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Introduction: Mesenteric volvulus is a rare cause of abdominal pain and bowel obstruction in elderly patients. When a mesenteric volvulus occurs in adult patients, the symptoms are often non-specific, which contributes to delays in diagnosis.Case Report: We present a case of a 75-year-old female who presented with non-specific abdominal pain. The rare whirlpool sign on computed tomography identified a mesenteric volvulus as the cause of small bowel obstruction. She was taken to the operating room and, after successful resection of the small bowel, she recovered and ultimately was discharged home.Conclusion: Early identification of a whirlpool sign and early surgical consultation are key to providing the best chance for salvage of ischemic small bowel due to mesenteric volvulus and to prevent a fatal outcome.

Background: Fixation of trochanteric fractures with an intramedullary nail in a non-physiological position can cause poor functional outcomes. The aim of this study is to evaluate the effect of intraoperative patient position on rotational alignment in intramedullary nail fixation of trochanteric fractures. Methods: The femoral rotational alignment of 84 trochanteric fracture patients who underwent intramedullary nailing was measured by computed tomography (CT) images. Patients were divided into two groups: the supine position on the fracture table (FT) (Group 1, n = 42) and the lateral decubitus (LD) position (Group 2, n = 42). Femoral malrotation angles were measured and divided into three subgroups: insignificant, significant, and excessive. The number of intraoperative fluoroscopy images, preparation time, surgery time, and anesthesia time in both groups were compared. Results: The malrotation degrees of patients in Group 1 ranged from 17° external rotation (ER) to 57° internal rotation (IR), with a mean of 10° IR. Of the patients in Group 1, 27 were insignificant, 5 were significant, and 10 were in the excessive subgroup. The malrotation degrees of patients in Group 2 ranged from 33° ER to 47° IR, with a mean of 11° IR. Of the patients in Group 2, 21 were insignificant, 12 were significant, and 9 were in the excessive subgroup. There was no statistically significant relationship between patient position and malrotation angle. The number of intraoperative fluoroscopy images, preparation time, and anesthesia time were statistically lower in Group 2. There was no statistically significant difference between Group 1 and Group 2 in terms of surgery time. Conclusion: Intramedullary nailing in the LD position is a reliable and practical surgical method in the treatment of femoral trochanteric fractures since there is no need for the use of a FT, the surgeon is exposed to less radiation, there is no risk of complications related to the traction of the FT, and there is a shorter operation time. [ABSTRACT FROM AUTHOR]

Background: Accurate implant placement in the optimal position is important to obtain favourable clinical outcomes and prevent complications in total joint arthroplasty. We aimed to assess the accuracy of implant placement based on three-dimensional (3D) preoperative planning for unlinked total elbow arthroplasty (TEA) and to clarify the effect of implant placement on clinical outcomes. Methods: This study included 20 patients (22 elbows, 17 with rheumatoid arthritis and 5 with osteoarthritis, with a mean follow-up period of 47 months) who underwent TEA with an unlinked-type implant after computed tomography (CT)-based 3D preoperative planning. Implant placement was planned preoperatively and several parameters were set to reflect it intraoperatively. TEA was performed based on the plan, and postoperative CT was conducted to evaluate differences in implant placement by comparing the preoperative plan and postoperative implant placement. Furthermore, we evaluated the relationship between implant placement differences and postoperative clinical outcomes, including range of motion, Visual Analogue Scale, Mayo Elbow Performance Score 1 year after surgery and complications at the last follow-up. Results: The mean absolute translation was within 2 mm, the mean absolute tilt was within 4°, the mean absolute rotation of the humeral component was within 4° and the mean absolute rotation of the ulnar component was 10.2° ± 6.8°. In the ulnar components, 15/22 (68%) cases were externally rotated, and the mean external rotation was 7.1° ± 10.2°. We defined the absolute ulnar component's rotational difference of more than 10° as a 'malrotation' group (n = 8) and 10° or less as a 'control' group (n = 14). We compared the clinical outcomes between both groups, however, no significant differences were observed in clinical outcomes and complications. Conclusions: We observed notable malrotation in the postoperative positioning of the ulnar component. Intraoperative support devices may be necessary to accurately reproduce the preoperative plan in the surgical field. Level of Evidence: Level IV (Therapeutic) [ABSTRACT FROM AUTHOR]

Background: Malrotation is a congenital condition that predisposes individuals to midgut volvulus, which can result in significant bowel resection. While most cases of malrotation are diagnosed by the age of 1 year, typically presenting with symptoms related to volvulus or bowel obstruction, some cases remain asymptomatic. In children with visceral malposition, gastroschisis, omphalocele, or diaphragmatic hernia, malrotation may be suspected before symptoms manifest. However, isolated malrotation without midgut volvulus diagnosed prenatally is rare. We herein present a case of isolated malrotation without midgut volvulus that was prenatally diagnosed and successfully treated with laparoscopic surgery. Case presentation: A 30-year-old woman (gravida 3, para 1) underwent routine obstetric ultrasound, which revealed increased blood flow in the lower uterine segment and abnormal placental attachment. To rule out placenta percreta, magnetic resonance imaging was performed at 34 weeks of gestation. Incidentally, abnormal fetal intestinal arrangement was noted, with the colon localized in the left hemi-abdomen and the small intestine distributed in the right hemi-abdomen, raising suspicion of malrotation. Postnatal contrast studies confirmed the diagnosis of malrotation without midgut volvulus. Given the risk of midgut volvulus, a laparoscopic Ladd's procedure was performed on day 6 of life. The postoperative course was uneventful, and the patient was still symptom-free 1 year postoperatively. Conclusions: This case illustrates that malrotation can be prenatally diagnosed using fetal magnetic resonance imaging. Considering the risk of midgut volvulus, prophylactic Ladd's procedure should be performed in neonatal period. In cases where malrotation is not complicated by midgut volvulus, a laparoscopic Ladd procedure can be safely performed in neonates. [ABSTRACT FROM AUTHOR]

Pediatric digestive volvulus is a serious condition that carries with it a high rate of morbidity and mortality. This review highlights the pearls and pitfalls of pediatric digestive volvulus, including the presentation, diagnosis, and management in the emergency department (ED) based on current evidence. Pediatric digestive volvulus is a deadly condition most commonly associated with malrotation. It occurs when the stomach or small intestine twists on itself, resulting in ischemia and potentially strangulation with necrosis and perforation. Presentation differs based on the gastrointestinal (GI) segment affected, degree of twisting, and acuity of the volvulus. Gastric volvulus most commonly presents with retching with or without nonbilious emesis and epigastric distension with pain, while midgut volvulus typically presents with bilious emesis in infants. Patients with GI necrosis and perforation may present with hemodynamic compromise and peritonitis. If suspected, emergent consultation with the pediatric surgery specialist is necessary, and if this is not available, transfer to a center with a pediatric surgeon is recommended. Imaging includes plain radiography, ultrasound, or upper GI series, while treatment includes resuscitation, administration of antibiotics, and emergent surgical decompression and detorsion of the involved segments. An understanding of pediatric digestive volvulus and its many potential mimics can assist emergency clinicians in diagnosing and managing this deadly disease. [ABSTRACT FROM AUTHOR]

Asynclitism, a misalignment of the fetal head with respect to the plane of passage through the birth canal, represents a significant obstetric challenge. High degrees of asynclitism are associated with labor dystocia, difficult operative delivery, and cesarean delivery. Despite its clinical relevance, the diagnosis of asynclitism and its influence on the outcome of labor remain matters of debate. This study analyzes the role of the degree of asynclitism (AD) in assessing labor progress and predicting labor outcome, focusing on its ability to predict intrapartum cesarean delivery (ICD) versus non-cesarean delivery. The study also aims to assess the performance of the AIDA (Artificial Intelligence Dystocia Algorithm) algorithm in integrating AD with other ultrasound parameters for predicting labor outcome. This retrospective study involved 135 full-term nulliparous patients with singleton fetuses in cephalic presentation undergoing neuraxial analgesia. Data were collected at three Italian hospitals between January 2014 and December 2020. In addition to routine digital vaginal examination, all patients underwent intrapartum ultrasound (IU) during protracted second stage of labor (greater than three hours). Four geometric parameters were measured using standard 3.5 MHz transabdominal ultrasound probes: head-to-symphysis distance (HSD), degree of asynclitism (AD), angle of progression (AoP), and midline angle (MLA). The AIDA algorithm, a machine learning-based decision support system, was used to classify patients into five classes (from 0 to 4) based on the values of the four geometric parameters and to predict labor outcome (ICD or non-ICD). Six machine learning algorithms were used: MLP (multi-layer perceptron), RF (random forest), SVM (support vector machine), XGBoost, LR (logistic regression), and DT (decision tree). Pearson's correlation was used to investigate the relationship between AD and the other parameters. A degree of asynclitism greater than 70 mm was found to be significantly associated with an increased rate of cesarean deliveries. Pearson's correlation analysis showed a weak to very weak correlation between AD and AoP (PC = 0.36, p < 0.001), AD and HSD (PC = 0.18, p < 0.05), and AD and MLA (PC = 0.14). The AIDA algorithm demonstrated high accuracy in predicting labor outcome, particularly for AIDA classes 0 and 4, with 100% agreement with physician-practiced labor outcome in two cases (RF and SVM algorithms) and slightly lower agreement with MLP. For AIDA class 3, the RF algorithm performed best, with an accuracy of 92%. AD, in combination with HSD, MLA, and AoP, plays a significant role in predicting labor dystocia and labor outcome. The AIDA algorithm, based on these four geometric parameters, has proven to be a promising decision support tool for predicting labor outcome and may help reduce the need for unnecessary cesarean deliveries, while improving maternal-fetal outcomes. Future studies with larger cohorts are needed to further validate these findings and refine the cut-off thresholds for AD and other parameters in the AIDA algorithm. [ABSTRACT FROM AUTHOR]

Abstract Background Fixation of trochanteric fractures with an intramedullary nail in a non-physiological position can cause poor functional outcomes. The aim of this study is to evaluate the effect of intraoperative patient position on rotational alignment in intramedullary nail fixation of trochanteric fractures. Methods The femoral rotational alignment of 84 trochanteric fracture patients who underwent intramedullary nailing was measured by computed tomography (CT) images. Patients were divided into two groups: the supine position on the fracture table (FT) (Group 1, n = 42) and the lateral decubitus (LD) position (Group 2, n = 42). Femoral malrotation angles were measured and divided into three subgroups: insignificant, significant, and excessive. The number of intraoperative fluoroscopy images, preparation time, surgery time, and anesthesia time in both groups were compared. Results The malrotation degrees of patients in Group 1 ranged from 17° external rotation (ER) to 57° internal rotation (IR), with a mean of 10° IR. Of the patients in Group 1, 27 were insignificant, 5 were significant, and 10 were in the excessive subgroup. The malrotation degrees of patients in Group 2 ranged from 33° ER to 47° IR, with a mean of 11° IR. Of the patients in Group 2, 21 were insignificant, 12 were significant, and 9 were in the excessive subgroup. There was no statistically significant relationship between patient position and malrotation angle. The number of intraoperative fluoroscopy images, preparation time, and anesthesia time were statistically lower in Group 2. There was no statistically significant difference between Group 1 and Group 2 in terms of surgery time. Conclusion Intramedullary nailing in the LD position is a reliable and practical surgical method in the treatment of femoral trochanteric fractures since there is no need for the use of a FT, the surgeon is exposed to less radiation, there is no risk of complications related to the traction of the FT, and there is a shorter operation time.

Background: Intussusception in young and old children is different. A study of clinical features, associations, and outcomes of these cases would enhance understanding to guide proper management. Objectives: Analysis of the epidemiology, associations, clinical features, and management outcomes of intussusception in children younger than 2 years. Patients and Methods: A retrospective descriptive study on intussusception patients younger than 2 years was conducted from January 2018 to December 2022 in the department of pediatric surgery at a tertiary center. Demographic details, clinical features, and management outcomes data were collected and analyzed. Results: A total of patients were 133 with mean, median, and modal age of 9.5, 7, and 6 months, respectively; the maximum incidence was in March. 81.95% of cases were idiopathic; important lead points were Meckel diverticulum, inflamed appendix, roundworm, cecal duplication, and intraluminal polyps. Two postoperative cases occurred in Wilms’ tumor and congenital diaphragmatic hernia patients, whereas two postrotavirus vaccination cases were seen. Ten (7.5%) had associated malrotation which necessitated Ladd’s procedure. Only 15 cases presenting early responded to nonoperative treatment (9/15 hydrostatic reduction and 6/15 conservative management); among late presenters, 12.71% had manual reduction, 68.64% had resection and anastomosis while in 16.95%, temporary stoma was needed. Wound infection, burst abdomen, subacute intestinal obstruction, recurrent intussusception, peristomal excoriation, and stomal prolapse were a few complications along with one death. Conclusion: Intussusception in children younger than 2 years is a heterogeneous group. Although mostly idiopathic, several associations and well-defined lead points require additional intervention. Early diagnosis and prompt intervention ensure a favorable outcome with fewer complications.

We herein report a rare case of duodeno-duodenal intussusception (IS) presenting with obstruction caused by tubulovillous adenoma in an adult with malrotation that was managed by a novel laparoendoscopic hybrid technique. This was done by passing transjejunal nasogastric tube (NG) through one of the ports and manoeuvring it towards the IS. Two hundred and fifty millilitre of saline was flushed by aseptosyringe with pressure connected to the NG. This hydrostatic reduction technique resulted in distension of the jejunal and duodenal loop achieving reduction of IS. Intraoperative endoscopy was performed to exactly localise the mass lesion. The duodenum was kocherised and was delivered through a 4-cm transverse incision. Anterior duodenotomy was performed; the mass was excised; and duodenotomy was closed transversely. An extensive literature search did not show any case report of duodenoduodenal IS being managed by this technique. The combination of novel retrograde decompression and intraoperative endoscopy helped us to manage this rare case by this novel technique.

Midgut malrotations are rarely diagnosed beyond infancy. Delays in recognition and diagnosis can result in death. Here, we report the case of a 5-year-old girl who presented with a 1-year history of intermittent abdominal pain and vomiting. An abdominal computed tomography scan with contrast confirmed the diagnosis of midgut malrotation with obstruction; therefore, the Ladd procedure was performed, and the child was discharged uneventfully. Clinicians must maintain a high level of suspicion because this diagnosis is unusual in this age group.

Introduction: Ladd’s procedure, originally described in 1936 for the treatment of malrotation, does not traditionally include appendectomy as a standard step. We conducted a multinational survey to investigate the current consensus on the role of appendectomy in Ladd’s procedure. Methodology: An anonymous online survey was distributed to pediatric surgeons worldwide. The survey collected demographic data and explored surgical preferences related to the management of malrotation. Open-ended questions were used to assess the opinions regarding the necessity of appendectomy, decision-making factors, and complications associated with appendectomy during Ladd’s procedure. Results: A total of 343 responses were received from 46 countries. Of the respondents, 319 (93%) were consultants and 24 (7%) were residents/trainees. When asked about the choice between open and laparoscopic Ladd’s procedure, 292 (85%) preferred open surgery. Overall, 184 (53%) respondents favored appendectomy in both open and laparoscopic Ladd’s procedure. Furthermore, 172 (50%) surgeons advocated for appendectomy in all malrotation cases, citing concerns about potential future appendicitis. While differences existed between all comparisons, none of them reached statistical significance. The factors influencing the decision to preserve the appendix included the risk of postoperative complications and the potential future use of the appendix as a surgical conduit. The surgical complications following appendectomy included surgical site infections in 14 (33%) patients, adhesive obstruction in 13 (31%) patients, intrabdominal abscesses in 10 (24%) patients, and fecal fistulas in 5 (12%) patients. Conclusion: The majority of surgeons aim to perform appendectomy in all malrotation cases, considering the potential risks and benefits of this approach. These findings offer valuable insights for clinical practice and may inform future guidelines and decision-making algorithms.

Resumen: Introducción: La artroplastia total de rodilla (ATR) ha demostrado ser un procedimiento exitoso y coste-efectivo en cuanto a la mejoría del dolor en pacientes con artrosis de rodilla sintomática. Sin embargo, en torno a un 20% de pacientes no están satisfechos con el resultado de la intervención. Material y métodos: Realizamos un estudio transversal de casos y controles, unicéntrico con casos hospitalarios, obtenidos mediante la revisión de historias clínicas. Se seleccionaron 160 pacientes portadores de ATR con un seguimiento mínimo de un año. Se registraron variables demográficas, escalas funcionales (WOMAC y EVA) y la rotación del componente femoral mediante análisis de imágenes obtenidas por TC. Resultados: La muestra final estuvo compuesta por 133 pacientes divididos en grupo control, formado por 70 pacientes con una edad media de 69,59 años (23 hombres y 47 mujeres), y grupo dolor, formado por 63 pacientes con una edad media 69,48 años (13 hombres y 50 mujeres). No encontramos diferencias en cuanto al análisis de la rotación del componente femoral. Tampoco hubo diferencias significativas al aplicar una estratificación por sexo. El análisis de la malrotación del componente femoral, definiendo unos límites de valor de rotación considerados como extremos, no mostró diferencias significativas en ninguno de los casos. Conclusiones: Los resultados del estudio confirman que la malrotación del componente femoral no tuvo influencia sobre la presencia de dolor a un mínimo de un año de seguimiento tras la implantación de una ATR. Abstract: Introduction: The total knee arthroplasty (TKA) has been shown to be a successful and cost-benefit procedure in terms of pain improvement in patient with symptomatic knee osteoarthritis. However, almost a 20% of the patients are not satisfied with the result of the surgery. Material and method: We have carried out a transversal unicentric cases controls study with clinical cases of the own hospital, obtained by a clinical records revision. A total of 160 patients with a TKA with at least 1 year of follow-up were selected. Demographic variables, functional scales (WOMAC and VAS) and rotation of the femoral component through the analysis of the images obtained by CT scan were collected. Results: The total was 133 patients that was divided in two groups. A control group and pain group. The control group was made up of 70 patients with a mean age of 69.59 years (23 men and 47 women) and the pain group was made up of 63 patients with a mean age of 69.48 years (13 men and 50 women). We did not found difference regarding the analysis of the rotation of the femoral component. In addition, we were not found significant differences when applying a stratification by sex. The analysis of the malrotation of the femoral component, previously defining limits of value rotation considered as extreme, in any of the case did not show significant differences. Conclusion: The results of the study confirm that malrotation of the femoral component had no influence on the presence of pain at a minimum of one year of follow-up after TKA implantation.

Purpose: Intestinal malrotation, characterized by abnormal intestinal positioning, can lead to severe complications like volvulus and internal hernias, especially in neonates and children. Our aim was to evaluate the diagnostic methods, treatment results and postoperative follow-up of pediatric patients treated for intestinal malrotation. Methods: This retrospective study reviewed medical records of pediatric patients who underwent surgery for intestinal malrotation between January 2013 and January 2022. Data on demographics, symptoms, diagnostic approaches, surgical interventions, and postoperative outcomes were analyzed. Results: The study included 45 patients, with a male predominance (68.8%). Ages ranged from 1 day to 15 years, averaging 1.54 years. Presenting symptoms were acute abdomen (n = 21) and chronic abdominal pain with vomiting (n = 24). Diagnoses were established via physical exams and imaging, including upper gastrointestinal contrast studies and abdominal ultrasonography. All patients received the Ladd procedure, with some requiring necrotic bowel resection due to volvulus. Conclusion: The diagnosis and management of pediatric intestinal malrotation present significant challenges due to its variable symptoms and potential for life-threatening complications. Early and accurate diagnosis, followed by appropriate surgical management, is crucial. This study emphasizes the importance of diligent postoperative follow-up to identify and mitigate complications, particularly in younger and severely affected patients. [ABSTRACT FROM AUTHOR]

We herein report a rare case of duodeno-duodenal intussusception (IS) presenting with obstruction caused by tubulovillous adenoma in an adult with malrotation that was managed by a novel laparoendoscopic hybrid technique. This was done by passing transjejunal nasogastric tube (NG) through one of the ports and manoeuvring it towards the IS. Two hundred and fifty millilitre of saline was flushed by aseptosyringe with pressure connected to the NG. This hydrostatic reduction technique resulted in distension of the jejunal and duodenal loop achieving reduction of IS. Intraoperative endoscopy was performed to exactly localise the mass lesion. The duodenum was kocherised and was delivered through a 4-cm transverse incision. Anterior duodenotomy was performed; the mass was excised; and duodenotomy was closed transversely. An extensive literature search did not show any case report of duodenoduodenal IS being managed by this technique. The combination of novel retrograde decompression and intraoperative endoscopy helped us to manage this rare case by this novel technique. [ABSTRACT FROM AUTHOR]

Background: Malrotation and volvulus classically present with bilious vomiting. It is more common earlier in life, but there are other causes of bile‐stained vomiting. This leads some clinicians to 'watch and wait'. In the presence of a volvulus, this is potentially a fatal decision. It is not clear from the literature if there is a safe time window in which children can be observed in the hope of avoiding transfers or radiological investigations. Aim: To determine whether time to identification and management of midgut volvulus correlated with morbidity and mortality; and whether there were patterns to transition of care. Methods: Multicentre, retrospective review of all children with malrotation ± volvulus at two tertiary children's hospitals in Brisbane from 2000 to 2012. Data collected included age at presentation, timing between symptom onset and presentation, radiological findings, and definitive surgical management. Outcomes included patient length of stay (LOS), total parenteral nutrition (TPN) duration, re‐operations and death. Results: There were 96 cases of malrotation identified, with 23 excluded (elective operation, insufficient data). Neonates made up 66% of included cases. Only 14% of cases were over 12 months old. Bilious vomiting or bile‐stained aspirates were the presenting symptoms in 71% (52). Overall mortality was 5.56%. Time from symptom onset to presentation or management was not significantly associated with morbidity or mortality. More than half (53%, 39/73) of patients received total parenteral nutrition; 20/39 for more than 10 days. Neonates and infants had a significantly higher rate of TPN compared with older children (P < 0.001). Those requiring TPN post‐operatively had a significantly higher mortality compared with those who did not (P = 0.02). Time from symptom onset to presentation or definitive management was not significantly associated with LOS, TPN duration, or need for re‐operation. Conclusion: Malrotation remains a time‐critical diagnosis to secure and treat. Even a short duration of symptoms can be associated with high morbidity or mortality. There is no place for 'watch and wait' for such patients, and malrotation/volvulus should be emergently actively excluded with contrast studies. [ABSTRACT FROM AUTHOR]

Introduction Intestinal malrotation (IM) is characterized by abnormal intestinal rotation and fixation predisposing to a risk of midgut volvulus. The aim of this study was to describe the clinical presentation and outcome of IM from birth through childhood. Materials and Methods This was a retrospective study of children with IM managed at a single center between 1983 and 2016. Data were retrieved from medical records and analyzed. Results Three hundred nineteen patients were eligible for the study. Using strict inclusion and exclusion criteria, 138 children were included. Vomiting was the most common symptom up to 5 years of age. At 6 to 15 years of age, abdominal pain was the predominant symptom. One hundred twenty-five patients underwent a Ladd's procedure and of 124 patients with available data, 20% had a postoperative complication (Clavien-Dindo IIIb-V) within 30 days. The odds ratio to develop postoperative complications was significantly increased in extremely preterm patients (p = 0.001) and in patients with severely affected intestinal circulation (p = 0.006). Two patients had intestinal failure due to midgut loss after midgut volvulus, one of whom needed intestinal transplantation. Four patients, all extremely preterm, died related to the surgical procedure. In addition, seven patients died of reasons not related to IM. Fourteen patients (11%) had adhesive bowel obstruction and one patient had recurrent midgut volvulus requiring surgical treatment. Conclusions IM presents with different symptoms through childhood depending on age. Postoperative complications are common after Ladd's procedure, particularly among extremely preterm infants and patients with severely affected circulation caused by midgut volvulus. [ABSTRACT FROM AUTHOR]

Ultrasound (US) is gaining acceptance for the evaluation of midgut volvulus in children. However, its impact on clinical outcomes is unknown. We aim to determine whether using US as a first-line modality changes imaging mobilization, time to surgery and re-feeding, length of stay, and frequency of bowel necrosis, short bowel syndrome, and death. An IRB-approved retrospective cohort study was performed at a tertiary pediatric institution. Eighty children with surgically confirmed midgut volvulus from 2014 to 2021 were compared before and after implementation of US as first-line imaging and based on the modality used to diagnose midgut volvulus. Outcomes were not statistically different pre- versus post-implementation. Compared with patients who had UGI only, those who had US only or both had significantly quicker imaging mobilization (median: −33 min; 95% CI: −61.2, −4.8; p = 0.023 and median: −31 min; 95% CI: −58.5, −3.6; p = 0.028 respectively). Patients with US only were less likely to have bowel necrosis compared with those who had UGI only (9.1% versus 43.8%, p = 0.042). Patients who had US only or both were less likely to develop short bowel syndrome compared to UGI only (4.8% US only, 0% both, 40% UGI only; p = 0.027 for US only, p = 0.005 for both). No statistically significant change in outcomes was found after implementation of US as first-line imaging for midgut volvulus. However, patients diagnosed with US only or US in combination with UGI had quicker imaging mobilization and decreased frequency of bowel necrosis and short bowel syndrome. Findings suggest that US has potential to improve patient outcomes. III. • What is currently known about this topic? US has higher sensitivity for midgut volvulus than UGI, with comparable specificity. US is both quicker and cheaper than UGI, even when a radiologist is involved in scanning. • What new information is contained in this article? This is the first study to evaluate clinical outcomes based on the type of imaging exam used to diagnose midgut volvulus. [ABSTRACT FROM AUTHOR]

Introduction: Ladd's procedure, originally described in 1936 for the treatment of malrotation, does not traditionally include appendectomy as a standard step. We conducted a multinational survey to investigate the current consensus on the role of appendectomy in Ladd's procedure. Methodology: An anonymous online survey was distributed to pediatric surgeons worldwide. The survey collected demographic data and explored surgical preferences related to the management of malrotation. Open-ended questions were used to assess the opinions regarding the necessity of appendectomy, decision-making factors, and complications associated with appendectomy during Ladd's procedure. Results: A total of 343 responses were received from 46 countries. Of the respondents, 319 (93%) were consultants and 24 (7%) were residents/trainees. When asked about the choice between open and laparoscopic Ladd's procedure, 292 (85%) preferred open surgery. Overall, 184 (53%) respondents favored appendectomy in both open and laparoscopic Ladd's procedure. Furthermore, 172 (50%) surgeons advocated for appendectomy in all malrotation cases, citing concerns about potential future appendicitis. While differences existed between all comparisons, none of them reached statistical significance. The factors influencing the decision to preserve the appendix included the risk of postoperative complications and the potential future use of the appendix as a surgical conduit. The surgical complications following appendectomy included surgical site infections in 14 (33%) patients, adhesive obstruction in 13 (31%) patients, intrabdominal abscesses in 10 (24%) patients, and fecal fistulas in 5 (12%) patients. Conclusion: The majority of surgeons aim to perform appendectomy in all malrotation cases, considering the potential risks and benefits of this approach. These findings offer valuable insights for clinical practice and may inform future guidelines and decision-making algorithms. [ABSTRACT FROM AUTHOR]

A paraduodenal hernia is a rare cause of an internal hernia that may require massive bowel resection; prompt diagnosis and surgical treatment are essential. In cases of malrotation, strangulation may occur both inside and outside the hernial sac. Strangulation outside the hernial sac makes the preoperative diagnosis more difficult. Herein, we report a patient with a right paraduodenal hernia, intestinal malrotation, and strangulation outside the hernia. An 86-year-old woman was admitted to our hospital with abdominal pain. Enhanced computed tomography showed a closed-loop obstruction of the hypo-enhancing small bowel and absence of a horizontal duodenal leg. The patient underwent an emergency laparotomy and was diagnosed with strangulated bowel obstruction due to a right paraduodenal hernia and malrotation. The patient underwent resection of the ischemic ileum, closure of the hernial orifice, and repositioning of the intestine. The postoperative course was uneventful. The patient reported no abdominal discomfort after 7 months of follow-up. [ABSTRACT FROM AUTHOR]

The position of the fetal head during engagement and progression in the birth canal is the primary cause of dystocic labor and arrest of progression, often due to malposition and malrotation. The authors performed an investigation on pregnant women in labor, who all underwent vaginal digital examination by obstetricians and midwives as well as intrapartum ultrasonography to collect four "geometric parameters", measured in all the women. All parameters were measured using artificial intelligence and machine learning algorithms, called AIDA (artificial intelligence dystocia algorithm), which incorporates a human-in-the-loop approach, that is, to use AI (artificial intelligence) algorithms that prioritize the physician's decision and explainable artificial intelligence (XAI). The AIDA was structured into five classes. After a number of "geometric parameters" were collected, the data obtained from the AIDA analysis were entered into a red, yellow, or green zone, linked to the analysis of the progress of labor. Using the AIDA analysis, we were able to identify five reference classes for patients in labor, each of which had a certain sort of birth outcome. A 100% cesarean birth prediction was made in two of these five classes. The use of artificial intelligence, through the evaluation of certain obstetric parameters in specific decision-making algorithms, allows physicians to systematically understand how the results of the algorithms can be explained. This approach can be useful in evaluating the progress of labor and predicting the labor outcome, including spontaneous, whether operative VD (vaginal delivery) should be attempted, or if ICD (intrapartum cesarean delivery) is preferable or necessary. [ABSTRACT FROM AUTHOR]

Background. Anatomic reduction is crucial to avoid malalignment in tibial shaft fractures in adolescents quickly approaching physeal closure. While surgical treatment is becoming more common, casting and immobilization are still widely done for appropriately selected fractures. Local radiographic and clinical outcomes of non-surgical treatment need to be explored. Objective. The primary objective of this study was to report residual lower limb deformity of tibial shaft fractures treated non-surgically in adolescents nearing skeletal maturity. The study also identified factors or fracture characteristics that may predict these deformities and reported the clinical outcomes using the Lower Extremity Functional Scale. Methodology. This was a cross-sectional study of 31 adolescents nearing skeletal maturity at the time of injury with acute closed tibial shaft fractures treated non-surgically at the Philippine Orthopedic Center from 2017 to 2020. Skeletal maturity and residual sagittal & coronal angulation were analyzed through radiographs. Rotational alignment and leg length discrepancies were evaluated clinically. Functional outcome was measured using the Lower Extremity Functional Scale (LEFS). Result. Coronal plane angulation (r = -0.397; p = 0.05) and leg length discrepancy (r = -0.394; p = 0.05) were inversely correlated with Lower Extremity Functional Scale (LEFS) scores. Coronal plane angulation was also correlated with ipsilateral fibular fractures (p = 0.007). Lower Extremity Functional Scale (LEFS) scores were 79.39 on average (range 75 to 80). Conclusion. Among adolescents nearing skeletal maturity with isolated acute tibial shaft fractures, closed reduction and casting followed by close monitoring remains useful and effective.

Urgent investigation is crucial for infants with bilious vomiting, potentially indicating bowel obstruction. Upper gastrointestinal fluoroscopy aids diagnosis, but is not without its challenges. This case report describes a rare case of neonatal intestinal malrotation and mid-gut volvulus with an additional complication of congenital peritoneal encapsulation. Contribution: This case study offers insights into associated diagnostic challenges and underscores the value of utilising fluoroscopy in diagnosing complex gastrointestinal conditions.

We are sharing a rare presentation of congenital duodenal obstruction with combined intrinsic and extrinsic causes with situs inversus, namely, duodenal stenosis with gastrointestinal malrotation in a neonate. The patient underwent successful exploratory laparotomy, Ladd's procedure, and appendicectomy were carried out. Early recognition of signs and symptoms, prompt corrective surgery, and adequate optimization of metabolic components post-operatively are important to determine the decreased morbidity and mortality of neonates.

Purpose: The objective of this scoping review was to describe the extent and type of evidence of using guided growth to correct rotational deformities of long bones in children. Methods: This scoping review was conducted in accordance with the JBI methodology for scoping reviews. All published and unpublished studies investigating surgical methods using guided growth to perform gradual rotation of long bones were included. Results: Fourteen studies were included: one review, three clinical studies, and ten preclinical studies. In the three clinical studies, three different surgical methods were used on 21 children. Some degree of rotation was achieved in all but two children. Adverse effects reported included limb length discrepancy (LLD), knee stiffness and rebound of rotation after removal of tethers. Of the ten preclinical studies, two were ex vivo and eight were in vivo. Rotation was achieved in all preclinical studies. Adverse effects reported included implant extrusions, LLD, articular deformities, joint stiffness and rebound of rotation after removal of tethers. Two of the studies reported on histological changes. Conclusions: All studies conclude that guided growth is a potential treatment for rotational deformities of long bones. There is great variation in animal models and surgical methods used and in reported adverse effects. More research is needed to shed light on the best surgical guided growth method, its effectiveness as well as the involved risks and complications. Based on current evidence the procedure is still to be considered experimental. Level of evidence: 4

Background: Rapid diagnosis is crucial for pediatric patients with midgut volvulus and malrotation to prevent serious complications. While the upper gastrointestinal study (UGIS) is the traditional method, the use of ultrasound (US) is gaining prominence. Objectives: To assess the diagnostic sensitivity and specificity of US compared to UGIS for malrotation and midgut volvulus. Methods: A cross-sectional study was performed on 68 pediatric patients who underwent US and/or UGIS before surgery for suspected midgut volvulus or malrotation in Kuala Lumpur (PPUKM and HTA), referencing surgical outcomes as the gold standard. Results: US demonstrated a higher specificity (100%) than UGIS (83%) for diagnosing malrotation, with a slightly lower sensitivity (97% vs. 100%). For midgut volvulus, US surpassed UGIS in sensitivity (92.9% vs. 66.7%) while maintaining comparable specificity. The SMA/SMV criteria showed better sensitivity (91.1%) than the D3 assessment (78.9%) on US, though both had high specificity. Conclusion: US is equivalent to UGIS for identifying malrotation and is more sensitive for detecting midgut volvulus, supporting its use as a primary diagnostic tool. The study advocates for combined US and UGIS when either yields inconclusive results, optimizing diagnostic precision for these conditions. [ABSTRACT FROM AUTHOR]

Intestinal atresia is a common cause of neonatal bowel obstruction. Atresias are often associated with other congenital anomalies. The purpose of the study was to evaluate associated anomalies, operative management, and postoperative outcomes of infants with intestinal atresia. A review of patients presenting to a single free-standing children's hospital from March 2012 through February 2022 was performed. The variables examined were type of atresia, additional congenital anomalies, type of operative intervention, and postoperative outcomes. Standard statistical methods were utilized. A total of 75 patients with intestinal atresia were identified and several of these patients had multiple atresias. Isolated duodenal atresia patients were the most common (49.3%), followed by jejunal (32%) and ileal (12%). Mixed atresias were rare at 4%, with isolated pyloric and colonic also rare at 1.3% each. Malrotation was associated with 13% of patients and equally associated with duodenal and jejunoileal atresias. A low percentage (3%) of intestinal atresias was seen in conjunction with gastroschisis and concomitant malrotation. A majority of infants with duodenal atresia underwent standard duodenoduodenostomy (19% laparoscopic, 81% open). In infants with jejunoileal atresia, most underwent resection with primary anastomosis. A tapering enteroplasty was performed primarily in 13% of atresias. There were no significant differences noted in time to first feed or length of stay between those with and without tapering enteroplasty. Eleven percent of patients required subsequent intervention for stricture or small bowel obstruction. There was one death in this series. Consistent with other literature, duodenal atresia was the most common type of intestinal atresia. However, we demonstrated that malrotation was equally associated with duodenal and jejunoileal atresias while prior reports had shown a higher association with duodenal atresia. In our patient population, the use of tapering enteroplasty did not appear to be associated with outcomes. Overall, these infants have a low morbidity and mortality rate with a rare need for reoperation. [ABSTRACT FROM AUTHOR]

Background: The standard imaging technique for the diagnosis of intestinal malrotation remains the upper gastro-intestinal series (UGIS). The lateral view is promoted as important for making a diagnosis. For this, the lateral view should be of adequate quality, and radiologists must know the normal appearance as well as the appearance of duodenal variants, as misdiagnosis may lead to unnecessary surgery. Objective: We aimed to evaluate the quality, findings including the prevalence of the "descending staircase" configuration and its correspondence to a diagnosis of duodenum redundum. Materials and Methods: This was a retrospective study and was conducted in a large tertiary children's hospital in the United States. A retrospective review of UGI fluoroscopy exams in children aged ≤ 18 years between January and December 2018 was performed by a pediatric radiologist. First, the lateral view images/cine-loops were assessed independently, followed by the anteroposterior (AP) view. The studies which were designated to have an adequate lateral view were evaluated for configuration of the duodenum and recorded as: normal, abnormal, or normal variant. Also, the presence of a descending staircase configuration was correlated with an AP view for a diagnosis of duodenum redundum. Results: A total of 26 children (26%) (males:16; females:10) with age range 0 to 16 years had adequate lateral views during UGI exams for inclusion. Of the 26, 18 (69%) were reported as normal, 7 (27%) were reported as having a descending staircase and 1 (4%) was reported as abnormal. The AP view demonstrated 2 abnormal studies (1 malrotation and 1 non-rotation), 6 duodenum redundum and 18 normal exams. The one abnormal lateral duodenum was confirmed as a non-rotation on AP view; the second patient with an abnormal AP view had a normal appearance on the lateral view. Conclusions: A total of 26% of UGI studies had adequate lateral views for interpretation. Of these, nearly a quarter (23%) demonstrated the descending stair-case sign corresponding to a diagnosis of duodenum redundum on the AP view. If the lateral view had been used alone, there would have been a missed diagnosis in one patient. [ABSTRACT FROM AUTHOR]

Key Clinical Message A whirl sign on contrast‐enhanced abdominal CT scan is indicative of intestine twisted around the mesenteric vessels, and is observed in cases of strangulated obstruction, signaling compromised intestinal circulation. In cases of intestinal volvulus, surgery is necessary to untwist the affected bowel, and resection is necessary if necrosis is present. Abstract A 31‐year‐old Japanese man presented with acute lower abdominal pain and vomiting. Contrast‐enhanced abdominal computed tomography (CT) revealed a 1440‐degree clockwise torsion of superior mesenteric artery and a whirl sign. Intestinal volvulus in adulthood with a background of malrotation is extremely rare. Contrast‐enhanced CT is effective for diagnosis.

Abstract Purpose In this study, we aimed to investigate the effects of postoperative malrotation alignment on the outcomes of Gartland type III/IV paediatric supracondylar humeral fracture (SCHF) treated by close reduction and percutaneous K-wire fixation. Methods Between January 2014 and December 2021, 295 Gartland type III/IV paediatric SCHFs treated by close reduction and percutaneous K-wire fixation were selected for this retrospective study. The demographic, clinical and radiographic parameters of all cases were collected. The lateral rotation percentage (LRP) was measured on X-rays to evaluate postoperative malrotation alignment of the fracture. All cases were categorized into 4 groups according to LRP: LRP ≤ 10% (210, 71.2%), 10% 30% (18, 6.1%). The carrying angle, ranges of multidirectional motions, Mayo Elbow Performance Score (MEPS) and Flynn’s Standard Score (FSS) of the injured elbow were assessed 6 months postoperation and compared among different groups. ROC analysis based on LRP and the excellent/good rate of FSS was performed to determine the acceptable maximum degree of postoperative malrotation alignment. Results There was no difference in the demographic characteristics (age, sex, injured side and fracture type), postoperative Baumann angle, carrying angle or range of forearm rotation among the 4 groups (P > 0.05). The operation time and time from operation to K-wire removal were longer in the 20% 30% groups than in the LRP 30% groups than in the LRP

Key Clinical Message: A whirl sign on contrast‐enhanced abdominal CT scan is indicative of intestine twisted around the mesenteric vessels, and is observed in cases of strangulated obstruction, signaling compromised intestinal circulation. In cases of intestinal volvulus, surgery is necessary to untwist the affected bowel, and resection is necessary if necrosis is present. A 31‐year‐old Japanese man presented with acute lower abdominal pain and vomiting. Contrast‐enhanced abdominal computed tomography (CT) revealed a 1440‐degree clockwise torsion of superior mesenteric artery and a whirl sign. Intestinal volvulus in adulthood with a background of malrotation is extremely rare. Contrast‐enhanced CT is effective for diagnosis. [ABSTRACT FROM AUTHOR]

Femoral shaft fractures are increasingly common due to various traumatic injuries. Intramedullary nail (IMN) is considered the gold standard treatment for these fractures, but comorbidities often require thorough trauma life support and intensive care. The primary goal of treatment is rigid fixation, early mobilisation, and long-term functional recovery. This article reviews current concepts in the treatment of femoral shaft fractures, including the effects of early or delayed operation, differences between antegrade or retrograde intramedullary nailing, alternative methods to using a fracture table, methods to predict nail length before operation, assessing femoral rotation during an operation, and complications.

Abstract Background The objective of this study was to evaluate the safety and efficacy of laparoscopic Ladd’s procedure (LL) for intestinal malrotation (IM) in small infants. Methods All patients aged

Purpose: In this study, we aimed to investigate the effects of postoperative malrotation alignment on the outcomes of Gartland type III/IV paediatric supracondylar humeral fracture (SCHF) treated by close reduction and percutaneous K-wire fixation. Methods: Between January 2014 and December 2021, 295 Gartland type III/IV paediatric SCHFs treated by close reduction and percutaneous K-wire fixation were selected for this retrospective study. The demographic, clinical and radiographic parameters of all cases were collected. The lateral rotation percentage (LRP) was measured on X-rays to evaluate postoperative malrotation alignment of the fracture. All cases were categorized into 4 groups according to LRP: LRP ≤ 10% (210, 71.2%), 10% < LRP ≤ 20% (41, 13.9%), 20% < LRP ≤ 30% (26, 8.8%) and LRP > 30% (18, 6.1%). The carrying angle, ranges of multidirectional motions, Mayo Elbow Performance Score (MEPS) and Flynn's Standard Score (FSS) of the injured elbow were assessed 6 months postoperation and compared among different groups. ROC analysis based on LRP and the excellent/good rate of FSS was performed to determine the acceptable maximum degree of postoperative malrotation alignment. Results: There was no difference in the demographic characteristics (age, sex, injured side and fracture type), postoperative Baumann angle, carrying angle or range of forearm rotation among the 4 groups (P > 0.05). The operation time and time from operation to K-wire removal were longer in the 20% < LRP ≤ 30% and LRP > 30% groups than in the LRP < 10% and 10% < LRP ≤ 20% groups (P < 0.001). The shaft condylar angle, range of elbow flexion, MEPS and FSS of the injured elbow 6 months postoperatively were lower in the 20% < LRP ≤ 30% and LRP > 30% groups than in the LRP < 10% and 10% < LRP ≤ 20% groups (P < 0.001). ROC analysis based on LRP and the excellent/good rate of FSS showed an area under the curve of 0.959 (95% CI 0.936–0.983), with a cutoff value of 26.5%, sensitivity of 95.3% and specificity of 90.1%. Conclusion: A certain degree of residual malrotation alignment deformity of the SCHF may reduce the shaft condylar angle and extend the time from operation to removing the K-wire and affect elbow function, especially the range of elbow flexion. The acceptable maximum degree of residual malrotation deformity expressed as the LRP value was 26.5%. [ABSTRACT FROM AUTHOR]

Background: The objective of this study was to evaluate the safety and efficacy of laparoscopic Ladd's procedure (LL) for intestinal malrotation (IM) in small infants. Methods: All patients aged < 6 months with IM who underwent Ladd's procedures between January 2012 and December 2019 were enrolled. The perioperative demographics and midterm follow-up results were retrospectively reviewed and compared between patients who underwent LL and open Ladd's operation (OL). Results: Fifty-five patients were enrolled for analysis. The baseline characteristics were well matched in the two groups. The rate of volvulus was similar in the two groups (76.2% vs. 73.5%, P = 0.81). Two cases in the LL group were converted to OL due to intraoperative bleeding and intestinal swelling. The operative time (ORT) was not significantly different between the two groups (73.8 ± 18.7 vs. 66.8 ± 11.6 min, P = 0.76). Compared to the OL group, the LL group had a shorter time full feed (TFF) (3.1 ± 1.2 vs. 7.3 ± 1.9 days, P = 0.03) and a shorter postoperative hospital stay (PHS) than the OL group (5.5 ± 1.6 vs. 11.3 ± 2.7 days, P = 0.02). The rate of postoperative complications was similar in the two groups (9.5% vs. 11.8%, P = 0.47). The LL group had a lower rate of adhesive obstruction than the OL group, but the difference was not significant (0.0% vs. 11.8%, P = 0.09). One patient suffered recurrence in the LL group, while 0 patients suffered recurrence in the OL group (4.8% vs. 0.0%, P = 0.07). The rate of reoperation in the two groups was similar (4.8% vs. 8.8%). Conclusions: The LL procedure for IM in small infants was a safe and reliable method that had a satisfactory cosmetic appearance and shorter TFF and PHS than OL. [ABSTRACT FROM AUTHOR]

Restoring femoral rotation alignment and limb length after distal femur resection and endoprosthetic reconstruction is crucial to avoid poor outcomes. This technical note presents a simple and reliable intraoperative technique for restoring femoral rotation and length during distal femur resection and endoprosthetic reconstruction without the need for extensive preoperative planning or complex perioperative modalities. The method utilizes an external fixator frame as a guiding device to assess and restore the native alignment. This approach provides a practical alternative to relying solely on the position of the linea aspera, which has been shown to be an unreliable landmark for rotational alignment. Implementing this technique can contribute to improved functional outcomes in patients undergoing distal femur endoprosthetic reconstruction.

Abstract Introduction Amyand hernia (AH) is a rare disease, so there are no standard strategies and there are many different aspects at each stage of its management. Based on our own experience, we encountered these differences even in a small number of cases and therefore sought to review the literature to highlight the diversity of approaches to this pathology. This review of the literature was not intended to describe the statistical findings found in the clinical case series, but rather to highlight the clinical and surgical difficulties of AH in children. Nevertheless, we conducted an introductory statistical study based on data from PubMed and Google Scholar to understand the global prevalence of AH. Materials and methods The search for the key terms Amyand hernia, Amyand’s hernia, and “children” between 2003 and 2023 resulted in 52 PubMed and 548 Google Scholar articles. Results After the exclusion of irrelevant studies, 101 articles were found. A total of 83 case reports describing 182 pediatric patients were used to understand the demographic distribution of this pathology. Given the impossibility of further comprehensive statistical analysis (due to heterogeneous data), a narrative design was used to describe the remaining aspects of AH management. Finally, three clinical cases demonstrated the mentioned aspects. Discussion As a result of the search, conclusions were drawn about the main difficulties in the management of AH in children, which were discussed.

Ladd’s syndrome is a violation of intrauterine intestinal rotation. The midgut remains fixed at one point at the origin of the superior mesenteric artery. As a result, conditions are created for the occurrence of a volvulus around the root of the mesentery and acute strangulation intestinal obstruction develops. Ladd’s syndrome includes three features: a high position of the caecum dome, duodenal hyperfixation, and lack of mesenteric fixation. In newborns, this condition is manifested by acute complete high strangulation intestinal obstruction, up to the development of shock. Examination for suspected Ladd’s syndrome should be comprehensive and include a survey abdominal radiography, abdominal ultrasound, gastric and duodenal radiography with oral contrast, irrigography. The article considers clinical cases of Ladd’s syndrome in newborns at the age of 3 and 5 days of life. Echograms made in B-mode using color Doppler sonography are presented. The high informativeness of ultrasound diagnostics for the detection of this syndrome in newborns with a clinic of bile vomiting is shown. In one of the observed cases, a pathognomonic echographic symptom of midgut volvulus was established (a whirlpool sign). In the second observation, a clearly defined vascular ring was not detected due to 180° torsion, which was subsequently confirmed intraoperatively.

Intestinal malrotation and duplication of the inferior vena cava are rarely diagnosed in adult patients; however, incidence is likely underestimated as they are usually asymptomatic. These congenital malformations have been previously reported in the same patient twice but never with colonic obstruction or ischaemia. A 25-year-old female presented with nausea, vomiting, obstipation, and abdominal pain, and on computed tomography of the abdomen and pelvis was diagnosed with a caecal volvulus and pneumatosis coli associated with intestinal malrotation requiring emergency right hemicolectomy. Incidentally, the patient was noted to have duplication of the inferior vena cava, azygos continuation of the inferior vena cava, and splenic fragmentation. This constellation of symptoms has not been reported in the literature previously. The pattern of malformations follows that of polysplenia syndrome. Although rare, awareness of these malformations can be useful to clinicians. [ABSTRACT FROM AUTHOR]

Objective: Talon distalfix intramedullary nails have been developed as a solution to the technical difficulties experienced during the placement of locking screws. We aimed to evaluate the radiological and clinical results of retractable talon distal fix for the treatment of femoral shaft fractures. Material and Method: Between January 2017 and January 2022, 28 patients with femoral shaft AO type 32-A and B fractures were treated with Talon distalfix nails. AO Type 32-A and B fractures were included in the study. Demographic characteristics, follow-up times, ASA of Anesthesiologists classification and fracture type were recorded. The duration of the operation, intraoperative blood loss, fluoroscopy time (in min), and time to bone union were recorded. General and technical complications (nonunion, malunion, malrotation, and shortening) were evaluated. Clinical functional outcomes were evaluated using the Knee Injury and the Osteoarthritis Outcome Score Physical Function Shortform (KOOS-PS), Hip Injury and Osteoarthritis Outcome Score Physical Function Shortform (HOOS-PS) and Thoresen criteria. Results: A total of 28 patients (11 female and 17 male) were included in the study. The mean age was 46.8 years and the mean follow-up was 23.7 months. . The mean time to bone union was 22.6 weeks. No nonunion was observed in any of the patients. The mean hospital stay was 3.4 days and the mean Body Mass Index was 24.2. The mean operation time was 40.3±3.4 minutes and the mean scope time was 26.9 seconds. The mean KOOS-PS score and HOOS-PS were 83.4 and 85.6, respectively. Conclusion: Talon distalfix nails can be safely used in AO type A-B fractures of the midshaft femur. Talon distalfix nail application provides advantages including shorter operation times, less radiation exposure, fewer surgical incisions, and less blood loss. In addition, it should be emphasized that the union time is prolonged compared with that of conventional nails.

Malrotation leading to massive chylous ascites is rare. A 9-year-old girl was investigated for slowly increasing abdominal distension under a year. She had no vomiting, weight loss, or pain, but was bothered in social situations. Medical investigations, including ultrasound and computed tomography scans, revealed massive ascites. Laparocentesis yielded milk-colored fluid, confirmed as lymph through laboratory analysis. A complete blood count, liver function and hematologic parameters, chyle cytology, bacterial cultures, and polymerase chain reaction for tuberculosis were all within normal limits.