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1.  Functional Outcome of Transphyseal Reconstruction of the Anterior Cruciate Ligament in Skeletally Immature Patients 
Knee Surgery & Related Research  2012;24(3):173-179.
In anterior cruciate ligament (ACL) injury, conventional adult reconstruction techniques have to face the potential risk of growth disturbance or angular deformities in skeletally immature patients. The aim of this study was to evaluate the clinical outcomes of ACL reconstruction by conventional transphyseal tunnel technique.
Materials and Methods
On a retrospective basis, we reviewed 25 skeletally immature patients; all the patients showed skeletal maturity at last follow-up, and the mean age was 16.4 years. The average injury to surgery interval was 12.6 months. Clinical outcomes were assessed at a mean of 74.4 months postoperatively using the Lysholm Knee Scoring Scale, the Tegner activity level, the International Knee Documentation Committee (IKDC), and plain radiographs.
All the patients had undergone transphyseal reconstruction of ACL. The mean Lysholm score was 48.36 points preoperatively and 93.32 points postoperatively; the mean Tegner activity level was changed from 3.0 points to 5.6 points. The mean IKDC level was categorized as C preoperatively and changed to A postoperatively.
Our midterm outcome at an average 6 years after surgery was satisfactory without significant leg length discrepancies or abnormal alignment of the knee joint. Transphyseal reconstruction of ACL is a good treatment modality in the skeletally immature patient.
PMCID: PMC3438279  PMID: 22977795
Anterior cruciate ligament; Skeletally immature; Adolescent
2.  How Reliable Are Standard Radiographic Measures of the Foot and Ankle in Children With Achondroplasia? 
Radiographic measurements are typically used in achondroplasia (ACH) during correction of lower limb alignment. However, reliabilities for the measurements on weightbearing radiographs of the foot and ankle in patients with ACH have not been described, and the differences between the ACH population and subjects without ACH likewise have not been well characterized; these issues limit the use of studies on this subject.
We proposed (1) to measure the inter- and intraobserver reliability of a number of radiographic measures of ankle and foot alignment in an achondroplastic cohort of patients; and (2) to compare our radiographic measurement values with age-matched literature-based normative values.
Ten radiographic measurements were applied to foot and ankle radiographs of 20 children (40 feet) with ACH (mean age, 10 years; range, 8–16 years). Interobserver and intraobserver reliabilities of these radiographic measurement methods were obtained and expressed by intraclass correlation coefficients (ICCs). The mean values were calculated and compared with the literature-based values.
The interobserver reliability was excellent for eight measurements with ICCs ranging from 0.801 to 0.962, except for lateral talo-first metatarsal angle and mediolateral column ratio, which were much lower. The intraobserver reliability was excellent for all 10 radiographic measurements with ICCs ranging from 0.812 to 0.998. Compared with existing literature-based values, all 10 measurements had a significant difference (p < 0.01).
We suggest tibiotalar angle, calcaneal pitch angle, tibiocalcaneal angle, talocalcaneal angle, naviculocuboid overlap, talonavicular coverage angle, metatarsal stacking angle, and AP talo-first metatarsal angle with excellent interobserver and intraobserver reliabilities should be considered preferentially in analysis of foot and ankle alignment in children with ACH.
Level of Evidence
Level II, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC3734405  PMID: 23609814
3.  Can Residual Leg Shortening Be Predicted in Patients With Legg-Calvé-Perthes’ Disease? 
Although Legg-Calvé-Perthes’ disease (LCPD) is frequently associated with varying degrees of femoral head deformity and leg length discrepancy (LLD), no factors that predict residual shortening have been clearly identified.
We attempted to determine whether (1) the extent of femoral head involvement; (2) varus osteotomy; and (3) patient demographic characteristics are associated with LLD at skeletal maturity in patients with LCPD.
We retrospectively reviewed the records of 168 skeletally mature patients with unilateral LCPD. The mean age at diagnosis was 7 years (range, 2–14 years). The extent of femoral head involvement was determined from the initial radiographs using the Herring lateral pillar and Catterall classifications. LLD was defined as shortening by ≥ 1.0 cm as measured from scanograms. The patient’s sex and the treatment modalities used were also recorded.
LLD ranging from 10 to 38 mm (mean, 19 mm) occurred in 93 (55%) patients and was associated with the extent of femoral head involvement. Varus osteotomy was not associated with residual shortening. The patient’s age at diagnosis did not affect the LLD at skeletal maturity. The strongest predictor of LLD was a lateral pillar classification of B/C or C (odds ratio, 3.5; 95% confidence interval, 1.39–8.79).
The extent of femoral head involvement, but not the patient’s age at diagnosis or sex or the treatment modality, can predict the LLD at skeletal maturity in patients with unilateral LCPD.
Level of Evidence
Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC3705048  PMID: 23616268
4.  Role of hybrid monolateral fixators in managing humeral length and deformity correction 
Acta Orthopaedica  2013;84(3):280-285.
Background and purpose
Humeral lengthening and deformity correction are now being done increasingly for various etiologies. Monolateral external fixators have advantages over traditional Ilizarov circular fixators; they are easy to apply, they are less bulky, and they are therefore more convenient for the patient. We assessed the effectiveness of hybrid monolateral lateral fixators in humeral lengthening and deformity correction.
We retrospectively reviewed 23 patients (40 humeri) with various pathologies who underwent lengthening—with or without deformity correction using monolateral external fixator—between 2003 and 2008. Mean age at the time of the surgery was 14 (10–22) years. The mean follow-up time was 3.4 (1–7) years.
The average duration of external fixator use was 8.3 (6–19) months. The mean lengthening achieved was 8.8 (4–11) cm and percentage lengthening was 49% (19–73). The healing index was 28 (13–60) days/cm. The major complications were refracture in 3 humeri and varus angulation of 2 humeri. The minor complications were superficial pin tract infection (6 segments), transient radial nerve palsy (1 segment), and elbow flexion contracture (5 segments). All complications resolved.
Hybrid monolateral fixators can be used for humeral lengthening and deformity correction. The advantage over circular fixators is that they are less bulky and patients can perform their day-to-day activities with the fixator in situ.
PMCID: PMC3715829  PMID: 23506166
5.  Congenital pseudarthrosis of the tibia treated with a combination of Ilizarov’s technique and intramedullary rodding 
Acta Orthopaedica  2012;83(5):515-522.
Background and purpose
Ilizarov’s technique and intramedullary rodding have often been used individually in congenital pseudarthrosis of the tibia. In this series, we attempted to combine the advantages of both methods while minimizing the complications.
We reviewed 15 cases of congenital pseudoarthrosis of the tibia (CPT) who were treated with a combination of Ilizarov’s apparatus and antegrade intramedullary nailing between 2003 and 2008. The mean age at surgery was 7.5 (3–12) years and the mean limb length discrepancy was 2.5 (1.5–5) cm. At a mean follow-up time of 4.5 (1.6–7.2) years after the index surgery, the patients were evaluated clinically and radiographically for ankle function (AOFAS score) and for malalignment, signs of union, limb length discrepancy, and complications.
14 patients achieved union, in 6 patients primary union and in 8 patients after secondary procedures. The AOFAS score improved from a preoperative mean of 40 (20–57) to 64 (47–75). The main complication was refracture in 1 patient, and non-union in 1 patient.
The combination of the Ilizarov technique and conventional antegrade intramedullary nailing was successful in achieving union with few complications, though this should be shown in long-term studies lasting until skeletal maturity.
PMCID: PMC3488180  PMID: 23043268

Results 1-5 (5)