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We investigated the potential of exogenous hyaluronic acid (HA) associated with corticosteroid injections to improve pain and function for the treatment of post-traumatic subtalar osteoarthritis, in comparison with isolated intra-articular corticosteroid. Twenty-five symptomatic participants (50 ± 8 years) with a minimum follow-up of 1 year after surgery for calcaneus fractures were enrolled. Participants were randomly assigned into a therapeutic group that underwent isolated corticosteroid intra-articular subtalar injection (Corticosteroid Group, n = 12) or a combination of HA plus corticosteroid (HA+C Group, n = 13). All participants underwent three repeated injections with intervals of 1 week. We assessed the visual analog scale of pain (VAS) and the AOFAS scores at 4 moments: before treatment (pre), 4-, 12-, and 24-weeks following the last injection. HA+C Group showed lower VAS at the 12th (p = .003) and 24th weeks (p = .003) and greater AOFAS at the 4th (p = 0.040), 12th (p = .014), and 24th weeks (p = .021), in comparison to Corticosteroid Group. We observed a reduction in VAS in the Corticosteroid Group only at the 4th week (p = .007), compared with pretreatment values. In the HA+C Group, VAS presented lower levels at the 4- (p.001), 12- (p.001), and 24 weeks (p.001). In the Corticosteroid Group, participants presented higher AOFAS score only at the 4th week (p.001), while in the HA+C Group, the AOFAS scores were greater at the 4th, 12th, and 24th weeks compared to baseline (p.001). The combination of exogenous HA and corticosteroid showed greater and longer analgesic effects and function improvement in comparison with isolated intra-articular corticosteroids.

Objective: To perform a systematic review and meta-analysis to compare clinical and surgical outcomes of posterior versus anterior approach to primary total hip arthroplasty (THA). Methods: This study followed the standard methodology established by the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two independent reviewers searched for randomized controlled trials comparing posterior an anterior approach to primary THA with at least one quantifiable functional outcome published in the PubMed, Cochrane, and Virtual Health Library databases. Results: The analysis included ten randomized controlled trials conducted with 774 patients. The posterior approach was associated with shorter operative time (mean of 15.98 minutes shorter, 95% CI 11.21 to 20.76, p < 0.00001) while the anterior approach was associated with shorter length of hospital stay (0.31 days or about eight hours shorter, 95% CI 0.12 to 0.51, p = 0.002) and greater earlier improvement in functional outcomes up to six months from the procedure (mean Harris Hip Score of 4.06 points greater, 95% CI 2.23 to 5.88, p < 0.0001). Conclusion: Whereas the posterior approach to primary THA is associated with a shorter operative time, the anterior approach has the potential to decrease the length of stay and provide greater short-term functional restoration. Level of evidence I, Systematic Review and Meta-Analysis. RESUMO Objetivo: Realizar uma revisão sistemática e metanálise para comparar os resultados clínicos e cirúrgicos entre a via posterior e via anterior para ATQ. Métodos: Este estudo seguiu as diretrizes Cochrane e PRISMA (Principais Itens para Relatar Revisões Sistemáticas e Meta-Análises). Dois investigadores independentes procuraram estudos randomizados controlados nas plataformas de busca PubMed, Cochrane e Biblioteca Virtual em Saúde. Estudos comparando a via posterior com a via anterior para ATQ primária com pelo menos um escore funcional de resultado clínico foram incluídos. Resultados: Dez estudos com 774 pacientes foram incluídos. A via posterior foi associada a um tempo operatório menor (média de 15.98 minutos menor, IC 95% 11.21 a 20.76, p < 0.00001), enquanto a via anterior foi associada a um tempo de internação hospitalar menor (0.31 dia ou cerca de oito horas a menos, IC 95% 0.12 a 0.51, p = 0.002) e melhora superior dos resultados funcionais em até seis meses após a cirurgia (Harris Hip Score médio de 4.06 pontos maior, IC 95% 2.23 a 5.88, p < 0.0001). Conclusão: A via posterior foi associada a um tempo operatório menor, enquanto a via anterior tem o potencial de diminuir o tempo de hospitalização e fornecer melhor recuperação funcional no curto prazo. Nível de Evidência I, Revisão Sistemática e Metanálise.

BACKGROUND The epiphyseal tubercle, the corresponding metaphyseal fossa, and peripheral cupping are key stabilizers of the femoral head-neck junction. Abnormal development of these features in the setting of supraphysiologic physeal stress under high forces (for example, forces that occur during sports activity) may result in a cam morphology. Although most previous studies on cam-type femoroacetabular impingement (FAI) have mainly focused on overgrowth of the peripheral cupping, little is known about detailed morphologic changes of the epiphyseal and metaphyseal bony surfaces in patients with cam morphology. QUESTIONS/PURPOSES (1) Does the CT-based bony morphology of the peripheral epiphyseal cupping differ between patients with a cam-type morphology and asymptomatic controls (individuals who did not have hip pain)? (2) Does the CT-based bony morphology of the epiphyseal tubercle differ between patients with a cam-type morphology and asymptomatic controls? (3) Does the CT-based bony morphology of the metaphyseal fossa differ between patients with a cam-type morphology and asymptomatic controls? METHODS After obtaining institutional review board approval for this study, we retrospectively searched our institutional database for patients aged 8 to 15 years with a diagnosis of an idiopathic cam morphology who underwent a preoperative CT evaluation of the affected hip between 2005 and 2018 (n = 152). We excluded 96 patients with unavailable CT scans and 40 patients with prior joint diseases other than cam-type FAI. Our search resulted in 16 patients, including nine males. Six of 16 patients had a diagnosis of bilateral FAI, for whom we randomly selected one side for the analysis. Three-dimensional (3-D) models of the proximal femur were generated to quantify the size of the peripheral cupping (peripheral growth of the epiphysis around the metaphysis), epiphyseal tubercle (a beak-like prominence in the posterosuperior aspect of the epiphysis), and metaphyseal fossa (a groove on the metaphyseal surface corresponding to the epiphyseal tubercle). A general linear model was used to compare the quantified anatomic features between the FAI cohort and 80 asymptomatic hips (aged 8 to 15 years; 50% male) after adjusting for age and sex. A secondary analysis using the Wilcoxon matched-pairs signed rank test was performed to assess side-to-side differences in quantified morphological features in 10 patients with unilateral FAI. RESULTS After adjusting for age and sex, we found that patients with FAI had larger peripheral cupping in the anterior, posterior, superior, and inferior regions than control patients who did not have hip symptoms or radiographic signs of FAI (by 1.3- to 1.7-fold; p < 0.01 for all comparisons). The epiphyseal tubercle height and length were smaller in patients with FAI than in controls (by 0.3- to 0.6-fold; p < 0.02 for all comparisons). There was no difference in tubercle width between the groups. Metaphyseal fossa depth, width, and length were larger in patients with FAI than in controls (by 1.8- to 2.3-fold; p < 0.001 for all comparisons). For patients with unilateral FAI, we saw similar peripheral cupping but smaller epiphyseal tubercle (height and length) along with larger metaphyseal fossa (depth) in the FAI side compared with the uninvolved contralateral side. CONCLUSION Consistent with prior studies, we observed more peripheral cupping in patients with cam-type FAI than control patients without hip symptoms or radiographic signs of FAI. Interestingly, the epiphyseal tubercle height and length were smaller and the metaphyseal fossa was larger in hips with cam-type FAI, suggesting varying inner bone surface morphology of the growth plate. The docking mechanism between the epiphyseal tubercle and the metaphyseal fossa is important for epiphyseal stability, particularly at early ages when the peripheral cupping is not fully developed. An underdeveloped tubercle and a large fossa could be associated with a reduction in stability, while excessive peripheral cupping growth would be a factor related to improved physeal stability. This is further supported by observed side-to-side differences in tubercle and fossa morphology in patients with unilateral FAI. Further longitudinal studies would be worthwhile to study the causality and compensatory mechanisms related to epiphyseal and metaphyseal bony morphology in pathogenesis cam-type FAI. Such information will lay the foundation for developing imaging biomarkers to predict the risk of FAI or to monitor its progress, which are critical in clinical care planning. LEVEL OF EVIDENCE Level III, prognostic study.

BACKGROUND: Contemporary studies have described the rotational mechanism in patients with slipped capital femoral epiphysis (SCFE). However, there have been limited patient imaging data and information to quantify the rotation. Determining whether the epiphysis is rotated or translated and measuring the epiphyseal displacement in all planes may facilitate planning for surgical reorientation of the epiphysis. QUESTIONS/PURPOSES: (1) How does epiphyseal rotation and translation differ among mild, moderate, and severe SCFE? (2) Is there a correlation between epiphyseal rotation and posterior or inferior translation in hips with SCFE? (3) Does epiphyseal rotation correlate with the size of the epiphyseal tubercle or the metaphyseal fossa or with epiphyseal cupping? METHODS: We identified 51 patients (55% boys [28 of 51]; mean age 13 ± 2 years) with stable SCFE who underwent preoperative CT of the pelvis before definitive treatment. Stable SCFE was selected because unstable SCFE would not allow for accurate assessment of rotation given the complete displacement of the femoral head in relation to the neck. The epiphysis and metaphysis were segmented and reconstructed in three-dimensions (3-D) for analysis in this retrospective study. One observer (a second-year orthopaedic resident) performed the image segmentation and measurements of epiphyseal rotation and translation relative to the metaphysis, epiphyseal tubercle, metaphyseal fossa, and the epiphysis extension onto the metaphysis defined as epiphyseal cupping. To assess the reliability of the measurements, a randomly selected subset of 15 hips was remeasured by the primary examiner and by the two experienced examiners independently. We used ANOVA to calculate the intraclass and interclass correlation coefficients (ICCs) for intraobserver and interobserver reliability of rotational and translational measurements. The ICC values for rotation were 0.91 (intraobserver) and 0.87 (interobserver) and the ICC values for translation were 0.92 (intraobserver) and 0.87 (intraobserver). After adjusting for age and sex, we compared the degree of rotation and translation among mild, moderate, and severe SCFE. Pearson correlation analysis was used to assess the associations between rotation and translation and between rotation and tubercle, fossa, and cupping measurements. RESULTS: Hips with severe SCFE had greater epiphyseal rotation than hips with mild SCFE (adjusted mean difference 21° [95% CI 11° to 31°]; p < 0.001) and hips with moderate SCFE (adjusted mean difference 13° [95% CI 3° to 23°]; p = 0.007). Epiphyseal rotation was positively correlated with posterior translation (r = 0.33 [95% CI 0.06 to 0.55]; p = 0.02) but not with inferior translation (r = 0.16 [95% CI -0.12 to 0.41]; p = 0.27). There was a positive correlation between rotation and metaphyseal fossa depth (r = 0.35 [95% CI 0.08 to 0.57]; p = 0.01), width (r = 0.41 [95% CI 0.15 to 0.61]; p = 0.003), and length (r = 0.56 [95% CI 0.38 to 0.75]; p < 0.001). CONCLUSION: This study supports a rotational mechanism for the pathogenesis of SCFE. Increased rotation is associated with more severe slips, posterior epiphyseal translation, and enlargement of the metaphyseal fossa. The rotational nature of the deformity, with the center of rotation at the epiphyseal tubercle, should be considered when planning in situ fixation and realignment surgery. Avoiding placing a screw through the epiphyseal tubercle—the pivot point of rotation— may increase the stability of the epiphysis. The realignment of the epiphysis through rotation rather than simple translation is recommended during the open subcapital realignment procedure. Enlargement of the metaphyseal fossa disrupts the interlocking mechanism with the tubercle and increases epiphyseal instability. Even in the setting of a stable SCFE, an increased fossa enlargement may indicate using two screws instead of one screw, given the severity of epiphyseal rotation and the risk of instability. Further biomechanical studies should investigate the number and position of in situ fixation screws in relation to the epiphyseal tubercle and metaphyseal fossa. LEVEL OF EVIDENCE: Level III, prognostic study.

Acrodysostosis is a rare syndrome of peripheral dysostosis, neurodevelopment delay, and skeletal abnormalities. The most common bone changes are peripheral dysostosis with severe brachydactyly of the lesser toes. The first ray of the feet is often not affected or may present hyperplasia resulting in an unbalanced transverse arch of the forefoot, with potential negative effects on function. Additionally, the insufficiency of the lesser toes may be associated with complex congenital hallux valgus deformities. Surgical approaches include growth plate epiphysiodesis, bulk reduction procedures, bone shortening, osteotomies, or amputation. Here, we report a case of a 14-year-old girl with acrodysostosis and severe discrepancy of the first ray and hallux valgus deformity simultaneously treated by a modified scarf osteotomy. Levels of Evidence Level V: Case report

Objective: The objective of this study was to evaluate current percutaneous foot surgery practice among Brazilian specialists. Methods: A cross-sectional observational study was conducted, surveying members of the Brazilian Foot and Ankle Society (ABTPé) by emailing electronic questionnaires in 2017 and 2019. The information requested included demographic data and the profile of their practice with relation to percutaneous foot surgery. A total of 74 participants completed the survey questionnaire in 2017 and 82 in 2019 (response rates of 15 and 14% respectively). Results: A total of 49 participants in 2017 (65.33%) and 57 in 2019 (69.51%) were performing percutaneous foot surgery. Among respondents who were not performing percutaneous foot surgery, 15 in 2017 (57.69%) and 10 in 2019 (40%) stated that they believed in the method, but had not been trained to perform it. Exclusively spinal anesthesia was used by 19 surgeons in 2017 (38.77%) and 23 in 2019 (40.35%). When correcting Hallux Valgus, 13 surgeons in 2017 (26.53%) and 3 in 2019 (5%) did not use any type of fixation. The most frequently reported complication was poor reduction in both periods, reported by 36 (73.46%) participants in 2017 and 39 (68.42%) in 2019. Conclusion: In Brazil, a lack of specific training is one factor that limits the practice of percutaneous foot surgery. The technique is used by a greater number of younger surgeons. The most frequent complication is poor reduction and there is a growing trend to employee fixation hardware. Level of Evidence V; Expert Opinion.

Purpose To investigate whether body mass index (BMI) percentile impacts the morphology of the capital femoral epiphysis in children and adolescents without hip disorders. Methods We assessed 68 subjects with healthy hips who underwent a pelvic CT for evaluation of appendicitis. There were 32 male patients (47%) and the mean age was 11.6 years (sd 2.3). The BMI (k/m2) was calculated for sex- and age-related percentiles according to the Centers for Disease Control and Prevention growth charts. CT images were segmented, and the epiphysis and metaphysis were reformatted using 3D software. We measured the epiphyseal tubercle (height, width and length), the metaphyseal fossa (depth, width and length) and the peripheral cupping of the epiphysis. All measurements were normalized to the diameter of the epiphysis. Pearson's correlation analysis was used to assess the correlations between the variables measured and BMI percentile adjusted for age. Results Following adjustment to age, increased BMI correlated to decreased tubercle height (r =-0.34; 95% confidence interval (CI) -0.53 to -0.11; p = 0.005), decreased tubercle length (r = -0.32; 95%CI -0.52 to -0.09; p = 0.008) and decreased tubercle width (r = -0.3; 95% CI -0.5 to -0.07; p = 0.01). There was no correlation between BMI and metaphyseal fossa and epiphyseal cupping measurements. Conclusion The association between increased BMI percentile and decreased epiphyseal tubercle size, without changes of the metaphyseal fossa and peripheral cupping suggests another morphological change of the femur that may be associated with decreased growth plate resistance to shear stress. Further study is necessary to investigate whether the epiphyseal tubercle size plays a role in the pathogenesis of slipped capital femoral epiphysis in obese children and adolescents. Level of Evidence Level IV

The epiphyseal tubercle plays an important role in epiphyseal stabilization. While the majority of studies have focused on tubercle morphology, there is a paucity of information on the morphological features of the metaphyseal fossa, where the tubercle sits on the metaphysis. The goal of this study was to determine the developmental changes in the capital femoral metaphyseal fossa. Computed tomography of the pelvis from 80 children and adolescents 8-15 years old were used to create three-dimensional models of the proximal femur. Depth, width, length, and surface area of the metaphyseal fossa were measured and the impact of age and sex on fossa morphology was assessed using the linear regression and two-way analysis of variance, respectively. The metaphyseal fossa was located in the posterosuperior quadrant of the metaphysis without any variations in the location with increasing age (P .1). However, with increasing age, there was a reduction in all metaphyseal fossa measurements including the depth, length, width, and surface area (P .01). No significant differences were noted for the metaphyseal fossa measurements between males and females (P .1). The metaphyseal fossa reduces in size from 8 to 15 years of age in a similar fashion in males and females. As the metaphyseal fossa adjacent to the tubercle matches the area where a focal radiolucency has been observed in early slipped capital femoral epiphysis (SCFE), further studies should clarify the mechanisms by which the interlocking interaction of the epiphyseal tubercle and its fossa contributes to or is affected by SCFE.

To evaluate the acetabular morphology in healed Legg–Calvé–Perthes disease after skeletal maturity using computed tomography (CT) scan and to compare with matched controls. We identified 33 (37 hips) patients with healed Legg–Calvé–Perthes disease and closed triradiate cartilage who underwent pelvic CT scan. Each patient was matched based on sex, age and side to a subject with no history of hip disease who had undergone pelvic CT evaluation because of abdominal pain. Both cohorts had 23 (70%) males and mean age of 16.4–16.5 ± 3.6 years. Two independent readers assessed lateral center-edge angle (LCEA), acetabular inclination angle (IA), acetabular depth-width ratio (ADR), acetabular version 10 mm below the dome (cranial) and at the acetabular center and anterior (AASA) and posterior acetabular sector angles (PASA). All measurements had good to excellent interobserver agreement (intraclass coefficients ≥ 0.87). The hips in the Legg–Calvé–Perthes disease cohort had a smaller mean ± standard deviation (SD) superior, anterior and posterior acetabular coverage as assessed by LCEA (13.2° ± 10.7° versus 28.2° ± 3.4°; P

Purpose To compare the 3D morphology of the metaphyseal fossa among mild, moderate and severe stable slipped capital femoral epiphysis (SCFE) and normal hips. Methods We identified pelvic CT of 51 patients (55% male; mean 12.7 years (sd 1.9; 8-15)) with stable SCFE. In all, 16 of 51 hips (31%) had mild, 14 (27%) moderate and 21 (41%) severe SCFE. A total of 80 patients (50% male; mean age 11.5 years (sd 2.3; 8 to 15)) with normal hips who underwent pelvic CT due to abdominal pain made up the control cohort. CT scans were segmented, and the femur was reformatted using 3D software. We measured the metaphyseal fossa depth, width, length and surface area after the epiphysis was subtracted from the metaphysis in the 3D model. Results The metaphyseal fossa width was significantly larger in severe (adjusted difference: 6.9%; 95% confidence interval (CI) 2.1 to 11.8; p = 0.001), moderate (6.5%; 95% CI 0.8 to 12.2; p = 0.02) and mild SCFE (6.2%; 95% CI 0.8 to 11.6; p = 0.01), in comparison with normal hips. Severe SCFE showed larger fossa length compared with mild SCFE (6.8%; 95% CI 0.6 to 13.0; p = 0.02) and normal hips (6.0%; 95% CI 1.4 to 10.6; p = 0.004). The fossa surface area was larger in severe (3.5%; 95% CI 1.3 to 5.7; p < 0.001) and moderate SCFE (2.7%; 95% CI 0.1 to 5.2; p = 0.03) when compared with normal hips. There were no differences in fossa depth between SCFE and normal hips. Conclusion The metaphyseal fossa is wider and more extensive but not deeper in hips with moderate and severe SCFE in comparison with normal hips. Although hips with severe SCFE had larger length and surface area than mild SCFE hips, further research is needed to clarify whether enlargement of the metaphyseal fossa is a consequence of slip progression. Level of Evidence III

To quantify pelvic retroversion during clinical evaluation of hip flexion with accelerometers and to verify the reliability of these sensors to measure hip flexion.An accelerometer was positioned laterally in the pelvis to measure pelvic retroversion. Another accelerometer was positioned anteriorly on the thigh to evaluate hip flexion amplitude. The evaluations were performed with volunteers in supine position by three raters. For evaluation of pelvic retroversion, the mean ± SD (minimum-maximum) was calculated. Reliability of the accelerometer between raters was determined by intraclass correlation coefficients (ICC). The linear correlation coefficient between hip flexion was determined by using goniometer and accelerometer.The mean pelvic retroversion was 7.3° ± 0.93° (6°-11°) in the clinical limit of the hip range of motion, which was 106.25° ± 10.46° (93°-130°). The ICC between two raters were 0.60, 0.71 and 0.74 (goniometer) and 0.46, 0.71 and 0.83 (accelerometer). The linear correlation between hip flexion measurements with goniometer and accelerometer was 0.87.During clinical evaluation of the final range of hip flexion, there was an associated pelvic movement of approximately 7.3º. Accelerometers have proven to be reliable for measurement of hip flexion.Quantificar a retroversão pélvica durante avaliação clínica da flexão do quadril com acelerômetros e verificar a confiabilidade destes sensores para mensurar flexão do quadril.Posicionou-se um acelerômetro lateralmente na pelve para mensurar retroversão pélvica. Outro foi posicionado anteriormente sobre a coxa para avaliar flexão do quadril. As avaliações foram realizadas com voluntários, em decúbito dorsal, por três avaliadores. Para avaliação da retroversão pélvica, determinou-se a média ± DP (mínimo-máximo). Avaliou-se a confiabilidade dos acelerômetros entre avaliadores pelo coeficiente de correlação intraclasse (CCI). Determinou-se o coeficiente de correlação linear entre as mensurações de flexão do quadril com goniômetro e acelerômetro.A retroversão pélvica média foi de 7,3° ± 0,93° (6°-11°), mensurada no limite clínico da flexão do quadril, que foi de 106,25° ± 10,46° (93°-130°), ambos com acelerômetro. Os CCI entre dois avaliadores diferentes nas avaliações de flexão do quadril foram de 0,60, 0,71 e 0,74 (goniômetro) e 0,46, 0,71 e 0,83 (acelerômetro). A correlação linear entre as mensurações de flexão do quadril com goniômetro e acelerômetro foi de 0,87.Durante avaliação clínica da amplitude final de flexão do quadril, houve movimentação associada da pelve aproximadamente de 7,3°. Acelerômetros mostraram-se confiáveis para mensuração da flexão do quadril. Nível de evidência III, Estudo de pacientes não consecutivos sem padrão de referência “ouro” aplicado uniformemente.

Calcifying aponeurotic fibroma (CAF) is a rare lesion that can affect the feet and should be considered as a differential diagnosis of plantar tumors. The treatment is given by surgical resection, and the definitive diagnosis is confirmed by histopathological analysis. This case report shows the presentation and treatment of a 17-year-old patient with CAF and emphasizes the importance of proper imaging planning to reduce risks and recurrence. Level of Evidence V; Therapeutic Studies; Expert Opinion.

Resumo Objetivo Avaliar a artéria de Adamkiewicz por angiotomografia computadorizada por multidetectores (ATCM) em uma população brasileira. Métodos Dois observadores independentes avaliaram 86 exames de ACTM. As variáveis estudadas incluíram a identificação da artéria de Adamkiewicz no nível de origem e o lado de entrada da artéria na coluna vertebral. Resultados A artéria de Adamkiewicz foi identificada em 71 (82,5%) exames. O nível de origem foi identificado entre a 9a e a 11a vértebras torácicas (T9 e T11) em 56 (79,2%) pacientes. Em 65 (91,5%) pacientes, a artéria foi identificada no lado esquerdo. A identificação da artéria de Adamkiewicz usando ACTM mostrou elevada reprodutibilidade. Conclusões Obtivemos resultados consistentes com os da literatura prévia quanto à identificação da artéria de Adamkiewicz utilizando angiotomografia computadorizada por multidetectores. Nossos resultados sugerem que a ATCM pode ser considerada como uma opção para identificar a artéria de Adamkiewicz. Além disso, encontramos uma distribuição da artéria de Adamkiewicz na população brasileira semelhante à de outras populações, com a artéria de Adamkiewicz originando-se mais comumente no lado esquerdo, entre a 8a e a 12a vértebras torácicas (T8–T12).

ResumoA luxação do cotovelo é relativamente incomum em crianças, sendo que a maioria dos casos ocorre com fraturas associadas. A luxação isolada do cotovelo é relativamente rara, podendo implicar em uma maior probabilidade de lesões graves dos tecidos moles. Uma possível complicação é o desenvolvimento da ossificação heterotópica, que geralmente é assintomática, mas pode alterar o movimento articular. Descrevemos o caso de uma menina de 11 anos que sofreu luxação do cotovelo sem fraturas associadas, mas com ruptura parcial distal do músculo braquial. Após a redução fechada, a paciente desenvolveu ossificação heterotópica no terço distal anterior do úmero, com perda da amplitude do movimento articular do cotovelo. O tratamento cirúrgico, com excisão da ossificação heterotópica, por meio de uma abordagem lateral direta, proporcionou um excelente resultado. A ossificação heterotópica é uma possível complicação após luxação do cotovelo em crianças, sendo que a excisão cirúrgica mediante uma abordagem lateral é sempre uma opção de tratamento quando há limitação funcional. Antes de ser tomada a decisão cirúrgica, a maturação do processo de ossificação deve ser observada.

Objective: To compare the clinical outcomes between patients with moderate and severe slipped capital femoral epiphysis (SCFE) treated with osteotomy at the base of neck and osteoplasty and with healthy individuals. Methods: Comparative cohort with 12 patients (14 hips) with moderate and severe SCFE who underwent osteotomy at the base of neck and osteoplasty between 2007 and 2014. The mean age at surgery was 13.3 ± 2.5 years and the mean follow-up was 3.8 ± 2.2 years. We assessed the level of hip pain by the visual analog scale (VAS) and anterior impingement test (AIT); the level of function using the Harris Hip Score (HHS) and 12-Item Short Form Health Survey (SF-12), the range of motion (ROM) by goniometry and Drehmann sign, and the hip muscular strength by isokinetic and Trendelenburg sign. Results: The level of pain was slightly higher in the SCFE cohort compared with healthy hips (VAS, 0.8 ± 1.4 vs 0 ± 0, 0.007; AIT, 14% vs 0%, p = 0.06; respectively). No differences were observed between the SCFE and control cohort for the functional scores (HHS, 94 ± 7 vs 100 ± 1, p = 0.135); except for ROM, with increased internal rotation (37.3º ± 9.4º vs 28.7º ± 8.2º, p < 0.001), and strength, with decreased abduction torque (75.5 ± 36.9 Nm/Kg vs 88.5 ± 27.6 Nm/Kg, p = 0.045) in the SCFE cohort. Conclusion: The osteotomy at the base of neck and the osteoplasty restored the hip motion and muscle strength, except for the abductor strength, to near normal levels, representing a viable option for the treatment of moderate and severe SCFE. Level of Evidence III, Ambidirectional Cohort Study. RESUMO Objetivo: Comparar resultados clínicos de pacientes com escorregamento epifisário proximal do fêmur (EEPF) moderado e grave tratados com osteotomia basocervical e cervicoplastia com indivíduos saudáveis. Métodos: Coorte comparativa com 12 voluntários saudáveis e 12 pacientes (14 quadris) com EEPF moderado e grave submetidos à osteotomia basocervical e cervicoplastia entre 2007 e 2014. A média de idade na cirurgia foi de 13,3 ± 2,5 anos e o seguimento médio de 3,8 ± 2,2 anos. Avaliou-se nível de dor no quadril utilizando a escala visual analógica (EVA) e o teste de impacto anterior (TIA); nível de função usando o Harris Hip Score (HHS) e o 12-Item Short Form Health Survey (SF-12); amplitude de movimento (ADM) com goniometria e sinal de Drehmann; e força muscular do quadril com dinamômetro isocinético e sinal de Trendelenburg. Resultados: O nível de dor foi ligeiramente maior na coorte de EEPF comparado a quadris saudáveis (EVA, 0,8 ± 1,4 vs 0 ± 0, 0,007; TIA, 14% vs 0%, p = 0,06; respectivamente). Não foram observadas diferenças entre os grupos EEPF e controle para os escores funcionais (HHS, 94 ± 7 vs 100 ± 1, p = 0,135), exceto para ADM, com aumento da rotação interna (37,3º ± 9,4º vs 28,7º ± 8,2º, p < 0,001), e força, com diminuição do torque de abdução (75,5 ± 36,9 Nm/Kg vs 88,5 ± 27,6 Nm/Kg, p = 0,045), para o grupo EEPF. Conclusão: A osteotomia basocervical e a cervicoplastia restauraram o movimento do quadril e a força muscular, com exceção da força abdutora, a níveis próximos do normal, representando uma opção viável para o tratamento de EEPF moderado e grave. Nível de Evidência III, Estudo de Coorte Ambidirecional.

Objective: The plantar pressure distribution can be assessed quantitatively by computerized baropodometry such as carpet or insole. An insole-type system with wireless transmission was developed and plantar pressure results were previously validated by force platform. However, the reproducibility of the system had not been determined. Our objective was to evaluate the reliability of the results in different gait cycles, clinical characteristics and in different plantar anatomical sites. Methods: 41 healthy adults (age, 34 ± 13 years; body mass index, 25 ± 5 kg/m2; 26 [63%], male, 26 [63%] practicing physical activity) were evaluated. Baropodometer evaluations were performed in 3 walking cycles with 100 m each, and the reliability between the cycles was examined. Pressure points on the heel, first metatarsal, fifth metatarsal and total plantar pressure were analyzed and compared. Results: Moderate agreement was identified between the second and third cycles (ICC, 0.66; 95% CI, 0.14-0.83). Physical activity practitioners showed higher total plantar pressure (70.8 vs 68.2 Kpa; p = 0.04) and higher pressure in the heel (70.7 vs 68.1 Kpa; p = 0.036) in relation to sedentary ones. Conclusion: The insole was able to assess plant pressure with moderate reliability from the adaptation period. Level of Evidence III, Case control study - Investigating a diagnostic test. RESUMO Objetivo: A distribuição da pressão plantar pode ser avaliada quantitativamente por baropodometria computadorizada tipo tapete ou palmilha. Um sistema tipo palmilha com transmissão sem fio foi desenvolvido, cujos resultados de pressão plantar foram previamente validados por plataforma de força. No entanto, a reprodutibilidade do sistema não havia sido determinada. Nosso objetivo foi avaliar a confiabilidade dos resultados em relação a diferentes ciclos de marcha, características clínicas e em diferentes sítios anatômicos plantares. Métodos: Foram avaliados 41 adultos saudáveis (idade, 34 ± 13 anos; índice de massa corpórea, 25 ± 5 kg/m2; 26 [63%], sexo masculino, 26 [63%] praticantes de atividade física). Avaliações com o baropodômetro foram realizadas em 3 ciclos de marcha com distância de 100 m, e avaliada a concordância entre os ciclos. Pontos de pressão no calcanhar, primeiro metatarsal, quinto metatarsal e a pressão plantar total foram analisados e comparados. Resultados: Houve moderada concordância entre o segundo e terceiro ciclos (CCI, 0,66; IC95%, 0,14-0,83). Praticantes de atividades físicas apresentaram pressão plantar total (70,8 vs 68,2 Kpa; p = 0,04) e no calcanhar (70,7 vs 68,1 Kpa; p = 0,036) aumentada em relação aos sedentários. Conclusão: A palmilha foi capaz de avaliar a pressão plantar com confiabilidade moderada a partir do período de adaptação. Nível de Evidência III, Estudo diagnóstico - Investigando um teste diagnóstico.

Epiphyseal tubercle and peripheral cupping can influence the development of slipped capital femoral epiphysis (SCFE) and Cam morphology. During normal skeletal growth, epiphyseal tubercle shrinks while the peripheral cupping grows. We hypothesized that epiphyseal tubercle act as the primary stabilizer of the head-neck junction at early stages and this role is gradually transferred to epiphyseal cupping as the tubercle shrinks and cupping grows. From a cohort of 80 boys and girls (8-15 years old) with normal hips, CT scans of 5 subjects corresponding to minimum, 25th percentile, median, 75th percentile and maximum relative tubercle and cupping height were used to develop 3D finite element models. In vivo measured hip loads were used to study load sharing between the tubercle and peripheral cupping under combined and uniaxial loads exerted on femoral head during a range of daily activities. Lower epiphyseal tubercle height, larger epiphyseal cupping height and bigger differences in tubercle and cupping heights were strongly associated with increased epiphyseal cupping to epiphyseal tubercle stress ratios (R2 > 0.7). We found lower peripheral cupping stresses relative to the tubercle (cupping to tubercle stress ratio 1). Both tubercle and cupping play a substantial role in sharing the generated stresses across the head-neck junction under all tested loading conditions. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1571-1579, 2019.

Background Femoral morphology may influence the etiology of slipped capital femoral epiphysis (SCFE). We investigated whether radiographic parameters of femoral head-neck morphology are associated with a subsequent contralateral slip in patients presenting with unilateral SCFE. Methods We evaluated 318 patients treated for unilateral SCFE between 2000 and 2017. There were 145 males (46%), and the mean age in the series was 12.4 ± 1.7 years. The patients were followed for a minimum of 18 months or until the development of a contralateral slip (70 patients, 22%). We measured the epiphyseal tilt, epiphyseal extension ratio, alpha angle, and epiphyseal angle of the uninvolved, contralateral hip at initial presentation. Multivariable logistic regression analysis was used to assess whether femoral measurements were associated with the occurrence of a contralateral slip. Receiver operating characteristic (ROC) curves were used to determine optimal thresholds of radiographic measures to determine an increased risk of a contralateral slip. A number-needed-to-treat (NNT) analysis was conducted to evaluate the effectiveness of the femoral measurement thresholds in preventing a contralateral slip. Results Multivariable analysis, controlling for triradiate cartilage status, identified the lateral tilt angle and the superior epiphyseal extension ratio as independent factors associated with the likelihood of a contralateral slip. For each additional degree of posterior tilt, the odds of a contralateral slip increase by 8% (odds ratio [OR] = 1.08; 95% confidence interval [CI] = 1.02 to 1.14; p = 0.008), and for each 0.01 increase in the superior epiphyseal extension ratio, the odds of a contralateral slip decrease by 6% (OR = 0.94; 95% CI = 0.88 to 0.99; p = 0.03). A threshold for the epiphyseal tilt of 10° corresponded to a predicted probability of a contralateral slip of 54% in patients with open triradiate cartilage and an NNT of 3.3. Conclusions In patients presenting with unilateral SCFE, a higher posterior tilt of the epiphysis increases the risk while an increased superior extension of the epiphysis reduces the risk of a contralateral slip. Our findings may assist the discussion about contralateral prophylactic pinning in patients with unilateral SCFE. Level of evidence Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

STUDY DESIGN Cross-sectional study. OBJECTIVE To evaluate morphometric variations of the cervical spine in patients with cervical spondylotic myelopathy (CSM) using a standard technique of dynamic magnetic resonance imaging (MRI), to assess the inter- and intraobserver reliability of measurements of morphometric parameters based on this imaging, and to compare the resulting measurements with those previously published. SUMMARY OF BACKGROUND DATA Because dynamic factors may contribute to the etiology and severity of CSM, dynamic (flexion-extension) MRI may be useful to better evaluate for spinal stenosis and cord compromise. METHODS Dynamic cervical MRI was obtained using a standard protocol with the neck in neutral, flexion, and extension positions. The morphometric parameters considered were anterior length of the spinal cord (ALSC), posterior length of the spinal cord (PLSC), spinal canal diameter, and spinal cord width. Two observers analyzed the parameters independently, and the inter- and intraobserver reliabilities were assessed by the intraclass correlation coefficient (ICC). RESULTS A total of 18 patients were included in the study and all completed the dynamic MRI acquisition protocol. The inter- and intraobserver reliabilities demonstrated "almost perfect agreement" (ICC >0.9, P

Distal tibiofibular syndesmosis is a complex anatomical structure that is essential for the stability and function of the ankle. Ankle fractures are a common source of chronic syndesmosis instability with associated functional impairments and early development of osteoarthritis. Case presentation: we described a case of a 28-year-old patient who presented with symptomatic ankle subluxation and chronic syndesmosis instability. Eight months earlier, the patient sustained a minimally displaced ankle fracture that had been treated conservatively elsewhere. The surgical approach included the anatomical realignment of the distal fibula with a lengthening derotational osteotomy and tibiofibular syndesmosis reconstruction using an autologous semitendinosus tendon graft. One year after surgery, the ankle function was restored, and the patient was asymptomatic. Conclusion: The instability of ankle fractures should be carefully evaluated during the treatment decision-making. Surgical treatment of syndesmosis instability should be performed even in chronic cases to restore function. The reconstruction of syndesmosis with semitendinous tendon graft associated with fibular length and realignment improves the ankle stability and function.

BACKGROUND Peripheral cupping of the capital femoral epiphysis over the metaphysis has been reported as a precursor of cam morphology, but may also confer stability of the epiphysis protecting it from slipped capital femoral epiphysis (SCFE). The purpose of this study was to investigate the relationship between a novel morphologic parameter of inherent physeal stability, epiphyseal cupping, and the development of SCFE in a dual-center matched-control cohort study. METHODS We performed a dual-center age-matched and sex-matched cohort study comparing 279 subjects with unilateral SCFE and 279 radiographically normal controls from 2 tertiary children's hospitals. All SCFE patients had at least 18 months of radiographic follow-up for contralateral slip surveillance. Anteroposterior and frog lateral pelvis radiographs were utilized to measure the epiphyseal cupping ratio and the current standard measure of inherent physeal stability, the epiphyseal extension ratio. RESULTS Control hips were found to have greater epiphyseal cupping than the contralateral uninvolved hip of SCFE subjects both superiorly (0.28±0.08 vs. 0.24±0.06; P

BACKGROUND: The diagnosis of slipped capital femoral epiphysis (SCFE) often is delayed. Although lack of clinical suspicion is the main cause of delayed diagnosis, typical radiographic changes may not be present during the initial phases of SCFE. The peritubercle lucency sign for follow-up of the contralateral hip in patients with unilateral SCFE may be beneficial in assisting the early diagnosis. However, the accuracy and reliability of this sign in patients with SCFE is unknown. QUESTIONS/PURPOSES: (1) What is the accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the peritubercle lucency sign on radiographs for the early diagnosis of SCFE compared with MRI as the gold standard? (2) What are the interobserver and intraobserver reliabilities of the peritubercle lucency sign on radiographs? METHODS: Between 2000 and 2017, 71 patients underwent MRI for an evaluation of pre-slip or a minimally displaced SCFE. Sixty percent of hips (43 of 71) had confirmed SCFE or pre-slip based on the presence of hip pain and MRI changes, and these patients underwent in situ pinning. Three independent experienced observers reviewed MR images of the 71 hips and agreed on the presence of a juxtaphyseal bright-fluid signal suggesting bone marrow edema in these 43 hips with SCFE, and absence MRI changes in the remaining 28 hips. The same three experienced observers and two inexperienced observers, including a general radiologist and an orthopaedic surgery resident, blindly assessed the radiographs for the presence or absence of the peritubercle lucency sign, without information about the diagnosis. Diagnostic accuracy measures including sensitivity, specificity, PPV, and NPV were evaluated. Intraobserver and interobserver agreements were calculated using kappa statistics. RESULTS: The overall accuracy of the peritubercle lucency sign on radiographs was 94% (95% CI 91 to 96), sensitivity was 97% (95% CI 95 to 99), specificity was 89% (95% CI 90 to 96), PPV was 93% (95% CI 90 to 96), and NPV was 95% (95% CI 92 to 99). All accuracy parameters were greater than 85% for the five observers, regardless of experience level. Intraobserver agreement was perfect (kappa 1.0), and interobserver agreement was excellent for the peritubercle lucency sign on radiographs across the five observers (kappa 0.81 [95% CI 0.73 to 0.88]). The reliability was excellent for experienced observers (kappa 0.88 [95% CI 0.74 to 1.00]) and substantial for inexperienced observers (kappa 0.70 [95% CI 0.46 to 0.93]), although no difference was found with the numbers available (p = 0.18). CONCLUSIONS: The peritubercle lucency sign on radiographs is accurate and reliable for the early diagnosis of SCFE compared with MRI as the gold standard. Improving the early diagnosis of SCFE may be possible with increased awareness, high clinical suspicion, and a scrutinized evaluation of radiographs including an assessment of the peritubercle lucency sign. LEVEL OF EVIDENCE: Level III, diagnostic study.

Background Subtalar pain following intra-articular calcaneus fractures may be associated with disability, pain, and a negative impact on the quality of life. Salvage procedures as subtalar fusion are associated with further consequences as stiffness, altered ankle biomechanics, and adjacent articular overloading with degenerative changes. The objective of the present study is to evaluate the short-term effects of viscosupplementation with intra-articular hyaluronic acid (HA) on function and pain, in patients with painful subtalar joint after calcaneus fracture. Methods We searched for patients who underwent osteosynthesis of intra-articular calcaneus fracture between January 2011 and July 2015 and were diagnosed during the follow-up with pain and subtalar osteoarthritis. Between January and December of 2018, 13 patients (50 ± 10 years) accepted to participate in this study and received intra-articular HA injections. Three consecutive doses of 20 mg of HA were administered within a week interval, through anterolateral injections into the subtalar joint. We prospectively evaluated the function using the ankle/hindfoot American Orthopaedic Foot & Ankle Society score (AOFAS) and level of pain using the visual analog scale (VAS) before the intervention and 4, 12, and 24 weeks after the first injection. Results Hindfoot function improved with an increase of AOFAS from 55 ± 19 before the intervention to 88 ± 20 at the 24th week ( P = .001). Similarly, we observed relief of pain during the 24 weeks following intra-articular hyaluronic acid injection, with a decrease in VAS from 8.3 ± 1.3 before treatment to 2.2 ± 3.0 at the 24th week ( P = .001). Conclusion For patients experiencing pain and dysfunction with subtalar osteoarthritis after intra-articular calcaneus fracture, viscosupplementation with intra-articular HA may be associated with improvement in function and pain in the short term. Furthermore, patients with higher grades of osteoarthritis may have limited benefit in pain relief and function improvement. Level of evidence: IV, Case series

Aims The aims of this study were to evaluate the abductor function in moderate and severe slipped capital femoral epiphysis (SCFE), comparing the results of a corrective osteotomy at the base of the femoral neck and osteoplasty with 1) in situ epiphysiodesis for mild SCFE, 2) contralateral unaffected hips, and 3) hips from healthy individuals. Patients and Methods A total of 24 patients (mean age 14.9 years (sd 1.6); 17 male and seven female patients) with moderate or severe SCFE (28 hips) underwent base of neck osteotomy and osteoplasty between 2012 and 2015. In situ epiphysiodesis was performed in seven contralateral hips with mild slip. A control cohort was composed of 15 healthy individuals (mean age 16.5 years (sd 2.5); six male and nine female patients). The abductor function was assessed using isokinetic dynamometry and range of abduction, with a minimum one-year follow-up. Results We found no differences in mean peak abductor torque between the hips that underwent osteotomy and those that received in situ epiphysiodesis (p = 0.63), but the torque was inferior in comparison with contralateral hips without a slip (p < 0.01) and hips from control individuals (p < 0.001). The abduction strength was positively correlated with the range of hip abduction (R = 0.36; p < 0.001). Conclusion Although the abductor strength was not restored to normal levels, moderate and severe SCFE treated with osteotomy at the base of the femoral neck and osteoplasty showed abductor function similar to in situ epiphysiodesis in hips with less severe displacement. Cite this article: Bone Joint J 2018;100-B:1524–32.

A rotational mechanism of slipped capital femoral epiphysis (SCFE) in which the epiphyseal tubercle acts as a fulcrum has been recently described. However, there is limited radiographic evidence supporting this theory. We aimed to investigate whether a radiographic lucency around the epiphyseal tubercle (peritubercle lucency sign) could be observed before or at the diagnosis of a subsequent slip in patients initially presenting with unilateral SCFE.We evaluated 70 patients with unilateral SCFE who were followed until a contralateral slip was diagnosed, and 180 patients with unilateral SCFE who had no contralateral slip until skeletal maturity between 2000 and 2017. We revised anteroposterior and lateral radiographs from the initial presentation, surveillance, and diagnosis of a contralateral SCFE. The presence or absence of the peritubercle lucency sign in the contralateral initially uninvolved hip was recorded for every radiograph. The presence of hip pain, and the presence of classic radiographic parameters for SCFE diagnosis (epiphyseal tilt and Klein's line) were recorded when the peritubercle lucency sign became noticeable.The peritubercle lucency sign was observed in 84% [59/70; 95% confidence interval (CI), 73%-92%] of the patients who developed contralateral slip. Most patients (46/59=78%; 95% CI, 65%-87%; P0.001) had the peritubercle lucency sign visible within 9 months after the initial diagnosis of unilateral SCFE. The sign preceded the definitive diagnosis of the contralateral slip at a median of 9 weeks (interquartile range, 0 to 10 wk). At the time of first observation of the peritubercle lucency sign, 36% (25/70; 95% CI, 25%-48%) of the patients were asymptomatic and 49% (34/70; 95% CI, 36%-61%) of the hips showed no abnormalities in the tilt angle or the Klein line. Among patients who did not experience a contralateral slip (n=180), the sign was observed in 2 patients (1.1%; 95% CI, 0.2%-4.4%). The sensitivity was 84% and specificity was 99%.A peritubercle lucency is an early imaging sign, present in80% of contralateral slips following an initial presentation of unilateral SCFE. The presence of the peritubercle lucency sign may be helpful for contralateral hip surveillance. Future studies are necessary to establish the clinical validity of the peritubercle lucency sign and whether it may serve as a predictor of contralateral involvement.Diagnostic level III.

The incidence of hip instability in children with Down syndrome is 1% to 7%. The natural history is often progressive, with the typical onset of hypermobility of the hip evolving to habitual dislocation, persistent subluxation, and fixed dislocation, and eventually leading to the loss of independent mobility. Treatment focuses on stabilizing the hip joint and depends on the patient's age and the severity of the disease. Typically, surgical intervention is recommended for the treatment of patients with habitual dislocation, subluxation, and complete dislocation of the hip. When indicated, surgical management must take into account associated anatomic abnormalities of the femur and acetabulum. Hip instability in Down syndrome may persist despite surgical intervention and remains a difficult condition to manage.

BACKGROUND The treatment of hip dysplasia in patients with Down syndrome is challenging. We investigated the clinical, functional, and radiographic outcomes of periacetabular osteotomy (PAO) as well as factors associated with its failure at a minimum of 5 years of follow-up. METHODS Between 1992 and 2011, 19 patients with Down syndrome (26 hips) underwent PAO at a mean age of 16.2 ± 4.7 years. Hip pain and function were assessed with use of the modified Harris hip score (HHS) and the Gross Motor Function Classification System (GMFCS). The criteria for PAO failure were progression of osteoarthritis with a recommendation for total hip arthroplasty or hip arthrodesis, or an HHS of

BACKGROUND: Hip osteoarthritis has been reported in the contralateral hip in patients who had been treated for unilateral slipped capital femoral epiphysis (SCFE) during adolescence. Although this might be related to the presence of a mild deformity, the morphologic features of the contralateral hip in unilateral SCFE remains poorly characterized. QUESTIONS/PURPOSES: Do measurements of (1) femoral head-neck concavity (α angle and femoral head-neck offset), (2) epiphyseal extension into the metaphysis (epiphyseal extension ratio and epiphyseal angle), and (3) posterior tilt of the epiphysis (epiphyseal tilt angle) differ between the contralateral asymptomatic hips of patients treated for unilateral SCFE and hips of an age- and sex-matched control population without a history of hip disease? METHODS: From January 2005 to May 2015, 442 patients underwent surgical treatment for SCFE at our institution. Patients were included in this study if they had a pelvic CT scan and unilateral SCFE defined by pain or a limp in one hip without symptoms or obligatory external rotation with flexion in the contralateral hip and no evidence of SCFE findings on available radiographs. Seventy-two (16%) patients had a pelvic CT scan; however, 32 patients with bilateral involvement and one patient with CT imaging of inadequate quality for multiplanar reformatting were excluded. Thirty-nine control subjects were identified from a preexisting database of patients who underwent pelvic CT between January 2008 and January 2014 for assessment of abdominal pain in the setting of suspected appendicitis. Patients in the contralateral asymptomatic hip group then were matched to control subjects using a modified nearest-neighbor approach based on sex and age. Patients in the contralateral asymptomatic hip group were separated in males and females and control subjects were assigned to an appropriate sex category. Then subjects closest in age were matched with each patient. If more than one subject was available as a match for a given patient, the control subject with the closest BMI was selected. The contralateral asymptomatic hip and matched groups had 19 (49%) male patients and 20 (51%) female patients, with mean ages (± SD) of 16 (± 3) years and 16 (± 3) years, respectively (p = 0.16). Matched subjects had a mean BMI of 25 ± 4 kg/m(2) and the mean BMI difference among groups was 5 ± 5 kg/m(2) (p < 0.001). According to the Southwick radiographic criteria nine patients (23%) had a mild slip, 10 (26%) had a moderate slip, and 19 (49%) had severe SCFE. The α angle and femoral head-neck offset, epiphyseal extension ratio and epiphyseal angle, and epiphyseal tilt were assessed in the anterior, anterosuperior, and superior femoral planes on radially reformatted CT by one observer not involved in clinical care of the patients. Inter- and intrarater reliability were determined on 10 randomly selected hips assessed by the same observer and another observer and it was found to be excellent for all femoral measurements (intraclass correlation coefficients > 0.85). Paired t-tests were used to compare the contralateral asymptomatic hip of patients with SCFE and control hips. RESULTS: The head-neck junction showed decreased concavity in the contralateral femur of patients with unilateral SCFE compared with control subjects as assessed by slightly higher mean α angle in the anterosuperior plane (51° ± 6° versus 48° ± 7°; mean difference, 2°, 95% CI, 0°-5°; p = 0.04) and slightly higher median α angle in the superior plane (45° [range 37°-72°] versus 42° [range, 36°-50°], median shift, 4° [range, 2°-5°], p < 0.001), and slightly lower head-neck offset (anterosuperior: 5 mm ± 2 mm versus 6 mm ± 2 mm, mean difference, -1mm [range, -1 mm to 0 mm], p = 0.009; superior: median, 6 mm [range, 1 mm-8 mm] versus 7 mm [range, 5 mm-9 mm]; median shift, -1 mm [range, -1 mm to 0 mm], p < 0.001). There was less epiphyseal extension in the anterosuperior plane as evidenced by lower epiphyseal extension ratio (72% ± 6% versus 75% ± 6%; p = 0.005) and higher epiphyseal angle (64° ± 7° versus 60° ± 7°; p = 0.003). The epiphysis was slightly more posteriorly tilted (anterior plane tilt: 8° ± 6° versus 5° ± 4°; p = 0.03) and more vertically oriented (superior plane tilt 11° ± 5° versus 14° ± 4°; p = 0.006) in the contralateral asymptomatic hip of patients with SCFE. CONCLUSIONS: The contralateral femur in patients treated for unilateral SCFE shows decreased concavity of the head-neck junction assessed by a higher α angle and reduced head-neck offset compared with age- and sex-matched control subjects. Because we noted lower epiphyseal extension but a more posteriorly tilted epiphysis, the reduced concavity resembles a mild slip deformity rather than an idiopathic cam morphologic feature. CLINICAL RELEVANCE: Although we noted a difference in the morphologic features of the head-neck junction between the two groups, the clinical significance is unclear because most differences were rather small. However, our findings suggest that the uninvolved hip in patients with unilateral SCFE may have a subtle asymptomatic cam morphologic feature that may be identified only with advanced imaging (CT or MRI). Future studies should investigate whether these morphologic changes influence development of contralateral SCFE or symptomatic femoroacetabular impingement in the contralateral hip of patients with unilateral SCFE and establish thresholds for indication of prophylactic fixation to avoid further slip and worsening of the morphologic features of the cam-femoroacetabular impingement.

Purpose To investigate the outcomes of an anteverting triple periacetabular osteotomy for the treatment of hip instability in skeletally immature patients with Down syndrome. Methods We evaluated 16 patients (21 hips) with Down syndrome and hip instability who underwent an anteverting triple periacetabular osteotomy between 2007 and 2016. There were nine females and seven males with an average age of 7.4 years SD 2.0. We assessed the level of hip pain, gait ability and clinical stability at a minimum of one year after surgery. Radiographic evaluation included pre- and postoperative lateral centre-edge angle (LCEA), Tönnis acetabular angle and extrusion index. Result After an average follow-up of 4.1 years SD 2.6, 20 of 21 hips (95%) remained clinically stable. In all, 12 of 16 (75%) patients had a full gait without a major limp, but three patients (19%) had a persistent limp. Of the 21 procedures, one hip (5%) was considered a failure due to persistent instability. There was a mean increase of 18.3º SD 15.3º of the LCEA (p < 0.001); a mean decrease of 15.2º SD 11.6º (p < 0.001) for the Tönnis angle and the extrusion index had a mean decrease of 0.27 SD 0.20 (p < 0.001). The most common complications were minor and included nonunion of the pubis or ischium (24%) and stress fractures of the pubis and ischium (14%). Only one patient required unplanned surgery for the treatment of an infection; which was considered a major complication. Conclusion The anteverting triple periacetabular osteotomy provided global deformity correction and achieved hip stability in 95% of the hips after a mean follow-up of 4.1 years. Level of Evidence Therapeutic level IV.

Aims Our aim was to describe the mid-term appearances of the repair process of the Achilles tendon after tenotomy in children with a clubfoot treated using the Ponseti method. Patients and Methods A total of 15 children (ten boys, five girls) with idiopathic clubfoot were evaluated at a mean of 6.8 years (5.4 to 8.1) after complete percutaneous division of the Achilles tendon. The contour and subjective thickness of the tendon were recorded, and superficial defects and its strength were assessed clinically. The echogenicity, texture, thickness, peritendinous irregularities and potential for deformation of the tendon were evaluated by ultrasonography. Results The appearance of the Achilles tendon was slightly abnormal, with more thickening and less conspicuous contours than a normal tendon. Its strength was grossly normal, with no insufficiency of the triceps surae. Ultrasonographic findings revealed a mild fusiform thickening in 12 children (80%). The tissue at the site of the repair had a slightly hypoechoic, fibrillar quality with hyperechoic striation and the anterior contour was irregular and blurred. There was a focal narrowing within the healing tissue in two children. Conclusion This mid-term evaluation of the ability of the Achilles tendon to repair after division suggests a combination of intrinsic and extrinsic mechanisms. There were minor abnormalities which did not appear to affect function. Cite this article: Bone Joint J 2017;99-B:139–44.

BACKGROUND The inner surface of the capital femoral epiphysis is important for growth plate stability. However, abnormalities of epiphyseal morphology associated with the pathogenesis of slipped capital femoral epiphysis (SCFE) remain poorly understood. This study compares the 3-dimensional anatomy of the epiphyseal tubercle and peripheral cupping in hips with SCFE and normal hips. METHODS We created 3-dimensional models of the capital femoral epiphysis with use of computed tomography (CT) imaging from 51 patients with SCFE and 80 subjects without hip symptoms who underwent CT because of abdominal pain. The height, width, and length of the epiphyseal tubercle and the peripheral cupping were measured and normalized by the epiphyseal diameter and presented as a percentage. We used analysis of variance for the comparison of the measurements between SCFE and control hips after adjusting for age and sex. RESULTS Compared with normal hips, hips with mild SCFE had smaller mean epiphyseal tubercle height (0.9% ± 0.9% compared with 4.4% ± 0.4%; p = 0.006) and length (32.3% ± 1.8% compared with 43.7% ± 0.8%; p < 0.001). The mean epiphyseal tubercle height was also smaller in hips with moderate (0.6% ± 0.9%; p = 0.004) and severe SCFE (0.3% ± 0.8%; p < 0.001) compared with normal hips. No differences were observed for measurements of epiphyseal tubercle height and length between SCFE subgroups. The mean peripheral cupping was larger in hips with mild (16.3% ± 1.0%; p < 0.001), moderate (16.4% ± 1.1%; p < 0.001), and severe SCFE (18.9% ± 0.9%; p < 0.001) overall and when assessed individually in all regions compared with normal hips (10.6% ± 0.5%). CONCLUSIONS Hips with SCFE have a smaller epiphyseal tubercle and larger peripheral cupping compared with healthy hips. A smaller epiphyseal tubercle may be a predisposing morphologic factor or a consequence of the increased shearing stress across the physis secondary to the slip. Increased peripheral growth may be an adaptive response to instability as other stabilizers (i.e., epiphyseal tubercle and anterior periosteum) become compromised with slip progression. Future studies are necessary to determine the biomechanical basis of our morphologic findings.

Overcoverage of the femoral head by the acetabulum, increased acetabular depth and retroversion have been associated with the etiology of slipped capital femoral epiphysis (SCFE). However, limited evidence exists about the impact of the acetabular morphology on the development of a contralateral slip following an initial presentation of unilateral SCFE. We aimed to investigate whether acetabular overcoverage as assessed by an increased lateral center-edge angle (LCEA) and low Tonnis angle, increased acetabular depth assessed by the acetabular depth-width ratio (ADR) and the presence of coxa profunda; and acetabular retroversion assessed by the presence of the crossover sign were associated with a contralateral slip in patients presenting with unilateral SCFE. We evaluated 250 patients with initial diagnosis of unilateral SCFE (average age, 12.5 ± 1.7 years), who had not undergone prophylactic fixation on the contralateral hip for a median follow-up of 49 months (interquartile range: 25-76 months). Endpoints were the development of a contralateral slip (70 patients, 28%) or skeletal maturity assessed by complete closure of the proximal femoral growth plate (180 patients, 72%). We measured the LCEA, Tonnis angle, ADR, and the coxa profunda sign on an anteroposterior pelvic radiograph. The crossover sign was assessed in 208 hips who had a secondary ossification center in the posterior acetabular rim. For each additional degree of LCEA, the odds of contralateral slip decreased 8% [odds ratio = 0.92; 95% confidence interval (CI), 0.87-0.98; P = 0.009]. Tonnis angle (P = 0.11), ADR (P = 0.20) and coxa profunda (p = 0.37) had no association with a contralateral slip. The presence of crossover sign increased two and half times the odds for a contralateral slip (odds ratio = 2.5; 95% CI = 1.12-5.64; P = 0.03). Acetabular retroversion, but not acetabular overcoverage or increased acetabular depth, was associated with contralateral SCFE development in patients with unilateral SCFE. Level of evidence: prognostic level II.

Objective: To evaluate morphometric variations of the cervical spine in patients with cervical spondylotic myelopathy (CSM) using dynamic magnetic resonance imaging (MRI) in neutral, flexion and extension positions. Methods: This is a prospective study of patients with CSM secondary to degenerative disease of the cervical spine. The morphometric parameters were evaluated using T2-weighted MRI sequences in the sagittal plane in neutral, flexion and extension position of the neck. The parameters studied were the anterior length of the spinal cord (ALSC), the posterior length of the spinal cord (PLSC), the diameter of the vertebral canal (DVC) and the diameter of the spinal cord (DSC). Results: The ALSC and PLSC were longer in flexion than in extension and neutral position, with statistically significant difference between the flexion and extension position. The DVC and the DSC were greater in flexion than in extension and neutral position, however, there was no statistically significant difference when they were compared in the neutral, flexion and extension positions. Conclusion: Dynamic MRI allows to evaluate morphometric variations in the cervical spinal canal in patients with cervical spondylotic myelopathy. RESUMO Objetivo: Avaliar variações morfométricas da coluna vertebral cervical em pacientes portadores de mielopatia cervical espondilótica (MCE) por meio da ressonância magnética dinâmica nas posições neutra, em flexão e em extensão. Métodos: Este é um estudo prospectivo de pacientes portadores de MCE secundária à doença degenerativa da coluna vertebral cervical. Os parâmetros morfométricos foram avaliados pelas sequências de ressonância magnética ponderadas em T2, no plano sagital em posições neutra, flexão e extensão. Os parâmetros estudados foram o comprimento anterior da medula espinhal (CAME), o comprimento posterior da medula espinhal (CPME), o diâmetro do canal vertebral (DCV) e o diâmetro da medula espinhal (DME). Resultados: O CAME e o CPME foram mais longos em flexão do que nas posições neutra e em extensão, sendo encontrada diferença estatisticamente significativa entre a posição em flexão e extensão. O DCV e o DME foram maiores em flexão do que nas posições neutra e em extensão, no entanto não foi encontrada diferença estatisticamente significativa quando comparados nas posições neutra, em flexão e em extensão. Conclusão: O exame de ressonância magnética dinâmica permite avaliar as variações morfométricas do canal vertebral cervical em pacientes portadores de mielopatia cervical espondilótica. RESUMEN Objetivo: Evaluar las variaciones morfométricas de la columna cervical en pacientes con mielopatía cervical espondilótica (MCE) mediante resonancia magnética dinámica en la posición neutra, en flexión y extensión. Métodos: Se trata de un estudio prospectivo de pacientes con MCE secundaria a la enfermedad degenerativa de la columna cervical. Los parámetros morfométricos fueron evaluados en las secuencias ponderadas en T2 en el plano sagital en la posición neutra, en flexión y extensión de la resonancia magnética. Los parámetros estudiados fueron la longitud anterior de la médula espinal (LAME), la longitud posterior de la médula espinal (LPME), el diámetro del canal espinal (DCE) y el diámetro de la médula espinal (DME). Resultados: La LAME y la LPME fueron más largas en flexión que en las posiciones neutra y en extensión, con diferencia estadísticamente significativa entre la posición en flexión y extensión. El DME y el DCE fueron mayores en flexión que en extensión y la posición neutra, sin embargo no hubo diferencia estadísticamente significativa cuando se compararon en la posición neutral, en flexión y extensión. Conclusión: El examen de resonancia magnética dinámica permite evaluar los cambios morfométricos en el canal espinal cervical en pacientes con mielopatía cervical espondilótica.

Hereditary motor and sensory neuropathies, especially Charcot-Marie-Tooth disease, are frequently expressed with an acquired cavusvarus foot which is characterized by a fixed increase of the plantar arch and hindfoot inversion. Diagnosis of the underlying condition achieved through careful patient assessment and local evaluations is the keystone for decision-making about the adequate treatment. The cavus may present as an isolated deformity of the forefoot, hindfoot or it may be a combination of both locations. Related deformities, mainly the varus and toe clawing require appropriate evaluation; clinical characteristics such as severity of the deformity, impairment of the muscular power, flexibility and patient's age are important characteristics in the treatment decision. Conservative treatment of the cavusvarus foot with physiotherapy, insoles and shoe modifications are reserved to young patients and mild deformities. However, there is a tendency of the deformity to become more severe over time because of the progressive feature of the underlying neurological condition. So, the surgical treatment by using classical techniques is performed in early stages. Most importantly is the identification of the primary and main components of each deformity to properly correct them, if possible. Muscular transfers are used to treat the dynamic unbalance, retracted structures should be either divided or lengthened and localized osteotomies should be preferred over arthrodeses, which are reserved for stiff and severely deformed feet in adults.

Purpose To investigate changes in acetabular morphology during the follow-up of slipped capital femoral epiphysis (SCFE) and search for factors associated with acetabular dysplasia at skeletal maturity. Methods We evaluated 108 patients with unilateral SCFE (mean age at slip, 12.3 years sd 1.7) to skeletal maturity, with a minimum follow-up of two years (median 4.5 years; interquartile range 3.2 to 6.2). Acetabular parameters obtained from initial and most recent radiographs included the lateral centre-edge angle (LCEA), Tönnis angle (TA) and acetabular depth-width ratio (ADR). Acetabular dysplasia was considered for LCEA < 20° or TA > 10°. Femoral parameters consisted of the most recent head diameter, neck-shaft angle, neck length, articulotrochanteric distance and alpha angle. Results At SCFE onset, the affected hip showed a slightly lower LCEA (26.4° sd 6.1° versus 27.3° sd 5.7°; p = 0.01) and ADR (330 sd 30 versus 340 sd 30; p < 0.001) compared with the uninvolved hip. At final follow-up, the affected hip showed lower LCEA (24.5° sd 7.6° versus 28.8°sd 6.6°; p < 0.001) and ADR (330 sd 40 versus 350 sd 40; p < 0.001), and TA was larger (5.5° sd 5.4° versus 2.3° sd 4.2°; p < 0.001) compared with the uninvolved hip. Acetabular dysplasia was observed in 27 (25%) of 108 hips with SCFE. Femoral head overgrowth, age at slip and SCFE severity were independent factors associated with acetabular dysplasia (p < 0.05). Conclusion Acetabular coverage and depth are not increased in SCFE, and the acetabular coverage tends to decrease up to skeletal maturity. A potential disturbance in the acetabular growth and remodelling exists mainly for young children with severe SCFE, and a potential for acetabular insufficiency may be observed at the diagnosis and follow-up of SCFE. Level of Evidence Prognostic Level IV

The authors sought to determine the intra- and interrater reliability of contemporary measures of acetabular morphology among a group of hip surgeons and to determine the correlations between measures of acetabular morphology. On 2 separate occasions, 3 hip surgeons independently performed blinded evaluations of anteroposterior pelvic radiographs of 40 patients. The lateral center-edge angle, medial center-edge angle, acetabular arc, extrusion index, acetabular index, Sharp's angle, posterior wall sign, crossover sign, femoro-epiphyseal acetabular roof index, acetabular wall indexes, and delta angle were assessed. A linear mixed model was used for variance estimation, and kappa and intra-class correlation coefficients were assessed for reliability. Pearson correlation coefficients were calculated for all possible pairs of radiographic measures. The acetabular index had the greatest interrater agreement (0.90; 95% confidence interval [CI], 0.84–0.93), whereas the lateral center-edge angle had the higher intrarater agreement (0.96; 95% CI, 0.92–0.98). The acetabular arc angle had the lowest interrater agreement (0.44; 95% CI, 0.29–0.57), and the Sharp's angle had the lowest intrarater agreement (0.66; 95% CI, 0.41–0.84). The posterior wall sign had an interrater agreement of 0.35 (95% CI, 0.11–0.54) and an intrarater agreement of 0.68 (95% CI, 0.49–0.86). The crossover sign had an interrater agreement of 0.66 (95% CI, 0.43–0.84) and an intrarater agreement of 0.85 (95% CI, 0.52–0.89). The acetabular index, lateral center-edge angle, and extrusion index presented with high coefficients of correlation. In addition, acetabular anteversion correlated with severity of dysplasia. Commonly used parameters such as the acetabular index, lateral center-edge angle, and extrusion index are reliable radiographic parameters to assess acetabular morphology. However, correlation between measures suggests that they may be redundant in quantifying acetabular morphology. [ Orthopedics . 2018; 41(5):e629–e635.]

OBJECTIVE The goals of this work were to analyze the skeletal muscle changes after complete spinal cord injury (SCI) in rats and to compare the effects of electrical stimulation and whole-body vibration on prevention of muscle hypotrophy in these animals. DESIGN Seven-week-old male Wistar rats were divided into four groups: (1) sham operation (sham, n = 12), (2) SCI (n = 10), (3) SCI + electrical stimulation (n = 9), and (4) SCI + whole-body vibration (n = 9). Complete SCI was generated by surgical transection of the cord at the T10 level. Therapies were initiated 3 days after the surgery and continued for 30 days at a frequency of 3 days per week, 20 mins per day. The animals were killed on day 33 after injury for subsequent analyses. RESULTS SCI caused a significant decrease in muscle mass and fibers, perimeter measurements, and mechanical resistance to traction as well as an increase in fibrotic tissue. Electrical stimulation, but not whole-body vibration, resulted in significant partial muscle hypotrophy prevention. CONCLUSIONS Electrical stimulation may be a potentially beneficial therapeutic modality to prevent muscle hypotrophy after SCI.

The aim of this study was to compare clinical outcomes and radiographic correction after modified Dunn procedure versus inadvertent closed reduction and percutaneous pinning for the treatment of unstable slipped capital femoral epiphysis (SCFE).We evaluated 45 patients with unstable SCFE treated using the modified Dunn procedure (n = 27) or percutaneous pinning (n = 18) during a minimum follow-up of one year. Clinical outcomes were assessed using the Heyman and Herndon scores. The Southwick angle, alpha angle, and femoral head-neck offset were used to assess radiographic correction. The occurrence of complications and unplanned re-operations were recorded.At latest follow-up, 67% (18/27) in the modified Dunn procedure group and 28% (5/18) in the in situ pinning group had good or excellent Heyman and Herndon outcomes (p = 0.016). The morphology of the femoral head and neck was improved in the modified Dunn procedure group compared to percutaneous pinning (Southwick angle, alpha angles; femoral head-neck offset; p 0.001). The proportion of osteonecrosis (26 vs. 28%; p 0.999) and unplanned re-operations (26 vs. 33%; p = 0.894) was similar in both groups.Compared to inadvertent reduction and percutaneous pinning, the modified Dunn procedure provided better clinical and radiographic outcomes with similar proportion of osteonecrosis and unplanned re-operations following an unstable SCFE.

The etiology of hip instability in Down syndrome is not completely understood. We investigated the morphology of the acetabulum and femur in patients with Down syndrome and compared measurements of the hips with those of matched controls.Computed tomography (CT) images of the pelvis of 42 patients with Down syndrome and hip symptoms were compared with those of 42 age and sex-matched subjects without Down syndrome or history of hip disease who had undergone CT for abdominal pain. Each of the cohorts had 23 male and 19 female subjects. The mean age (and standard deviation) in each cohort was 11.3 ± 5.3 years. The lateral center-edge angle (LCEA), acetabular inclination angle (IA), acetabular depth-width ratio (ADR), acetabular version, and anterior and posterior acetabular sector angles (AASA and PASA) were compared. The neck-shaft angle and femoral version were measured in the patients with Down syndrome only. The hips of the patients with Down syndrome were further categorized as stable (n = 21) or unstable (n = 63) for secondary analysis.The hips in the Down syndrome group had a smaller LCEA (mean, 10.8° ± 12.6° compared with 25.6° ± 4.6°; p0.0001), a larger IA (mean, 17.4° ± 10.3° compared with 10.9° ± 4.8°; p0.0001), a lower ADR (mean, 231.9 ± 56.2 compared with 306.8 ± 31.0; p0.0001), a more retroverted acetabulum (mean acetabular version as measured at the level of the centers of the femoral heads [AVC], 7.8° ± 5.1° compared with 14.0° ± 4.5°; p0.0001), a smaller AASA (mean, 55.0° ± 9.9° compared with 59.7° ± 7.8°; p = 0.005), and a smaller PASA (mean, 67.1° ± 10.4° compared with 85.2° ± 6.8°; p0.0001). Within the Down syndrome cohort, the unstable hips showed greater femoral anteversion (mean, 32.7° ± 14.6° compared with 23.6° ± 10.6°; p = 0.002) and worse global acetabular insufficiency compared with the stable hips. No differences between the unstable and stable hips were found with respect to acetabular version (mean AVC, 7.8° ± 5.5° compared with 7.6° ± 3.8°; p = 0.93) and the neck-shaft angle (mean, 133.7° ± 6.7° compared with 133.2° ± 6.4°; p = 0.81).Patients with Down syndrome and hip-related symptoms had more retroverted and shallower acetabula with globally reduced coverage of the femoral head compared with age and sex-matched subjects. Hip instability among those with Down syndrome was associated with worse global acetabular insufficiency and increased femoral anteversion, but not with more severe acetabular retroversion. No difference in the mean femoral neck-shaft angle was observed between the stable and unstable hips in the Down syndrome cohort.Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

To evaluate the age in which the secondary ossification centers of the elbow appear and fuse in the Brazilian population.Nearly thirty radiographs were randomly selected for each age group from 0 to 18 years, with a total of 544 radiographs from 439 patients, between 2010 and 2015, without abnormalities secondary to trauma, metabolic or bone tumor diseases. Radiographs were retrospectively evaluated by two blind and independent observers, according to the presence or not of the ossification centers, and the fusion between them.The age interval of appearance and fusion were, respectively: capitulum (0 to 1 year; 10 to 15 years), radius head (2 to 6 year; 12 to 16 years), medial epicondyle (2 to 8 years; 13 to 17 years), trochlea (5 to 11 years; 10 to 18 years), olecranon (6 to 11 years; 13 to 16 years), e lateral epicondyle (8 to 13 years; 12 to 16 years). Appearance and fusion were earlier in girls compared to boys (exception to capitulum and radius head).The chronological order was similar to the literature. For girls, the radius head and medial epicondyle appeared simultaneously. There was a tendency of the olecranon center to appear before the trochlea for both sexes.Avaliar a idade de surgimento e a união dos centros secundários de ossificação do cotovelo na população brasileira.Foram selecionadas aleatoriamente aproximadamente 30 radiografias simples do cotovelo na faixa etária de 0 a 18 anos, no total de 544 radiografias de 439 pacientes, entre 2010 e 2015, sem alterações secundárias a trauma, doença osteometabólica ou tumor. Foram avaliadas retrospectivamente de forma cega e independente por dois observadores, quanto à presença dos centros de ossificação secundária e a união entre eles.O intervalo de idade de aparecimento e de união dos centros foram, respectivamente: capítulo do úmero (0 a 1 ano; 10 a 15 anos), cabeça do rádio (2 a 6 anos; 12 a 16 anos), epicôndilo medial (2 a 8 anos; 13 a 17 anos), tróclea (5 a 11 anos; 10 a 18 anos), olécrano (6 a 11 anos; 13 a 16 anos), e epicôndilo lateral (8 a 13 anos; 12 a 16 anos). No sexo feminino, o aparecimento e união são mais precoces do que no masculino (exceto capítulo do úmero e cabeça do rádio).A ordem cronológica foi semelhante à da literatura. No sexo feminino, o centro da cabeça do rádio e do epicôndilo medial surgiram simultaneamente. Houve tendência não significativa de o olécrano surgir antes da tróclea em ambos os sexos.