Introduction: Values for acetabular index (AI) were defined in 1976 based on a normal population - these are still used to diagnose DDH. We aimed to define a range of normal and dysplastic AI values in patients ‘at-risk’ of developing DDH. Methods: Babies born with risk factors for DDH were screened using plain radiography and followed up with radiographs and examination. Data were collected over a 9 year period and included demographics, risk factors and clinical examination. Serial AIs were measured on pelvic radiographs. Patients subsequently requiring any intervention were excluded. Results: 2548 AIs were measured from 1274 radiographs in 1000 children between the ages of 4 months and 4 years. All patients were treated with observation alone with clinical examination and/or repeat radiographs after a mean follow up of 11 months. In girls, the values for mean AI (left hips) and for severe dysplasia (+2 standard deviations) were: 24.1/33.7 at 6 months, 22.5/31.5 at 1 year, 23.3/32.1 at 2 years, 22.8/30.2 at 3 years, 19.8/28.1 at 4 years. The mean AI was higher at any age in girls and in the left hip. All hips remained clinically/radiographically stable throughout. Conclusion: Our results provide new reference ranges for AIs in at-risk children as opposed to the general population. Compared to current reference values, our values suggest that higher AIs may be tolerated where the hip is clinically and radiographically stable and reduced, potentially reducing the need for unnecessary intervention.

Objective To guide pediatric orthopedic doctors to pay attention to the morphological observation of the image by analyzing the measurement and classification of Graf hip ultrasound image. Methods A network questionnaire survey was conducted to collect the measurement and classification results of three hip ultrasound images of the participants, and make relevant statistical analysis. Results A total of 245 people participated in the questionnaire survey, and 215 valid questionnaires were collected. The measurement accuracy of the first image was 35.3%, the classification accuracy was 83.7%, the second image was 15.8% and 87%, the third image was 23.3% and 45.6%. Conclusion the classification accuracy of the three images is higher than the measurement accuracy, indicating that the measurement error in the actual work is greater than the classification error, suggesting that the clinical work can not simply judge whether the hip joint is normal according to the measurement angle, we should combine with the morphological observation of the image, so as to correctly interpret the ultrasonic report of the hip joint.

Introduction: In a developing country many children present with DDH at very late age when the child is walking. The outcomes of survival of femoral head and the morphology of hip in the long term mainly depend on the time of intervention to contain the femoral head in the acetabulum. We present our approach and outcomes in managing untreated DDH in a walking child. Materials and methods: This study included a total number of 64 children with 85 hips were treated and with a minimum follow up of one year. All children were treated with open reduction and capsulorrhaphy through a standard anterior approach to the hip. Femoral shortening and an acetabulopalsty were done as and when needed for the coverage of the femoral head. The children were evaluated clinically and radiologically for a minimum period of one year. Results: Open reduction was done in all children and acetabular procedure was required in 25 children, femoral shortening osteotomy in 32 children. 75% of the patients had hip stiffness during early postoperative period which resolved in 6 months. Re-dislocation was seen in 4 hips, and some signs of avascular necrosis was observed in 7 hips. Clinically as per McKay criteria all patients except three had excellent to good results Conclusion: DDH in a walking child can be managed with open reduction to give good functional outcome but carries more complication rates than early intervention. An additional procedures in selected patients is necessary for good concentric reduction of the hip joint.

introduction:Bladder exstrophy is a very rare developmental condition with a rate ranging from 1:10000 to 1:50000 in live births per year, the consistent part of the pathology is the associated musculoskeletal and genitourinary abnormalities, a defect in the midline of the anterior abdominal wall exposing the bladder is the most classic and common form, associated with pelvic bony.
Methods: 65 child were included in this retrospective prospective study who underwent the formal Sponseller’s osteotomy or Salter’s osteotomy cut to facilitate the urological intervention and closure either modern staged repair of exstrophy (MSRE) or complete primary repair, then the children below age of 2 years were put in the Spica cast with the position of flexion, slight abduction 10o and internal rotation for 6 weeks, while older than 2 years were stabilized using external fixator for 6 weeks.Failure was defined as urological wound dehiscence due to failure of achieving tension free repair and closure in the form of bladder dehiscence.
Results:65 osteotomies assisted closures were included in this study with the age ranging from one month to 11 years, they were 25 girls and 40 boys during the period from March 2016 to February 2023.17 Salter’s osteotomy were performed while 48 Sponseller’s osteotomy were performed, then the children were immobilized either in our modified Spica cast or pelvic ex fix .Out of 17 Salter osteotomy 7 failed with failure rate up to 41.2%, While Sponseller’s osteotomy showed failure in 2 patients of Sponseller’s osteotomy performed with a percentage of 5.4%

Purpose: Pediatric femoral neck fractures (PFNF) represent a rare injury with a high complication risk. Greater initial displacement is associated with increased risk of avascular necrosis (AVN) in adults. We aimed to compare complications and radiographic outcomes of children with displaced PFNF treated by open (ORIF) or closed reduction and internal fixation (CRIF) and investigate risk factors of AVN. Methods: Patients < 18 years treated for displaced PFNF over twelve years were included. Demographics, Delbet classification, intraoperative data, and complications were recorded. The greatest displacement on any x-ray projection was measured. Follow-up radiographs were graded by Ratliff’s criteria. Chi-Square or Fisher’s exact were used for categorical variables and the Student’s t-test was used for continuous variables. Results: Forty-one patients (54% male) were included. Average age was 11.8 (± 3.89) years. Treatment included 29 (71%) CRIF, and 12 (29%) ORIF with no differences in age, gender or mechanism of injury. The ORIF cohort had a shorter time-to-operation (9.35 vs 15.2 hours, P=.01), more Delbet Type 3 fractures (58% vs 21%, P=.03), associated injuries (33% vs 3%, P=.02), and greater initial displacement (19.2 vs 9.3 mm, P<.001). No differences in Lowell’s criteria or complications (P=.30) were observed. Three CRIF patients developed AVN, which was moderately positively correlated with preoperative displacement (r2=0.49, P<.007). Discussion: AVN only occurred in the CRIF group and was associated with greater preoperative displacement. This may have implications for the decision to open reduce femoral neck fractures in children but whether ORIF is protective against AVN warrants further investigation.

Introduction:
Leg-lengthening procedures are becoming increasingly popular to improve physical appearance or alleviate functional deficits caused by leg-length discrepancies. This case report aims to highlight the potential risks of uncontrolled leg-lengthening.
Case presentation.
A 22-year-old transgender male patient presented at our department due to uncontrolled femur lengthening of 11 cm following a bilateral leg-distraction procedure for aesthetical reason 5 months ago. Mechanical lengthening nails were used, and the lengthening process was achieved via rotation of the femur, accompanied by a clicking noise. The patient experienced uncontrollable clicking while walking, stretching, sleeping, and presented with a severe bilateral hip-extension deficit of 45°, consecutive hyperlordosis and severe pain requiring opioid therapy. After three months of physiotherapy no clinical improvement was achieved. Therefore, we indicated a revision surgery with nail exchange and a bilateral shortening of 2.5 cm. Following the operation, the patient was able to walk upright and discontinued pain medication.
Conclusion:
In our experience, a maximum leg-lengthening of 8 cm per operation due to soft tissue compromise can be recommended. Additionally, we prefer the use of magneto-mechanical nails, which can be controlled transcutaneously in both directions.

Introduction: Fibular Hemimelia (FH) is the commonest longitudinal limb deficiency. When it is associated with femoral shortening, there will be significant limb length discrepancy (LLD) that necessitates long treatment time and multiple settings to compensate for LLD. The objective of this study is to evaluate the outcome of simultaneous femoral and tibial lengthening using Ilizarov frame. Materials and Methods: This retrospective study included the cases of 12 children who have severe limb length discrepancy caused by combined FH and ipsilateral femoral shortening in the period from May 2014 and May 2021. The total LLD ranged from 7 to 14.5 cm. All patients underwent single session femoral and tibial lengthening using Ilizarov ring external fixator technique. Additional procedures were performed in the same setting and included Achilles tendon lengthening, fibular anlague excision, peroneal tendons lengthening and iliotibial band release. Follow up ranged from two to four years. Results: the planned limb lengthening was achieved in ten cases (83%). No cases of joint subluxation or dislocation were encountered. No neurovascular injury has occurred during the treatment course. The bone healing index was better on the femoral side compared to the tibia in all cases. Poor regenerate and deformity of the tibia occurred in two cases (16.6%). Conclusion: Simultaneous femoral and tibial lengthening using Ilizarov fixator is a relatively safe procedure with the result of correction total LLD in one session in a shorter time and less morbidity.

Clubfoot consists of four components: ankle equinus, forefoot adductus, hindfoot varus, and midfoot cavus. Ponseti technique is considered the golden standard treatment. Some literature has investigated the efficacy of accelerated Ponseti casting. However, few studies have reviewed the difference between those intervention systematically.the aim of the current study is to compare the outcomes of the accelerated and standard Ponseti method. Methodology: This is a systematic review and meta-analysis of relevant randomized controlled trials and nonrandomized comparative studies. A systematic search had been conducted to identify the relevant studies through PubMed, Google Scholar and Cochrane depending on PRISMA guidelines. Results: The review was conducted among 13 studies where eight studies were prospective comparative studies, and five studies were randomized prospective comparative studies which were published in the period between 2015-2022. Statistically, accelerated Ponseti showed superior impact over standard Ponseti considering duration of treatment (22.53 days vs 40.61 days, P<0.001). No significant difference was reported between the two methods considering final Pirani score (0.64 vs 0.56, P=0.194), number of casts ((5.23 vs 5.25), rate of tenotomy (66.2 % vs 63.1 %, ), relapse rate (9.51 % vs 8.54 %) and complication rate (14.4 % vs 13.1 %,).Conclusion: The present meta-analysis supports the published conclusions that the accelerated Ponseti method can achieve comparable efficacy to the standard method in terms of post-procedure Pirani score, tenotomy rate, relapse rate, complications rate, and number of casts needed by the patients with advantage of requiring shorter duration of treatment which is associated with more patient’s compliance.

Multiple epiphyseal dysplasias (MED) are a clinically and genetically heterogeneous group of skeletal dysplasias with a predominant lesion in the epiphyses of tubular bones. Variants in the SLC26A2 gene cause their autosomal recessive form (rMED or MED type 4). The accumulation of data regarding the genotype–phenotype correlation can help in the diagnosis and proper management of these patients. The aim of this study was to survey the clinical and genetic characteristics of 55 patients with MED type 4 caused by variants in the SLC26A2 gene. Diagnosis confirmation was carried out by radiography and custom panel sequencing consisting of 166 genes responsible for the development of hereditary skeletal pathology. This was followed by the validation of the identified variants using automated Sanger sequencing (for six patients) and the direct automatic Sanger sequencing of the coding sequence and the adjacent intron regions of the SLC26A2 gene for 49 patients. Based on the clinical and genetic analysis of our sample of patients, two main MED type 4 phenotypes with early and late clinical manifestations were identified. An early and more severe form of the disease was observed in patients with the c.835C > T variant (p.Arg279Trp), and the late and milder form of the disease was observed in patients with the c.1957T > A variant (p.Cys653Ser) in the homozygous or compound heterozygous state with c.26 + 2T > C. T primary analysis of these variants will contribute to the optimal molecular genetic diagnostics of MED type 4.

Early intervention is the best management of any health condition. This includes developmental dysplasia of the hip (DDH). DDH can be treated conservatively with early and precocious intervention to prevent any future surgical interventions. The impact of coronavirus disease-19 (COVID-19) pandemic on these cases remains controversial. This paper aims to review and summarize the published evidence of the pandemic’s impact on delaying the diagnosis and management of DDH. This systematic review protocol included searching various databases for English language studies published during the COVID-19 pandemic from 2019 to 2021. Six studies were included that met the inclusion criteria. Two of were retrospective studies, two were letters to the editor, one was a case report, and finally, one descriptive review. The first retrospective study was conducted in Turkey with a sample size of 935, and the second study was conducted in Italy in two centers with a sample size of 294. The Turkish study had 13 patients diagnosed with DDH, six of them had pathological hips compared to the two patients diagnosed in the year before the pandemic. Similarly in Italy, 28 patients in the pandemic period were diagnosed when compared to eight in the year before the pandemic. The case report that was conducted in Italy concluded that treatment is more complicated in a delayed diagnosis of DDH. Although screening programs can be considered a mode for transmitting infection of COVID-19, the risk of delaying diagnosis and management of DDH might become a heavier burden than treating the infection itself.

Background: limb length discrepancy can be caused in many ways one of the causes are warfare injuries especially in areas where there is war for example Afghanistan.
Objectives :Bone loss is not only a cosmetic concern but it’s also functional concern especially in lower limb, the main objective of our study is how to replace the bone loss to have an equal limbs . Methods : Thisdescriptive study is done from 2020/06/01-2023/03/30 on 40 patients in 300 bed Police Central Hospital and Mohammadi WARDAK Orthopaedic Hospital in Kabul .40(100%) patients had lower limb discrepancy. 38(95%)  patients were male ,age 12-35 years. 2(5%)  patients were females, age 15-35 years. The procedure of lengthening 2(5% ) patients with Intramedullary nailing along with Ilizarov , 4(10% )patients with Ilizarov external fixator ,2(5%)patients with fibula vascularized transportation.32(80% ) patients with Nasir Awais external fixators. According to the cause of bone lose, 8(20%) patients Mine explosions and 28(70%) patients due to Gun shout injuries.2(5%)patients with RTA and 2(5%) patients with osteomyelitis. Results: 40 patients with limb length discrepancy ranging from 5-20 cms average was 7cm that were included in this study.
A: 24(60%) Excellent result.  B: 8(20%) good results.C: 6(15%) poor results.D: 2(5%)complications, first patients infected and failed second patient was with nonunion.Majority of our patients were male and with G.S and Mine explosion. Conclusion: we used Nasir Awais External fixators more than others because it’s more easy to apply in a short time with simple technique of distraction.

Introduction : Congenital vertical talus is a rare disorder, more commonly associated with other neuromuscular condition with more rigid deformity and less favorable outcome. If not treated will end up with painful rocker bottom deformity which will affect the patient ambulation and quality of life. Surgical treatment is the treatment of choice but differ in the stages and types of incisions. The aim of this study is to evaluate the one stage correction of severe CVT secondary to arthrogryposis multiplex congenita ( AMC) , by complete subtalar release ( CSTR), through three incisions.Methods: 10 feet ( 6 cases ) has arthrogryposis , was operated upon by single stage complete subtalar release using three incisions, posteromedial , lateral and anterior mid leg incisions and talonavicular fixation by K.wire. Patients were evaluated clinically and radiologically with follow up average of 9.8 years ( ranged 7 to 19 years). Results : All cases have painless plantigrade feet . One case has avascular necrosis of the talus . Results based on clinical and radiological outcome according to scores modified from Zorer et al,2002. There are two excellent, 7 good and one fair results . There is significant improvement in the lateral talo-first metatarsal angles ,lateral tibiocalacaneal angle and lateral talocalcaneal angle and talonavicular relationship grade Conclusions: Surgical treatment of congenital vertical talus secondary to arthrogryposis by complete subtalar release using three incisions has good result clinically and radiologically with relative long follow up.

INTRODUCTION. To evaluate the role of MRI in developmental dysplasia of the hip (DDH) after closed reduction and casting.

METHODS
From 2020 to 2022, 19 infants (16 females and 3 males) with DDH type II C or more according to Graf classification, were prospectively enrolled. Between them 10 had a bilateral DDH, 10 had a bilateral DDH, for a total of 29 affected hips. All the patients underwent closed reduction and hip casting and had an MR examination after each casting. A total of 37 MR hip scans performed without sedation nor contrast medium were obtained.

RESULTS. MR examinations detected the position of the femoral heads in their acetabular cavities: 31 MR scans (84%) revealed well centered heads while 6 MR scans (16%) showed head luxation that needed new reduction and casting.
11/37 (30%) MR scans showed the presence of an hypertrophic acetabular labrum, of which 5/37 (14%) displayed a labral introflexion. 8/37 revealed the presence of joint effusion (22%), 1/19 patients developed an hypertrophic round ligament, as well as 1/19 patients showed the fibrofatty pulvinar hypertrophy and the presence of proliferative fibrous tissue in the joint cavity, the so called “limbus”.

CONCLUSIONS MRI is useful to assess the position of the femoral head after closed reduction without ionizing radiations (X-ray and CT scan) and can easily study also the extra-osseous structures of the hip joint, the morphology and signal of the labrum, the pulvinar and the round ligament, in order to help surgeons to choose the appropriate treatment strategies.