In our study we aim to evaluate and to identify the causes of failure of primary open reduction and determine the outcome of revision surgery in DDH. We identified patients who underwent revision surgery for DDH following primary open reduction done at our center or referred from other hospitals. The patients who underwent revision surgeries were followed up to assess the clinical and radiographic outcomes with McKay criteria and Severin classification respectively. A total of 22 patients who underwent revision surgeries and met the inclusion criteria were included in the study. The mean age of the patients at the time of revision surgery was 6.5years. The most common cause of failure of primary surgery were insufficient release of soft tissues, inadequate capsulorrhaphy, posterior acetabular deficiencies, shallow acetabulum, and improper position/ duration of immobilization with Spica cast. A majority of them required bony procedures during revision. At a mean follow-up period of 12 months, the radiographic outcome was Severin class 1 or 2 in majority of the cases and Severin class 4 in two patients. Clinically as per McKay criteria all patients except three had excellent to good results. There was significant improvement in acetabular depth ratio and acetabular index post revision surgery. We found that the main cause of failure of primary surgery was inadequate soft tissue release, insufficiency of acetabulum and improper position/ duration of immobilization with Spica cast. The outcome of revision surgery of DDH has good results if identified and intervened at early age.

Introduction: The aim of this study was to evaluate the early and mid-term results of patients who underwent Tönnis Lateral Acetabuloplasty (TLA) for developmental hip dysplasia (DDH). Methods: TLA was performed on 66 hips of 41 patients (36 girls, 5 boys), and evaluated retrospectively. The mean age of the patients was 32.3 months (11- 132 months). Bilateral DDH was present in 25 patients. According to Tönnis classification, 10 hips (15.1%) were classified as grade 2, 18 hips (27.2%) were classified as grade 3, and 38 hips (57.5%) were classified as grade 4. While 52 hips (79%) underwent adductor tenotomy and TLA, 14 hips (21%) underwent varization with femoral shortening osteotomy in addition to other treatments. Closed TLA was applied to 38 of 66 hips without opening the joint capsule. Acetabular index and lateral migration index (Reimer) were measured on preoperative and final control radiographs. The mean follow-up period was 27 months (12-47 months). Results According to McKay criteria, 51 hips (77.2%) were excellent, 10 hips (15.1%) were good and 4 hips (6%) were moderate. While the mean acetabular index was 36.1 degrees in the preoperative period, it decreased to 18.6 degrees in the postoperative period. Reimer index was 89.7% preoperatively and decreased to 10.5% postoperatively. Conclusion: Tönnis Lateral Acetabuloplasty was found to be a safe, effective, and successful treatment method with a low education curve in short-term follow-up of patients with DDH.

This study reports morphological findings of the femur in the Ortolani DDH specimens at Institute of Anatomy of the University of Padua. This collection comprises 14 normal and dysplastic infant dissections (28 hips) age newborn to one year who died of unrelated causes during the pre-antibiotic era. Anteversion angle was measured using a photographic and direct measurements. Femoral head diameters were measured with calipers. Four representative specimens were evaluated by high-resolution CT scan and were compared to the measured angles for validation. We identified 11 DDH cases and 17 controls. Mean anteversion was 30.8 degrees in DDH cases, and 29.7 degrees in controls This difference was not statistically significant. The mean difference between maximum and minimum head diameter was 1.07 mm in DDH cases, and 0.81 mm in controls. This difference was statistically significant. Ortolani's collection has great historical value, and has not been previously measured. The results of the present study show that anteversion values do not differ between cases and controls, even though there is a wide range of infant femoral anteversion in healthy and in dysplastic hips. Thus, increased femoral anteversion does not appear to be a primary pathogenic factor in the development of DDH. Difference between femoral head's maximum and minimum diameters is a slightly greater in cases than in controls. However, these findings do not explain whether this alteration is a cause or a consequence of hip dysplasia.

Background: DDH is a common paediatric Orthopaedic problem. The older child carries a different challenge in giving them a normal hip. We present our experience in dealing with such patients. Materials and methods: 104 children with 142 hips were evaluated and treated from 2006-2016 with a minimum follow up of 3 years. Children with idiopathic DDH previously untreated were included . All children were treated with open reduction and capsuloraphy. Femoral shortening, acetabuloplasty were done as and when needed. The children were evaluated radiologically, clinically and patient satisfaction were tabulated. Results: The mean age was 5 years (3-10years) of which 68 children had unilateral and 37 had bilateral dislocation. Open reduction, capsuloraphy was done in all with an additional acetabuloplasty in 13 children, femoral shortening in 45 children and both were done in 31 children. Inferior subluxation noted in 1 child, Re dislocation in 10 hips, and AVN in 17 hips. In the latest follow up according to Severin criteria 85.9% were type I and II while 14.1% showed type III and IV, no hips were rated as Severin V or VI. Conclusion: In our experience the late presenting DDH itself is an indication for an open reduction and capsuloraphy. A femoral shortening osteotomy improves stability and reduces incidence of re-dislocations and AVN of the femoral head. In cases of bilateral dislocations surgeries in the same sitting to yield good results. Giving the child concentric functional hip is possible even in cases of untreated DDH in a walking child

Introduction: Accurately timed epiphysiodesis is effective in addressing leg length discrepancy (LLD) at skeletal maturity. Melenaus 'rule of thumb' arithmetic method and Paley multiplier method are convenient and commonly used for predicting final LLD and timing epiphysiodesis, but no gold standard exists. We aim to identify the best method in predicting LLD after epiphysiodesis in children. Methods: Patients who received epiphysiodesis during 1990-2017 with follow up until skeletal maturity were screened. Guided growth for angular deformities, limb lengthening, or patients with incomplete follow up were excluded. Actual LLD was compared against predictions calculated using the 'rule of thumb' and multiplier methods as originally described. The primary outcome was prediction accuracy, in terms of difference between actual and predicted LLD. Results: 106 growing physes and 86 epiphysiodesed counterparts in 96 segments were included. The mean difference between actual and predicted LLD was -12.7 +/- 10.4 mm using 'rule of thumb' (p<0.001), and -19.1 +/- 13.8 mm with multiplier method (p<0.001). Both methods were inaccurate, as differences were statistically significant. As skeletal age was different from chronological age (p<0.001), we devised modifications using skeletal (instead of chronological) age. The ‘modified rule-of-thumb’ generated the most accurate predictions with mean difference of -0.46 +/- 8.19mm, while the ‘modified multiplier method’ produced mean difference of -3.5 +/- 10.7mm. Conclusion: 'Rule of thumb' and multiplier methods per originally described are inaccurate for children in our study. The best method is the modified rule-of-thumb using skeletal instead of chronological age.

Purpose: Traditional infant swaddling or binding with hips and knees extended is a known risk factor for Developmental Dysplasia of the Hip (DDH), while ‘hip-safe swaddling’ with hips and knees flexed is believed to eliminate this risk. We conducted a survey to determine the prevalent practices for infant swaddling in India; why mothers practice swaddling and who teaches them; and whether Paediatricians, nurses and caregivers are aware of hip-safe swaddling. Methods: Anonymous one-time surveys were conducted in three groups – Paediatricians, Nurses and caregivers – at a tertiary-care, urban based, paediatric and maternity hospital. Results: Forty-five paediatricians, 219 nurses and 100 caregivers were surveyed. Ninety percent caregivers practiced traditional swaddling, for on average 10.2 hours a day, starting soon after birth, up to 4.2 months of life. Traditional swaddling was advocated by 99% of nurses and 53% of Paediatricians. Reasons for swaddling included sleep, warmth and the misbelief that the child’s legs would remain bowed if not bound straight; contrarily few mothers (8%) avoided swaddling out of superstition. Mothers learnt swaddling mainly from relatives (94%) and nurses (64%). Most nurses (70%) had learned the practice during nursing training. Only 6.6% of Paediatricians, 4% of caregivers and 0% nurses were aware of ‘hip-safe swaddling’. Conclusion: Traditional swaddling of infants is a practice deeply rooted in many cultures, born out of misbeliefs, and propagated by lack of awareness. Training in hip-safe swaddling targeted at nurses and Paediatricians, would be an effective initial step in creating awareness among mothers and changing their practices.

Introduction: Since 2017, five Indian centres have enrolled into the International Hip Dysplasia Registry for prospective collection of data on Developmental Dysplasia of Hip (DDH). Aims: To assess how baseline patient characteristics and initial treatment modalities differ across these five centres. Methods: Registry data collected over three years was analyzed. Children with DDH that had radiograph-based diagnosis were included. Results: Collectively, there were 234 hips (186 patients), of which 218 had undergone surgery. Overall, median age at presentation was 25.3 months (IQR16.82–45.04); female/male ratio was 2.6:1 (range 1.46–4.75:1); with 42%, 29% and 29% unilateral left, bilateral and unilateral right hip dislocations respectively. Most were IHDI grade IV dislocations (77%). Closed reduction was performed at all but one centre, at median 15.34 months (IQR9.56–21.10). Open reduction (OR) as a stand-alone procedure was performed at all centres, at median 20.84 months (IQR15.43–24.89). Combination of OR with a single osteotomy, femoral (FO) or acetabular (AO), was performed at all centres at median 29.69 months (IQR22.08–43.54). However, for the same age group, three centres exclusively performed FO, whereas the other two exclusively performed AO. The combination of OR with both FO and AO was used at all centres, at median 53.36 months (IQR42.05 – 70.78). Conclusions: The preliminary findings of this multi-centre study indicate that there are significant differences in patient demographics and treatment protocols at the five Indian centres. Comparison of treatment regimens, using ‘centre’ as a predictive variable, should allow us to identify protocols that give superior outcomes.

Fractures of tibial tuberosity in adolescents are rare, with an incidence of 0.4% to 2.7%, mainly affecting young males, aged between 12-16 years.
The injury mechanism is a violent active knee extension or passive flexion against a contracted quadriceps, usually caused by a jump with incorrect ground return. These types of lesions are characterized by a fracture line that crosses the physis of the tuberosity, penetrating the ossification nucleus. It is important to make a differential diagnosis with Osgood-Schlatter disease.
Case 1: A 14-year-old male, went to the emergency department after a trauma to the proximal 1/3 of his left leg during sports. At the emergency room, he had pain in the palpation of the tibial tuberosity associated with edema. Difficulty performing flexion of the left knee.
Case 2: A 12-year-old male adolescent went to the emergency department after high-energy trauma to the left knee. He had diffuse pain on palpation of the left knee, associated with moderate joint effusion, associated with functional impotence of the affected limb.
In both cases, the X-ray revealed a fracture / avulsion of the left anterior tibial tuberosity with significant deviation (> 5 mm) - Ogden Type II and III. In both cases, closed reduction and osteosynthesis of the tibial tuberosity were performed with cannulated screws, under control with fluoroscopy.
Fractures of the tibial tuberosity are uncommon and can be easily undiagnosed. While most require surgical treatment, the outcomes are mostly sucessfull.

Introduction: Pediatric trigger thumb(PTT) is a condition of flexion deformity of the interphalangeal(IP) joint in children. There have been debates about the results of surgical treatment in older children, even though many studies showed excellent results in PTT. Although the surgical outcome is satisfactory, the indications for nonoperative treatment for this condition are not clear. The purpose of this study is to evaluate the treatment results according to the treatment methods and age, and present the criteria for when and what treatment should be performed. Materials & Methods: Data on 166 thumbs in 137 children were collected prospectively. We divided patients according to treatment methods into surgery group and conservative treatment group and according to age into two groups( A: under 4 years, B: over 4 years). We investigated the presence or absence of IP joint flexion deformity, triggering and complications. Results: In surgery group, 92% of group A and 96.5% of group B were experienced complete symptom relief but there was no statistical significance. In conservative treatment, the younger age group had the higher rate of recovery. The older patient also showed about 50% of patients spontaneous resolution. Conclusions: Conservative treatment of trigger thumb in children showed a high rate of success, especially in young age group. Surgical treatment for over 4 years of age resulted in successful resolution of trigger thumb and satisfactory clinical outcome. We can expect satisfactory results of surgical treatment in PTT even in the case of delayed diagnosis or late treatment.

Background: Distal radius fractures in children are known for redisplacement after manipulation. Cast index (CI) is a measure to indicate how well the cast is moulded to the contours of the forearm. the aim of this study is to evaluate its predictability to secondary loss of reduction in distal forearm fractures in children. Materials and Methods: 127 patients with a mean age of 7.2 years (range: 2–15 years) were included in this retrospective study. All patients underwent manipulation in the operation theatre under general anaesthesia and a moulded below elbow cast was applied. The CI was measured on follow up radiographs and redisplacement was noted. Redisplacement was defined as more than 15 degrees of angulation and or more than 50 percent of translational displacement on check radiographs at 2 weeks. Results: Redisplacement occurred in 12 patients (9.4%). The mean CI in these 12 patients was 0.89, which was significantly greater than the mean CI in the other children (0.76). Of these (81%) with a CI of less than 0.8 the displacement rate was 3.8%. patients (19%) with a CI greater than 0.8 the redisplacement rate was 33.3%. Conclusion: The CI is a simple and reliable tool to Predict redisplacement following closed manipulation of distal forearm fractures in children. A high CI in post-manipulation radiographs indicates increased risk of redisplacement and must be avoided while moulding the cast.
Keywords: Children, cast index, conservative treatment, distal forearm fracture

Introduction: Paediatric and adolescent forearm fractures continue to present treatment challenges. Traditional guidelines for nonsurgical treatment have been challenged in favour of surgical intervention. Methodology: prospectively studied 196 children presented with closed diaphyseal fractures managed conservatively from 2016 to 2019. Acceptable reductions maintained in above elbow POP were followed at regular interval. Factors like demography, pre and post plaster angulation, quality of reduction, cast index, cast related complications, failure of reduction, after plaster removal forearm length, wrist / elbow range of movements, supination pronation arc and duration of clinic-radiological unionwere noted and analysed. Results: Majority of children were male. The overall re-displacement rate was 18% out of which in only 20% of cases fell into unacceptable category. Majority of re-displacement occurred between first to 3rd week. Evaluation of range of motion at the latest follow-up showednormal elbow and wrist motion in all patients.Multivariable analysis showed that age, laterality, type of fracture, initial angulation more than 10 degrees, poor reduction, cast index were related with re-displacement. Out of fractures continued with conservative method about 94% showed excellent to good results at 6th month follow up.At the latest follow-up, none of children had no subjective symptoms. None of the patients had nerve dysfunction after treatment. No complex regional pain syndrome was encountered in any of them. Conclusion: Conservation treatment of paediatric and adolescent both bone fracture forearm is a viable modality with excellent to good clinico- radiological outcomes in majority of patients but these results are dependent on factors analysed for re-displacement

Background: Transverse and oblique deep inferior epigastric artery perforator (DIEP) flaps are used to reconstruct small and large wounds. This report presents our experience in choosing different perforators for designing transverse and oblique DIEP flaps based on an anatomical study and clinical cases.Methods: A detailed anatomical investigation of the DIEP flap was conducted using a standardized injection of lead oxide in 10 fresh cadavers. Thirty-five boy patients (age 5 – 12 years) underwent lower extremity reconstruction with a DIEP flap. A transverse DIEP flap was used when the defect template did not exceed zone IV, while an oblique DIEP flap was used when the defect template exceeded zone IV. Results: Perforators located below the umbilicus in zone I and II were rich in transverse anastomoses across the midline of the abdominal wall, which is the basis for the transverse DIEP flap. Perforators lateral to the umbilicus in zone I had true anastomoses with the musculophrenic artery, which is the morphological basis for the oblique DIEP flap. The DIEP flap design was transverse in 20 patients and oblique in 15. Flap sizes ranged from 8 × 4.5 cm2 to 24 × 9 cm2.Conclusions: The transverse DIEP flap design based on the perforator located below the umbilicus in zone I is recommended for small skin and soft tissue defects. The oblique DIEP flap design based on the perforator lateral to the umbilicus in zone I can be used as an extended flap for large defects, without poor perfusion in the distal part.

Juvenile osteochondritis dissecans (OCD) injuries of the knee are a relatively common cause of gonalgia in young people who have not yet reached skeletal maturity, with rising incidence.
A retrospective study was carried to identify all consecutive cases of skeletally immature patients to whom knee OCD lesions were surgically fixed, from 2014 to 2019. Fixation result was evaluated with X-ray and MRI at latest follow-up. Functional outcome was evaluated with Lysholm score and Hughston rating criteria.
11 patients, 6 male, 5 female with mean age 14 years (13-16), all with lesions in the medial femoral condyle, mean pre-operative symptoms duration of 22,4 months (18-44) and mean follow-up of 19 months. At the end of the follow-up, 10 of the 11 patients had radiographic signs of integration of the osteochondral fragment. All scored 4 in the Hughston rating criteria, and improved their Lyshom score during follow-up with a mean at latest follow-up of 97. It was not necessary to reintervene any patient, nor were there any complications resulting from the surgical procedure.
Our results are consistent with the available literature, internal fixation of the unstable osteochondral fragment allows for adequate stability. Although there is a slight decrease in functional scores in the medium term, the fixation of OCD permit the return to daily and moderate activities with only residual symptoms and final satisfactory results.