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Musculoskeletal injuries in children offer unique challenges compared with those in adults. Even low-energy injuries that involve the physis have the potential to cause a growth disturbance that could require treatment. Higher-energy injuries can be complicated by the same soft-tissue disruption, fracture contamination, and bone loss that are seen in adults. However, small patient size and injury proximity to a physis can complicate both immediate and long-term management. It is important to be aware of treatment tools and strategies when managing complex injuries in young patients.

Background: Limb lengthening procedures are performed for various indications, including limb length discrepancies (LLDs) and short stature. This systematic review and meta-analysis compares the efficacy and safety of the newer motorized intramedullary lengthening nails (MILNs) with the traditional alternative techniques (ATs) for femoral limb lengthening., Methods: We conducted a comprehensive literature search in the Medline, Embase, Cochrane, Web of Science, and Scopus databases, inclusive of all dates through July 1, 2023, and without language restrictions. Factors mediating outcomes included problems, obstacles, complications, total adverse events, healing/consolidation index, time to full weight-bearing, lengthening accuracy, percentage of lengthening goal achieved, and duration of hospital stay. Effect sizes were quantified using STATA 17.0. Statistical algorithms employed were random effects model standardized mean differences (SMDs) for continuous outcomes and log risk ratios (RRs) for dichotomous outcomes, both with 95% confidence intervals (CIs)., Results: Our meta-analysis included 10 studies comparing MILN with AT: 180 femurs in the MILN group and 160 femurs in the AT group. This was exclusively comprised of retrospective cohort studies. When compared with AT, limb lengthening procedures utilizing MILNs had significantly lower problems (log RR, -1.35; 95% CI, -1.93 to -0.77; p < 0.001), complications (log RR, -0.56; 95% CI, -0.90 to -0.22; p = 0.001), and total adverse events (log RR, -0.69; 95% CI, -1.17 to -0.21; p = 0.005), as well as a superior bone healing index (SMD, -0.80; 95% CI, -1.32 to -0.28; p = 0.003). However, no significant differences were found in obstacles, percentage of lengthening goal achieved, lengthening accuracy, time to full weight-bearing, and duration of hospital stay., Conclusion: Limb lengthening with MILNs vs. AT may offer more favorable patient outcomes, lowering risk for problems, complications, and total adverse events, while optimizing the bone healing/consolidation index. However, the limitation of nonrandomized retrospective studies and high heterogeneity should be acknowledged., Level of Evidence: Level II (meta-analysis of cohort studies). See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/B160)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Introduction: Despite the recognized importance of managing vascular injury associated with knee dislocation, studies have been limited by small patient sizes, data older than five years, and lack of inclusion of newer procedural and diagnoses codes. This has been reflected in the reported frequency of knee dislocation associated with vascular injury ranging from 1.6 % to 64 %. As such, we sought to determine: (1) the frequency of knee dislocations associated with vascular injuries; (2) the frequency of knee dislocations associated with vascular injuries that required repair; as well as (3) independent risk factors for knee dislocation with vascular injury that require repair, across different age groups, sexes, and United States geographic regions., Methods: A national, all-payer database was queried from January 1, 2010 to June 31, 2022. The frequency of a vascular injury was calculated by dividing the number of vascular injuries within 30 days of all knee dislocations by the total number of knee dislocations in each category. The frequency of a vascular injury that required repair was calculated by dividing the number of vascular injuries that required repair associated with knee dislocation by the total number of vascular injuries associated with knee dislocations. Patients were categorized by year of diagnosis, age, sex, and US geographic region. Multivariable logistic regressions were calculated to determine independent risk factors for knee dislocation with vascular injury., Results: From 2010 to 2022, there were 99,688 knee dislocations. Of the total knee dislocations, there were 1066 (1.1 %) vascular injuries associated with knee dislocations, 96,530 (96.8 %) were closed dislocations, and 3158 (2.2 %) were open dislocations. Of the 1066 vascular injuries associated with knee dislocations, 262 (24.6 %) vascular injuries required repair. Male sex (P < 0.001), Elixhauser Comorbidity Index (ECI) > 3 (P < 0.001), alcohol abuse (P = 0.006), congestive heart failure (P = 0.01), hypothyroidism (P = 0.003), and obesity (P < 0.001), were independent risk factors for knee dislocation with vascular injuries., Conclusion: Our study provides a refined understanding of the historically low incidence of knee dislocation with vascular injury as well as an increase in vascular injuries requiring repair from 2010 to 2022. Given the large expense of irreversible injury in these patients, vulnerable patient populations identified in our study, such as obese patients with additional comorbidities, should be a focus of future intervention. These findings can guide physicians in a clinical setting to appropriately manage the expectations of patients as well as minimize the morbidity and mortality associated with this presentation., Competing Interests: JN- Arthritis Foundation: Board or committee member, Journal of Arthroplasty, Journal of the American Osteopathic Medicine Association, Orthopedic, Knowledge Online: Editorial or governing board, Journal of Knee Surgery: Editorial or governing board, Knee: Editorial or governing board, Microport: Paid consultant; Paid presenter or speaker; Research support, Stryker: Research support, United: Research support. PM- Biocomposites: Other financial or material support, MHE Coalition: Other financial or material support, Novadip: Paid consultant; Research support, Orthofix, Inc.: Other financial or material support; Paid consultant, OrthoPediatrics: Other financial or material support; Paid consultant, Pega Medical: Other financial or material support, Smith & Nephew: Other financial or material support; Paid consultant, Stryker: Other financial or material support, Synthes: Other financial or material support; Paid consultant, Wishbone: Paid consultant, Zimmer: Other financial or material support. RD- Baltimore City Medical Society.: Board or committee member, DePuy Synthes Product, Inc.: Research support, Orthofix, Inc.: Research support, Smith & Nephew: Research support, Stryker: Research support, Tissue Gene: Research support., (© 2024 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights are reserved, including those for text and data mining, AI training, and similar technologies.)

Introduction: Surgical site infection (SSI) related to magnetic intramedullary lengthening nails (MILNs) can lead to delayed consolidation or loss of limb function, resulting in deleterious effects to a patient's quality of life. With the rise of MILNs, we sought to determine the incidence rate and risk factors for infection during limb lengthening with MILNs., Methods: We reviewed a consecutive series of patients who underwent femoral and/or tibial lengthening with an MILN at a single institution between 2012 and 2020 (n = 420). SSI was defined according to CDC-NHSN criteria (including superficial and deep infections) with postoperative surveillance time of 12 months. Demographic, health metrics, comorbidities, limb- and surgery-related factors, were assessed as potential risk mediators of SSI., Results: Incidence of SSI was 3.3 % (14/420). This was divided into superficial (0.5 %,2/420) and deep (2.9 %, 12/420) infections. Of deep infections, 75 % (9/12) were osteomyelitis. Of the 14 limbs that developed SSI, 57 % (8/14) had a history of prior external fixation in the same limb and 38 % (5/14) had a previous infection of the same limb. A subanalysis of patients with a history of prior external fixation in the same bone was associated with SSI, as compared to those without previous external fixation. None of the surgery-related infection risk factors reached statistical significance., Discussion and Conclusion: The total incidence of infection with MILNs was 3.3 % at 24 months follow-up. The risk of deep infection was 2.9 %. Patients with a history of previous external fixation and prior infection show an independent association with increased rate of infection recurrence in the same bone. These patients could be considered a high-risk group for developing deep tissue infection. Potential algorithms include prolonged oral antibiotics after MILN insertion or simultaneous injection of absorbable antibiotic at the time of the nail insertion., Competing Interests: JD- None. SB-None MM- None. PM-receives support from Biocomposites: Other financial or material support, MHE Coalition: Other financial or material support, Novadip: Paid consultant; Research support, Orthofix, Inc.: Other financial or material support; Paid consultant, OrthoPediatrics: Other financial or material support; Paid consultant, Pega Medical: Other financial or material support, Smith & Nephew: Other financial or material support; Paid consultant, Stryker: Other financial or material support, Synthes: Other financial or material support; Paid consultant, Wishbone: Paid consultant, Zimmer: Other financial or material support Data availability- Available in a respository upon request. JH- receives support from DePuy Synthes: Other financial or material support, Nuvasive: Other financial or material support; Paid consultant, Orthofix, Inc.: Other financial or material support; Paid consultant, OrthoPediatrics: Other financial or material support; Paid consultant, Paragon 28: Other financial or material support, Pega Medical: Other financial or material support, Smith & Nephew: Other financial or material support; Paid consultant, Stryker: Other financial or material support, Turner Imaging Systems: Other financial or material support, WishBone Medical: Other financial or material support CG-is a paid consultant for Globus Medical., (© 2024 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Introduction: The advantages of outpatient surgery have been shown in other orthopedic subspecialities to be a means of driving down costs and reducing the average length of hospital stay. However, there is a scarcity of literature examining the utility of a specific, hospital-based facility performing such procedures for limb lengthening. Considering this, we aimed to investigate surgical factors, patient characteristics, and the incidence of outpatient postoperative complications for patients undergoing surgery and subsequent distraction osteogenesis utilizing the Precice® nail, a state-of-the-art magnetic intramedullary nail (MILN)., Methods: We performed a retrospective review of medical records pertaining to outpatient limb lengthening procedures occurring between January 2012 and September 2023 at a single institution, as performed by three surgeons. Variables of interest included baseline demographics, type of anesthesia, operative bone, laterality, preoperative diagnosis, osteotomy level, procedure performed, prosthesis, point of entry, nail diameter/length, goal length, goal achieved, postoperative complications, and elective nail removal., Results: The cohort comprised 20 limbs, with an average age at index surgery of 24.8 (SD 7.96). There were no complications related to the outpatient nature of the procedure. Five of the 20 limbs had postoperative complications, including deep vein thrombosis (DVT), screw backout, and nail breakage., Conclusion: Our initial investigation of outpatient limb lengthening at a specific, hospital-based facility demonstrated favorable postoperative outcomes for those patients undergoing limb lengthening procedures with an MILN. The field would certainly benefit from future research assessing outcomes of pediatric surgeries in the outpatient setting on a larger scale, as well as across hospital systems, the country, and globally. With the proven advances and benefits of MILNs, prioritizing examination of their efficacy in an outpatient population is imperative. Furthermore, the success of outpatient procedures in other orthopedic subspecialities, such as total joint arthroplasty, is a logical, driving precedent for this rationale., Competing Interests: JD- None. SB-None. MM- None. MA-receives support from DePuy, A Johnson & Johnson Company: Unpaid consultant, Orthofix, Inc.: Unpaid consultant, Orthopediatric: Unpaid consultant. PM-receives support from Biocomposites: Other financial or material support, MHE Coalition: Other financial or material support, Novadip: Paid consultant; Research support, Orthofix, Inc.: Other financial or material support; Paid consultant, OrthoPediatrics: Other financial or material support; Paid consultant, Pega Medical: Other financial or material support, Smith & Nephew: Other financial or material support; Paid consultant, Stryker: Other financial or material support, Synthes: Other financial or material support; Paid consultant, Wishbone: Paid consultant, Zimmer: Other financial or material support, (© 2024 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Background: While previous research has addressed conversion arthroplasty scenarios, there is limited data on outcomes of staged or concurrent removal of intramedullary (IM) nails during total knee arthroplasty (TKA). Our study aimed to explore the association between the timing of IM nail removal and the incidence of periprosthetic joint infection (PJI), surgical site infection (SSI), manipulation under anesthesia (MUA), and aseptic revision at 90 days, 1 year, and 2 years after TKA when IM nail removal is performed in either a (1) staged or (2) concurrent manner., Methods: We queried a national, all-payer database of all patients who underwent a primary TKA and hardware removal of an IM tibial nail. The group was separated into mutually exclusive cohorts with removal performed either (1) in a staged manner (n = 287) or (2) on the same day of TKA (n = 2,958). Surgical complications included the following: PJIs, SSIs, MUAs, and aseptic revisions. Surgical complications were collected at 90-day, 1 year, and 2-year time points., Results: Patients who had staged nail removal before TKA demonstrated the highest incidence of PJI at 90 days, 1 year, and 2 years (13.9, 16.7, and 17.1%, respectively). Adjusted multivariate regression analyses demonstrated significantly higher odds of a PJI, SSI, and MUA at 90 days, 1 year, and 2 years for all patients who had staged nail removal TKA (P < .001)., Conclusions: There was an observed association between concurrent IM nail removal and a decreased risk of PJI, SSI, and MUA when compared to patients who had nail removal in a staged fashion. However, this does not discount the utility of the staged approach, as it may be necessary for patients less tolerant to longer operative times., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Aims & Objectives: Prior to the popularization of magnetic intramedullary nails (MILNs), gradual deformity correction using external fixation was the norm in limb lengthening. Trauma literature has shown MILN via a suprapatellar approach (SP) to be associated with less knee pain than either an infrapatellar entry (IP) or external fixation. Yet, no research has investigated chronic knee pain and MILNs. We assessed differences in chronic knee pain following lengthening via an IP or SP approach with an MILN versus external fixation., Materials & Methods: We reviewed 147 limbs (55 MILN/IP, 22 MILN/SP, 71 external fixator) in 124 patients who underwent tibial lengthening with ≥12 months follow-up between February 2012 and July 2020. Knee pain was assessed pre- and postoperatively at 6 and 12 months, with the Lysholm Knee Scoring Scale (LKSS) and numeric pain scale (0-10). Differences in knee pain outcomes were compared across methods, with subgroup analysis of MILN/SP and MILN/IP., Results: Mean LKSS was 96.3 for external fixation and 88.5 for MILN ( P  = .011). In the MILN subgroups, mean LKSS was 91.7 for IP and 85.3 for SP. The IP group reported a lesser mean pain score (0.6 versus 2.1) at 12 months. Bilateral nail recipients demonstrated no knee pain differences versus unilateral. At 12 months postoperative, external fixation had better knee outcomes., Conclusion: Tibial lengthening with external fixation was associated with less chronic anterior knee pain and better functional outcomes than MILN overall. In terms of MILN approach, IP surpassed SP on subjective pain scores. Larger tibial lengthening and knee pain studies are warranted., (© 2023 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Background: Congenital synostosis of the knee is a rare condition with limited data on treatment options and outcomes. This study reports clinical findings, treatment approach, and surgical/clinical outcomes for congenital synostosis of the knee., Methods: An institutional review board-approved retrospective review of patients with congenital synostosis of the knee presenting to 2 institutions between 1997 and 2021 was performed., Results: Eight patients (13 knees) with a median follow-up of 11.3 years (3.3 to 17 y) were included. Seven patients had associated syndromes. Patients presented with an average knee flexion deformity of 100° (range 60 to 130°) and delayed walking ability. Seven patients had associated upper extremity hypoplasia/phocomelia. The average age at the index surgery was 4.3 years (range 1.2 to 9.2 y). Synostosis resection with gradual deformity correction was performed in most patients. An attempt was made at a mobile knee in some patients, but all went on to knee fusion. Mean flexion deformity at final follow-up was 11.6° (range: 0 to 40°) and 5 limbs were fused in full extension. Mean limb length discrepancy at final follow-up was 6.8 cm (range: 0 to 8 cm). All patients maintained their improved ambulation status at final follow-up. Twenty-two complications were identified., Conclusions: Reliable correction of the deformity associated with congenital knee synostosis was achieved at a median follow-up of 11 years. Importantly, all patients maintained their improved ambulation at final follow-up. This is the largest study on patients with congenital knee synostosis and outlines a reconstructive approach to improve ambulatory status., Level of Evidence: Level IV., Competing Interests: T.P.K.M. is a consultant for DePuy Synthes Companies, Novadip, NuVasive Specialized Orthopedics, Orthofix, and Smith & Nephew. J.E.H. is a consultant for NuVasive Specialized Orthopedics, Orthofix, OrthoPediatrics, and Smith & Nephew. The following organizations supported the institution of N.J.N., P.K.M. and J.E.H.: DePuy Synthes, NuVasive Specialized Orthopedics, Orthofix, OrthoPediatrics, Paragon 28, Pega Medical, Smith & Nephew, Stryker, Turner Imaging Systems, and WishBone Medical. The remaining authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Clubfoot management has advanced in the 21st century with increases in formal training, practitioner experience, and improved casting/bracing constructs. The Ponseti method is the gold standard, yet variations in application persist. This survey aims to identify current treatment practices among clubfoot practitioners within the Pediatric Orthopaedic Society of North America (POSNA). A 23-question online survey of members was conducted between June and August 2021. Eighty-nine respondents self-identified as clubfoot providers. Of these, 93.1% had an MD degree, 23.6% possessed >30 years' experience, and the majority (65.6%) worked in a teaching hospital associated with a medical school. Most responders (92.0%) were pediatric fellowship trained. A total of 51.7% had participated in a clubfoot training course. More than half (57.5%) noted changes to clubfoot management practices throughout their training. A majority used between four and seven (88.7%) long leg casts (98.4%), changed at seven-day intervals (93.4%). Plaster (69.4%) was most commonly used. The most common bracing device was Mitchell-Ponseti (72.9%). A mean 84.8% of clubfeet required tenotomy. The most common anesthetic agent was numbing gel (43.0%). Tenotomies mostly occurred in patients aged <6 months (63.1%). Tenotomy locations were operating room (46.5%), clinic (45.4%) and procedure room (8.1%). Cast removal was primarily performed with saws (54.7%). The mean incidence of observed cast burns was 5.5%. Most providers did not use a device to prevent cast burns (76.6%). Reported cast complications included slippage (85.9%), skin irritation (75.8%), and saw-related injuries (35.9%). Clubfoot management variations exist in orthotics, tenotomy indications and practices, and cast material. Casting complications continue to be a problem. Further studies are warranted to determine if certain practices predispose patients to specific complications., Competing Interests: J.E.H. is a consultant for MD Orthopedics, NuVasive Specialized Orthopedics, Orthofix, OrthoPediatrics, Smith & Nephew, and WishBone Medical. P.K.M. is a consultant for DePuy Synthes Companies, Novadip, NuVasive Specialized Orthopedics, Orthofix, and Smith & Nephew. O.C.S. and L.P.H. report no conflicts of interest. The following organizations supported the institution of the authors: DePuy Synthes, NuVasive Specialized Orthopedics, Orthofix, OrthoPediatrics, Paragon 28, Pega Medical, Smith & Nephew, Stryker, Turner Imaging Systems, and WishBone Medical.

Background: Magnetic intramedullary lengthening nails (MILNs) have gained popularity in recent years for the treatment of limb-lengthening discrepancies. We sought to catalog mechanical failures and their prevention and management in a large, single-institution series. We specifically assessed the rate of mechanical failures, the types of failures observed, and management strategies., Methods: We retrospectively reviewed 377 patients (420 limbs) who underwent limb lengthening with early (P1) or later (P2) MILN iterations with ≥12-month follow-up. Mechanical failure was defined as mechanical breakage of the instrumentation or nail and/or failure of the internal lengthening mechanism. Failure assessment was arranged by lengthening phases and was sorted with a complication classification system. All lengthening and alignment parameters were assessed radiographically., Results: Mechanical failure was observed in 40 nails (9.5%), most of which (63%) were corrected with an additional surgical procedure. The mechanical failure rate was 11.3% in P1 nails and 9% in P2 nails. Two nails failed the intraoperative distraction test, and 1 nail was found to have a broken washer during the insertion phase. Sixteen nails had mechanical failures in the lengthening phase. Some nails (8 of 16) required nail replacement surgery. Thirteen nails failed during the consolidation phase; 7 of these cases were managed by replacement with either a functional MILN or a conventional intramedullary nail. Eight failures happened during the extraction phase and were managed intraoperatively., Conclusions: A 9.5% overall rate of mechanical failure of MILNs was observed in this large series. Resolution was achieved with an additional surgery in most cases. Nail distraction and weight-bearing compliance should be closely monitored during the lengthening and consolidation phases. Nail removal can be difficult and requires a careful study of radiographs for locking-screw bone overgrowth and backup removal equipment., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/H333)., (Copyright © 2022 by The Journal of Bone And Joint Surgery, Incorporated.)

Aim: Radiographic analysis of lower limb alignment is crucial for the planning and evaluation of deformity correction. Assessment in the sagittal plane is often overlooked compared with the coronal plane for a variety of reasons. We aimed to investigate the relationship between the femoral head in the sagittal plane and femoral neck version in the axial plane, and how sagittal femoral bowing angle (sFBA) may contribute., Materials and Methods: Twenty-five each of high (1-2 standard deviations above mean), normal (2.5° below to 2.5° above the mean), and low (1-2 standard deviations below the mean) version femurs were randomly selected from an osteological collection database, photographed and measured for sFBA and sagittal offset of femoral head from the distal femur axis. Lines were drawn within the proximal and distal quartiles of the shaft to create sFBA. The offset of the distal quartile line and the femoral head was also measured. High intra- and inter-observer correlations were established. The relationship between parameters was assessed using the Pearson coefficient ( r )., Results: Sagittal offset of the femoral head from the distal femur axis was found to be highly correlated with sFBA ( r = 0.78), and only mildly with femoral neck version ( r = 0.52). Sagittal femoral bowing angle and femoral neck version share no relationship ( r = 0.05)., Conclusions: Neither the sFBA nor sagittal femoral head offset is strongly associated with femoral neck version., Clinical Significance: Our data reinforce the need for long leg lateral films to include the femoral head in sagittal deformity analysis, as imaging limited to the knee will not account for the effect of bowing on femoral head position., How to Cite This Article: Ho D, Liu RW, Mcclure PK. Correlation between Femoral Neck Version, Sagittal Femoral Bowing Angle and Sagittal Offset of the Femoral Head from the Distal Femur Axis in an Osteological Collection. Strategies Trauma Limb Reconstr 2023;18(1):12-15., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2023; The Author(s).)

This study aims to develop multipliers for the spine and sitting height to predict sitting height at maturity. With the aid of longitudinal and cross-sectional clinical databases, we divided the total sitting height, cervical, thoracic, and lumbar lengths at skeletal maturity by these same four factors at each age for each percentile given. A series of comparisons were then carried out between the multipliers as well as the percentiles and the varied racial and ethnic groups within them. Regarding sitting height, there was little variability and correlated with the multipliers calculated for the thoracic and lumbar spine. The multiplier method has demonstrated accuracy that is not influenced by generation, percentile, race, and ethnicity. This multiplier can be used to anticipate mature sitting height, the heights of the thoracic, cervical, and lumbar spine, as well as the lack of spinal growth after spinal fusion surgery in skeletally immature individuals.

In situ stabilization is a widely accepted treatment for slipped capital femoral epiphysis (SCFE) despite risks of avascular necrosis (AVN) and femoroacetabular impingement (FAI). The modified Dunn procedure with surgical hip dislocation attempts to maintain epiphyseal perfusion and allows anatomic epiphyseal repositioning, theoretically reducing AVN and FAI risks. We systematically evaluated the literature, elucidating overall and stability-stratified rates of AVN following the modified Dunn procedure, and revision rates in non-AVN patients. Using Ovid and MEDLINE (PubMed), studies involving the modified Dunn procedure were evaluated for age, stability, preoperative slip (Southwick) angle, ROM at follow-up, outcome metrics, and revisions. Utilizing a random effect model of proportions, we determined overall and stability-stratified AVN rates, and revision rates in patients without AVN.673 patients (688 SCFEs) who underwent modified Dunn procedure were included. Overall AVN rate was 14.3% with a 95% Confidence Interval (CI) of 9.3 to 20.2%. AVN rate in stable slips was 10.9% (95% CI: 6.0 to 17.1%) and 19.9% (95% CI: 12.8% to 28.1%) in unstable slips. Revision rate in non-AVN patients was 13.3% (95% CI: 8.3% to 19.2%). Fixation failures occurred following K-wire or small-caliber (<6.5 mm) screw fixation. Overall mean Harris Hip Score (HHS) was excellent (>90 points). Mean HHS was 98.9 points (range of means: 86 to 99 points) in stable cases, and 90.5 points (range of means: 73 to 98 points) in unstable cases. Patients undergoing modified Dunn procedure had excellent clinical outcomes and low incidences of AVN. Further studies are needed to determine if modified Dunn osteotomy with surgical hip dislocation is a viable alternative to in situ pinning for treatment of severe SCFE.

Aim: Evaluate the validity of a recent approach to calculate the knee flexion or extension contracture contributing to the overall sagittal deformity using the sagittal mechanical axis angle (SMAA) for the overall alignment assessment and sagittal joint line angle (SJLA) for soft tissue contribution. The methods of evaluating these angles and their clinical applications are discussed., Materials and Methods: In total, 107 normal limbs met the criteria and were divided into two groups: skeletally mature and immature. Sagittal alignment was evaluated using the Bone Ninja iPad application, and the posterior distal femoral angle (PDFA), posterior proximal tibial angle (PPTA), SMAA and SJLA were recorded., Results: In skeletally immature patients, mean SJLA was 13.46° [standard deviation (SD), 4.55°], and in mature patients, it was 16.91° (SD, 2.948°). The PDFA and PPTA were consistent with previously published measurements., Conclusion: The SJLA method is a practical way to quantify the soft tissue contribution and degree of contracture. It can also be used for monitoring deterioration or improvement of knee range of motion during lengthening or physical therapy., Clinical Significance: All patients in this study presented to our clinic with symptoms on the contralateral side. This, in addition to the retrospective nature, was a limitation in our study.We recommend a validity study to compare our SJLA method to the classic anterior cortical line angle (ACL) method in addition to an inter-observer and intra-observer reliability study for the SJLA. We also recommend a study on completely normal asymptomatic subjects to better standardise the angle measurements in skeletally immature patients at different ages., How to Cite This Article: Abalkhail TB, McClure PK. Sagittal Plane Assessment in Deformity Correction Planning: The Sagittal Joint Line Angle. Strategies Trauma Limb Reconstr 2022;17(3):159-164., Competing Interests: Source of support: Nil Conflict of interest: PKM is a consultant for DePuy Synthes Companies, Novadip, NuVasive Specialized Orthopedics, Orthofix, and Smith & Nephew. The following organizations supported the institution of PKM: DePuy Synthes, NuVasive Specialized Orthopedics, Orthofix, OrthoPediatrics, Paragon 28, Pega Medical, Smith & Nephew, Stryker, Turner Imaging Systems, and WishBone Medical., (Copyright © 2022; The Author(s).)

Charcot neuroarthropathy of the hindfoot and ankle poses substantial challenges due to deformity, segmental bone loss, chronic infection, and difficulty with bracing. Hindfoot or ankle arthrodesis is often employed at high rates of complications and nonunion. This study reports 15 consecutive patients with Charcot neuroarthropathy who underwent tibiotalocalcaneal or tibiocalcaneal fusion with simultaneous distal tibial distraction osteogenesis with a mean follow-up period of 20.2 ± 5.66 months. Arthrodesis rate was 93.3% (14 patients) with mean time to fusion of 4.75 ± 3.4 months. One hypertrophic nonunion occurred at the arthrodesis site. Complete consolidation of 4 cortices was achieved at the distraction site in 93.3% of patients (14 patients) with a mean duration to consolidation of 9.8 ± 3.3 months. One patient experienced hypertrophic nonunion at the regeneration site. The authors report a technique to enhance arthrodesis rates in Charcot neuroarthropathy by combining distal tibial distraction osteogenesis with simultaneous tibiotalocalcaneal or tibiocalcaneal arthrodesis for hindfoot fusion and salvage. Distraction osteogenesis supports enhanced vascularity to the arthrodesis site. Level of Clinical Evidence: Level 4 .

Background: Shortening and deformity of the tibia commonly occur during the treatment of congenital pseudarthrosis of the tibia (CPT). The role of osteotomies in lengthening and deformity correction remains controversial in CPT. This study evaluates the approach to and outcome after osteotomy performed in CPT., Methods: We performed an IRB approved retrospective review of consecutive patients with CPT treated at our institution from 2010 through 2019. Patients who underwent osteotomies were included in this study., Results: Nine patients (10 osteotomies-5 proximal metaphyseal and 5 diaphyseal) with a median age at osteotomy of 8.9 years (range: 4 to 21 y) were included. Six patients had neurofibromatosis-1, 1 had cleidocranial dysplasia, and 2 patients had idiopathic CPT. Four osteotomies were performed for deformity correction, 3 osteotomies to allow intramedullary instrumentation, and 3 osteotomies for lengthening. Five osteotomies were preceded by zolendronate treatment before surgery. Nine were fixed with a rod supplemented with external fixation (7) or locking plates (2). One osteotomy was stabilized with locked intramedullary nailing alone. Four osteotomies were supplemented with autologous bone graft, and bone morphogenic protein-2 was utilized in 3 osteotomies. Median time to healing was 222.5 days (range: 124 to 323 d). One osteotomy (locked intramedullary nailing) required grafting at 5.5 months and then healed uneventfully. Median healing index for patients undergoing lengthening was 57.9 days/cm (range: 35 to 81 d/cm). All 3 osteotomies performed for lengthening required a second osteotomy for preconsolidation at a mean of 34 days. Other complications included compartment syndrome requiring fasciotomy (n=2), tibial osteomyelitis (n=1), and fracture distal to cross-union (n=1)., Conclusions: Contrary to much of the established practice, osteotomies may be safely performed in CPT for various indications. All osteotomies healed with only 1 osteotomy requiring secondary bone grafting. Although time to healing of the osteotomy was generally prolonged, this study suggests, somewhat surprisingly, that preconsolidation can occur frequently in lengthening procedures., Level of Evidence: Level IV-case series., Competing Interests: J.E.H. is a clinical advisor for Bonus BioGroup and a consultant for NuVasive Specialized Orthopedics, Orthofix, OrthoPediatrics, OrthoSpin, Smith & Nephew, and WishBone Medical. P.K.M. is a consultant for DePuy Synthes Companies, Novadip, Orthofix, and Smith & Nephew. The remaining authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Concerns surrounding osteolysis near and around the modular junction of a stainless-steel intramedullary lengthening rod prompted a manufacturer recall from the United States market in early 2021. These actions were preceded by similar steps taken in Europe. A concomitant review of stainless-steel lengthenings at our institution demonstrated signs of adverse tissue reaction including periosteal reaction and osteolysis at the modular junction and/or male-sided locking screws. Nearly half of our patients presented with these findings on radiographic images. At the time of the previous review, only half of the nearly 60 implanted stainless-steel devices met a 6-month follow-up. At this juncture, many patients have had their devices explanted. Given the suspected adverse tissue reactions caused by a component of the internal device, we sought to examine the rate of osteolysis post-explantation following removal of a stainless-steel nail. We reviewed a consecutive series of patients who underwent implantation of a stainless-steel limb lengthening device in the femur and/or tibia at a single institution between December 2018 and December 2020. Patients were included if their device was explanted. Periosteal reaction and osteolysis was classified according to a novel and validated classification system, as analyzed by five fellowship-trained surgeons. In addition, changes observed prior to explantation were tracked post-explantation to assess for resolution. The incidence of periosteal reaction and osteolysis prior to explantation was 22/57 (39%) and 15/57 (26%), respectively. Of the 15 patients with osteolysis pre-explantation, 14 patients' implants were explanted. Of these, eight patients had available follow-up films. Two patients were identified as having partial osteolysis resolution at mean 1-year follow-up, while six patients were identified as having complete osteolysis at mean 18-months follow-up. Periosteal tissue reaction and osteolysis largely resolved following explantation in a subset of patients. These results provide further support to the claim that the stainless-steel device contributed to the changes seen. Further follow-up is warranted to examine the longer-term effects of adverse tissue reaction in this patient population.

Congenital pseudarthrosis of the tibia (CPT) is characterized by anterolateral tibial bowing and hamartomatous periosteum that predisposes it to fracture. Fassier-Duval telescopic rods can improve the structural integrity of bone segments after reconstruction. We present our experience treating CPT with the Fassier-Duval rod and a novel technique for Fassier-Duval exchange that was developed after extraction failed in one patient. Patients were identified who underwent treatment with Fassier-Duval rods for CPT between 2007 and 2016 and had undergone their first rod exchange. Medical records were reviewed, and complications were classified using the system of Cherkashin. Four patients had an average age at the initial insertion of 6 years 4 months (4-9 years). The average follow-up duration after initial Fassier-Duval implantation was 5.4 years (2.7-8.1 years). Seven Category 2 complications were associated with the Fassier-Duval rod: interlocking K-wire migration (2), lengthening failure (2), explant failure (1), distal migration of female rod through physis (1) and male rod portion proximally migrating through physis (1). Three patients underwent one rod exchange [average 3.2 years after implantation (range, 2.7-3.9 years)]. One patient underwent two rod exchanges (2.9 and 6.9 years after initial implantation). The second attempt at exchange failed; this failure prompted the development of custom trephines to remove the hard bone that can encase the distal male segment. The use of custom trephines was made necessary by dense sclerotic bone at the previous pseudarthrosis site. We recommend that custom trephines be available during Fassier-Duval rod extraction to avoid failed retrieval. Level of evidence: Level IV (Case series)., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: There are several alternative methods for accomplishing epiphysiodesis of the longer limb to address limb length discrepancy (LLD). Consensus is lacking regarding the optimal timing of the intervention and which method is most efficacious. We reviewed a large group of patients with anisomelia treated by tethering with tension band plates (TBP) and who had attained skeletal maturity. We discuss our preferred timing and technique while noting the complications and how they were managed., Materials and Methods: With IRB approval, we reviewed 66 subjects including 32 boys and 34 girls, ranging in age from 3 to 16.6 years at the time of physeal tethering, who were destined to have between 2 and 9 cm LLD at maturity. Inclusion criteria were: (1) at least 1 year of predicted growth at the time of tethering; (2) minimum 18-month follow-up and (3) minimum Risser stage 1 (R1) in the last radiologic study. There were 35 distal femoral, 25 pan genu and five proximal tibial procedures. Patients were seen bi-annually with weight-bearing full-length radiographs to ascertain neutral alignment and assess limb lengths., Results: We defined a successful outcome to be <1.5 cm of residual discrepancy. Iatrogenic mechanical axis deviation, observed in nine patients (five varus and four valgus), was successfully managed by repositioning the implants. While the under-corrected patients presented too late to achieve equalization, they benefited from partial improvement. Due to lack of timely follow-up, one patient over-corrected by 2 cm and had a femoral shortening at the time of correcting contralateral femoral anteversion. One patient required a distal femoral osteotomy to correct recurvatum at maturity., Conclusion: Properly timed and executed, TBP is an efficacious and reversible means of growth deceleration, rather than growth arrest, that may be applied in a wide age range of patients with modest anisomelia regardless of aetiology. This method offers potential advantages over purportedly rapid and definitive techniques such as percutaneous epiphysiodesis (PE) or percutaneous epiphysiodesis with transphyseal screws (PETS)., Level of Evidence: Level III. Retrospective series without controls., How to Cite This Article: Stevens P, Desperes M, McClure PK, et al. Growth Deceleration for Limb Length Discrepancy: Tension Band Plates Followed to Maturity. Strategies Trauma Limb Reconstr 2022;17(1):26-31., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2022; The Author(s).)

Case: We report a 15-year-old female patient who underwent femur lengthening with a stainless steel intramedullary lengthening Stryde nail that broke at the end of the lengthening course and required removal. Given the solid noncannulated nature of the nail, this required special strategy to remove broken parts., Conclusion: Stryde nails are stainless steel lengthening nails that were developed to allow more freedom with weight bearing. Regardless of this change, hardware failure remains possible. In addition to maintaining regenerate integrity, a surgeon must be creative when attempting to remove solid nail types because many techniques for removing failed hardware were developed for cannulated devices., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B744)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Case: We describe a case of 2 individually rare diseases existing comorbidly in the form of congenital pseudarthrosis of the tibia (CPT) coincident with cleidocranial dysostosis and provide a review of the literature, including the sole preexisting documented coincidence., Conclusion: Understanding, treatment, and surgical protocol of CPT have changed considerably since this comorbidity was last reported. Updates include synostosis, periosteal grafting, the use of bone morphogenetic protein, and bisphosphonates. Our case varies from the previous in associated disorder and family history. The relationship between CBFA1 and RUNX2 genes may hold the key, but further study is needed., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B712)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Segmental bone defects of the tibia are amenable to multiple treatment options including classic bone transport, shortening and then lengthening, induced membrane technique, transport over a nail, free fibular grafting, and medial transport of the ipsilateral fibula. These treatment options have relative advantages and disadvantages, depending on defect size, soft-tissue characteristics, the presence or absence of infection, and associated morbidity. Relatively, few large comparative studies exist, and surgeons are left to their own experience and the opinion of experts within the field to guide surgical decision-making., (Copyright © 2021 by the American Academy of Orthopaedic Surgeons.)

Three pediatric patients presented with histologically confirmed osteolysis after limb lengthening with a magnetic, telescoping, stainless-steel device. The first patient's findings were discovered radiographically before routine removal of the device. In all cases, intraoperative histologic specimens taken from around the modular junction demonstrated particle-laden macrophages with suspicion for metal debris. Silicone debris was also identified. We found definitive osteolysis secondary to metal at the modular junction of three stainless-steel lengthening implants. This process is not well-understood in the setting of limb lengthening and should be examined further., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Previous studies on lengthening for achondroplasia have reported bilateral extensive femoral lengthening followed by bilateral extensive tibial lengthening. To decrease trauma on soft tissues and joints, we propose bilateral simultaneous moderate femoral lengthening and moderate tibial lengthening followed by a similar repeat lengthening a few years later. Fifty patients with achondroplasia underwent 65 simultaneous bilateral femoral and tibial lengthening procedures. Segment lengthening amount and adverse events were obtained from medical records. Mean follow-up after bone healing was 35.6 months. Mean tibial lengthening was 52 mm; mean femoral lengthening was 72 mm. Average healing index was 1.4 months/cm for the tibia and 1 month/cm for the femur. Mean duration of treatment with external fixation was 6.7 months (range, 4.4-10.5 months). Thirty-eight (76%) of 50 patients experienced one or more adverse events during lengthening. We observed 78 adverse events, 35 (45%) of which required additional surgical procedures. All resolved by the end of treatment. Mechanical axis deviation improved from a mean of 15 mm medially to 8 mm medially. Simultaneous lengthening of four segments in patients with achondroplasia is a feasible strategy. Compared with isolated femoral or tibial lengthening, distributing the lengthening between the femur and tibia decreases total external fixator time.

Summary: The challenging problem of long bone infection and limb length difference cannot be addressed using only an antibiotic-coated nonmagnetic static nail. The combined use of resorbable calcium sulfate and magnetic lengthening nails offers a possible solution to this dilemma, as well as for infected nonunions that require compression. We present a combined technique to treat or prevent infection using femoral or tibial intramedullary antibiotic delivery with an absorbable calcium sulfate depot and concomitant internal lengthening or compression using a nail. Adequate débridement is required in cases of established infection and is a prerequisite for this technique., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.)

Growth modulation has become a mainstream treatment for frontal plane angular lower extremity deformities in children. Few articles address the effect of growth modulation on sagittal deformity. Our aim is to compare two anterior distal femoral growth modulation techniques for fixed knee flexion contracture. Electronic medical records were reviewed for patients who underwent anterior femoral growth modulation for fixed flexion contracture. Patients were excluded if adequate preoperative/postoperative radiographs were unavailable. A cohort was subdivided based on surgical technique: screws alone versus dual tension-band plates. Complications were recorded; radiographs were evaluated preoperatively and at hardware removal. Posterior distal femoral angle (PDFA), posterior proximal tibial angle (PPTA), and anterior cortical line (ACL) angle were evaluated. Of 35 patients identified, 20 patients (29 knees) were included. Thirteen knees were treated with dual anterior tension-band plates; 16 knees had transphyseal screws. Sagittal alignment improved in both groups. Statistically significant PDFA changes were observed in the tension-band plate group (P = 0.0095); a trend was noted toward improvement in ACL angle (P = 0.08). PPTA did not change. No changes reached significance in the transphyseal screw group (PDFA: P = 0.181, ACL: P = 0.64). Tension-band plate migration was noted in one (7.7%) of 13 knees, and transphyseal screw migration in nine (56.3%) of 16 knees (P < 0.01). Anterior distal femoral growth modulation improves sagittal alignment without significant remodeling at the proximal tibia. Hardware migration occurred more often with transphyseal screws (P < 0.01). We recommend dual anterior tension-band plating over placement of paired screws for sagittal growth modulation to treat knee flexion contracture.

Magnetically controlled intramedullary lengthening nails (MCILN) have revolutionized the field of limb lengthening and deformity correction. They allow for accurate and precise distraction with excellent patient outcomes and satisfaction. Though potentially technically easier than external fixation, general deformity principles and bone and soft-tissue biology must be considered for successful use. MCILN can address deformities of a wide range of etiologies including congenital, posttraumatic, post-infectious, tumor, and many others with excellent healing rates and outcomes as well as better patient satisfaction and similar cost compared to external fixation. Of the approximately 10,000 MCILN that have been implanted (written communication, NuVasive, Inc., San Diego, California), about 749 cases have been reported in the published literature. Applications outside of deformity correction are on the rise, with new uses reported in reconstruction after tumor resection and acute trauma. This review of MCILN summarizes the history, recent advances, and results of MCILN treatment in a multitude of clinical applications.

Background: Lower extremity malalignment is a common problem presented to pediatric orthopaedists. Risk for early arthritis is often a concern among parents seeking advice and treatment. We seek to review previous research with regard to the natural history of malalignment., Methods: A search of available literature on PubMed was constructed to capture articles covering the natural history of malalignment, secondary to childhood fracture as well as congenital and acquired pediatric deformity. In order to remain strictly relevant to pediatrics, articles reviewing deformities acquired in adulthood were not referenced. Biomechanical data and animal studies were included when deemed appropriate., Results: High-quality data with regard to long-term risk of arthritis due to malalignment is lacking. Through a combination of biomechanical data, animal models, and a small body of longitudinal clinical data, it is clear that some patients with malalignment progress to early arthritic change. Unfortunately, detailed risk factors of who is at high risk versus low risk remains difficult to determine., Conclusions: Treatment of minor lower extremity malalignment is not supported by the current orthopaedic literature. Treatment plans should focus on the presence of symptoms, and in asymptomatic but severe cases. Even in more severe cases, strong evidence to support prophylactic realignment is not available. Evidence to suggest that preventative realignment is superior to intervention at the time of symptom onset does not exist.

Aim: To report whether Bone Ninja (BN) is a reliable tool to teach the reverse planning method (RPM) for implantable intramedullary (IM) limb-lengthening devices and for deformity correction surgery., Background: Motorised fully implantable implantable intramedullary (IM) lengthening devices have been gaining popularity all over the world for limb-lengthening procedures. Multiple advantages have been demonstrated over external fixator-controlled lengthening. Mechanical axis deviation may result if careful preoperative planning and surgical intervention are not completed for femur cases. The RPM proposed by Baumgart has been shown to be an accurate means of arriving at the desired end point. The RPM addresses the ideal correction position accounting for length, angulation, and translation created during lengthening along the nail axis. The original description calls for the use of life-size paper tracings of the bone and large light boxes to allow planning. We propose an alternative method using a digital tool that is readily available. The BN mobile app was developed for patient/physician education and is available for the Apple iPad platform. Bone Ninja has been shown to have similar accuracy for measurements of the limb length and deformity angles when compared to the gold standard picture archiving and communication systems (PACSs)., Technique: We used BN (version 4.2) on an iPad mini to perform the same RPM steps, using the same terminology originally described by Baumgart., Conclusion: Bone Ninja is a simple validated deformity correction tool with accuracy comparable to PACS. It is a reasonable alternative to paper/pencil cutouts for applying RPM for IM limb lengthening and deformity correction surgery., Clinical Significance: We proposed a digitised RPM for internal limb-lengthening surgeries, which is highly feasible and practical to use conveniently without the need for the traditional tedious paper-cutting procedure and related equipment., How to Cite This Article: Hung AL-H, McClure PK, Franzone JM, et al. Bone Ninja Mobile App for Reverse Planning Method in Internal Limb Deformity and Lengthening Surgery. Strategies Trauma Limb Reconstr 2019;14(2):72-76., Competing Interests: Source of support: Nil Conflict of interest: Dr Herzenberg reports personal fees from OrthPediatrics, Orthofix, NuVasive Specialized Orthopedics, Smith and Nephew, and WishBone Medical, outside the submitted work. Dr Standard reports personal fees and other from NuVasive Specialized Orthopedics, Smith and Nephew, and Pega Medical, outside the submitted work. Dr Herzenberg, Dr McClure, and Dr Standard are employees of Sinai Hospital who publish the BN mobile app and their institution received support for an annual course for orthopedic surgeons from the following entities: Avitus Orthopaedics, CyMedica Orthopedics, DePuy Synthes, MHE Coalition, NuVasive Specialized Orthopedics, Orthofix, OrthoPediatrics, Paragon 28, Smith and Nephew, Stryker, Vilex, and Zimmer Biomet, (Copyright © 2019; Jaypee Brothers Medical Publishers (P) Ltd.)

Objectives: With rising rates of obesity in the United States, the burden of knee dislocations in this population remains unknown. This national epidemiologic study was designed to analyze the association of obesity with closed knee dislocation and vascular complications., Design: Retrospective cohort study., Setting: The deidentified Nationwide Inpatient Sample database was used to access the US inpatient data from 2000 to 2012., Patients/participants: Patients with noncongenital closed knee dislocations were included. Examined variables included patient age, sex, vascular injury, and obesity status., Main Outcome Measures: Outcome measures included hospital length of stay, amputation, and inpatient hospitalization charge., Results: From 2000 to 2012, a total of 19,087 knee dislocations were identified, including 2265 in overweight/obese patients (11.9%). The annual incidence of knee dislocations reported in patients diagnosed as either obese or morbidly obese increased over the 13-year period (P < 0.0001). The overall average rate of vascular injury requiring intervention was 5.63%, whereas 7.2% of obese patients and 11.3% of morbidly obese patients with knee dislocations (P < 0.0001) sustained a vascular injury requiring intervention. The average length of stay and amputation rate for obese and morbidly obese patients who sustained a knee dislocation was not statistically different from nonobese patients when vascular injury was controlled. When patients with a vascular injury were excluded, obese and morbidly obese patients who sustained a knee dislocation had higher average cost of hospital stay than nonobese patients (P = 0.0262)., Conclusions: This study demonstrates significant increases in costs of stay with obese patients sustaining knee dislocations when compared with normal weight knee dislocation patients. Vascular injuries were found to be far more common in obese and morbidly obese patient groups than nonobese patients. Providers should be on high alert when managing knee dislocations in obese patients because a significant number require prompt vascular intervention., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Reconstruction of segmental bone defects requires a large commitment both on the part of the patient and the physician. Investing in preoperative evaluation and optimization is the only logical way to pursue such an endeavor. Unfortunately, detailed studies regarding segmental bone defects and preoperative factors are relatively lacking owing to the relatively low incidence of the problem. Fortunately, other orthopaedic pathologies (arthritis, ligamentous injuries about the knee) have high prevalence and consistency, allowing detailed analysis of preoperative factors. We review this literature, and that directly involving segmental bone defects when available, to guide surgeons planning segmental bone defect reconstruction.

Introduction: Achondroplasia is the most common skeletal dysplasia with a rate of nearly 1/10,000. The development of lower extremity deformity is well documented, and various modes of correction have been reported. There are no reports on the use of growth modulation to correct angular deformity in achondroplasia., Methods: Medical Records from 1985 to 2015 were reviewed for the diagnosis of achondroplasia and growth modulation procedures. Patients who had been treated for angular deformity of the legs by growth modulation were identified. A detailed analysis of their medical record and preoperative and final lower extremity radiographs was completed., Results: Four patients underwent growth modulation procedures, all to correct existing varus deformity of the legs. Three of the 4 patients underwent bilateral distal femoral and proximal tibial growth modulation. The remaining patient underwent tibial correction only. Two of the 4 patients had a combined proximal fibular epiphysiodesis. All limbs had some improvement of alignment; however, 1 patient went on to bilateral osteotomies. Only 1 limb corrected to a neutral axis with growth modulation alone at last follow-up, initial implantation was done before 5 years of age., Conclusions: Growth modulation is an effective means for deformity correction in the setting of achondroplasia. However implantation may need to be done earlier than would be typical for patients without achondroplasia. Osteotomy may still be required after growth modulation for incomplete correction.

Objectives: To compare the static and dynamic mechanical properties of a modified crossed cannulated screw (CS) configuration, the inverted triangle (IT) cannulated screw configuration, and a compression hip screw (CHS) with derotation screw in Pauwels type III femoral neck fractures., Methods: Thirty synthetic femora were divided into 3 groups, and vertical femoral neck osteotomies were made. Ten osteotomized femora were fixed with a CS configuration, 10 were fixed with 3 parallel screws in an IT configuration, and the remaining 10 osteotomized femora were fixed with a CHS construct. All groups were tested using a cyclic (up to 15,000 load cycles) axial loading protocol, and survivors were statically loaded to failure. Cycles to failure, load to failure, and stiffness were calculated. The Kaplan-Meier method was used to estimate survival functions and were compared among fixation methods. The relationship between construct structural properties (maximum load and stiffness) and treatment were assessed using general linear modeling., Results: All CHS fixation constructs survived the 15,000 cycle loading protocol. They endured longer (P = 0.034) than the CS fixation constructs (mean failure 13,332 cycles), but were not different from IT fixation constructs (mean failure 13,592 cycles). Maximum loads to failure for CS (3870 N) and IT (3756 N) fixation constructs were not different, but were less (P < 0.0001) than the maximum loads to failure for the CHS fixation constructs (5654 N). These findings parallel the results of the axial stiffness measurements: CS fixation constructs (663.01 N/mm) were not stiffer than IT fixation constructs (620.0 N/mm), but were less (P = 0.0005) than the axial stiffness of the CHS fixation constructs (1241.86 N/mm)., Conclusions: The biomechanical performance of the CHS fixation method was superior to both the CS fixation method and the IT fixation method using a synthetic femoral model and this test protocol. Biomechanical performance of the latter 2 groups was indistinguishable. We recommend the use of CHS with the derotational screw construct for Pauwels III femoral neck fractures whenever possible.

Background: The introduction of the 80-hour work week for Accreditation Council for Graduate Medical Education (ACGME) accredited fellowship programs initiated many efforts to optimize surgical training. One particular area of interest is on recording and tracking surgical experiences. The current standard is logging cases based on Current Procedural Terminology codes, which are primarily designed for billing. Proposed guidelines from the ACGME regarding logging exist, but their implementation is unknown, as is the variation in case volume across fellowship programs. The purpose of this study was to investigate variability in the national case log data, and explore potential sources of variation using fellow surveys., Methods: National ACGME case log data for pediatric orthopaedic fellowships from 2012 to 2015 were reviewed, with particular attention to the domains of spine, pelvis/hip, arthroscopy, trauma, and other (which includes clubfoot casting). To explore potential sources of case log variability, a survey on case logging behavior was distributed to all pediatric orthopaedic fellows for the academic year 2015 to 2016., Results: Reported experiences based on ACGME case logs varied widely between fellows with percentage difference of up to 100% in all areas. Similarly, wide variability is present in coding practices of pediatric orthopaedic fellows, who often lack formal education on the topic of appropriate coding/logging. In the survey, hypothetical case scenarios had an absolute difference in recorded codes of up to 13 and a percentage difference of up to 100%., Conclusions: ACGME case log data for pediatric orthopaedic fellowships demonstrates wide variability in reported surgical experiences. This variability may be due, in part, to differences in logging practices by individual fellows. This observation makes meaningful interpretation of national data on surgical volume challenging. Proposed surgical experience minimums should be interpreted in light of these data, and may not be advisable unless accompanied by standardized and specific guidelines for case log entry. Efforts to optimize training in the post 80-hour era will require accurate data to serve as a starting point for future educational efforts.

Decades of research support the fact that much age-related deterioration is the result of the effects of sedentary lifestyles and the development of medical conditions rather than of aging itself. Elite older athletes, who demonstrate enhanced performance compared with historic cohorts and even some younger peers, are models of this paradigm. Many non-elite middle-aged adults and older adults continue to remain increasingly active throughout middle age and beyond. A continually growing body of basic science and clinical evidence demonstrates how active persons modulate physical decline through training. An updated understanding of how active adults defy age helps orthopaedic surgeons not only manage their patients' performance but also improve their lives. A large segment of sedentary older adults will benefit from counseling that encourages the pursuit of more active and healthier lifestyles., (Copyright 2014 by the American Academy of Orthopaedic Surgeons.)