Background: Limb lengthening using an external fixator requires a long period of external fixation and may be associated with several complications such as axial deformity, fracture of the regenerated bone, and joint stiffness. With the goal of reducing the time of external fixation as well as some of these complications, we performed femoral or tibial lengthening over an intramedullary nail, according to Paley’s technique, in 28 patients, followed up after a mean period of 8 years.Materials and methods: Twenty-eight patients treated for lower limb discrepancy by limb lengthening over an intramedullary nail were reviewed from 5 to 11 years after healing of regenerated bone. There were 20 femurs and 8 tibiae, with average age at surgery of 14.2 years and average length inequality of 6.1 cm for femurs and 5.3 cm for tibiae.Results: The mean lengthening was 5.8 cm for femurs and 4.8 cm for tibiae. The mean period of radiographic consolidation of the regenerated bone was 6 months for femoral lengthening and 4.5 months for tibial lengthening. At follow-up, we observed 8 excellent results, 15 good results, 4 fair results, and 1 poor result, based on Paley’s evaluation criteria. The main complications were one deep infection, one nonunion of the distracted segment, one breakage of the distal fiche of the external fixator, and one breakage of both distal locking screws of the intramedullary nail.Discussion: We believe that limb lengthening over an intramedullary nail still represents a good method to treat limb length discrepancy because it reduces the time of external fixation, prevents axial deformities and fractures of regenerated bone, and allows early rehabilitation. The new intramedullary lengthening nails, which theoretically are the ideal device for treating limb length inequality, are still very expensive and need longer follow-up for definitive evaluation.Level of evidence: 4.

Background: Scoliosis is a structured rotatory deformity of the spine defined as >10° Cobb. Functional scoliosis (FS) is a curve < 10° Cobb, which is non-rotational and correctable. FS is often secondary to leg length inequality (LLI). To observe vertebral rotation (VR) in functional scoliosis due to LLI, one must demonstrate a correlation between LLI, sacral shelf inclination (SSI), and VR and discover a predictive value of LLI capable of inducing rotation. Methods: We studied 89 patients with dorso-lumbar or lumbar curves < 15° Cobb and radiographs of the spine and pelvis. We measured LLI, SSI, and VR. The patients were divided into VR and without rotation (WVR) groups. Statistical analysis was performed. Results: The mean LLI value was 6.5 ± 4.59 mm, and the mean SSI was 2.8 ± 2.53 mm. The mean value of LLI was 5.2 ± 4.87 mm in the WVR group and 7.4 ± 4.18 mm in the VR group. The mean SSI value for WVR was 1.4 ± 2.00 and that for VR was 3.9 ± 2.39. For each mm of LLI, it was possible to predict 0.12° of rotation. LLI ±5 mm increased the probability of rotation (R2.08 p < 0.0016), while this was ±2 mm for SSI (R2 0.22 p < 0.01). Each mm of LLI corresponded to 0.3 mm of SSI (R2 0.29, p < 0.01). Conclusions: FS secondary to LLI can cause VR, and 5 mm of LLI can cause SSI and rotation.

Flexible idiopathic flatfoot is very common in growing age and rarely causes pain or disability. Surgery is indicated only in severe symptomatic cases that are resistant to conservative treatment, and numerous surgical procedures have been proposed. Lateral column calcaneal lengthening as described by Evans and modified by Mosca is a widely used surgical technique for the correction of severe symptomatic flexible flatfoot. In the present study, we report the long-term clinical and radiographic results in 14 adolescent patients (mean age: 12.8 years) affected by severe symptomatic flexible flatfoot, surgically treated by Evans–Mosca procedure, for a total of 26 treated feet (12 cases bilateral and 2 unilateral). In all cases, surgery was indicated for the presence of significant symptoms resistant to nonsurgical management. Clinical evaluation was made according to the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, the Foot and Ankle Disability Index (FADI) Score, and Yoo et al.’s criteria. Radiographic evaluation was made using anteroposterior and lateral weight-bearing radiographs of the feet to evaluate Meary’s angle and Costa–Bertani’s angle and to evaluate possible osteoarthritic changes in the midtarsal joints. At follow-up (mean: 7 years and 7 months), we observed a satisfactory result in all patients. The mean average score of the AOFAS Ankle-Hindfoot Scale improved from 60.03 points to 95.26; the mean FADI score improved from 71.41 to 97.44; and according to Yoo et al.’s criteria, the average clinical outcome score was 10.96. At radiographic examination, nonunion of the calcaneal osteotomy was never observed. Meary’s angle improved from an average preoperative value of 25° to 1.38° at follow-up; Costa–Bertani’s angle improved from an average preoperative value of 154.2° to 130.9° at follow-up. In no case, significant radiographic signs of midtarsal joint arthritis were observed. According to our results, we believe that Evans–Mosca technique is a valid option of surgical treatment for severe idiopathic flexible flatfoot and allows a satisfactory correction of the deformity with a low rate of complications.

Background: The concern around repeated exposure to X-rays has been motivating doctors involved in scoliosis to seek alternative solutions. Surface topography (ST) analysis is a modern system that has been shown to have good results. The purpose of the study is to validate the new BHOHB hardware for the investigation of scoliosis in adolescents by comparing it to X-ray examinations and to assess the reliability of intraoperator and interoperator tests. Methods: Ninety-five patients were enrolled in our study. All the patients were analyzed via the BHOHB method 2 times by 2 independent physicians (t0) and for a second time 2 or 3 months later (t1). The Pearson correlation coefficient was used to evaluate the relationship between the measurements obtained by BHOHB and the gold standard. The intraclass correlation coefficient (ICC) was used to assess intra- and interoperator reliability. Statistical analysis was performed with the GraphPad Prism 8 software. Results: The correlations between the first and second operators in the measurements and between the BHOHB method and X-ray showed a very good to excellent r for both. A very good correlation was also confirmed for prominence measured by operators and by the BHOHB machine. Intra- and interoperator reliability was found to be very positive for both the first and the second physicians. Conclusions: We can state that ST can be useful for diagnosing and treating scoliosis. The recommendation is to use it primarily to evaluate the evolution of the curve, as in this mode, you can reduce the patient’s exposure to X-rays. The results indicate that BHOHB measures are comparable to radiographs and not influenced by the operator.

Background: An algorithm for managing open fractures in children is still being debated; the present study suggests an evidence-based way to manage these patients in the emergency department. Methods: The literature on “Open fractures in children” was carefully analyzed using keywords. The primary sources were The Cochrane Library, PubMed, and Researchgate. Conclusion: We proposed an evidence-based algorithm for managing open fractures in children to standardize clinical practice and improve the care of these patients.

The authors report the long-term outcome in a series of 26 patients surgically treated for a fracture-dislocation of the ankle by open reduction and internal fixation (ORIF), reviewed after an average followup of 5.2 years. The average age of the patients was 46.8 years; 17 were female and 9 male; the right side was involved in 22 patients and the left side in 4; 10 patients had a unimalleolar fracture, 11 a bimalleolar fracture, and 5 a trimalleolar fracture. The quality of reduction was excellent in 14 cases and good in 12. The functional results were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) score, while radiographic results followed the Van Dijk classification. At followup, the AOFAS score ranged from 75 to 98 points with an average of 87.9, while the radiographic results were evaluated as grade 0 in 16 ankles and grade I in 10. Fracture-dislocations of the ankle occurred more frequently after high-energy traumas in younger patients on the right side, but they were also observed in older females after low-energy trauma. Excellent reduction was correlated with better radiographic results at long term followup. However, these injuries may lead to a poor functional outcome, despite an anatomical reduction and good radiographic results; in fact, in nine of our cases (34.6 percent), the AOFAS score was less than 90 points.