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Nicolau syndrome (NS) is a rare cutaneous drug reaction in response to injections administered via any route. Based on the available studies in the medical literature, NS presents as skin and subcutaneous fat necrosis, and typically, it does not cause severe complications such as acute limb ischemia or death. In this study, we report the case of a 6-year-old boy who received an intramuscular injection of benzathine penicillin G for the treatment of bacterial pharyngitis, and subsequently developed a severe case of NS, which eventually led to below-knee amputation of the right lower limb. Although a few approaches have been suggested for the management of NS, they might not be effective under certain circumstances. Early detection, close monitoring, and consistent interventions, such as surgical fasciotomy and debridement procedures, might be necessary in severe cases of NS.

Treatment of persistent or recurrent equinus after repeated surgical releases can be challenging in patients with clubfoot. Anterior distal tibial epiphysiodesis has recently been used in patients with recurrent progressive equinus deformity, with inconsistent outcomes. Herein, we used this technique in a carefully selected subgroup (8 children, 9 feet) of patients with a severe equinus deformity and a flat-top talus. The patients were followed up with radiological and clinical measures for 12 to 18 months. The mean angle of the ankle improved significantly (25.5°, p < .0001). The mean anterior distal tibial angle decreased from 86.3° to 69° (p < .0001). Plantigrade foot was obtained in all patients, except 1 with arthrogryposis. When applied to carefully selected patients, anterior distal hemiepiphysiodesis of the tibia is an effective method for management of recurrent equinus deformity.

Background: Limited information is available on how to properly manage to implant nonsterile devices in the medical literature. To the best of our knowledge, there is no guideline for managing nonsterile medical devices implanted inadvertently. Case Presentation: A 3.5-year-old boy was operated on because of femur fracture malunion. After the completion of the operation and discharging the patient, we were informed that the nail has not been sterilized. The parents were immediately informed about the complication and the patient was re-admitted to the hospital. The situation and its complication were thoroughly discussed with the family. By active involvement of the parents, infectious specialist, and the orthopedic surgeon, a shared decision was made to treat the complication. The patient was closely observed. In a radiograph obtained at the 4th week after the index surgery, the sign of callus formation was observed. At this time, we decided to remove the Titanium Elastic Nail (TEN) and continue casting for another two weeks. Conclusion: The primary “take-away” lesson of this case report is that honest disclosure of our mistake facilitated the additional necessary treatment. One single case is not enough for making a recommendation or offer a guideline for this kind of error during or after an orthopedic procedure; however, this case presents a successful method. Although the consequences of infection could be dire, it is prudent to take “not-to-harm” as the first step in benefiting.

BACKGROUND Congenital pseudarthrosis of the tibia is a rare condition that has long been one of the most challenging concerns in pediatric orthopedic surgery. When the fracture occurs, a recalcitrant nonunion is expected. This is why successful treatment means maintaining a long-term union. In this study, we aimed to assess the therapeutic outcomes for the middle and distal third fractures of the tibia and to explore whether the treatment of concurrent fibular pseudoarthrosis affects the outcome. METHODS We studied 12 patients with congenital pseudarthrosis of the tibia (Crawford type 4) from 2014 to 2019. A combination approach including intramedullary rod, Ilizarov apparatus, corticocancellous bone graft, and periosteal graft was used. In the initial surgery, we did not fix the ankle and subtalar joints. RESULTS As a result, the union was achieved in 67% of the cases after the index surgery. All of the cases with primary nonunion were related to the concurrent fibular and distal third tibial pseudarthrosis. In addition, ignoring the treatment of fibular pseudarthrosis in the index surgery led to ankle valgus deformity both in the middle and in the distal third tibial pseudarthrosis. We finally achieved a 100% union rate in all cases, with no subsequent refracture. CONCLUSIONS Surgery at an early age was associated with favorable results and minimized deformity. In concurrent fibular and distal third tibial pseudarthrosis, it is recommended to transfix the ankle and subtalar joints to create a cross-union with fibula so that the intense union can be confidently obtained with more cross-section to prevent ankle valgus deformity. LEVEL OF EVIDENCE Level IV-case series.

Background To evaluate and quantify the intraoperative effect of capsulorrhaphy on the deep seating of femoral head within the acetabulum as measured by medial joint space, a surrogate measure of acetabular-head contact. Methods In order to determine the exact effect of capsulorrhaphy, we prospectively scrutinized a consecutive sample of 18 patients with unilateral dysplastic hips aging > 18 months and followed them for a period of at least 12 months. The procedure of open reduction is described in detail. Two pediatric orthopedists carried out the operations from August 2014 to January 2019 at a tertiary pediatric hospital. Intraoperatively, AP radiographs of the pelvis were obtained before and after capsulorrhaphy. The distance between the inferomedial edge of the proximal femoral metaphysis and the lateral edge of the obturator foramen was recorded. To determine if there were differences in medial joint space due to capsulorrhaphy, a generalized linear model was run on the study sample. All patients were followed for at least 12 months to determine the rate of re-dislocation. Results Mean age (±standard deviation) of the participants was 37.5 (±24.7) months. All cases underwent Salter osteotomy, 5 cases needed femoral shortening (27.8%) and none needed derotational osteotomy. Capsulorrhaphy lead to a statistically significant decrease in the mean medial joint space from 1.59 cm before (95% CI: 1.12–2.05) to 0.76 cm after (95% CI: 0.50–1.02) the capsulorrhaphy (P Conclusions Capsulorrhaphy, independently, of age was associated with a 1-cm decrease in the mean medial hip joint space and a more deeply seated femoral head. Furthermore, this study presents a successful experience with capsulorrhaphy to prevent hip instability.

Background: Talipes equinovarus, also known as clubfoot, is a congenital anomaly that affects one newborn per 1000 live births. Its standard treatment strategy is the Ponseti casting management. This study aims to report the long-term outcomes of the Ponseti treatment in Iran.Methods: A prospective cohort study was enrolled to evaluate clinical outcomes, radiological results, pedobarographic measurements, and quality of life after the Ponseti treatment in patients with clubfoot who were followed for at least five years.Results: In this study, 25 clubfeet of 18 patients were included. Significant reductions in Pirani, Dimeglio, and CAP scores, improved ankle dorsiflexion, and acceptable pedobarographic indices were observed in this study. From the radiological evaluation indices, the calcaneal pitch and lateral talus-first metatarsal angles were significantly reduced. The quality of life of patients after five years of treatment was favorable, which was better in females. This study showed that the results of the Ponseti treatment remained acceptable after five years.Conclusions: The Ponseti management for clubfoot in the long term appears to maintain significant improvements. However, the rate of recurrence – albeit without disruption to daily activities - cannot be ignored.

The epidemiology of traumatic injuries in elderly patient fractures varies widely among countries. There is quantitative information to determine the prevalence and gender/age distribution of traumatic injuries in the elderly patient. The aim of the current study was to reveal the prevalence and age and gender distribution of various traumatic injuries in an elderly patient refers to as a tertiary orthopedic hospital in Iran. In a prospective descriptive study, all elderly patients with traumatic injuries attending the Orthopedic Trauma Unit of our center in 2001-2011 were included. Demographic details, the cause of injury, injury classification was recorded. For each gender, we calculated the numbers with fractures, dislocations, soft tissue injuries, ligamentous injuries, and lacerations and derived average age and gender-specific prevalence. During a period of 10 years, a total of 1172 elderly patients were admitted, 588 (50.1%) males, and 584 (49.9%) females. 849 patients (72.4%) had fractures. 323 (27.5%) of the patient had other limb injuries were include soft tissue injuries, lacerations, ligamentous injuries, and dislocations. The three most common fracture sites were proximal femur (40.02%), distal radius/ulna (12.47%), and proximal humerus (6.53%). The most prevalent traumatic injury among the elderly was fractures with a higher rate in females. The most common fracture sites were proximal of the femur and distal of radius and ulna bones.

ntroduction: Patella alta is an extremely rare condition, refers to an abnormally high position of the patella. Surgical treatment of habitual dislocation of the patella aims at a step-by-step correction of the abnormality. Case Presentation: A 4-year-old boy presented with a rare superior dislocation of the patella. Clinical examination and radiographs confirmed the dislocation of the patella. The patella was reduced with proper reduction technique under sedation, resulting in the improvement of active range of motion. onclusion: Congenital patella alta is a rare deformity in children. Treatment and diagnosis in the early stages are of our priority in the treatment. Our non-surgical treatment is our preferred treatment in this patient. The surgical treatment approach is performed in patients that have no response to non-surgical treatments.

Septic arthritis in pediatric population is a serious condition that needs to be diagnosed and dealt with immediately to avoid major and irreversible complications. Most researches through past 30 years focus on finding an accurate and rapid way in the diagnosis of septic arthritis in children, but the studies failed to find a single rapid and accurate diagnostic test to distinguish between transient synovitis and septic arthritis in children.

Introduction: Metacarpal fractures are common in childhood and adolescence and bone healing is the rule. Case Presentation: We present a two-year-old boy with an established nonunion of the fourth and fifth metacarpal fractures, treated successfully without any complications. Both fractures resulted from a high-energy trauma; although initial treatment seemed appropriate, nonunion occurred. The child was referred to our center for nonunion and humpback deformity. The patient was treated with open reduction/internal fixation and bone graft. All metacarpal fractures healed radiographically and clinically without any problem. The final functional and cosmetic result was excellent. Conclusions: Although the occurrence of metacarpal nonunion is rare in children, careful follow-up must be done to achieve osseous union.

BACKGROUND: The most common congenital orthopaedic condition requiring treatment is clubfoot. The Ponseti method, which has improved the recurrence rate, is at present the most attractive method of treatment in the north of America. The purpose of this study was to evaluate the outcome of this method in an Iranian population and look for characteristics that may affect the treatment process. METHODS: A total of 78 patients (129 feet) were treated by precisely adhering to the technique originally introduced by Ponseti. Relapse was defined as any return of each of 4 clubfoot components according to the Dimeglio-Bensahel system. The mean follow-up period was 24.7 months and relapse was analyzed with respect to severity of primary disorder, number of casts, compliance with postcorrection bracing and stretching exercise, and educational level of parents. RESULTS: At the end of the follow-up, 24 (18.6%) clubfeet experienced relapse as defined. The mean time to relapse was 13.7 months, 30 feet had brace noncompliance, and stretching was not done for 35 feet. Significant association was detected between recurrence and severity of clubfoot, number of casts for complete correction, and bracing and stretching exercise noncompliance. CONCLUSIONS: The Ponseti method is a successful treatment protocol for idiopathic clubfoot. Its success rate will increase with use of abduction orthosis after complete correction and also by performing regular stretching exercises. LEVEL OF EVIDENCE: Therapeutic level II.