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The evaluation of hip abductor strength is useful in assessing of the outcome of hip surgery. Hand-held dynamometers are available, but they are less reliable in assessing hip abductor strength than some other muscle groups. We describe a new device designed to measure hip abductor strength, which is practical in a clinical setting. A system of constraints, pads and reference points was devised to make force measurements as little examiner-dependent as possible. Reproducibility was assessed in a controlled setting. The abductor strength of ten healthy young subjects (average age 28 years) was tested twice on each side by two independent examiners. Tests were performed in a supine position, eliminating the influence of gravity and examiner intervention. The results indicated high reproducibility, the maximal measurement uncertainty being within 1 N. Intra-class correlation coefficients ranged from 0.85-0.98 for intra-rater reproducibility, and 0.81-0.96 for inter-rater reporoducibility. The coefficient of variation was lower than 10%. The device described may be suitable for routine clinical assessment of patients after hip surgery. [ABSTRACT FROM AUTHOR]

Background/objectives: Nail alterations are commonly seen in cases of idiopathic clubfoot and may cause parental concern. The nature of and whether these changes are congenital or develop secondary to treatment has been poorly investigated. The aim of this study was to evaluate toenail morphology in clubfoot patients at presentation, to re-evaluate them during the course of treatment for the clubfoot, and to analyze findings in the light of the few literature reports for healthy children of the same age., Methods: Thirty infants (21 males and 9 females) with idiopathic clubfoot were prospectively enrolled at the Anna Meyer Children's University Hospital. Nails of affected and non-affected feet were evaluated by a team of pediatric dermatologists at presentation and re-evaluated once per patient during the bracing period of Ponseti treatment., Results: Toenails of affected (47) and non-affected (13) feet were abnormal at presentation in 43.3% of patients, in both clubfeet (40.4%) and non-affected feet (38.5%), but most changes were physiologic or transitory alterations, commonly found in healthy children, with nail concavity (koilonychia) being the most common finding (29.7%). Changes were not related to clubfoot severity or laterality (P > .05). In most (76.9%) unilateral cases, there was concordance of nail changes between clubfoot and non-affected foot. At re-evaluation (follow-up time 410 ± 207 days), nail problems were more frequent (53.3%); ingrown toenail was the most common (21.6%)., Conclusions: The presence of nail alterations seems not to be caused by clubfoot pathology and could be related to unfavorable local condition in the brace., (© 2021 Wiley Periodicals LLC.)

BACKGROUND Femoral fractures are common in patients with Duchenne muscular dystrophy (DMD) and represent a critical moment in the natural history of the disease. The immobilization required for fracture healing frequently leads to further weakening and worsening (or definitive loss) of functional abilities. Surgical treatment has been advocated in ambulatory and nonambulatory patients with rapid mobilization of patients as the main goal; however, it exposes patients to considerable anesthetic risk. CASE REPORT We present a previously unreported experience of flexible intramedullary nailing (FIN) in 2 DMD patients (aged 11.7 and 12.8 years) who were still able to walk or stand when the supracondylar femoral fractures occurred. The surgical procedures were performed with sufficient reduction and stabilization of fractures. Rapid mobilization of the patients was achieved, including muscle strengthening exercises. A prompt recovery of the upright standing position and successive ambulation was accomplished in the patient with the higher functional status before the fracture, whereas the standing ability was not recovered in the other patient. No increase of knee flexion contractures and no growth disturbances were recorded at the follow-up. CONCLUSIONS The operative treatment option should be considered by a multidisciplinary team; they should evaluate the advantages and risks for each patient considering their functional status. For ambulatory children (or patients still able to stand), FIN can represent a valid, minimally invasive, apparently growth-sparing and sufficiently stable osteosynthesis, allowing rapid rehabilitation of the patient that can limit, but not completely avoid the consequences of the femoral fracture.

Purpose: Epidemiological studies on idiopathic clubfeet have shown a typical distribution consistent across ethnic groups: bilaterality in about 50% of cases and a male to female ratio of 2:1. Whether this corresponds also to differences in severity according to laterality and sex has been poorly evaluated. As well, the correlation between family history and severity has not been previously investigated. The aim of this study was to investigate how laterality, sex and family history influence severity and treatment., Methods: In all, 97 infants with idiopathic clubfoot (81 male, 16 female; 55 unilateral, 42 bilateral; 19 with a first or second-degree relative affected) consecutively treated with Ponseti method were prospectively enrolled. Initial severity (according to Dimeglio and Pirani scores) and treatment (number of casts and need for tenotomy) were analyzed in the different subgroups., Results: Initial severity according to Pirani (p = 0.020) and Dimeglio score (p = 0.006), number of casts (p = 0.000) and tenotomy (p = 0.045) were significantly higher in bilateral than in unilateral cases. In bilateral cases, a significant correlation was found between the right and left foot of each patient in terms of initial severity, number of casts and tenotomy performed. No statistically significant difference was found according to sex and family history., Conclusions: This study has confirmed the different behaviour of bilateral cases reported by previous studies; bilateral cases are more severe and show similar features in their right and left foot. This could be the result of different pathogenic mechanisms, likely on a genetic basis. Sex and family history did not seem to influence severity., Level of Evidence: Level of evidence II., (Copyright © 2020, The author(s).)

Introduction: Trigger finger is ten times less common than trigger thumb in infants and children and, unlike trigger thumb, may arise from a variety of underlying causes. To our knowledge, we describe the first case of pediatric trigger finger secondary to an extraskeletal chondroma., Case Presentation: We report the case of an 11-year-old girl presenting with a typical history of triggering of the fourth finger, in whom a nodule attached to the flexor digitorum superficialis was found; clinical, ultrasound, and operative findings are described. Histological analysis was diagnostic of extraskeletal chondroma, also known as chondroma of soft tissues., Conclusion: This is a very uncommon benign cartilaginous tumor, mostly reported in patients aged 30 to 60 years (just one pediatric extraskeletal chondroma of the hand has been described), and presentation with trigger finger has been reported just once, in a 76-year-old man. This condition should be considered in the differential diagnosis of pediatric trigger finger., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (Copyright © 2020 Giada Salvatori et al.)

Purpose: A mild delay in gross motor milestones and walking age has been reported in infants with clubfoot. The influence of different treatments on motor development has been poorly investigated. Some parents and physical therapists express concern that the Ponseti method (PM) and its constraints (abduction brace, casts) would affect development more than the French physical therapy method (FM) due to greater immobilization and lesser stimulation.The purpose of this study was to evaluate achievement of three motor milestones (pull-to-standing, cruising and independent walking) in two groups of clubfoot patients treated at two experienced institutes respectively with the PM and FM., Methods: In all, 52 consecutive infants (full-term at birth, mean age at beginning of treatment 24.3 days (sd 10), mean Dimeglio score 12 (sd 3.4)) were prospectively enrolled (26 patients per centre) and followed up to walking age recording milestones., Results: The two groups were not different in terms of age at the beginning of treatment (p = 0.067) and rate of tenotomy. Age at tenotomy was significantly lower in the PM group (p = 0.000). Severity (p = 0.004) and number of bilateral cases (p = 0.012) were higher in the PM group. A non-significant difference was found for age of achievement of pull-to-standing (p = 0.109), cruising (p = 0.253) and independent ambulation (p = 0.349) between the two groups. Overall, milestones were achieved approximately two months later than normal population. Sex, severity, laterality and need of tenotomy were not found to significantly influence milestones., Conclusion: Our results confirmed that infants with clubfoot are expected to have a minimum delay in motor development. Infants treated with the PM and those treated with the FM did not show significant differences in gross motor milestones achievement at walking age., Level of Evidence: Level II - Prospective comparative therapeutic studies., (Copyright © 2019, The author(s).)

Purpose: Diméglio (DimS) and Pirani (PirS) scores are the most commonly used scoring systems for evaluation of clubfoot, with many centres performing both. Interobserver reliability of their global score has been rated high in a few studies, but agreement of their subcomponents has been poorly investigated. The aim of the study was to assess interrater reliability of global scores and of items in a clinical setting and to analyse overlapping features of the two scores., Methods: Fifty-six consecutive idiopathic clubfeet undergoing correction using the Ponseti method were independently evaluated at each casting session by two trained paediatric orthopaedic surgeons using both scores. Interobserver reliability of collected data was analysed; a kappa coefficient > 0.60 was considered adequate., Results: For DimS and PirS, the Pearson correlation coefficients were 0.87 and 0.91 (p < .0001) respectively, and kappa coefficients were 0.23 and 0.31. Among subcomponents, kappa values were rated > 0.60 only for equinus and curvature of lateral border in PirS; muscular abnormality in DimS was rated 0.74 but a high prevalence index (0.94) indicated influence of scarce prevalence of this feature. All other items showed k < 0.60 and were considered to be improved.For overlapping features: posterior and medial crease showed similar agreement in the two systems, items describing equinus and midfoot adduction were much more reliable in PirS than in DimS., Conclusions: In a clinical setting, despite a high correlation of evaluations for total scores, the interobserver agreement of DimS and PirS was not adequate and only a few items were substantially reliable. Simultaneous use of two scores seemed redundant and some overlapping features showed different reliability according to criterion or scale used. Future scoring systems should improve these limitations., Level of Evidence: Level I - Diagnostic studies., (Copyright © 2019, The author(s).)

Purpose: The Dimeglio and the Pirani scores are largely used to rate clubfoot at presentation and monitor correction. To date, the accuracy of these scores in predicting appropriate treatment is controversial. The aim of this study was to investigate the accuracy of Dimeglio and Pirani scores in predicting the number of casts and the need for tenotomy in clubfoot correction using the Ponseti method., Methods: Ninety-one consecutive feet (54 patients; mean age at presentation: 28 ± 15 days) undergoing clubfoot correction using the Ponseti method were prospectively followed from first casting to correction. All feet were scored according to the Dimeglio and Pirani score. The relationships between the two scores, the number of casts and the need for tenotomy were analysed., Results: Initial correction was achieved in all feet. Both Dimeglio (r = .73; p value < .0005) and Pirani scores (r = .56; p value < .000) showed good association with the number of casts. Multiple linear regression showed a high collinearity of the two scores but a more significant contribution of the Dimeglio score. Among subcomponents, hindfoot score, midfoot score, varus and muscular abnormality were independent predictors of the number of casts. Both Dimeglio and Pirani scores were significantly associated with the need for tenotomy (p value = .0000), and odds ratios and cut-off points were calculated. The receiving operator curve (ROC) analysis showed slightly better performance of the Dimeglio in comparison with the Pirani score in predicting the need for tenotomy, but the difference between the two areas under the curve (AUC) was not significant (p = .48)., Conclusions: A quite accurate prediction of the number of casts and the need for tenotomy can be performed in most cases. The Dimeglio score showed slightly better accuracy in predicting both steps of Ponseti treatment.

Purpose: The modality of progression of the correction along casting sessions of Ponseti method has been poorly investigated and information regarding evolution of muscular abnormalities is missing. The aim of the study was to investigate dynamics of correction of the different components of clubfoot deformity in a clinical setting., Methods: In a prospective study, 124 clubfeet consecutively treated by a single orthopaedic surgeon were evaluated with the Dimeglio system at each casting session and score progression was determined., Results: For each component a typical pattern was recorded. Cavus and medial crease showed a rapid correction. Rotation, adduction and varus corrected gradually and simultaneously. The posterior crease usually persisted until final cast was discontinued. Equinus improved progressively after each cast and then to a larger extent with Achilles tenotomy. The parameter describing poor muscular condition, reported at presentation in 39 feet (31.5%), was the only item showing extremely different dynamics of correction (from rapid and complete resolution to persistence at last cast removal), which could be explained by the large diversity of entities included (hypertonia, imbalance, fatty infiltration, fibrosis, aplasia)., Conclusions: This study confirmed that dynamics of correction in clinical setting correspond essentially to theoretical principles of Ponseti method. Muscle abnormalities are not uncommon in clubfeet and have great influence on the progression of correction. If abnormalities are recorded, their evolution along the treatment should be monitored. A more objective evaluation would be required.

Background: Modular megaprostheses are now the most common method of reconstruction after segmental resection of the long bones in the lower extremities. Previous studies reported variable outcome and failure rates after knee megaprosthetic reconstructions., Questions/purposes: The objectives of this study were to analyze the results of a modular tumor prosthesis after resection of bone tumor around the knee with respect to (1) survivorship; (2) failure rate; (3) comparative survivorship against different sites of reconstructions and of primary and revision implants; and (4) functional results on the Musculoskeletal Tumor Society (MSTS) scoring system., Methods: Between 2003 and 2010, 247 rotating-hinge Global Modular Reconstruction System (GMRS) knee prostheses were implanted in our institute for malignant and aggressive benign tumors. During this time, that group represented 23% of the patients who had oncologic megaprosthesis reconstruction about the knee after resection of primary or metastatic bone tumors (247 of 1086 patients). In the other 77% of cases we used other types of oncologic prostheses. Before 2003 we used the older Howmedica Modular Resection System and Kotz Modular Femur/Tibia Replacement from 2003 we used mostly the GMRS but we continued to use the HMRS in some cases such as patients with poor prognoses, elderly patients, or metastatic patients. Sites included 187 distal femurs and 60 proximal tibias. Causes of megaprosthesis failure were classified according to Henderson et al. in five types: Type 1 (soft tissue failure), Type 2 (aseptic loosening), Type 3 (structural failure), Type 4 (infection), and Type 5 (tumor progression). Followup was at a minimum oncologic followup of 2 years (mean, 4 years; range, 2-8 years). Kaplan-Meier actuarial curves of implant survival to major failures were done. Functional results were analyzed according to the MSTS II system; 223 of the 247 were available for functional scoring (81%)., Results: At latest followup, among 175 treated patients for primary reconstruction, 117 are continuously disease-free, 26 have no evidence of disease after treatment of relapse, eight are alive with disease, and 24 died from disease. The overall failure rate of the megaprostheses in our series was 29.1% (72 of 247). Type 1 failure occurred in 8.5% (21 of 247) cases, Type 2 in 5.6% (14 of 247), Type 3 in 0%, Type 4 in 9.3% (23 of 247), and Type 5 in 5.6% (14 of 247). Kaplan-Meier curve showed an overall implant survival rate for all types of failures of 70% at 4 years and 58% at 8 years. Prosthetic survivorship for revisions was 80% at 5 years and for primary reconstructions was 60% at 5 years (p = 0.013). Survivorship to infection was 95% at 5 years for revision patients and 84% at 5 years for primary patients (p = 0.475). The mean MSTS score was 84 (25.2; range, 8-30) with no difference between sites of localization (24.7 in proximal tibia versus 25.4 in distal femur reconstruction; p = 0.306)., Conclusions: Results at a minimum of 2 years with this modular prosthesis are satisfactory in terms of survivorship (both oncologic and reconstructive) and causes and rates of failure. Although these results seem comparable with other like implants, we will continue to follow this cohort, and we believe that comparative trials among the available megaprosthesis designs are called for., Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Background and Objectives: Retrospectively analyze outcomes of current-generation Global Modular Replacement System (GMRS) modular tumor endoprosthesis for the lower limb in primary and secondary implantation procedures., Methods: Two hundred ninety five prostheses were implanted, 197 were primary implants, 98 were for revision surgery; revision procedures included 84 failed tumor reconstructions and 14 failed non-tumor reconstructions. Anatomic sites included: distal femur 199; proximal tibia 60; proximal femur 32;total femur 4. Endoprosthesis failures were classified as soft-tissue failures (Type 1), aseptic loosening (Type 2), structural fracture (Type 3), infection (Type 4), and tumor recurrence (Type 5). MSTS functional scores were measured., Results: The overall failure rate was 28.8% and failure occurred at a median of 1.7 years (range, 1 month to 7 years). At a mean oncologic follow up of 4.2 years (range, 2-8 years), 195 patients are continuously NED, 43 NED after treatment of relapse, 10 AWD, 33 DWD. There was a significant difference in implant survival of all modes of failure between primary and revision implants (P = 0.03). No prosthetic fracture occurred. The average functional score was 81.6% (24.5)., Conclusions: Mid-term results with GMRS are promising, with good functional results and low incidence of complications for primary implants., Level of Evidence: Therapeutic study, level IV-1 (case series)., (© 2013 Wiley Periodicals, Inc.)

Background: Total hip replacement has been advocated for the treatment of degenerative hip diseases secondary to slipped capital femoral epiphysis; nonetheless, outcomes of this procedure have not been well established. We reviewed the outcomes of modern total hip replacements in patients who suffered from slipped capital femoral epiphysis., Methods: A retrospective study was carried out on 32 total hip replacements performed on 28 patients who suffered from slipped capital femoral epiphysis from August 1994 to January 2007. The average age at the time of surgery was 45 years. Clinical evaluation was performed using the Harris Hip Score, radiographic assessment measuring cup and stem orientation, the extent of osteolysis around the implant, and leg length discrepancy. The average follow-up was 98 months (range 25-204 months)., Results: Two total hip replacements failed, one for stem aseptic loosening and the other for modular neck failure. The cumulative survival rate at 9 years was 92.8 %. If the end point was revision for implant loosening, the survival rate improved to 96.8 % at 9 years. The only complication recorded was an intraoperative fracture of the lesser trochanter immediately treated with cerclage wire. At the latest follow-up, the Harris Hip Score averaged 86 (range 70-97). Leg length discrepancies greater than 1 cm were present in 18 cases before surgery, and in only 6 cases after surgery., Discussion: We recommend total hip replacement for patients who suffer from slipped capital femoral epiphysis because of the satisfactory survival, low complication rate, and the possibility of restoring leg length.

Neuropathic arthropathy (Charcot's joint) is a degenerative process that affects peripheral or vertebral joints as a consequence of a disturbance in proprioception and pain perception. The knee is one of the most frequently affected joints, but even when the diagnosis is made at an early stage there is no consensus on the best treatment options. An early diagnosis of neurosyphilis was made in a 55-year-old woman presenting a delayed union of an asymptomatic Schatzker type IV fracture of the proximal tibia. A medial opening wedge tibial osteotomy was performed to achieve fracture healing, to correct the medial depression of the articular surface, and possibly to avoid an early arthritis typical of the disease. To our knowledge, a knee osteotomy has never been reported at an early stage of neuropathic arthropathy. Even though the clinical and radiographic evaluation performed at 4 months follow-up showed a good stage of healing of the osteotomy and no typical features of neuropathic joint degeneration, at 8 months follow-up the knee was markedly deranged.

Introduction: Biopsy of the musculoskeletal system is useful in the management of bone lesions particularly in oncology but they are often challenging procedures with a significant risk of complications. Computed tomography (CT)-guided needle biopsies may decrease these risks but doubts still exist about their diagnostic accuracy. This retrospective analysis of the experience of a single institution with percutaneous CT-guided biopsy of musculoskeletal lesions evaluates the results of these biopsies for bone lesions either in the appendicular skeleton or in the spine, and defines indications., Materials and Methods: We reviewed the results of 2027 core needle biopsies performed over the past 18 years at the authors' institution. The results obtained are subject of this paper., Results: In 1567 cases the correct diagnosis was made with the first CT-guided needle biopsy (77.3% accuracy rate), in 408 cases the sample was not diagnostic and in 52 inadequate. Within 30 days these 408 patients underwent another biopsy, which was diagnostic in 340 cases with a final diagnostic accuracy of 94%. Highest accuracy rates were obtained in primary and secondary malignant lesions. Most false negative results were found in cervical lesions and in benign, pseudotumoral, flogistic, and systemic pathologies. There were 22 complications (18 transient paresis, 3 haematomas, 1 retroperitoneal haematoma) which had no influence on the treatment strategy, nor on patient outcome., Conclusion: This technique is reliable and safe and should be considered nowadays the gold standard for biopsies of the musculoskeletal system., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)