Limb salvage and deformity correction have always been a vexing challenge for orthopaedic surgeons. The Ilizarov method of gradual correction has produced remarkable results and has been adopted worldwide as the last resort in the management of complex deformities. However, frame construction can be complicated and fine adjustments may not be possible without repeated visits to the operation theatre. With the adoption of the six-axis correction systems, it is possible to correct complex deformities with greater reproducibility. A single visit to the operating room is usually enough since all future adjustments can be simultaneously fine-tuned at any given point of time during the course of treatment.
Methods: 7 patients, aged under 10 years, with complex juxta-articular deformities, desirous of deformity correction, underwent a meticulous deformity analysis using a surgical planning software (Bone Ninja mobile application) on full-length radiographs of both limbs. The mechanical axis deviation (MAD), joint orientation angles (JOA), limb length discrepancy (LLD) and angular correction desired were recorded and a simulated correction was performed. After the surgical intervention (percutaneous osteotomy and fixator application), a software derived prescription for correction was obtained. Post-correction full-length x-rays were analyzed with the earlier planning software to assess the post-correction MAD, JOAs and LLD.
Results: There were no significant differences (P > 0.05) between the corrected values obtained with the planning software and those obtained post-operatively using the six-axis frame.
Conclusion: The simplification of treatment, upon adoption of this technological advancement, holds great promise and would benefit our clientele immensely.

Free vascularized fibular graft (FVFG) is one of the good surgical treatment procedure for congenital pseudarthrosis of the tibia patient(CPT). But limb-length discrepancy would occur frequently after treatment. The purpose of this study was to investigate the surgical results, complications and long term results of limblengthening after FVFG in the treatment of CPT.
Methods: Between 1978 and 2018, twenty four patients (12 females and 12 males) with CPT were treated at our
clinic with free fibula transfer. The mean age at the time of operation was 7.3 years (range, 1–40 years). After reconstruction with FVFG, was maintained with Ilizarov external fixation in all cases. Average postoperative follow up time was 8 years (range, 4–19 years). In all patients, both ends of the graft healed. Eight patients suffered from limb-length discrepancy due to differencing of limb growth against unaffected side after FVFG. We performed limb-lengthening for all 8 patients. Results: The mean age at the time of limb-lengthening was 15.2 years old. The mean limb length discrepancy was 5.8 cm (range 3.5 to 13cm) before lengthening. The mean length of distraction was 5.4 cm. The mean external fixation index was 48.2 days/cm (31–94.3). Complications were in the form of ankle arthrodesis in two patient, pin tract infection in six and residual shortening in six patients. Conclusion: In all cases, the complication rates were low. The complications are similar to other distraction procedure against native bone. In our experience, the limb-lengthening was possible procedure after FVFG for CPT patient.

Introduction: Various types of corrective osteotomies of the distal femur have been described in the literature for genu valgum deformities such as the lateral opening wedge, medial closing wedge, dome osteotomy. Objectives: We aimed in this study to evaluate the effectiveness of medial closing wedge osteotomy with K-wire fixation in correction of the deformity.
Materials and Methods: This study was done on 10 knees (7 patients) with ages ranging from 10 to 18 years with a mean
average of 13.61 ± 1.28 years. After recording history and physical examination, appropriate radiographs were taken.
We did varus distal femoral osteotomy then followed the patients clinically and radiographically. Results: Mean
operation time was 90.72 ± 10.4 minutes. The mean time to union of osteotomy was 9 weeks (ranging from 7 to 11 weeks). The mean preoperative LDFA was 72.5° improved after surgery to a mean postoperative value of 88.57° which was statistically significant (P < 0.001). Conclusion: Distal femoral closed wedge osteotomy with K-wire fixation can be a reliable procedure for the treatment of valgus knee deformity. Keywords: Genu valgum, closed wedge, Osteotomy.

Introduction: A frontal knee plane deformity in adolescents and young adults needs a corrective osteotomy to realign the mechanical axis. A traditional wedge osteotomy has the drawbacks of limb length discrepancies and translation deformities, which are not seen with focal dome osteotomy. Our study evaluated outcomes after femoral supracondylar focal dome osteotomy in children and young adults with frontal knee plane deformities in a tertiary care hospital. Methods: Our prospective study included 15 children/young adults with lower limb deformities eligible for surgery. These patients underwent a focal dome osteotomy, post which they were evaluated clinically, radiologically, functionally and cosmetically immediately after the procedure, and at 1.5 months, 3 months and 6 months, thereafter. Results: 16 distal femur focal dome osteotomies were done in 15 patients with frontal knee plane deformity. Clinically, the tibiofemoral angle and the Q angle were restored to normal post-surgery. Radiological evaluation confirmed that the anatomical and mechanical lateral distal femoral angle (aLDFA and mLDFA) was restored to normal in all patients with a mean aLDFA of 87.12° and mean mLDFA of 88°. Hospital of Special Surgery (HSS) scoring for functional outcome showed significant improvement with a score at 6 months being 86.38 (excellent). 6 month range of motion was restored back to normal. Cosmetic visual analogue score (VAS) and Patient Satisfaction Scores demonstrated good outcomes. Conclusion: Correction of frontal knee plane deformities in children and young adults, with a supracondylar femoral focal dome osteotomy, gives good clinical, radiological, functional and cosmetic outcomes.

Introduction : Blount’s disease is due to an idiopathic defect in the posteromedial proximal tibial physis resulting in increasing bowing of the leg in addition to lateral knee thrust with Lateral collateral ligament laxity.
Our rationale is to improve temporary epiphysiodesis of the fibula and tibia through guided growth by cannulated screws to solve the problem of lateral collateral ligament laxity.
Methods : This is a retrospective study conducted on 23 limbs with tibia vara treated between 2010 and 2017 followed up for 2-6 years. Ages ranged from 9–13 years with a late onset type Blount disease.
We used a percutaneous transphyseal fully threaded screws traversing the proximal tibial lateral hemiepiphysis, and another screw inserted traversing the proximal fibular epiphysis.
Results: There was a statistically significant improvement of the radiographic parameters especially in the form of joint line congruence angle (JLCA) in both supine and standing positions. All patients were clinically and radiographically completely corrected without complications, except one patient with surgical site superficial infection, treated medically.
Conclusion : Fibular guided growth surgery with lateral proximal tibia epiphysiodesis Is a minimally invasive technique which improves the corrective power of hemiepyphysiodesis of posterolateral compartment of the knee.

Background：The objective of this study was to report the midterm outcomes and complications of ankle Dias-Tachdjian pronation-eversion external rotation (PEER) physeal
fracture in children treated by ORIF with combined medial and lateral incision.
Methods：A total of 21 children with ankle Dias-Tachdjian PEER physeal fracture underwent open reduction internal fixation treatment with combined medial and lateral incision between January 2015 and October 2017. The lateral distal tibia angle (LDTA) was measured to evaluate angular deformity and the X-rays were taken to evaluate the premature physeal arrest.
Results：All patients were followed up for an average time of 20.1 months (ranging from 17 to 25 months). Bone healing was achieved in all cases. American Orthopedic Foot and Ankle Society Ankle and Hindfoot (AOFAS-AH) score of the patients improved from median 31 (11, 38) preoperation to median 68 (63, 73) postoperation to median score 91 (87, 96) at last follow-up. LDTA of the patients improved from 70.5 ± 4.9 preoperation to 90.0 ± 1.2 postoperation, to measure 90.6 ± 3.7 at last follow-up. The differences were statistically significant (P < 0.05). There is no premature physeal closure, ankle deformity in 19 cases. They could normally exercise and take part in normal sport activities. The remaining two cases had physeal bone bridge and premature physeal closure but could still carry on daily activities and thus were categorized as good.
Conclusions：ORIF with one-stage medial-lateral combined incision for ankle Dias-Tachdjian PEER physeal fracture can decrease the rate of premature physeal closure and should be a treatment choice.

Background：Hemiepiphysiodesis, osteotomy correction and gradual correction using external fixation have been applied to treat pseudoachondroplasia (PSACH) patients’s lower limb alignment deformities, but the standard treatment is controversial. Methods: We reviewed our PSACH patients who were operated in HKU-SZH during 2015-2021. Clinical information was collected. All patients had minimum one-year of follow up post-operation.Results:A total of 15 (7 Males, 8 Female，age median 5.7) PSACH patients were included. All were treated with surgeries because of lower limb alignment deformities (14 genus varum,average mTFA=34,average MAD=5.3cm; 1 genu valgum,mTFA=24.5, MAD=3.6cm combining with 4 knee flexion contracture). The treatment methods included 6 cases of hemiepiphysiodesis with 8-plates and only two mild patients showed alignement improvement(mTFA 21 to 9, MAD 3.6cm to 1.7cm). Nine patients receiving osteotomies achieved good postoperation alignment of lower limbs in coronal and sagittal planes, and maintained to the latest follow up (average 1.5 years,mTFA=5, MAD=0.7cm). Two patents (2 femurs and 2 tibias,age 14 and 17) underwent staged operations with limb lengthening and deformity correction using external fixation followed by plate fixation due to severe deformity(mTFA=15, MAD=2.7cm). The complications included one common peroneal nerve palsy, one pin tract infection, and two cast migrations. Conclusion:Hemiepiphysiodesis with 8-plate has limited ability to correct the lower limb deformities. Our case series suggested that early osteotomy correction is safe and effective. It is recommended to prevent deformity progression and ligamentous laxity. Gradual correction with external fixation is suitable for more mature patients requiring correction for severe deformity.

Introduction:WNT1 (type XV) mutations represented the biggest group of autosomal recessive OI in China. WNT1 signalling plays critical roles in bone healing and remodelling. However, long term results of the treatments were rarely reported. Our review may provide valuable information about this group of patients. Objectives:This research aims to understand the clinical characteristics of Type XV OI patients and to help develop treatment protocol.Method:Retrospective review of type XV OI patients admitted to HKU Shenzhen Hospital between 2014 and 2021. The genetic mutation profiles were confirmed. Information including the onset of disease, number of surgeries, use of medication, X-rays, and BMD were reviewed. The mobility metrics included GFAQ and FMS were used to evaluate the patients’ function. Results:23 (10 males,13 females) type XV OI patients were reviewed. Seven novel mutations of WNT1 were detected. They suffered from moderate to severe types of OI. The mean Z score of BMD before and after treatment were -5.2 and -3.2 respectively. Scoliosis was observed in 13 patients (56.5%), with two underwent spinal surgeries. Six (26.0%) had unilateral ptosis. 20% of the patients required walking aid. 40% of patients required revision surgeries due to Rush pin migration. Younger patients who received limb surgeries plus bisphosphonate treatment could have higher GFAQ (3.6v.s.2.1)and FMS scores(3.6v.s.2.1) than older patients.Conclusions:Type XV OI, seems to have with relatively more Rush pin migration. More attention is needed for such patients in clinical practice. Early surgical interventions are recommended for Type XV.

Introduction: Repair and reconstruction of Congenital Pseudoarthrosis of Tibia is often difficult, and use of osteogenic materal in form of autograft is essential for suitable outcome. However, it is associated with additional invasive procedure and graft site morbidities. Use of allograft in traumatic bone defects is rising with comparable results. We present preliminary results of our new innovative technique of using allograft and bone substitutes in treating congenital pseudoarthrosis of tibia with suitable outcome. Methods: Five patients with CPT were treated with standard surgical steps of corrective osteotomy, excising the diseased periosteum, freshening the bone edges, approximating them and fixing with intra-medullary implant. However, instead of autograft, freshly removed and processed allograft (from TKR surgery) was used along with the bone substitutes. Age of patients ranged from 3 years to 9 years. Allograft union and complications were assessed using clinical and radiological evaluation. Results: All three patients showed bony consolidation within 5 months. All three patients had superficial wound breakdown which recovers gradually. LLD was expected as it was not tackled at the time of surgery. All three patients started weight bearing in cast after 3 weeks. Average follow up of patients is 2 years. Conclusions: Allogenic bone graft in CPT could be an effective strategy with acceptable therapeutic effects, avoiding the problems of additional trauma at autologous bone graft donor site. However, long term follow up study with good amount of cases is needed for better world wide acceptance.

Introduction: Blount disease is multiplanar abnormalities consisting of tibia vara, procurvatum,internal rotation and disordered endochondral ossification. a depression of the medial tibial plateau causes joint incongruity and instability. Elevation of the medial tibial plateau with double osteotomy are recommended to obtain a well-aligned lower extremity with normal joint orientation. whether to use acute or gradual correction is still a matter of debate. Patient and method: This technique was performed for 16 limbs who underwent correction of neglected blount disease by elevation of medial plateau depression acutely and correction of the proximal tibial deformity by metaphyseal open wedge osteotomy and gradual correction using circular external fixator. The Patients were evaluated by assessing the(mMPTA, medial plateau depression angle and JLCA). Results: At a mean follow-up of 40 months,The mean mMPTA increased from71.25° to 84.33°. The mean medial plateau depression angle decreased from 53° to 6.12° and the mean JLCA from 19 ° to 3°.). Conclusion: Acute correction is a more accurate method of restoring joint orientation as Accurate assessment and reduction of posteromedial slope of tibial plateau with gradual correction can be challenging. One other hand, the Gradual correction appears to be a safe and reliable means of treating proximal tibial deformity as partial recurrence of deformity appeared to be due to under correction and subsequent worsening of the proximal tibial osteotomy and not collapse of the plateau elevation. So, with combination of acute and gradual technique the deformity is corrected, the articular surface is restored, and future recurrence can be reduced.

Background: Coronal knee deformities are common during childhood. Surgical treatment options include osteotomy or guided growth surgery. Osteotomy is considered the gold standard. However, it has been associated with increased expenses and morbidities such as overcorrection or undercorrection, neurovascular injury and recurrent deformity. In this series, we aim to prospectively evaluate the clinical and radiological outcomes of a new, less invasive percutaneous technique for managing coronal knee deformities in children. Methods: Thirty patients (52 knees) were enrolled in our study. Ten were males, and 20 were females. Their age ranged from 4 to 8 years. Thirty-eight limbs had genu valgum, while fourteen limbs had varus deformity. Eight patients had leg length discrepancy (LLD), ranging from 4 to 8 cm. All patients underwent percutaneous osteotomy. Fixation was achieved using pins incorporated in a cast. Patients were followed up for clinical and radiological correction for 6 months. Results: The range of hospital stay was 1 to 2 days. All osteotomies healed successfully after a mean of 2 months. Tibiofemoral angle and mechanical axis deviation significantly improved at the last follow-up. None of the patients had residual deformities or LLD. All patients reported a satisfactory outcome except two patients who had lost the last 5° of knee flexion. Superficial pin tract infection occurred in 5 patients, but no neurovascular injuries or deep infections occurred. Conclusion: The percutaneous technique is a safe and effective method for acute correction of coronal knee deformities in children.

Aims: Growth disturbances after transphyseal paediatric ACL reconstruction have led to the development of physeal-sparing techniques. However, evidence in their favour remains weak. This study reviews the literature to identify factors associated with growth disturbances in paediatric ACL reconstructions. Materials and Methods: Web of Science, Scopus and Pubmed were searched for case series studying paediatric ACL reconstructions. Titles, abstracts, text, results and references were examined for documentation of growth disturbances. Incidences of graft failures were also studied in these selected studies. Results: 78 studies with 2693 paediatric ACL reconstructions had 70 growth disturbances (2.6%). Of these 17 were varus, 26 valgus, 13 shortening, 14 lengthening and 5 patients had reduced tibial slope. Coronal plane deformities were seen more frequently with eccentric physeal arrest and lengthening with intraepiphyseal tunnelling. Shortening and reduced tibial slope were related to large central physeal arrest and anterior tibial physeal arrest respectively. Extraphyseal techniques were least likely to have growth disturbances. 62 studies documented 166 graft failures in 2120 patients (7.83%). Conclusion: Growth disturbances resulting from transphyseal ACL reconstruction can be minimised by keeping drill size small, drilling steep and away from the physeal periphery. Insertion of a bone plug, hardware or synthetic material through the drilled physis should be avoided. The evidence to accurately quantify such growth disturbances till skeletal maturity remains weak. Robust long term studies such as national ligament registries may standardise preoperative and postoperative outcome assessment to further characterise the risk of growth disturbance and re-ruptures.

Intramedullary nailing assisted with Poller screws have been used for reduction of fractures, their use has recently been introduced in deformity correction. Current study investigates the effectiveness of intramedullary interlocking nail guided by Poller screws for accurate correction of long-bone deformities. Nineteen patients with severe genu-valgum and varum of tibia and femur with magnitude of deformity ranged from 18°-32° were included. Retrograde intramedullary nailing was used in femur and ante-grade nailing in tibia. C-arm guided AP Poller screw was passed to mark the trajectory of nail in metaphyseal area and percutaneous osteotomy was done. After reaming, an appropriate size intramedullary interlocking nail was passed and proximal and distal locking done. Patients were allowed knee range of motion on first post-operative day. Patients were kept non weight bearing for 6 weeks and after that weight bearing was allowed. The age range of the patient included was between 14-38 years, among them almost 54% were males, 62% had bilateral deformity, 54% had deformity in both femur and tibia, 38% had only in tibia and 8% had in femur. 54% patients had valgus deformity, 30% had varus while 15% were having windswept deformity. All the deformities were corrected within 5° of mean reference value. During 6 months of follow-up only one valgus patient developed foot-drop after surgery and in one varus patient there was loss of correction by 10 degrees (25 degree correction done initially). Lower limb deformities can be corrected satisfactorily with the help of interlocking nail guided by Poller screws.

Diaphyseal forearm fractures are the second most common fractures in adolescents. Functional loss resulting from residual angulation or rotation demands anatomical reduction. Few studies have assessed the outcome of TEN for forearm fractures. We recruited 16 children of 5-16 years over a period of 2 years with minimum follow up of 6 months. Children with type 3 compound fractures, fractures with Neurovascular deficits and pathological fracture were excluded. In our study, 14 were male, 2 were female. Mean age was 10 years. Fall on outstretched hand was the most common mode of injury (81.3%). Right side was more commonly affected. 50 % were located in middle one third; 56.3 % were transverse, 37.5% were short oblique and 6.3 % were comminuted fractures. Mean canal size of radius was 3.81mm and ulna was 2.4mm. There was no significant relationship between nail-canal ratio and incidence of complications. Nail extrusion was present in three patients (18.75%) and skin irritation in 2 patients (12.5%). All patients gained full range of motion by 12 weeks postoperatively. Our patient series showed good functional outcomes for unstable paediatric both bone forearm fractures when treated with elastic stable intramedullary nailing with minor complications. We conclude from our results that Titanium Elastic Nailing is a relatively novel method of internal stabilization of unstable pediatric forearm diaphyseal fractures. Minor complications which we encountered can be avoided by following the basic principles of elastic nailing. Keywords : TEN, Paediatric forearm fractures

Background: Observing serious adverse events during treatment with the Precice Stryde bone lengthening nail (NuVasive, San Diego, CA, USA), we conducted a nationwide cross- sectional study.
Aim: To report the prevalence of adverse events from all 30 lengthened bone segments of the 27 patients treated in Denmark.
Materials and Methods: Radiographs of all bone segments were evaluated regarding radiographic changes in February 2021.
We determined the number of bone segments with late onset of pain and/or radiographically confirmed osteolysis, periosteal reaction, or cortical hypertrophy in the junctional area of the nail.
Results: In 30 bone segments of 27 patients we observed radiographic changes in 21/30 segments of 20/27 patients, i.e., 19/30 osteolysis, 12/30 periosteal reaction (most often multi-layered), and 12/30 cortical hypertrophy in the area of the junction between the telescoping nail parts. Late onset of pain was a prominent feature in 8 patients. This is likely to be a prodrome to the bony changes. Discoloration (potential corrosion) at the nail interface was observed in multiple removed nails. 15/30 nails were still at risk of developing complications, i.e., were not yet removed.
Interpretation / Conclusion: All Stryde nails should be monitored at regular intervals until removal. Onset of pain at late stages of limb lengthening, i.e., consolidation of the regenerate, should warrant immediate radiographic examination regarding osteolysis, periosteal reaction, and cortical hypertrophy, which are associated with mechanically-assisted crevice corrosion of the nail.