Deborah M. Eastwood

A new technique for stabilizing adolescent posteriorly displaced physeal medial clavicular fractures

BACKGROUND Adolescent posteriorly displaced physeal injuries of the medial clavicle are uncommon. Up to 50% of conservatively treated patients remain symptomatic, and late surgery is hazardous. Stability is rarely achieved with closed or open reduction alone, and internal fixation is usually required. Previously described options for fixation achieve stability of the medial clavicle by securing it to the intact epiphysis. Because the epiphyseal fragment is small, fixation is achieved using sutures or wires. This relies on the size and structural integrity of the medial fragment, which in our experience can be variable. We hypothesized that a novel technique of operative stabilization of these injuries, which does not require fixation to the epiphyseal fragment and uses no metalwork, is safe and effective in treating these injuries. MATERIALS AND METHODS The operative technique involves suturing the medial clavicle to the anterior platysmal and periosteal layer using absorbable sutures passed through drill holes in the medial clavicle. Patients were assessed clinically an average of 9 months after surgery. RESULTS We treated 7 patients with this method. There were no intraoperative complications. All patients were pain-free and symptom-free and had a full range of movement at follow-up. All patients had returned to their preinjury level of sports. CONCLUSIONS We recommend this technique for treating these uncommon injuries. It is simple, safe, and reproducible and it produces good results.

The Clubfoot: Congenital Talipes Equinovarus

The clubfoot is a common, classic, paediatric orthopaedic problem. Every orthopaedic surgeon knows what the deformity looks like but most find it more difficult to describe or to define. The etiology is still largely unknown but ideas about treatment have changed considerably over the last few years.

Posteromedial bowing of the tibia: a benign condition or a case for limb reconstruction?

Purpose To review the initial deformity and subsequent remodelling in posteromedial bowing of the tibia and the outcome of limb reconstruction in this condition. Patients and Methods In all, 38 patients with posteromedial bowing of the tibia presenting between 2000 and 2016 were identified. Mean follow-up from presentation was 78 months. A total of 17 patients underwent lengthening and deformity correction surgery, whilst three further patients are awaiting lengthening and deformity correction procedures. Results The greatest correction of deformity occurred in the first year of life, but after the age of four years, remodelling was limited. The absolute leg-length discrepancy (LLD) increased throughout growth with a mean 14.3% discrepancy in tibial length. In the lengthening group, mean length gained per episode was 45 mm (35 to 60). Mean duration in frame was 192 days, with a mean healing index of 42.4 days/cm. Significantly higher rates of recurrence in LLD were seen in those undergoing lengthening under the age of ten years (p = 0.046). Four contralateral epiphysiodeses were also performed. Conclusion Posteromedial bowing of the tibia improves spontaneously during the first years of life, but in 20/38 (53%) patients, limb reconstruction was indicated for significant residual deformity and/or worsening LLD. For larger discrepancies and persistent deformity, limb reconstruction with a hexapod external fixator should be considered as part of the treatment options. Level of evidence Level IV (Case series)

Truncated SALL1 Impedes Primary Cilia Function in Townes-Brocks Syndrome

Townes-Brocks syndrome (TBS) is characterized by a spectrum of malformations in the digits, ears, and kidneys. These anomalies overlap those seen in a growing number of ciliopathies, which are genetic syndromes linked to defects in the formation or function of the primary cilia. TBS is caused by mutations in the gene encoding the transcriptional repressor SALL1 and is associated with the presence of a truncated protein that localizes to the cytoplasm. Here, we provide evidence that SALL1 mutations might cause TBS by means beyond its transcriptional capacity. By using proximity proteomics, we show that truncated SALL1 interacts with factors related to cilia function, including the negative regulators of ciliogenesis CCP110 and CEP97. This most likely contributes to more frequent cilia formation in TBS-derived fibroblasts, as well as in a CRISPR/Cas9-generated model cell line and in TBS-modeled mouse embryonic fibroblasts, than in wild-type controls. Furthermore, TBS-like cells show changes in cilia length and disassembly rates in combination with aberrant SHH signaling transduction. These findings support the hypothesis that aberrations in primary cilia and SHH signaling are contributing factors in TBS phenotypes, representing a paradigm shift in understanding TBS etiology. These results open possibilities for the treatment of TBS.

Physeal Injury, Epiphysiodesis and Guided Growth

The evidence for the best treatment of acute physeal injuries is based mainly on epidemiologic studies, retrospective reviews, and expert opinion (LoE IV/V).

Clinical Surveillance, Selective or Universal Ultrasound Screening in Developmental Dysplasia of the Hip

Early detection of the child with developmental dysplasia of the hip (DDH) allows treatment to be commenced promptly, with potentially fewer requirements for surgical intervention and a better final outcome. Clinical examination has been the mainstay of early detection but the introduction of ultrasound examination provided the possibility for greater sensitivity. The ideal process for detection is still a subject of debate, with surveillance practices varying both between and within countries. Most screening programmes attempt to find a balance between missing a dislocated hip and overtreatment of ultrasonographic findings. This chapter considers the evidence related to screening programmes for DDH and looks at the efficacy of each method of detection, the risks of a screening programme and the question of whether late presentation of developmental dysplasia is a preventable occurrence.