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Congenital Clubfoot (CCF) treatment involves a surgical procedure on the Achilles tendon most of the time, i.e. tenotomy or, in selected cases, Z-plasty lengthening. Many authors have studied the outcomes of Achilles tenotomy, describing complete clinical and ultrasound tendon fibers integrity restoration 3-6 weeks after surgery. Nevertheless, little is known about the mechanical properties of the operated tendon. Recently, cases of subcutaneous rupture of the Achilles tendon have been described in adolescents who practiced sports and who had undergone Achilles tenotomy for congenital clubfoot in childhood. Authors report two cases of atraumatic Achilles tendon injury (subcutaneous rupture and intratendinous ossification) in adult patients who had been treated for congenital clubfoot in childhood. In both cases, no causes determining the injury were identified; in the medical history there was a Z-plasty lengthening of the Achilles tendon, performed within the first year of life, which could be considered a predisposing factor. The usefulness of long-term monitoring of patients treated for CCF with surgical procedures on the Achilles tendon is therefore hypothesized, in order to promptly identify by symptoms, clinical pictures and ultrasound criteria, tendon suffering that may predispose subcutaneous rupture.

Introduction: Congenital dislocation of the patella (CDP) is a rare condition and its treatment is not well defined. In CDP, patella is dislocated on the lateral aspect of the distal femur, laterally from the trochlear groove, it cannot be reduced manually and it is almost always associated with genu valgum, lateral torsion of the proximal tibia, and flexion contracture of the knee. This condition is present at birth, but the clinical findings can be subtle at birth due to the size and character of the structures being examined; early diagnosis is essential, but it may be delayed to late childhood or adulthood. If CDP is not promptly treated, the disability increases during growth, so surgical correction should be planned as soon as the diagnosis is confirmed. Case Report: We report a case of bilateral CDP associated with bilateral proximal radioulnar joint stiffness; the patient at the age of diagnosis was 11 years old and underwent a bilateral delayed surgical procedure; the 4-year follow-up results are satisfactory. Surgical treatment rationale and literature are reviewed. Conclusion: Surgical correction for CDP is generally recommended, but there is no agreement in literature on the ideal treatment and in some cases, with mild impairment of the knee function, observation alone has been suggested. The decision about a surgical treatment can be difficult and depends on the degree of disability of the patient. Keywords: Congenital dislocation of the patella, bilateral congenital dislocation, patella, Z-plasty quadriceps muscle, lateral retinaculum release, lack of active knee extension.

Many intra- and postoperative (early or late) complications are described with the use of circular external fixation, both conventional and hexapod, and the most widespread classification distinguishes between difficulties (divided into “problems” and “obstacles”) and true complications.

In cases of long bone fractures or deformities, the use of the external fixation, followed or not by a planned conversion to internal fixation, is frequently associated with the risk of deep tissue infection or, in the worst case scenario, of osteomyelitis.

Massive segmental defects of long bones represent a challenge to the orthopedic surgeon. Many techniques, including autologous graft, allograft, vascularized bone graft, induced membrane technique, megaprostheses, and other approaches with the aim of enhancing bone regeneration, have been proposed to fill these defects.

Costs associated with treatment of traumatic injuries and orthopaedic deformities of long bones are high and their assessment is complex. Cost analysis includes clinical outcomes (such as survival, rates of union or nonunion, and short-term morbidity) and functional outcomes (e.g., lost wages, quality of life, return to work, and emotional well-being). Cost analysis must also distinguish between direct costs (associated with all aspects of treatment) and indirect costs (associated with lost productivity).

Metatarsal fractures make up the greatest portion of foot fractures in children. Most of them are treated with closed reduction and non-weightbearing cast immobilization.Usually, these fractures heal uneventfully and delay union and pseudoarthrosis are rare. We report a case of a 10-year-old child with non-union of the second metatarsal following a traumatic fracture, caused by an accident 10 months before, and treated successfully by osteosynthesis with plate and screws. Good clinical outcome was achieved at 2 years follow-up.

Long bone deformities as a result of trauma may lead to complications such as chronic pain, abnormal functional loading, cosmetic abnormality, joint arthritis and, if located at the lower limbs, difficult walking. The introduction of the typical circular external fixation played a prominent role in improving the management of these deformities, and second-generation circular devices (hexapod systems connected to computer planning software), which allow for simultaneous correction of all kinds of deformities in adults and children, further improved versatility, patient tolerability and nursing.

Le indicazioni all’impiego della fissazione esterna nel trattamento delle fratture iuxta-articolari e dei loro esiti sfavorevoli dipendono dall’azione, sul segmento scheletrico interessato, di vari fattori strettamente collegati fra loro: sistemi di fissazione, tipo di patologia, tipo di trattamento (programma pre-operatorio, operatorio, post-operatorio), paziente, team ortopedico.

The evolution of medical and surgical therapies allows the increased survival rate of a growing number of children affected by rare pathologies. In this light osteoporotic disease is also of orthopaedic interest as it is sometimes the outward manifestation of serious pathologies (i.e. osteogenesis imperfecta). Sometimes, even in infancy and adolescence, osteoporosis is associated with complications due to fractures; in other cases it seems to have no immediate consequence. Nevertheless it must be considered as a fracture risk factor in adulthood as it negatively affects the achievement of peak bone mass. The evaluation of variations in bone mass that take place during growth is thus of particular importance in order to guarantee a level of bone health suitable for the next phase. These remarks compose the premise of a study on bone resistance carried out on a study population of between 6 and 18 years of age in the city of Pavia. To determine the resistance of the bone an ultrasound device was employed (Omnisense™ , Sunlight Medical Ltd, Tel Aviv, Israel) in two skeletal sites, distal radius and midshaft of tibia. The analysis of our results and a review of the relevant literature indicate that the median values of normality, against which we compare the measurements of the patients under examination, depend not only on age, sex, skeletal sites, race, and even ethnic group. The introduction of this new parameter, to be kept in mind when interpreting the results, invites us to be very prudent in determining the diagnostic threshold values in paediatric age. As with anthropometric data (weight, height, cranial circumference) it is possible to suggest an interpretation of the patient's SOS values comparing them with the 'centile curves' typical to the region the child belongs to. Of course, further studies are required to understand what are the variables involved and to determine the extension of the geographical area to be examined to obtain suitable reference curves.

Techniques for the management of infected nonunions of the long bones aim to solve three problems: infection, lack of bone continuity, and lack of skin coverage. These problems are always related to varying degrees: the lack of skin coverage can allow a superinfection; the persistence of infection damages the surrounding soft tissues; the lack of consolidation and the persistence of abnormal mobility improves infection [1]. Conventional treatment combines, in several operative stages, debridement, stabilization, and reconstruction. Debridement, associated with antibiotic therapy, attempts to sterilize the nonunion site. Stabilization aims to allow consolidation and to fight infection more effectively. Skin and bone grafts can be used for reconstruction. Concerning bone grafts, there are two possibilities: corticocancellous bone grafting with skin coverage (the use of corticocancellous graft requires skin closing since the cortical bone suffers from air exposure) and cancellous bone grafting without skin coverage (Papineau method).

There are a few basic elements of circular external fixation systems, as underlined by Kalnberz [1]. They can be summed up as: bone fixation elements, rings which encircle the bone segment, rods connecting the rings, connecting elements between rods and rings, and connecting elements between rings and bone fixation elements. Many other elements can be added (Fig. 1). However, they differ in importance and number from system to system, and their effectiveness is often questionable.

After their introduction in the Soviet Union in the 1950s, circular external fixation systems gradually spread in Western countries. From the 1980s a second generation of hexapod circular external fixators was developed, linked to computer planning software, that ensures a high accuracy in the simultaneous correction of all kinds of deformities or fracture displacements of the long bones, in adults and children.