Purpose: The aims of the study were to document the outcomes of percutaneous Achilles tenotomy (pAT) performed in older children with clubfoot treated by the Ponseti method, by assessing the clinical, functional and ultrasonographic evidence of Achilles tendon regeneration. Methods: A retrospective case series of older children with clubfoot treated between August 2011 and July 2020 were studied. Clinical assessment of ankle range of motion & calf strength, functional assessment of triceps surae muscle endurance by single leg heel-rise test, and ultrasonographic assessment of Achilles tendon echotexture and dimensions to assess tendon regeneration were performed. Results: Percutaneous Achilles tenotomy was performed on 31 children (48 clubfeet) at a mean age of 5.24 +2.14 years (1–10.2 years). At a mean follow-up of 4.86 +1.97 years, all children demonstrated normal calf strength with mean dorsiflexion range of 13.64 degrees (0–25 deg) and mean plantarflexion range of 37.95 degrees (10–40 deg). The heel-rise endurance test was completed by 27 children with mean 25.85 heel rises/minute (range 17–30) and mean height of heel rise of 6.29 cm (range 4–10 cm). Normal fibrillar tendinous echotexture with homogenous echogenicity was seen on ultrasonography in 41 feet (85.4%) with mean tendon width of 9.7mm (3.3–16mm) and thickness of 5.1mm (1.8–15mm), comparable with unaffected feet. Conclusions: Clinical, functional and ultrasonographic parameters unequivocally demonstrate complete regeneration of the Achilles tendon, when pAT is performed in older children with delayed-presenting idiopathic clubfoot treated using Ponseti principles upto 10 years of age.

Introduction: We combined Ilizarov technique and intramedullary nail fixation, with iliac cancellous bone auto graft and the use of Zoledronic Acid two weeks before surgery . The outcome of the last follow-up was evaluated. Methods: we retrospectively studied 15 cases of congenital pseudarthrosis of tibia treated from 2016 to 2024. The mean age of operation was 6.3 (5-18) years, and the mean follow-up was 62 months. The therapeutic effect was evaluated by comparing the length difference of both lower limbs, ankle joint function score and other postoperative complications. Results: According to the last follow-up, the union rate of tibial pseudojoint was 90%. The average difference of lower limb length was 3.51 (0.8-5.5) cm before surgery and 1.23 (0.5-2.3) cm after surgery, which was statistically significant (p < 0.05). The average ankle joint function score was 77.3 (55-92) points before surgery and 79.3 (65-92) points after surgery. Statistical analysis was not significant (p > 0.05). Other complications included refracture (1 case), abnormal tibial alignment (3 cases), and infection (1 case). Conclusion: The combination of Ilizarov technique and intramedullary nail fixation in the treatment of congenital tibial pseudojoint can effectively promote the healing of fracture site. Correcting the length disprepancy of the lower limbs, and preserve the function of the ankle joint.

Distal forearm fractures are frequent in children. Treatment of displaced, unstable metaphyseal fracture may be challenging. Different fixation techniques exist. Anterograde ESIN for distal radius fractures was not recommended due to risk of injury to motor branch of radial nerve. Recently, Du and Han (2019) published excellent results of this novel approach. We have analyzed our single center experience in the treatment of unstable distal radius fractures using anterograde ESIN. In the four-year period we have treated 26 patients (24 males and 2 females) with anterograde ESIN for unstable, displaced distal radius fractures. Mean age of patients was 11.01 years (range 5.63- 15.79), with left side predominance (21 vs. 5). Five patients had isolated radius fractures while 21 had concomitant distal ulna fracture. Mean time from injury to surgery was 1.95 days and from admission to surgery 0.91 days. Open reduction was performed in 4 radius and 5 ulna fracture while all other fractures were reduced by closed reduction. Mean duration of surgery was 61 minutes. Average length of postoperative cast immobilization was 31 days. Follow up was 15 months. Patients were followed-up clinically and by X-ray at one-month, three-months, six-months, nine-months and one-year visits. Functional results were assessed according to Daruwala’s criteria. There were 22 excellent and 4 good functional results. The results of our study are comparable with single so far published investigation of Du & Han in 2019. We can conclude that anterograde ESIn is safe and reliable technique for treatment od unstable distal radius fractures.

We investigated the possibility of closed reduction with percutaneous needle fixation for the treatment of Jakob type III LHCF in children. The patients were divided into a closed reduction percutaneous K-wire fixation group (CR group) and an open reduction K-wire fixation group (OR group). We recorded the demographic characteristics, surgical data, postoperative complications, and elbow joint scores in all patients. Twenty-one cases were in the CR group and 20 cases in the OR group. All patients were followed up for an average of 23 months. Among the 25 children who attempted closed reduction initially, 21 cases (84%) successfully achieved acceptable reduction. The surgical duration and hospitalization in the CR group was shorter than that in the OR group, and the bleeding during operation was lower in CR group, and all of the differences were statistically significant. There was no statistically significant difference in fracture healing. In terms of postoperative complications, lateral bone protrusions occurred in 13 cases (61.90%) in the CR group and 8 cases (40.00%) in the OR group, with no statistically significant difference. None of patients had bone and joint infection, early closure of epiphyses, bone non-union, or necrosis of the humeral head. Nineteen patients receiving CR treatment (90.48%) showed excellent efficacy, and 18 children receiving OR treatment (90.00%) achieved excellent efficacy. There was no statistically significant difference between the two groups. In conclusion, CR could be attempted firstly, and it might not be necessary to open reduction in most children with Jakob type III LHCF.

Intro: Tibial tubercle fractures (TTF) are uncommon injuries, comprising less than 3% of proximal tibial fractures. Rarely, they occur in conjunction with patellar tendon injury (PTI). We aimed to compare reoperation rates and short term post-operative outcomes in patients with TTF versus combined injuries. Methods: A retrospective review of patients presenting to a single, children's hospital with TTF was performed. Demographics, operative details, injury patterns, complications, and post-operative milestones were analyzed. Operative reports were reviewed to identify concomitant PTI. Outcomes included reoperation, weeks to full weight-bearing and full range of motion (ROM), and return to sport. Patients with <4 months of clinical follow-up were excluded from analysis. Results: We Identified 117 fractures in 111 patients (mean age: 13.75±1.27, 5% female). 101 fractures were isolated TTF and 16 were combined TTF with PTI. There were 31 secondary surgeries in the TTF group (30 implant removal, 1 limb-length correction), and eight in the combined group (7 implant removal, 1 reinjury). There were four post-operative complications in the TTF group and one complication in the combined group. There was no significant difference in secondary surgery rates (p=0.128), complications (p=0.527). There was no significant difference in time to full weight-bearing (p=0.253), return to sport (p= 0.401), time to full ROM (p=0.863). Conclusion: There is no significant difference in early outcomes between isolated TTF and combined TTF and PTI patients. No current guidelines exist for management of combined TTF and PTI. Our data suggests combined TTF and PTI can be managed similarly to isolated TTF.

To compare the outcome of percutaneous reduction with K-wire internal fixation versus traditional open reduction with absorbable rod fixation in O’ Brien II, and III type radial neck fractures in children.
According to the surgical management, there were two groups: Group A underwent open reduction with absorbable rod internal fixation, and Group B underwent percutaneous prying reduction with K-wire fixation. We evaluated the elbow joint function and compared the trauma time, surgical duration, hospitalization costs, and postoperative complications between two groups. A total of 28 children were enrolled in this study, including 13 males and 15 females. Nineteen cases were O’Brien type II and 9 cases were type III radial neck fractures. There are 12 cases in Group A (open reduction) and 16 cases in Group B (percutaneous prying reduction). Compared with in Group A, there was shorter surgical time, lower hospitalization costs, and less bleeding in Group B. There was no early closure of the epiphyses, infection, iatrogenic nerve injury, or ischemic necrosis of the radial head in both groups. The elbow function was evaluated at the last follow-up, there was no statistically significant difference between the two groups. In conclusion, both methods could have achieved good prognosis in the treatment of O’Brien type II, and III radial neck fractures in children. There have the advantages of minimal trauma, shorter duration of surgery, low cost, and no increase in the incidence of complications in percutaneous reduction group compared with open reduction group, however learning curve is needed.

Introduction: This study aimed to assess the clinical efficacy of two surgical approaches and the practicality of two internal fixation materials for treating pediatric humerus lateral condyle fractures. Methods: A total of 28 children, 15 males and 13 females, who underwent surgery for humerus lateral condyle fractures between June 2016 and June 2020 were included in the study. Patients were divided into two groups: cannulated screw (group A) (n=12) and Kirschner wire (group B) (n=16). Operation time, Dhillon Score (DiS), Mayo Elbow Performance Score (MDPS), postoperative carrying angle, Baumann angle, and X-ray measurements of distal humerus anteversion angle were compared, and surgery-related complications were recorded. Results: Operation times were 44±16 minutes in Group A and 48±14 minutes in Group B, with DiS of 8.0 ±0.8 in Group A and 8.2 ±0.6 in Group B, and MDPS of 92 ±5 in Group A and 89 ±4 in Group B (p > 0.05). There were no significant differences in carrying angle, Baumann angle, or distal humerus anteversion angle between the groups (p > 0.05). At follow-up, excellent or good elbow joint function was observed in both groups. Complications included skin irritation in 2 cases in Group A and avascular necrosis of the lateral condyle and extension/flexion loss in 1 case each in Group B. Discussion: Both surgical methods showed comparable outcomes in terms of operation time, elbow function recovery, and X-ray measurements for pediatric humerus lateral condyle fractures. Both approaches can be effectively utilized for treating such fractures.

Introduction. Distraction regenerate fracture is a common complication after femur lengthening surgery in children. A possible way to prevent it is performing internal fixation after external frame demounting. A surgical technique “lengthening and then nailing or plating” is frequently used in adult. But this method has been neglected in children till recently due to the lack of proper internal fixators.

Materials and methods. The study included 56 patients(85 femora) that underwent femur lengthening surgery with Ilizarov apparatus. Group 1 ( with subsequent plating or nailing) included 45 femora. Group 2 (with no subsequent plating or nailing) consisted of 40 femora. Reference lines and angles, amount of elongation, external fixation index, number of complications were analysed.

Results. Mean elongation was 7±1,82 cm in group 1 and 7±1,79 cm in group 2 (p>0.01). External fixation index was 31±7,7 days/ cm in group 1 and 45±8,4 days/ cm in group 2 ( p<0,01). Distraction regenerate fractures were observed in 15% in group 2 and 0,45% in group 1.

Conclusion. Subsequent external and internal fixation in femur lengthening decrease overall treatment period and prevents distraction regenerate fractures in children.

Introduction
Developmental dysplasia of the hip (DDH) represents a prevalent and consequential pediatric orthopedic condition while certain prevention strategies were reported to elevate awareness of risk factors and prevention methods, improve diagnostic and management standards, and decrease the need for surgical interventions. Our research aims to innovate a targeted disease-specific care (DSC) for DDH.

Materials and Methods
Our multidisciplinary team formulate individualized care strategies in alignment with contemporary guidelines, and conduct ongoing reviews, audits, and educational initiatives. Our integrated referral network with regional obstetric and pediatric healthcare facilities bolsters our service delivery. We then evaluate the efficacy of DSC.

Results
Implementing DSC for DDH, we adopted a case management approach within a structured care pathway for diagnosis including alliances with obstetric and pediatric institutions, ultrasound screenings for newborns with risk indicators or positive clinical findings, and refined swaddling methods. These interventions led to improvements in alpha/beta angles, femoral head coverage, and International Hip Dysplasia Institute (IHDI) grading, alongside a marked reduction in necessity of surgical interventions. Our quality metrics indicate outstanding achievements: 100% DDH-related education rate, 0% surgery, 97% ultrasound screening rate for at-risk individuals, and a patient satisfaction score of 4.7 out of 5.

Conclusions
The application of DSC for DDH at our facility employs quality indicators for ongoing monitoring and evaluation of our care processes, facilitating both vertical and horizontal integration of services. This approach has enhanced clinical outcomes, promoted the healthy development of neonatal hip joints, and contributed to significant decrease in the necessity for surgical interventions.

Introduction: Kirschner wires (K-wires) fixation is a standard treatment for pediatric supracondylar humeral fractures, in which crossed two pins and lateral two pins are most used. However, the smooth nature of K-wires can lead to complications, including sinking into the skin or slipping off. To solve these problems, a K-wire fixation device (KFD) was developed to improve the fixation stability. This study aims to investigate the effect of the KFD on crossed two pins and lateral two pins fixation by finite element analysis. Method: The humeral model was reconstructed using computed tomography images of an artificial pediatric humerus. We set torsion and bending as finite elements, and measured strain, stress, and displacement of the K-wire in below conditions: 1. Whether the bridge device was used or not, 2. Different bone-bar distance of the KFD. Result: In torsion analysis, the usage of the bridge device effectively enhances the stability of fixation. Besides, the closer the bridge device is to the articular surface, the higher the stability of the fixation. Discussion: These results were simulated using a computer program. Their consistency with reality needs to be verified through further studies. Conclusions: The use of the bridge device in both crossed and lateral K-wire fixation reduces relative displacement between fracture fragments, improving fixation stability.