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Objectives Our observational study's objective was to determine how effective guided growth with tension-band plates was to correct the deformity in Blount's disease. Methods We reviewed the records of 14 children (18 limbs) with Blount's disease who were treated with tension-band plates as the only surgical intervention at a single institution over eight years. Five children (seven limbs) had infantile Blount's disease with Langenskiold stage ≤2. Nine children (11 limbs) had late-onset Blount's disease. Results The mean age at operation was 7.2 years (SD, 3.1, range, 2.9-11.8). The tension-band plate effectively corrected the varus deformity in 78% (14/18) of limbs. Correction to normal mechanical alignment was achieved in 67% (n = 12) of limbs at a mean of 18 months (SD, 7, range, 9-31). Failure to achieve correction of the mechanical axis was due to delayed implant removal and overcorrection in 11% (2/18), mechanical failure due to screw fixation failure in 11% (2/18) and in 6% (1/18) due to a misplaced epiphyseal screw. There was a greater magnitude of correction in the Infantile Blount's disease group (mean, 26°, SD, 9°) when compared to the children with late-onset Blount's disease (13°, SD, 4°) (P = 0.021). The mean correction rate was 1.8°/month in the Infantile Blount's disease group and 0.7°/month in the late-onset Blount's disease group, respectively (P = 0.014). Conclusion Our findings support the use of tension-band plating in Blount's disease. Further research is required to determine the ideal indications and to investigate the long-term outcome of guided growth in Blount's disease. Level of evidence Level 4.

BACKGROUND Late-presenting or recurrent infantile Blount disease (IBD) is characterized by knee instability because of medial tibial plateau depression, multiplanar proximal tibial deformity, and potential distal femoral deformity. The surgical treatment strategy includes medial elevation osteotomy to stabilize the knee, together with proximal tibial osteotomy to correct alignment, and lateral epiphysiodesis to prevent a recurrence. This study's primary aim was to describe the clinical outcomes of medial elevation osteotomy for the management of late-presenting and recurrent IBD. METHODS The authors reviewed the records of 48 children (64 limbs) who had medial elevation osteotomies and lateral epiphysiodesis, combined with proximal tibial realignment in 78% (50/64) of cases in the same setting. IBD was bilateral in 33% (16/48), 77% (37/48) were female individuals, and 42% (20/48) were obese. RESULTS The mean age at surgery was 8.6 years (SD, 1.6; range, 5.8 to 12.8). The mean preoperative tibiofemoral angle (TFA) was 28±11 degrees (8 to 55 degrees), and the mean angle of depression of the medial plateau (ADMP) was 49±8 degrees (26 to 65 degrees). Distal femoral valgus was present in 27% (17/62) and varus in 10% (6/62) children. At a median follow-up of 3.2 years (range, 1 to 6.2 y), the median TFA was 1-degree valgus (interquartile range, 7-degree varus to 5-degree valgus), whereas the ADMP was corrected to 25±8 degrees (8 to 45 degrees). Obesity was associated with more severe deformity as measured by TFA (P

Background This study aimed to determine the recurrence rate in infantile Blount disease (IBD) in a cohort of patients treated with a tibial osteotomy; and also to identify which factors were associated with recurrence. Methods We reviewed the records of 20 patients, under the age of 7 years, with IBD (35 involved extremities) treated by proximal tibial realignment osteotomy to physiological valgus at a single institution over 4 years. We then analyzed the data to determine the rate of recurrence and identify the risk factors for recurrence. Results The mean age of the included patients was 4.2 years (range, 2 to 6 y). We observed a recurrence rate of 40% (n=14) at a mean follow-up of 42 months (range, 21 to 72 mo). Knee instability [odds ratios OR, 6.6; 95% confidence interval (CI), 2.0-22.2], Langenskiold stage (OR, 6.3; 95% CI, 2.0-19.4), and severity of the deformity, as measured by medial physeal slope (MPS) (OR, 1.2; 95% CI, 1.1-1.4), were associated with recurrence. On multiple logistic regression analysis, MPS remained the most relevant predictor of recurrence. Receiver operating curve analysis showed that an MPS ≥60 degrees predicted recurrence with a sensitivity of 79% and specificity of 95% (area under the curve=0.925). Postoperatively, increased varus alignment on weight-bearing as measured by the tibio-femoral angle was indicative of knee instability and associated with increased odds of recurrence (OR, 1.5; 95% CI, 1.1-1.9; P=0.004). Conclusions We observed a recurrence rate of 40% in children with IBD under 7 years treated with acute correction to a tibio-femoral angle of 5 to 10 degrees valgus through a dome proximal tibial osteotomy. Knee instability, Langenskiold stage, and MPS were associated with recurrence. Cases with an MPS ≥60 degrees seem to be particularly at risk for recurrence. Further research is needed to validate these findings. Level of evidence Level IV.

OBJECTIVE Early studies in Cape Town identified independent HIV-1 epidemics, with distinct viral subtypes, among men who have sex with men (MSM) and the heterosexual population. However, few recent HIV-1 subtype data are available for MSM in South Africa. We examined HIV-1 subtypes among MSM in Cape Town. DESIGN Cross-sectional survey. METHODS Self-identified MSM were recruited from geographically and racially disparate communities across Cape Town. Participants completed behavioral questionnaires and underwent HIV testing. Virus isolated from infected participants underwent complete env gp160 sequencing, and HIV-1 subtypes were assigned through phylogenetic analysis. RESULTS In total, 194 HIV-infected MSM were enrolled: 67% black African, 24% colored, and 9% white men. More black African men identified as bisexual or heterosexual compared with other races. Overall, 31%-66% of men reported a recent partner of another race. HIV-1 subtypes were confirmed for 143 participants: 81% were subtype C, 14% B, 1% A1, 1% F2, and 3 recombinant viruses. Subtype C virus was associated with black African race (P = 0.003 compared with colored; P < 0.001 compared with white), men who identified as bisexual/heterosexual (P = 0.01), and reported a female sexual partner in the last year (P = 0.02). Compared with previous studies, an increasing prevalence of subtype C virus was noted among white MSM. CONCLUSIONS This molecular epidemiology study provides novel evidence of sexual network links between the heterosexual and MSM epidemics and between historically racially disparate communities. These findings provide insights into the drivers of HIV epidemics in different population groups and may have implications for prevention strategies.

Objective(s): There is limited information on full-length genome sequences and the early evolution of transmitted HIV-1 subtype C viruses, which constitute the majority of viruses spread in Africa. The purpose of this study was to characterize the earliest changes across the genome of subtype C viruses following transmission, to better understand early control of viremia. Design: We derived the near full-length genome sequence responsible for clinical infection from five HIV subtype C-infected individuals with different disease progression profiles and tracked adaptation to immune responses in the first 6 months of infection. Methods: Near full-length genomes were generated by single genome amplification and direct sequencing. Sequences were analyzed for amino acid mutations associated with cytotoxic T lymphocyte (CTL) or antibody-mediated immune pressure, and for reversion. Results: Fifty-five sequence changes associated with adaptation to the new host were identified, with 38% attributed to CTL pressure, 35% to antibody pressure, 16% to reversions and the remainder were unclassified. Mutations in CTL epitopes were most frequent in thefirst 5 weeks of infection, with the frequency declining over time with the decline in viral load. CTL escape predominantly occurred in nef, followed by pol and env. Shuffling/toggling of mutations was identified in 81% of CTL epitopes, with only 7% reaching fixation within the 6-month period. Conclusion: There was rapid virus adaptation following transmission, predominantly driven by CTL pressure, with most changes occurring during high viremia. Rapid escape and complex escape pathways provide further challenges for vaccine protection. 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins AIDS 2013, 27:507‐518

[Introduction][1] Closed distraction of stiff tibial nonunions with a hexapod external fixator can predictably lead to union without the need for additional surgery or bone graft. [Indications & Contraindications][2] [Step 1: Fibular Osteotomy][3] Resect 5 to 10 mm of the fibula, from its distal half or at the level of the fibular deformity if present. [Step 2: Application of Hexapod Proximal Ring Using “Rings First” Method][4] Apply the proximal ring orthogonal to the proximal bone segment. [Step 3: Application of Hexapod Distal Ring Using “Rings First” Method][5] Apply the distal ring orthogonal to the distal bone segment. [Step 4: Connection of Struts and Application of Sterile Dressing][6] Connect the proximal and distal rings with 6 oblique struts. [Step 5: Postoperative Planning, Deformity Correction, and Distraction][7] Perform gradual deformity correction and distraction at a rate of 1 mm per day. [Step 6: Postoperative Care Until Union][8] Perform pin-site care and functional rehabilitation. [Step 7: “Trial of Union” and Frame Removal][9] Ensure adequate union prior to removal of the circular fixator. [Results][10] Hexapod closed distraction has been successfully used for the management of stiff hypertrophic tibial nonunions in our practice over the last 6 years. [Pitfalls & Challenges][11] [Introduction][1] Closed distraction of stiff tibial nonunions with a hexapod external fixator can predictably lead to union without the need for additional surgery or bone graft. [Indications & Contraindications][2] [Step 1: Fibular Osteotomy][3] Resect 5 to 10 mm of the fibula, from its distal half or at the level of the fibular deformity if present. [Step 2: Application of Hexapod Proximal Ring Using “Rings First” Method][4] Apply the proximal ring orthogonal to the proximal bone segment. [Step 3: Application of Hexapod Distal Ring Using “Rings First” Method][5] Apply the distal ring orthogonal to the distal bone segment. [Step 4: Connection of Struts and Application of Sterile Dressing][6] Connect the proximal and distal rings with 6 oblique struts. [Step 5: Postoperative Planning, Deformity Correction, and Distraction][7] Perform gradual deformity correction and distraction at a rate of 1 mm per day. [Step 6: Postoperative Care Until Union][8] Perform pin-site care and functional rehabilitation. [Step 7: “Trial of Union” and Frame Removal][9] Ensure adequate union prior to removal of the circular fixator. [Results][10] Hexapod closed distraction has been successfully used for the management of stiff hypertrophic tibial nonunions in our practice over the last 6 years. [Pitfalls & Challenges][11] [1]: #sec-13 [2]: #sec-14 [3]: #sec-17 [4]: #sec-18 [5]: #sec-19 [6]: #sec-20 [7]: #sec-21 [8]: #sec-22 [9]: #sec-23 [10]: #sec-24 [11]: #sec-25