2019. We used the FBPT technique to correct varus and sagittal plane deformity for early cubitus varus in young children. The clinical evaluation included measurement of varus angulation, sagittal plane, and range of motion at three, six, and twelve months post-intervention. The clinical and radiographic results were assessed according to the Bellemore criteria.ResultsPre-treatment humerus-elbow-wrist (HEW) angle measured on the affected side (varus deformity) ranged between -38° and -12° (average, -23.2°) while the post-treatment HEW angle ranged between -10° and + 15° (average, 8.8°). Compared with the unaffected side, no statistically significant difference was found in the affected side post-intervention (P > 0.05). According to the Bellemore criteria, we got excellent results in fourteen patients (77.8%), good results in three patients (16.7%), and poor result in one patient (5.5%). All patients and their parents (except one patient with residual varus deformities) were satisfied with the functional and cosmetic outcomes.ConclusionsThe FBPT is effective for the treatment of cubitus varus in children, especially for young children within 6 months of the injury.

Reliability improvement in Hallux Valgus measurement using weight-Bearing CT scan.

Background: Radiographic assessment of hallux valgus is an essential process. Residual rotational deformity was shown associated with higher recurrent rate. This study aims to comprehensively assess reliability of measurement of various parameters from plain films and weight-bearing CT scan. Methods: A total of 40 pre-operative plain radiographs, 40 post-operative plain radiographs, and 37 weight-bearing CT scan were evaluated to determine reliability of hallux valgus parameters. Results: TSP and head shape representing coronal plane deformity showed lower inter-observer reliability compared to other parameters using for transverse plane evaluation especially in post-operative period. (post-op TSP amongst 3 assessors: κ = 0.386, 0.520, 0.340; post-op head shape: κ = 0.374, 0.375, 0.295) Using α angle for evaluation 1st metatarsal rotation in weight-bearing CT scan demonstrated very good reliability for inter-observer (ICC = 0.853 (95% CI = 0.715-0.925)) and intra-observer (ICC = 0.902 (95% CI = 0.844-0.939)). Conclusion: Weight-bearing CT scan can improve reliability in post-operative coronal plane assessment.

Characterizing the Residual SCFE Deformity: Utility of the 45-degree Dunn View.

After treatment with in situ stabilization, slipped capital femoral epiphysis (SCFE) patients have variable degrees of deformity that can contribute to femoroacetabular impingement (FAI). To evaluate the severity of residual deformity most physicians currently use biplanar radiographs of an anteroposterior pelvis which profiles the lateral head-neck deformity and a frog lateral view which profiles the anterior head-neck deformity. However, the assessment of FAI morphology commonly relies on the 45-degree Dunn view to profile the anterolateral head-neck junction where FAI deformity is maximal. Therefore, the purpose of this study was to compare the magnitude of residual SCFE deformity detected on the frog lateral radiograph to the 45-degree Dunn radiograph. A retrospective review of radiographic images of 50 hips (47 patients) diagnosed with SCFE at a single academic institution from 2014 to 2018 was performed. The group included 25 hips evaluated postoperatively after fixation (Group 1) and 25 hips presenting with residual symptomatic SCFE deformity after previous pinning (Group 2). The alpha angle was assessed on both the 45-degree Dunn and frog lateral views for comparison. The modified Southwick slip angle was assessed on the frog lateral view only as a measure of SCFE severity. The Dunn view showed the maximal residual SCFE deformity as measured by the alpha angle in 88% (44/50) of cases. Overall, the mean alpha angle (70.7 degree vs. 60.1 degree, P <0.001) was significantly larger on the Dunn view as compared with frog lateral. Subgroup analysis showed a larger alpha angle on Dunn view compared with frog lateral in both immediate postoperative and residual SCFE deformities as well: Group 1 (69.5 degree vs. 60.9 degree, P <0.001) and Group 2 (71.9 degree vs. 59.3 degree, P <0.001). In patients with SCFE, the maximal residual deformity of the proximal femur can typically be seen on the 45-degree Dunn view, rather than on the frog lateral view. Our findings suggest the 45-degree Dunn view may be beneficial part of the postoperative assessment of SCFEs to quantify the true maximal deformity present. Level IV.

Simultaneous reconstruction of septic composite defects in lower extremities: Combination of fasciocutaneous perforator flap and Masquelet technique.

BackgroundManagement of composite defects with deep infection is a challenge to reconstructive surgeons. This study aimed to demonstrate the versatility, safety, and complications of simultaneous reconstruction of infectious composite defects with fasciocutaneous perforator flap combined with the Masquelet technique.MethodsThis study presents 10 patients in whom a fasciocutaneous perforator flap combined with the Masquelet technique was used to restore soft tissue and bone defects of the lower extremity, and were admitted in two level 1 trauma centers in Shanghai. The first stage included debridement of necrotic bone and infected tissues, implantation of a polymethylmethacrylate cement spacer to cover the void; bridging fixation of the osseous defect using external or internal fixators, and soft-tissue reconstruction with a fasciocutaneous perforator flap. The second stage included cement spacer removal with membrane preservation, refreshing bone edges, and grafting the cavity with bone morphogenetic proteins and autologous iliac bone graft.ResultsThe mean follow-up duration after autologous bone graft was 17.5 months. The average bony defects and average flap dimensions were 7.1 cm and 44.9 cm2, respectively. All flaps survived uneventfully. No recurrence of infection was detected in either the second stage of surgery or follow-up period. The mean duration of bone consolidation was 31.9 weeks. One patient had a 2 cm leg length discrepancy, and one patient had mild foot drop. No residual deformity requiring a secondary procedure occurred.ConclusionFasciocutaneous perforator flap combined with Masquelet technique provides a reliable and versatile alternative for patients with composite defects resulting from lower extremity infection.

Outcomes of two circular external fixation systems in the definitive treatment of acute tibial fracture related infections

IntroductionAcute tibial fracture-related infection (FRI) is one of the most feared and challenging complications after a tibial fracture. The most appropriate treatment in this scenario is far from a resolved topic. Circular external fixators (CEFs) offer multiplanar control and minimize soft tissue injury using temporary implants far from the infected area. This study aimed to investigate the outcomes of two different types of CEFs (Ilizarov and hexapod) in the treatment of a series of acute tibial FRIs. Material and MethodsA retrospective study at two specialized limb reconstruction centres identified all patients with an acute tibial FRI (≤4 weeks after index procedure) definitively treated with a CEF from January 2015 to December 2020. Primary outcomes: fracture healing and infection eradication rate with a minimum FU of 12 months after frame removal. Secondary outcomes: to investigate the differences between the two types of circular frames regarding final post-treatment deformity magnitude. ResultsWe included 31 patients with acute tibial FRIs: 18 treated with hexapod-type and 13 with Ilizarov-type CEFs. Average age was 45.5±16.56 years. Fracture healing and infection eradication were achieved in all patients (31/31) after a mean follow-up of 24.7 months (range 12.1-55.3). Patients treated with an Ilizarov-type fixator presented shorter time to fracture union (5.5±2.2 months vs. 9.2±6.0 months; p-value 0.021) and shorter duration of external fixation (p-value 0.001). Regarding residual post-treatment deformity, the hexapod system presented significantly less residual coronal translation deformity (p-value 0.034) and better callus quality. Fixator-related complications were similar when comparing the two groups. No significant differences were seen in pain (p-value 0.25), RTW rate (35% vs. 45%; p-value 0.7) or functionality (p-value 0.4). ConclusionsDefinitive circular external fixation is an excellent treatment for acute tibial FRI. Both Ilizarov and hexapod systems offer a very high rate of fracture healing and infection eradication. Although both presented very low radiological post-operative residual deformity, the hexapod system showed less residual coronal translation deformity and better callus quality.

Flexible intramedullary nails or Spica casting? A meta-analysis on the treatment of femur fractures in preschool children aged 2-5 years.

The objective of this study is to conduct a meta-analysis (1) to evaluate outcomes of flexible intramedullary nails (FIN) versus Spica casting for treating femur shaft fractures in children aged 2-5 years and (2) to investigate the associated complications. The PubMed , Cochrane Library , Embase and Web of Science databases were searched to identify available studies comparing the outcomes of FIN and Spica casting for the treatment of femoral shaft fracture in preschool children. Meta-analysis was conducted with adherence to Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Eight observational studies involving 4995 patients were included. Two were judged to be of moderate quality, with the remainder being high quality. There were 1573 patients treated by FIN and 3422 by Spica casting. Compared to Spica casting, FIN allowed a quicker return to normal activities (40.49 ± 13.43 vs. 46.97 ± 14.32 days; P < 0.001), had a lower incidence of malunion (0.88 vs. 4.19%; P = 0.01) and unplanned interventions (2.87 vs. 7.53%; P < 0.001), but had slightly longer hospital stay (2.01 ± 1.01 vs. 1.10 ± 0.93 days; P = 0.01) and required a second surgery to remove the nails. Compared with Spica casting, FIN has the advantages of faster returning to normal activities and lower incidence of residual deformities and unplanned reoperation, but a slightly longer time of hospitalization and needs a second surgery to remove the hardware. Existing studies on duration of care and financial burden are insufficient, so further studies are warranted on multicenter and high-level evidence studies. Level of evidence: III.

Stability of nasal symmetry following primary cleft lip and nasal repair: five years of follow-up

Despite advances in cleft lip treatment, various levels of residual deformity remain after primary repair of cleft lip and palate. The aim of the current study was to compare the stability of short- and long-term postoperative nasal symmetry. This retrospective study included 100 consecutive non-syndromic patients with unilateral complete cleft lip who underwent primary cleft lip repair with follow-up of 5 years. Measurements taken from basal and frontal standard photograph views, obtained preoperatively (T1) and immediately (T2), 1 year (T3), and 5 years postoperative (T4), were analysed. Paired and independent t-tests were applied to assess the significance of differences and relationships, while the inter-class correlation coefficient was used to assess reliability; P < 0.05 was considered significant. The male to female ratio was 1:1; mean age at the time of surgery was 0.43 ± 0.25 years. All patients showed significant improvements following unilateral complete cleft lip repair. All variables measured at T3 revealed a significant relapse when compared to T2, except alar base position, which showed a constant mean across all postoperative follow-ups. Late relapse (T3–T4) was not significant for alar collapse, alar base position, or columellar angle (all P > 0.05). On the other hand, columellar height (P = 0.003), and nostril height (P = 0.038) and width (P = 0.007) showed significant improvements during the late relapse period. In conclusion, the majority of the relapse and changes following the nasal cleft repair occurred within the first postoperative year. However, nasal asymmetries tended to remain stable or reduced during the first 5 postoperative years.

How much residual deformity is acceptable according to SRS-22r and satisfaction scores after posterior spinal fusion for Lenke type 1 and 2 curves in adolescent idiopathic scoliosis?

In recent years, it has become possible to predict postoperative correction and residual deformity in adolescent idiopathic scoliosis (AIS) surgery based on the technique used and extent of fixation. However, the recommended degree of correction has not yet been established. In this study, the authors aimed to clarify the extent to which a residual postoperative deformity would be acceptable according to Scoliosis Research Society (SRS)-22r and satisfaction scores after AIS surgery. Overall, 92 patients who underwent posterior spinal fusion for Lenke type 1 or 2 AIS were retrospectively included. The Patient Acceptable Symptom State (PASS) cutoff values for each SRS-22r domain were calculated using receiver operating characteristic (ROC) curves to obtain predictive values of treatment satisfaction 2 years after surgery. Multivariate logistic regression analysis was performed with deformity parameters and demographic data as explanatory variables, and achieving the PASS cutoff value of each SRS-22r domain and treatment satisfaction were objective variables. Cutoff values were calculated using ROC analysis. The PASS cutoff values for SRS-22r domains were 3.69 (area under the ROC curve [AUC] 0.86) for self-image, 4.25 (AUC 0.82) for mental health, and 4.22 (AUC 0.82) for the subtotal. The residual main thoracic Cobb angle was not remarkably related to SRS-22r or treatment satisfaction. The residual thoracolumbar/lumbar (TL/L) Cobb angle was significantly associated with treatment satisfaction, with a cutoff value of 12.5° (AUC 0.75). The parameters of deformity that were significantly associated with achieving the PASS cutoff value for self-image were the TL/L Cobb angle and main thoracic apical vertebral translation, although their respective AUCs were < 0.7. In patients with Lenke type 1 and 2 AIS, the residual postoperative TL/L Cobb angle was significantly associated with achieving the PASS cutoff values for self-image and treatment satisfaction. Satisfaction with treatment was more likely when the TL/L Cobb angle was ≤ 12.5°.

Outcomes of a Mini External Fixator System for the Treatment of Unstable Periphyseal Hand Fractures.

Background: Most unstable hand fractures in children are treated by closed methods. If osteosynthesis is required, Kirschner (K)-wires are commonly used, though they carry a risk of injury to the physis. We have been using a mini external fixator system (MEFS) for the treatment of unstable periphyseal fractures of the hand. The aim of this study is to describe the application and report the outcomes of MEFS for the treatment of periphyseal fractures of the hand. Methods: We retrospectively reviewed all the patients with periphyseal fracture of the hand treated with MEFS from March 2010 to December 2019. Data with regard to age, sex, hand dominance, digit and bone injured, mechanism of injury, medical records and related radiographs were collected. Salter-Harris classification was used to classify epiphyseal fractures and the Al-Qattan classification for categorising neck fractures. Range of motion and residual deformity of the affected fingers were evaluated during follow-up and at 3 months postoperatively. Results: Fourteen periphyseal unstable fractures were treated using closed reduction and MEFS. Only one patient with a fracture of the neck of the proximal phalanx of the little finger required revision surgery. No patient had pin site infection or pin loosening and the device was well tolerated by all patients. All fractures united and all the patients recovered a full range of motion at final follow-up. Conclusions: The MEFS is a reasonable alternative for unstable periphyseal fractures with good outcomes and avoids the risk of iatrogenic physeal injury from K-wire fixation. Level of Evidence: Level IV (Therapeutic).

Post Covid-19 Mixed Fungal Orbito-Pansinusitis Caused by Rhizopus Oryzae and Exophiala Jeanselmei-Review and Reports

We report a rare case of mixed fungal orbito-pansinusitis caused by Rhizopus oryzae and Exophiala jeanselmei in post-COVID-19 individuals. A 65-year-old patient was COVID-19-positive and treated as per the protocols. Following recovery after 3 weeks presents to the otorhinolaryngology outpatient department with complaints of nasal obstruction, stuffiness, pain over the maxilla, occasional fever spikes, and swelling over eyelids. He was diagnosed with a case of orbito-pansinusitis mucormycosis based on magnetic resonance imaging, nasal endoscopy, and microbiological findings. Intravenous (IV) fluconazole and amphotericin B were the conservative management initially followed by surgical debridement later. There was minimal residual deformity after patient recovery. Generally, secondary to immunosuppression or debilitating diseases leads to mucormycosis. The mode of entry for molds and spores of zygomycetes are through the respiratory tract through the nose and then reaches the sinuses, orbit, and intracranial structures. Hence, a good prognosis and to reduce morbidity by zygomycosis can be achieved by early clinical diagnosis, direct smears, and proper interventions. The diagnosis of fungal infections at the earliest is very important because the therapeutic management of fungal infection is quite challenging, especially in the case of R. oryzae and E. jeanselmei with immunocompromised state. The prophylactic drugs, steroids, and immunosuppressants for the treatment of COVID-19 should not be misused and must be used as per protocol and guidelines judiciously.

Clinical features and treatment outcome of wrist tuberculosis in adult- a retrospective study of 84 consecutive cases with minimum of 2 years follow up

BackgroundWrist tuberculosis (TB) is a rare disease that may result in residual deformity, pain, or stiffness even after proper antitubercular chemotherapy (ATT) and surgical intervention. The aim of our study is to present clinical features and functional outcomes of wrist TB in a consecutive series of 84 adult patients with a minimum of 2 years of follow-up.MethodsClinical features and treatment outcomes of 84 consecutive adult patients with wrist TB from January 2003 to June 2018 including 45 men and 39 women, with a mean age of 46.8 years (18–84) were retrospectively analyzed. Data were collected on participants’ demographic details. The primary outcome measures were QuickDASH score, grip strength, Visual Analogue Scale (VAS), and PRWHE. Secondary outcomes include health-related quality of life was evaluated using the EuroQol five-dimension five-level (EQ-5D-5L), assessment and postoperative complications of patients who underwent operation were also recorded.ResultsAll 84 patients with an average follow-up of 50.8 (24–105) months. The mean duration of symptoms before treatment was 10.5 months (2–21). There were 27 patients with bony and 57 with primarily soft-tissue involvement based on preoperative evaluation of plain radiographs and MRI. There were 33 patients treated with ATT and 51 patients were treated with surgery followed by ATT. Among them, 13 patients (15.5%) underwent incision and decompression, 14 patients (16.7%) underwent wrist synovectomy, 13 patients (15.5%) underwent wrist joint fusion by plate fixation, and 11 patients (13.1%) underwent wrist joint fusion by external fixation. At the last clinical visit, the QuickDASH, and PRWHE scores of all patients decreased significantly, the VAS improved from 5.9 to 1.4, EQ-5D-5L utility index improved from 0.36 to 0.88, EQ-VAS improved from 40.2 to 89.1. All patients indicated good wrist recovery at the last follow-up, and the treatment achieved satisfactory clinical outcomes.ConclusionThe onset of wrist TB is insidious; early diagnosis, good patient compliance, and surgery combined with ATT are crucial steps for treatment of wrist TB, and also essential for the patient's postoperative recovery. Wrist arthrodesis has achieved satisfactory results in the treatment of severe wrist TB.

Ellipsoidal Process of the Femoral Head in Legg-Calvé-Perthes Disease: Effect of Prophylactic Hemiepiphysiodesis.

Legg-Calvé-Perthes disease (LCPD) often causes the residual deformity, typically appearing as an ellipsoidal shape. In some cases, this ovalization is related to the asymmetric growth of the femoral head physis, which presents a growth-inhibiting necrotic area in the anterosuperior quadrant. The objective of the present study is to evaluate the effectiveness of selective hemiepiphysiodesis of the healthy physis in the posteroinferior quadrant as a means of disrupting femoral head ovalization in cases of LCPD with the previous onset of ovalization. We performed a prospective study of 39 LCPD hips operated on consecutively by selective hemiepiphysiodesis of the posteroinferior portion of the head during the reossification phase.Surgical indication was based on a progressive increase in the ellipsoidal index (EI), the presence of a double epiphyseal nucleus of reossification, physeal narrowing, and physeal angulation. Hemiepiphysiodesis was performed at the mean patient age of 8.8years (SD 1.5) and a mean of 4.7years (SD 1.4) following disease onset. Preoperative EI was 1.80 (SD 0.2), which was reduced to 1.72 (SD 0.2) postoperatively (P > 0.05). Physeal angulation increased from 50° preoperatively (SD 9.3) to 54.29° (SD 9.7) at the end of growth (P > 0.05). The final result according to the Stulberg classification revealed 20 class-II cases, 16 class III, and 3 class IV, and SDS was 25.97 (SD 9.95), range: 9.36-51.67. As revealed by the EI, the ellipsoidal process may be stopped by selective hemiepiphysiodesis in the posteroinferior quadrant of the femoral head. II.