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AimsTemporary hemiepiphysiodesis (HED) is applied to children and adolescents to correct angular deformities (ADs) in long bones through guided growth. Traditional Blount staples or two-hole plates are mainly used for this indication. Despite precise surgical techniques and attentive postoperative follow-up, implant-associated complications are frequently described. To address these pitfalls, a flexible staple was developed to combine the advantages of the established implants. This study provides the first results of guided growth using the new implant and compares these with the established two-hole plates and Blount staples.MethodsBetween January 2013 and December 2016, 138 patients (22 children, 116 adolescents) with genu valgum or genu varum were treated with 285 flexible staples. The minimum follow-up was 24 months. These results were compared with 98 patients treated with 205 two-hole plates and 92 patients treated with 535 Blount staples. In long-standing anteroposterior radiographs, mechanical axis deviations (MADs) were measured before and during treatment to analyze treatment efficiency. The evaluation of the new flexible staple was performed according to the idea, development, evaluation, assessment, long-term (IDEAL) study framework (Stage 2a).ResultsOverall, 79% (109/138) of patients treated with flexible staples achieved sufficient deformity correction. The median treatment duration was 16 months (interquartile range (IQR) 8 to 21). The flexible staples achieved a median MAD correction of 1.2 mm/month/HED site (IQR 0.6 to 2.0) in valgus deformities and 0.6 mm/month/HED site (IQR 0.2 to 1.5) in varus deformities. Wound infections occurred in 1%, haematomas and joint effusions in 4%, and implant-associated complications in 1% of patients treated with flexible staples. Valgus AD were corrected faster using flexible staples than two-hole plates and Blount staples. Furthermore, the median MAD after treatment was lower in varus and valgus AD, fewer implant-associated complications were detected, and reduced implantation times were recorded using flexible staples.ConclusionThe flexible staple seems to be a viable option for guided growth, showing comparable or possibly better results regarding correction speed and reducing implant-associated complications. Further comparative studies are required to substantiate these findings.Cite this article: Bone Joint J 2023;105-B(3):331–340.

Aims Distraction osteogenesis with intramedullary lengthening devices has undergone rapid development in the past decade with implant enhancement. In this first single-centre matched-pair analysis we focus on the comparison of treatment with the PRECICE and STRYDE intramedullary lengthening devices and aim to clarify any clinical and radiological differences. Methods A single-centre 2:1 matched-pair retrospective analysis of 42 patients treated with the STRYDE and 82 patients treated with the PRECICE nail between May 2013 and November 2020 was conducted. Clinical and lengthening parameters were compared while focusing radiological assessment on osseous alterations related to the nail’s telescopic junction and locking bolts at four different stages. Results Osteolysis next to the telescopic junction was observed in 31/48 segments (65%) lengthened with the STRYDE nail before implant removal compared to 1/91 segment (1%) in the PRECICE cohort. In the STRYDE cohort, osteolysis initially increased, but decreased or resolved in almost all lengthened segments (86%) after implant removal. Implant failure was observed in 9/48 STRYDE (19%) and in 8/92 PRECICE nails (9%). Breakage of the distal locking bolts was found in 5/48 STRYDE nails (10%) compared to none in the PRECICE cohort. Treatment-associated pain was generally recorded as mild and found in 30/48 patients (63%) and 39/92 (42%) in the STRYDE and PRECICE cohorts, respectively. Temporary range of motion (ROM) limitations under distraction were registered in 17/48 (35%) segments treated with the STRYDE and 35/92 segments (38%) treated with the PRECICE nail. Conclusion Osteolysis and periosteal reaction, implant breakage, and pain during lengthening and consolidation is more likely in patients treated with the STRYDE nail compared to the PRECICE nail. Temporary ROM limitations during lengthening occurred independent of the applied device. Implant-related osseous alterations seem to remodel after implant removal. Cite this article: Bone Joint J 2023;105-B(1):88–96.

Leg length discrepancies (LLD) are frequently associated with coronal malalignment. Temporary hemiepiphysiodesis (HED) is a well-established procedure for the correction of limb malalignment in skeletally immature patients. For treatment of LLD > 2 cm, lengthening with intramedullary devices gains increasing popularity. However, no studies have investigated the combined application of HED and intramedullary lengthening in skeletally immature patients. This retrospective single-center study evaluated the clinical and radiological outcomes of femoral lengthening with an antegrade intramedullary lengthening nail combined with temporary HED performed in 25 patients (14 females) between 2014 and 2019. Temporary HED through the implantation of flexible staples of the distal femur and/or proximal tibia was either performed prior (n = 11), simultaneously (n = 10) or subsequently (n = 4) to femoral lengthening. The mean follow-up period was 3.7 years (±1.4). The median initial LLD was 39.0 mm (35.0–45.0). Twenty-one patients (84%) presented valgus and four (16%) showed varus malalignment. Leg length equalization was achieved in 13 of the skeletally mature patients (62%). The median LLD of the eight patients with residual LLD > 10 mm at skeletal maturity was 15.5 mm (12.8–21.8). Limb realignment was observed in nine of seventeen skeletally mature patients (53%) in the valgus group, and in one of four patients (25%) in the varus group. Combining antegrade femoral lengthening and temporary HED is a viable option to correct LLD and coronal limb malalignment in skeletally immature patients; however, achieving limb length equalization and realignment may be difficult in cases of severe LLD and angular deformity, in particular.

Background: Symptomatic patients with severe brachymetatarsia are commonly treated with callus distraction using external mini-fixator (EF) or internal device (ID). This study points out advantages and limitations of both methods comparing clinical and radiographical parameters. Methods: Retrospective analysis of 21 metatarsal bones in twelve patients. Twelve metatarsals were treated with ID (Genos Mini), nine with EF (MiniRail). Results: Mean lengthening distance was 17.3 mm using EF and 11.7 mm using ID (p = 0.016). Adverse results were observed in 89% of metatarsals treated with EF and in 33% treated with ID (p = 0.011). Postoperative surgical intervention was required in 33% using EF compared to 0% using ID (p = 0.031). Mean total German Foot Function Index (FFI-T) improved from 49 to 33 using EF and from 47 to 22 using ID (p < 0.001). Conclusion: CD is a reliable surgical treatment for BMT. Surgeons should be aware of implant-related advantages and complications when counseling patients about treatment options.

Background Limb lengthening with magnetically driven intramedullary lengthening nails is a fast-developing field and represents an alternative to external fixators. Although previous studies have assessed the application of magnetically driven intramedullary lengthening nails, these studies have been heterogenous regarding the nailing approach, the bone treated, and the implant type; they also have analyzed relatively small patient groups at short follow-up durations. Questions/purposes (1) Is femoral lengthening with magnetically driven antegrade intramedullary lengthening nails accurate and precise? (2) What are the most common complications of treatment? (3) What factors are associated with unplanned additional surgery? Methods We retrospectively analyzed the longitudinally maintained database of our orthopaedic teaching hospital to identify all patients who underwent surgery for leg length discrepancy (LLD) between October 2014 and April 2019. In total, we surgically treated 323 patients for LLD of 2 cm or more. Of those 55% (177 of 323) were treated with distraction osteogenesis with magnetically driven intramedullary lengthening nails, 18% (59 of 323) with external fixation, and 27% (87 of 323) with epiphysiodesis around the knee. Based on that, 29% (93 of 323) of patients underwent unilateral femoral distraction osteogenesis with magnetically driven antegrade femoral lengthening nails and were eligible for analysis. No patient was excluded, and 3% (3 of 93) were lost before the minimum study follow-up of 2 years, leaving 97% (90 of 93) for analysis. Patients with a distal femoral deformity were treated via a retrograde femoral approach (10% [33 of 323]) or with external fixators (3% [10 of 323]) and were not included in this study. Distraction osteogenesis with magnetically driven intramedullary lengthening nails was not considered for patients with deep tissue infection, those with bone dimensions considered to be too small in relation to the available implants, and for patients younger than 8 years. This study included 90 patients (44 females, 43 left femora) treated for a median (interquartile range) preoperative LLD of 39 mm (32 to 52) at a median age of 15 years (14 to 17). The same limb lengthening system was applied in all patients. The median (IQR) follow-up was 35 months (24 to 78). Data were acquired through a chart review performed by someone not involved in the surgical care of the included patients. Data acquisition was supervised and curated by two of the involved surgeons. Accuracy was calculated as 100 - [(achieved distraction in mm - planned distraction in mm) / (planned distraction in mm) x 100] and precision as 100 - (relative standard deviation of accuracy). Treatment-associated complications were summarized descriptively and characterized as complications resulting in unplanned additional surgery or those not resulting in unplanned surgery. To analyze the risk of unplanned additional surgery by entity, we calculated odds ratios (ORs) comparing the incidence of unplanned additional surgery in the different entity cohorts with the idiopathic LLD cohort as a reference. By calculating ORs, we analyzed the risk for unplanned additional surgery depending on sex, age, surgery time, and previous lengthening. Due to the lack of long-term evidence about motorized lengthening nails remaining in situ and concerns about potential implant-related adverse effects, removal was routinely scheduled 1 year after consolidation. For implant removal, 92% (83 of 90) of patients underwent planned additional surgery, which was not recorded as an adverse event of the treatment. Ninety-seven percent (87 of 90) of patients completed lengthening with the implant remaining in situ until the end of distraction. The median (IQR) distraction length was 37 mm (30 to 45) with a median distraction index of 0.9 mm/day (0.7 to 1.0) and median consolidation index of 31 days/cm (25 to 42). Results The calculated accuracy and precision were 94% and 90%, respectively. In total, 76% (68 of 90) of our patients experienced complications, which resulted in 20% (18 of 90) of patients undergoing unplanned additional surgery. The most common complication overall was adjustment of the distraction rate in 27% (24 of 90) of patients (faster: 16% [14 of 90]; slower: 11% [10 of 90]) and temporary restriction of knee motion, which occurred in 20% (18 of 90) of our patients and resolved in all patients who experienced it. The most serious complications were bacterial osteomyelitis and knee subluxation, which occurred in 3% (3 of 90) and 1% (1 of 90) of our patients, respectively. With the numbers available, we found only one factor associated with an increased likelihood of unplanned additional surgery: Patients with postinfectious LLD had higher odds of unplanned additional surgery than patients with idiopathic LLD (7% [1 of 15] versus 50% [3 of 6], OR 14.0 [95% CI 1.06 to 185.49]; p = 0.02). However, we caution readers this finding is fragile, and the confidence interval suggests that the effect size estimate is likely to be imprecise. Conclusion Femoral distraction osteogenesis with magnetically driven antegrade intramedullary lengthening nails appears to be an accurate and reliable treatment for femoral lengthening. However, depending on the etiology, a high risk of unplanned additional surgery should be anticipated, and a high proportion of patients will experience temporary joint stiffness. We recommend close orthopaedic follow-up and physiotherapy during treatment. This treatment of LLD can be considered alongside other nails, external fixators, and epiphysiodesis. Multicenter studies comparing this with other approaches are needed. Level of evidence Level IV, therapeutic study.

(1) Purpose: Lower limb deformities can have a severe impact on health-related quality of life (HRQL). LIMB-Q Kids is a new patient-reported outcome measure (PROM) aiming to elucidate the experience of 8–18-year-old patients before, during and after treatment, and to measure the different aspects of HRQL. The aim of this study was to translate and culturally adapt LIMB-Q Kids to German. (2) Methods: The International Society for Pharmacoeconomics and Outcomes Research (ISPOR) guidelines were followed. Three forward translations, a backward translation, an expert panel meeting with eight participants, and twenty cognitive debriefing interviews led to the final German version of LIMB-Q Kids. (3) Results: In the forward translations, 4/159 items were difficult to translate, and 2/159 items in the backward translation differed from the original English version. Cognitive debriefing interviews with 20 patients identified 7/159 items that were difficult to comprehend/answer, and 2 of these items were changed. (4) Conclusions: Lower limb deformities can have a great impact on children, and it is important to measure and consider the impact on HRQL. In order to be able to use PROMs in different countries, conceptually equivalent translations and cultural adaptations should be performed in order to ensure comprehensibility. The final German version of LIMB-Q Kids is ready for use in an international field test.

BackgroundMany patients with achondroplasia experience functional impairments because of rhizomelic upper extremities (proximal limb shortening). Bilateral humeral lengthening may overcome these functional limitations, but it is associated with several risks, such as radial nerve palsy and insufficient bone regeneration. Only a few studies have reported on patient satisfaction and functional outcome after humeral lengthening in patients with achondroplasia. Furthermore, the reported numbers of adverse events associated with lengthening procedures using external fixators vary widely.Questions/purposes(1) Does bilateral humeral lengthening with a monolateral external fixator in patients with achondroplasia reliably improve patient function and autonomy, and what proportion of patients achieved at least 8 cm of humeral lengthening? (2) What adverse events occur after bilateral humeral lengthening with monolateral external fixators?MethodsBetween 2011 and 2019, 44 patients underwent humeral lengthening at our institution. Humeral lengthening was performed in patients with severe shortening of the upper extremities and functional impairments. In humeri in which intramedullary devices were not applicable, lengthening was performed with monolateral external fixators in 40 patients. Eight patients were excluded because they underwent unilateral lengthening for etiologies other than achondroplasia, and another four patients did not fulfill the minimum study follow-up period of 2 years, leaving 28 patients with bilateral humeral lengthening to treat achondroplasia available for analysis in this retrospective study. The patients had a median (interquartile range) age of 8 years (8 to 10), and 50% (14 of 28) were girls. The median follow-up time was 6 years (4 to 8). The median humeral lengthening was 9 cm (9 to 10) with a median elongation of 73% (67% to 78%) from an initial median length of 12 cm (11 to 13). To determine whether this treatment reliably improved patient function and autonomy, surgeons retrospectively evaluated patient charts. An unvalidated retrospective patient-reported outcome measure questionnaire consisting of nine items (with answers of "yes" or "no" or a 5-point Likert scale) was administered to assess the patient's functional improvement in activities of daily living, physical appearance, and overall satisfaction, such that 45 points was the highest possible score. The radiographic outcome was assessed on calibrated radiographs of the humerus. To ascertain the proportion of adverse events, study surgeons performed a chart review and telephone interviews. Major complications were defined as events that resulted in unplanned revision surgery, nerve injury (either temporary or permanent), refracture of the bone regenerate, or permanent functional sequelae. Minor complications were characterized as events that resolved without further surgical interventions.ResultsOn our unvalidated assessment of patient function and independence, all patients reported improvement at their most recent follow-up compared with scores obtained before treatment (median [IQR] 24 [16 to 28] before surgery versus 44 [42 to 45] at latest follow-up, difference of medians 20 points, p < 0.001). A total of 89% (25 of 28) of patients achieved the desired 8 cm of lengthening in both arms. A total of 50% (14 of 28) of our patients experienced a major complication. Specifically, 39% (11 of 28) had an unplanned reoperation, 39% (11 of 28) had a radial nerve palsy, 18% (5 of 28) had a refracture of the regenerate, and 4% (1 of 28) concluded treatment with a severe limb length discrepancy. In addition, 82% (23 of 28) of our patients experienced minor complications that resolved without further surgery and did not involve radial nerve symptoms. Radial nerve palsy was observed immediately postoperatively in eight of 13 segments, and 1 to 7 days postoperatively in five of 13 segments. The treatment goal was not achieved because of radial nerve palsy in 5% (3 of 56) of lengthened segments, which occurred in 7% (2 of 28) of patients. Full functional recovery of the radial nerve was observed in all patients after a median (IQR) of 3 months (2 to 5). Refractures of bone regenerates were observed in 11% (6 of 56) of humeri in 18% (5 of 28) of patients. Of those refractures, 1 of 6 patients was treated nonsurgically with a hanging cast, while 5 of 6 patients underwent revision surgery with intramedullary rodding.ConclusionMost patients with achondroplasia who underwent humeral lengthening achieved the treatment goal without permanent sequelae; nonetheless, complications of treatment were common, and the road to recovery was long and often complicated, with many patients experiencing problems that were either painful (such as refracture) or bothersome (such as temporary radial nerve palsy). However, using a subjective scale, patients seemed improved after treatment; nevertheless, robust outcomes tools are not available for this condition, and so we must interpret that finding with caution. Considering our discoveries, bilateral humeral lengthening with a monolateral external fixator should only be considered in patients with severe functional impairments because of rhizomelic shortening of the upper extremities. If feasible, internal lengthening devices might be preferable, as these are generally associated with higher patient comfort and decreased complication rates compared with external fixators.Level of EvidenceLevel IV, therapeutic study.

Background and purpose Total hip arthroplasty (THA) is a successful approach to treat unilateral symptomatic neglected hip dislocation (NHD). However, the extensive leg length discrepancy (LLD) can hereby only be partially corrected. In case of residual LLD of more than 2 cm, subsequent femoral lengthening can be considered. Patients/material/methods Retrospective analysis of clinical data and radiographs of five patients (age 38.1 (28–51) years) with unilateral NHD who underwent THA with (n = 3) or without (n = 2) subtrochanteric shortening osteotomy (SSO) and secondary intramedullary femoral lengthening through a retrograde magnetically-driven lengthening nail (follow-up 18.4 (15–27) months). Results LLD was 51.0 (45–60) mm before and 37.0 (30–45) mm after THA. Delayed bone union at one SSO site healed after revision with autologous bone grafting and plate fixation. Subsequent lengthening led to leg length equalisation in all patients. Complete consolidation was documented in all lengthened segments. Conclusion Staged reconstruction via THA and secondary femoral lengthening can successfully be used to reconstruct the hip joint and equalise LLD. The specific anatomical conditions have to be taken into consideration when planning treatment, and patients ought to be closely monitored.

Background: Patient-reported outcome measures are gaining increasing importance in clinical research and quality control. Clinical impairment through limb deformities can appear in various forms. This study aimed at translating and culturally adaptating the Limb Deformity-Scoliosis Research Society (LD-SRS) patient-reported outcome measure (PROM) into German by following the scientific rigor of the cross-cultural adaptation process as well as ensuring the reliability of the translated version. The LD-SRS is applicable in children and adults. Methods: The translation was performed in accordance with the creators of the LD-SRS following the Professional Society for Health Economics and Outcomes Research (ISPOR) guidelines for translation and cultural adaptation. Two forward translations were performed, and after a consensus meeting, a professional translator translated the PROM back to English. The creators reviewed the back translation of the preliminary German version. Thirty patients with upper and lower limb deformities participated in cognitive debriefing interviews. The version was proofread and, finally, the test-retest reliability was estimated. Results: The mean age was 19 years (range 6–61). Twenty-six patients (87%) completed the retest after 6 days (range 3–26). The internal consistency was estimated with a Cronbach’s alpha of 0.96 (range 0.94–0.97), and the intraclass correlation was 0.92 (range 0.89–0.94), indicating an excellent reliability. The scores were normally distributed. Thereafter, the German version was proofread and finalized. Conclusions: The German translation and cross-cultural adaptation of the LD-SRS score resulted in a high reliability and internal consistency. The German LD-SRS score is readily usable and may be applied in future studies of German-speaking limb deformity patients.

Introduction Arthrogryposis multiplex congenita (AMC) is a rare congenital condition that leads to severe joint contractures and deformities. As painful joint dysplasia and degeneration might develop over time, total joint replacement (TJR) can be a potential treatment option for these patients. The aim of this study is to investigate functional results, implant survivorship and potential complications in patients with AMC who undergo hip or knee arthroplasty. Materials and methods We retrospectively identified six TJR in three patients at a single centre performed between 2006 and 2019. The median patient age at surgery was 23 years and the median follow-up period was 69 (IQR 55–99) months. We analysed surgical technique, implant survivorship and complications as well as functional outcome determined by pain reported on the Numerical Rating Scale (NRS), patient-reported outcome scores [Oxford Hip Score (OHS), Harris Hip score (HHS), Oxford Knee Score (OKS)], range of motion and ambulatory status. Depending on data distribution means with ranges and median with interquartile range were compared with the Wilcoxon signed rank test or Student’s t test. The level of significance was defined at Results In hips, the mean range of motion in flexion/extension (52° vs. 85°, p = 0.014) and in rotation (28° vs. 68°, p = 0.02) as well as mean pain score on the NRS (8.5 vs. 0, p = 0.001), OHS (9 vs. 26, p = 0.031) and HHS (17 vs. 52, p = 0.007) significantly improved. In knees, mean range of motion (55° vs. 93°, p = 0.403), mean pain score on the NRS (0 vs. 7) and the OKS (2 vs. 21) also improved. While the ambulatory status did not change, the patients who were wheelchair dependent reported less problems with transfers to a bed or chair and the patient who ambulated reported an improved walking distance. One total knee arthroplasty (TKA) underwent revision for an acute, late infection 155 months following the initial surgery. Conclusions TJR is a safe procedure in patients with AMC that effectively improves function and reduces pain irrespective of preoperative ambulatory status.

Aims Temporary epiphysiodesis (ED) is commonly applied in children and adolescents to treat leg length discrepancies (LLDs) and tall stature. Traditional Blount staples or modern two-hole plates are used in clinical practice. However, they require accurate planning, precise surgical techniques, and attentive follow-up to achieve the desired outcome without complications. This study reports the results of ED using a novel rigid staple (RigidTack) incorporating safety, as well as technical and procedural success according to the idea, development, evaluation, assessment, long-term (IDEAL) study framework. Methods A cohort of 56 patients, including 45 unilateral EDs for LLD and 11 bilateral EDs for tall stature, were prospectively analyzed. ED was performed with 222 rigid staples with a mean follow-up of 24.4 months (8 to 49). Patients with a predicted LLD of ≥ 2 cm at skeletal maturity were included. Mean age at surgery was 12.1 years (8 to 14). Correction and complication rates including implant-associated problems, and secondary deformities as well as perioperative parameters, were recorded (IDEAL stage 2a). These results were compared to historical cohorts treated for correction of LLD with two-hole plates or Blount staples. Results The mean LLD was reduced from 25.2 mm (15 to 45) before surgery to 9.3 mm (6 to 25) at skeletal maturity. Implant-associated complications occurred in 4/56 treatments (7%), and secondary frontal plane deformities were detected in 5/45 legs (11%) of the LLD cohort. Including tall stature patients, the rate increased to 12/67 legs (18%). Sagittal plane deformities were observed during 1/45 LLD treatments (2%). Compared to two-hole plates and Blount staples, similar correction rates were observed in all devices. Lower rates of frontal and sagittal plane deformities were observed using rigid staples. Conclusion Treatment of LLD using novel rigid staples appears a feasible and promising strategy. Secondary frontal and sagittal plane deformities remain a potential complication, although the rate seems to be lower in patients treated with rigid staples. Further comparative studies are needed to investigate this issue. Cite this article: Bone Joint J 2021;103-B(8):1428–1437.

RigidTack™ is a newly developed implant for total temporary epiphyseodesis. The implant combines the technical advantages of the traditionally used rigid Blount-staples and the newer flexible eight-plates™. Thus, the implant is rigid like the Blount-staples, which may be a biomechanical advantage in temporary epiphyseodesis, and has an easy and guided implantation technique like the eight-plate™. As in eight-plates™, supposedly only two RigidTacks™ are sufficient for temporary epiphyseodesis compared to six Blount-staples in traditional treatment. The goal of this study was to compare Blount-staples and RigidTacks™ in regard to the total potential of growth arrest, the occurrence of postoperative implant-associated complications, secondary angular deformities, and central joint deformations. Twelve pigs were allocated in two groups (n = 6) for treatment of the proximal tibia. Total temporary epiphysiodesis was performed with either four Blount-staples or two RigidTacks™. Magnetic resonance imaging (MRI)-scans were performed before and 14 weeks after surgery, and the amount and distribution of growth arrest were evaluated by measuring the interphyseal distance in nine defined zones. Total temporary epiphysiodesis with two RigidTacks™ resulted in a similar amount of growth arrest as that of four Blount-staples. No significant coronal or sagittal angular deformities or joint deformities were observed in either group; however, one secondary loosening of a Blount-staple occurred. The study concluded that Blount-staples and RigidTacks™ are adequate implants for total temporary epiphysiodesis. Whether or not the precise implant-placement through the guided implantation technique of RigidTacks™ and a reduced number of implants indeed lead to a reduction of secondary angular deformities has to be investigated in further clinical trials. © 2019 The Authors. Journal of Orthopaedic Research® published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society. J Orthop Res 38:946-953, 2020.

Aim Presentation of the joint angle tool (JAT), a low-cost goniometer for intraoperative assessment of the lower limb alignment. Background Intraoperative assessment of coronal alignment is important when performing corrective osteotomies around the knee and ankle, limb lengthening, and trauma surgery. JAT provides surgeons with information about the anatomic and mechanical axes intraoperatively based on true anteroposterior radiographs. Technique JAT consists of pre-printed joint orientation angles of the anatomic and mechanical axis including normal variations on a plastic sheet. It is placed on the screen of the image intensifier after obtaining a true anteroposterior image. The pre-printed joint orientation angles can assist the surgeons intraoperatively in achieving the pre-planned axis correction. Here, its feasibility is demonstrated in four cases. Conclusion and clinical significance JAT is a modified goniometer that allows intraoperative assessment of the mechanical and anatomic axis. JAT is applicable throughout the entire surgical procedure irrespective of the method of internal fixation and may provide additional reassurance of correct alignment. JAT consists of a plastic sheet with printed joint orientation angles and their normal variation. JAT is freely available from profeedback.dk/JAT/JAT.pdf for use and modification according to the Creative Commons license (CC BY-SA 4.0) if this paper is attributed. How to cite this article Abood AA-H, Petruskevicius J, Vogt B, et al. The Joint Angle Tool for Intraoperative Assessment of Coronal Alignment of the Lower Limb. Strategies Trauma Limb Reconstr 2020;15(3):169–173.

Subtalar arthroereises (STA) is a minimally invasive and reversible surgery to correct symptomatic flexible flatfoot (FFF) in children. Various techniques were described either applying expandable sinus tarsi implants or lateral calcaneus stop screws. Studies comparing the outcome of STA with different devices are rare. This retrospective single-center cohort study analyzes the results of STA using three different implants. 113 STA were performed in 73 consecutive patients (28 females). Mean age at surgery was 10.8 years (range 5–16). Mean follow-up was 29.0 months (range 1–111). In 21 feet the non-absorbable Kalix® endorthesis and in 56 feet the absorbable Giannini endorthesis were applied. Subtalar extraarticular screw arthroereises (SESA) was conducted in 36 feet. Clinical, radiographic and pedobarographic parameters were analyzed. No intraoperative complications were observed. All three procedures achieved comparable improvements of the clinical, radiographic and pedobarographic parameters. The mean foot function index (FFI) improved from 36.4 (range 12–63) to 22.8 (range 2–55). The mean preoperative calcaneal inclination angle and the lateral talocalcaneal angle improved from 9.5° (range 0–22) and 42.3° (range 21–62) to 12.8° (range 0–26) and 37.6° (range 15–56), respectively. Pedobarographically determined values of the arch index, the medial midfoot contact area and the medial forefoot peak pressure decreased. In contrast to SESA (1/36, 3%), a higher incidence of implant-related complications was observed using Kalix® (6/21, 29%) and Giannini (10/56, 8%) sinus tarsi implants. Peroneal muscle contractures only occurred in the SESA group (4/36, 11%). Premature removal due to treatment-related complications was necessary in 6/21 Kalix® implants (29%), 4/56 Giannini implants (7%) and 4/36 SESA implants (11%). Implant choice for treatment of painful FFF in children with STA seems to play a subordinate role. Clinical, radiographic and pedobarographic outcomes are comparable between the applied implants. Surgeons and patients should be aware of the different spectrum of implant-related complications. Treatment can be reliably monitored by radiation-free pedobarography providing dynamic information about the deformity.

Introduction: D-dimer is a diagnostic criterion for periprosthetic joint infection (PJI) of the Musculoskeletal Infection Society (MSIS) in 2018. The aim of this study was to evaluate the serum D-dimer values in comparison to C-reactive protein (CRP) and interleukin-6 (IL-6) for the diagnosis of PJI. Materials and Methods: We included 119 patients (50 women, 69 men, 71 knees, 48 hips) undergoing revision arthroplasty with preoperative assessment of CRP, IL-6, and serum D-dimer. Cases were classified as infected or aseptic based on the MSIS criteria of 2018. Receiver operating curves and Youden&rsquo, s index were used to define an ideal cut-off value and sensitivity and specificity for the individual parameters, and respective combinations were calculated using cross-tables. Results: The median D-dimer level (2320 vs. 1105 ng/mL, p &lt, 0.001), the median CRP level (4.0 vs. 0.5 mg/dL, 0.001), and the median IL-6 level (21.0 vs. 5.0 pg/mL, 0.001) were significantly higher in the group of PJI compared to the group with aseptic failure. The calculated optimal cut-off values were 2750 ng/mL (AUC 0.767) for D-dimer, 1.2 mg/dL (AUC 0.914) for CRP, and 10.0 pg/mL (AUC 0.849) for IL-6. D-dimer showed a sensitivity of 38% and specificity of 94%, whereas the CRP and IL-6 had sensitivities of 88% and 76%, and specificities of 87% and 92%, respectively. Conclusion: In comparison with CRP and IL-6, serum D-dimer showed low sensitivity and specificity in our cohort. While CRP and IL-6 combination had the highest sensitivity, a combination of Il-6 and D-dimer or CRP and IL-6 had the highest specificity.

Aims The treatment of tibial aplasia is controversial. Amputation represents the gold standard with good functional results, but is frequently refused by the families. In these patients, treatment with reconstructive limb salvage can be considered. Due to the complexity of the deformity, this remains challenging and should be staged. The present study evaluated the role of femoro-pedal distraction using a circular external fixator in reconstructive treatment of tibial aplasia. The purpose of femoro-pedal distraction is to realign the limb and achieve soft tissue lengthening to allow subsequent reconstructive surgery. Methods This was a retrospective study involving ten patients (12 limbs) with tibial aplasia, who underwent staged reconstruction. During the first operation a circular hexapod external fixator was applied and femoro-pedal distraction was undertaken over several months. Subsequent surgery included reconstruction of the knee joint and alignment of the foot. Results The mean follow-up was 7.1 years (2 to 10). The mean age of the patients at the time of the application of the fixator was 2.3 years (1.1 to 5.0). The mean time under distraction was 139.7 days (81.0 to 177.0). A mean fibular distalization of 38.7 mm (14.0 to 67.0) was achieved. Pin infections occurred in four limbs (33.3%) and osteitis in one. A femoral fracture occurred in one patient. Premature removal of the frame was not required in any patient. Sufficient realignment of the leg as well as soft tissue lengthening was achieved in all patients, allowing subsequent reconstruction. All patients were able to mobilize fully weight bearing after reconstruction. Functional outcome was limited in all limbs, and five patients (50.0%) required additional reconstructive operations. Conclusion Regarding the functional results in the treatment of tibial aplasia, amputation remains superior to limb salvage. The latter procedure should only be performed in patients whose parents refuse amputation. Femoro-pedal distraction efficiently prepares the limb by realigning the leg and soft tissue lengthening. Minor complications are frequent, but usually do not hinder the continuation of distraction. Even though a fully weight-bearing limb is achieved, the functional outcome of reconstructive treatment remains limited. Recurrent deformities frequently occur and may require further operations. Cite this article: Bone Joint J 2020;102-B(9):1248–1255.

Simple bone cysts (SBCs) occur most frequently in the proximal aspect of the humerus and femur in growing age and are associated with intercurrent pathological fractures in up to 87%. Therapeutic management of SBCs remains controversial. The aim of this study was to examine the outcome of conservative and various surgical treatment modalities considering the specific anatomic location and integrity of the SBC.In this retrospective study, we analyzed 68 cases of SBCs who underwent a conservative or surgical treatment between 2009 and 2020 with a mean follow-up of 30.1 months. The epidemiological characteristics, complications, clinical, and radiographic outcome after conservative or surgical treatment were assessed.The study includes 50 male (73.5%) and 18 female (26.5%) patients with a mean age of 9.1 years. The most common locations were the proximal humerus (69.2%, n = 47) and femur (16.2%, n = 11). In 43 cases (63.2%; upper limb n = 40, lower limb n = 3) a pathological fracture occurred. Fifty patients (73.5%; upper limb n = 40, lower limb n = 10) underwent a conservative treatment. In 11 cases (16.2.1%; upper limb n = 4, lower limb n = 7) an intralesional curettage and defect reconstruction with bone substitute without stabilization were performed. Five patients (7.3%; upper limb n = 4, lower limb n = 1) received an osteosynthesis, in two cases (2.9%; upper limb 1; lower limb 1) combined with an intralesional curettage and defect reconstruction with bone substitute. All 32 pathological fractures treated conservatively (upper limb n = 31, lower limb n = 1) healed within 6 weeks; 17/43 patients (39.5%) suffered at least one second fracture. After intralesional curettage and defect reconstruction with bone substitute local recurrence was observed in 5/13 cases (38.5%). Spontaneous consolidation, at least partially, was observed in three cases (4.4%) following conservative treatment after fracture. No relevant secondary angular or torsional deformity was observed after treatment.The majority of SBCs can be treated conservatively, especially in the upper extremity. However, if a fracture is completely dislocated, joint affecting, unstable or open, surgical treatment is necessary. Load-dependent pain or the inability to mobilize timely after fracture can necessitate surgical treatment in SBCs affecting the lower extremity. Spontaneous resolution, especially after fracture, can be seen in rare cases.

Primary ciliary dyskinesia (PCD) is a genetically heterogeneous recessive disorder caused by several distinct defects in genes responsible for ciliary beating leading to defective mucociliary clearance often associated with randomization of left/right body asymmetry. PCD individuals with defective radial spoke heads are difficult to diagnose due to lack of gross ultrastructural defects and absence of situs inversus . Thus far, most radial spoke mutations identified are loss-of function mutations, and missense variants have been rarely described. Using immunofluorescence analyses (IF), we studied the consequences of different RSPH9 , RSPH4A , and RSPH1 mutations on the assembly of the radial spoke complex to improve diagnostics in PCD. We identified bi-allelic mutations in RSPH9, RSPH4A and RSPH1 including 7 novel mutations comprising missense variants in 21 PCD individuals (16 families). We performed IF using antibodies directed against the radial spoke head components RSPH9, RSPH1 and RSPH4A to analyzed respiratory cilia of these patients. Absence of RSPH4A due to mutations in RSPH4A results in deficient axonemal assembly of the radial spoke head components RSPH1 and RSPH9. RSPH1 mutant cilia, lacking RSPH1 fail to assemble RSPH9, while RSPH9 mutations result in axonemal absence of RSPH9 but do not affect the assembly of the other head proteins RSPH1 and RSPH4A. Interestingly, our results were identical in individuals carrying loss-of-function mutations, missense variants or one amino acid deletion. Thus, we conclude that Immunofluorescence analysis can improve diagnosis of PCD in patients with loss-of-function mutations as well as missense variants.

Primary ciliary dyskinesia (PCD) is a genetically heterogeneous recessive disorder caused by several distinct defects in genes responsible for ciliary beating, leading to defective mucociliary clearance often associated with randomization of left/right body asymmetry. Individuals with PCD caused by defective radial spoke (RS) heads are difficult to diagnose owing to lack of gross ultrastructural defects and absence of situs inversus. Thus far, most mutations identified in human radial spoke genes (RSPH) are loss-of-function mutations, and missense variants have been rarely described. We studied the consequences of different RSPH9, RSPH4A, and RSPH1 mutations on the assembly of the RS complex to improve diagnostics in PCD. We report 21 individuals with PCD (16 families) with biallelic mutations in RSPH9, RSPH4A, and RSPH1, including seven novel mutations comprising missense variants, and performed high-resolution immunofluorescence analysis of human respiratory cilia. Missense variants are frequent genetic defects in PCD with RS defects. Absence of RSPH4A due to mutations in RSPH4A results in deficient axonemal assembly of the RS head components RSPH1 and RSPH9. RSPH1 mutant cilia, lacking RSPH1, fail to assemble RSPH9, whereas RSPH9 mutations result in axonemal absence of RSPH9, but do not affect the assembly of the other head proteins, RSPH1 and RSPH4A. Interestingly, our results were identical in individuals carrying loss-of-function mutations, missense variants, or one amino acid deletion. Immunofluorescence analysis can improve diagnosis of PCD in patients with loss-of-function mutations as well as missense variants. RSPH4A is the core protein of the RS head.