Over the past two decades, the Ponseti ‘conservative’ (non-surgical) method of clubfoot treatment has been almost universally adopted worldwide. As a result, the need for operative treatment for clubfoot has decreased dramatically. However, even Ponseti himself routinely used surgery for certain patients: at least 90% of feet need percutaneous tenotomy, and 15% to 40% may require tibialis anterior tendon transfer. Additionally, relapses are common, sometimes necessitating further surgical intervention. Relapses are recurrent deformities in previously well corrected feet. Residual deformities may be defined as persistent deformities in incompletely corrected feet. In addition, in many parts of the developing world, neglected clubfoot is still a major challenge. Many neglected feet can be treated with Ponseti principles, particularly in younger children. However, in older children and adults, surgical approaches are more likely to be needed. Major reasons for relapsed/residual clubfoot include incomplete application of the Ponseti principles, inability to adhere to the foot abduction brace protocol, failure to recommend a complete course of bracing and inadequate follow-up. Sometimes, despite excellent treatment, and perfect adherence to the bracing protocols, there are still relapses, related to intrinsic muscle imbalance. We describe several solutions that include reinstitution of Ponseti casting and ‘á la carte’ operative treatment. As an alternative for particularly stubborn cases, application of a hexapod external fixator can be a powerful tool. In order to be a full-service clubfoot specialist, and not only a Ponseti practitioner, one must have in their toolbox the full gamut of adjunctive surgical options. Level of Evidence: V

Trauma Update Mark Eidelman, MD; Michael Zaidman, MD; Alexander Katzman, MD The Taylor Spatial Frame provides outstanding stability and computer accuracy and is a reliable and definite method for posttraumatic deformity correction. Limb deformity may result from various traumatic sequelae. The most common cause is fracture malunion, but in growing children, shortening and angulation secondary to physis injury is also common. Correction of posttraumatic deformities can be done by various approaches. Each method has pros and cons, but a combination of limb shortening and angulation justify external fixator application. Several external fixators are available. They can be divided into 2 groups: monolateral and circular. A monolateral external fixator may be more easily tolerated, but it is less stable and forgiving compared to the circular external fixator. The Ilizarov frame is a classic example of a circular external fixator. This frame allows excellent stability but has some disadvantages, such as a long surgeon learning curve and difficulty with rotational correction. The Taylor Spatial Frame (Smith & Nephew, Memphis, Tennessee) is a computerized external fixator with a virtual hinge and the ability to correct 6-axis deformities simultaneously. In contrast with the Ilizarov frame, there is no need for hinge application, multiple frame adjustments, or change of frame configuration to correct multiple plane deformities. The purpose of this study was to determine the effectiveness of the Taylor Spatial Frame for treatment of complex posttraumatic deformities in children and adolescents. Between 2003 and 2007, 18 patients with various posttraumatic deformities were treated with the Taylor Spatial Frame at our institution (Table). Average patient age at the time of frame application was 13.1 years (range, 8-17 years). There were equal numbers of proximal, mid, and distal tibial malunions; 2 patients had combined distal and proximal tibial malunions. Seven patients had deformities secondary to growth arrest: 3 patients had growth arrest of the distal femur, 3 had proximal tibial growth arrest, and 1 had distal radius deformity secondary to physis injury. Standing anteroposterior (AP) and lateral radiographs from pelvis to toes were obtained pre- and postoperatively and at final follow-up. Deformity analysis and measurements were made in all planes according to the principles described by Paley.¹ Surgical technique was described in detail in several reports.^1-5 All osteotomies were performed percutaneously by Gigli saw or the drilling and osteotome technique.¹ All deformities were analyzed using the total residual correction program and were gradually corrected. Minimum follow-up was 2 years after frame removal. In all patients, restoration of the mechanical axis and length equalization was achieved with no or minimal difference compared with anatomical parameters of contralateral extremity. At last follow-up, all patients were pain free and had regained preoperative range of motion (ROM). The frame was removed after a mean 12.3 weeks (range, 8-24 weeks). Average lengthening was 17.9 mm (range, 5-80 mm). Eight patients had superficial pin tract infection, which resolved with oral antibiotics or a short course of intravenous administration. One patient had transient peroneal palsy. Another patient had delayed union and needed 2 additional cast immobilizations after fixator removal. The most serious complication was angulation of the regenerate after 40 mm of femoral lengthening (Figure 1). This complication was caused by unstable ring fixation. The fixation block was revised and angulation was successfully and gradually corrected by the total residual program. No patient had deep infection or nonunion. Figure 1: Radiographs of a 13-year-old boy with a segmented fracture of the femur and damage of the distal femoral epiphysis (A, B). AP (C) and lateral (D) radiographs before frame application (1 year after trauma) showing distal femoral valgus, recurvatum, and external rotation. AP (E) and lateral (F) radiographs during correction showing regenerate of angulation. Note the distal fragment fixed with 1 ring and only 2 half pins. Radiograph after addition of the second ring and four 1.8 Ilizarov wires (G). Radiograph of normal femoral alignment after frame removal (H). Posttraumatic deformity correction in children with open physis can be a surgical challenge. Proximity of the growth plate restricts the use of intramedullary nail fixation, while shortening and pure soft tissue coverage restrict wide use of the plating technique. The obvious advantage of external fixator application in contrast to internal fixation devices is soft tissue preservation, which can be essential in posttraumatic conditions (Figure 2). Figure 2: Photograph of 16-year-old boy with 80-mm shortening and severe varus deformity secondary to damage of the proximal and distal epiphysis (A). Note the pure soft tissue coverage of the medial side of the tibia (B). AP radiographs before (C) and after (D) correction. Clinical appearance after correction (E). Several external fixators are available. They can be divided into 2 groups: monolateral and circular. A monolateral external fixator may be better tolerated but is less stable and forgiving.⁶ The stability of the circular frame allows early postoperative weight bearing and ROM maintenance, which can be essential for regenerate formation.^2,3 The Ilizarov circular frame is the classic choice for deformity correction and allows correction of almost all possible deformities.^7,8 However, correction of multiplanar deformities requires replacement of hinges and frequent frame readjustments. Successful use of the Ilizarov technique has a long learning curve, and correction of complex—especially multiplanar and rotational—deformities remains a difficult challenge, even for surgeons experienced with this...

Background: Supracondylar humeral fracture is probably the most common elbow fracture in children requiring surgical intervention. We observed a subtype of pediatric supracondylar humeral fracture with a sideward translation, without substantial displacement in the sagittal plane on initial radiographs. The purpose of this study was to calculate the incidence of this fracture subtype and suggest a modification to the standard operative technique, to achieve the desired fracture alignment and fixation. Methods: We reviewed the clinical records and radiographs of all pediatric patients with supracondylar humeral fractures surgically treated in our institution between the years 2006 and 2014. The fracture types, fixation configuration and any complications were recorded. Results: Overall, 263 consecutive patients were included. The incidence of supracondylar fracture of the humerus with solely sideward displacement was 6%. The fracture was characterized clinically and radiographically. We proposed a modification to the standard operative technique for this fracture subtype for successful closed reduction and percutaneous pinning. Conclusions: Special attention to this fracture subtype, including appropriate operating room setup and the application of a suitable reduction and pinning technique, has the potential to achieve successful results and avoid the need for open reduction.