Background: Management of ankle joint deformity and instability are challenging issues in congenital fibular hemimelia (FH). This study aims to assess how much the SUPERankle procedure improves ankle alignment and provides durable ankle stability in patients with severe FH. Methods: Seventeen children aged 53.4±44.1 months with severe form of FH, equinovalgus foot deformation, ankle instability, and tibial curvature (Paley type IIIC), affecting 19 limbs, underwent the SUPERankle procedure. Foot and ankle position was evaluated clinically and radiologically before surgery, immediately after, and at follow-up of 63.0±19.7 months. Mechanical lateral distal tibial angle (mLDTA), tibiocalcaneal angle (mTCA), and tibiocalcaneal distance (mTCD) were measured on the AP radiograms, while the anterior distal tibial angle (mADTA) and lateral tibiocalcaneal angle (mLTCA) were measured on the lateral radiograms. Recurrences, additional procedures, and complications were documented based on medical records. Quality of life was evaluated with Limb Deformity-SRS questionnaire. Results: On clinical examination, the normal tibia and ankle alignment, along with a plantigrade foot were achieved in all limbs after the first surgery. In 11 limbs (58%) this result was maintained at follow-up. Due to recurrence, additional procedures were necessary to provide durable ankle alignment in 7 limbs (37%), while in 1 limb (5%) the ankle joint remained in equinus at the last follow-up. Significant improvement of radiologic alignment was found in all parameters (preoperative vs. postoperative vs. FU) as follows—mLDTA: 71.4±11.2 versus 88.7±5.6 versus 88.1±2.7 degrees, P=0.0001; mTCA: 41.4±14.9 versus 8.7±8.4 versus 11.6±8.9 degrees, P=0.0001; mTCD: 22.3±7.9 versus 4.0±3.6 versus 7.7±6.5 mm, P=0.0001; mADTA: 99.5±19.4 versus 82.3±4.2 versus 81.5±5.9 degrees, P=0.0002; mLTCA: 116.7±23.9 versus 95.8±11.7 versus 93.5±15.1 degrees, P=0.0002. The mean follow-up LD-SRS score was 4.03. Conclusion: In children with severe fibular hemimelia, the SUPERankle procedure provided clinically and radiologically fully corrected ankle joint and plantigrade foot, suitable for further lengthening procedure. The 40% rate of deformity recurrence was managed with additional surgical intervention to achieve a good clinical, radiologic, and functional outcome in 95% of children at 5-year follow-up. Level of Evidence: Level IV.

Background: The effectiveness and safety of the pericapsular nerve group (PENG) block and lumbar erector spinae plane block (ESPB) in pediatric hip surgeries is limited mainly to case reports. This study assessed the efficacy of ultrasound-guided PENG block versus lumbar ESPB under spinal anesthesia. Methods: Ninety patients aged 2 to 7 years, ASA I-III scheduled for hip surgery were randomly assigned to 3 equal groups, each receiving the PENG block group (n=30), the ESPB group (n=30), or the control group (n=30). After the spinal anesthesia, the block was performed with 0.5 kg/mL of 0.2% ropivacaine. The primary outcome was the pain scores (FLACC) 48 hours after surgery. The secondary outcomes included postoperative FLACC pain scores, neutrophile-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and total opioid consumption. Results: The FLACC score was significantly lower in the lumbar ESPB and PENG groups compared with the control group (P<0.0001) at all time points. The NLR and PLR levels were substantially lower in the PENG and lumbar ESPB groups (P<0.0001) compared with the control group. The NLR and PLR levels were significantly lower in the PENG and lumbar ESPB groups compared with the control group (P<0.0001). The total opioid consumption was significantly lower in the PENG and lumbar ESPB groups compared with the control group (P<0.0001). Forty-three percent of children in the PENG group and 50% of children in the lumbar ESPB group did not require opioids postoperatively. Conclusions: The PENG block and the lumbar ESPB provide efficient postoperative analgesia in children undergoing hip surgery. The PENG block and lumbar ESPB lower cumulative opioid consumption and the stress response to surgery, expressed by NLR and PLR levels. Level of Evidence: Level I.

Background: Hip stability remains a major preoccupation during femoral lengthening in Congenital Femoral Deficiency (CFD). We aimed to review hip stability in Paley type 1a CFD patients undergoing femoral lengthening. Methods: A total of 33 patients with unilateral CFD, who were treated between 2014 and 2023, were retrospectively reviewed. In 20/33 cases (60.6%) the SUPERhip preparatory surgery was performed at a mean age of 4.3 years (range 2.7–8.1). The femoral lengthening using an external fixator was performed at a mean age of 7.8 years (range 4.3–14.3). Results: All patients presented with a stable hip joint after preparatory surgery and during femoral lengthening. Six cases of hip instability at a mean of 637 days after the external fixator removal were observed (range 127 to 1447 days). No significant differences between stable and unstable hips were noted for (1) Center-Edge Angle: 23.7 vs. 26.1 deg; (2) Acetabular Inclination: 12.8 vs. 11.7 deg; and (3) Ex-Fix Index: 35.6 days/cm vs. 42.4 days/cm; p > 0.05. Late hip instability was related to Coxa Vara and decreased femoral antetorsion before lengthening. Conclusions: Late hip joint instability in Paley type 1a CFD patients may occur long after femoral lengthening despite hip morphology appearing to be normal on radiograms before and at the end of femoral lengthening. Coxa Vara, femoral torsional deformity, and posterior acetabular deficiency might be risk factors for hip instability.

Background Concerns about opioid-related adverse effects and local anesthetic toxicity often limit effective postoperative pain management in pediatric patients. This study aimed to compare the analgesic efficacy and systemic effects of perineural dexamethasone (DEX) versus dexmedetomidine (DEM) when used as adjuvants to ropivacaine in pediatric popliteal sciatic nerve blocks. Methods In this triple-blinded, randomized controlled trial, 90 children aged 3 months to 7 years (American Society of Anesthesiologists (ASA) I–III) undergoing elective foot or ankle surgery at a single academic center were randomized to receive ultrasound-guided popliteal sciatic nerve blocks with 0.2% ropivacaine combined with either DEX (0.1 mg/kg), DEM (0.1 µg/kg), or saline (placebo). The primary outcome was time to first rescue opioid administration. Secondary outcomes included total opioid consumption (µg/kg nalbuphine), Face-Legs-Activity-Cry-Consolability (FLACC) pain scores at predefined intervals (4–48 hours) and systemic inflammatory markers (neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio). Statistical analysis included Kruskal–Wallis and Fisher’s exact tests with Bonferroni correction. Results Mean time to first opioid use was 19.4 ± 2.0 hours for DEX, 18.4 ± 1.7 hours for DEM, and 8.5 ± 1.2 hours for placebo (p < 0.0001); the difference between DEX and DEM was 1.0 hour (95% CI 0.04 to 2.06; p=0.0400). Nalbuphine was required in 23.3% of DEX, 33.3% of DEM, and 90% of placebo patients. Total opioid consumption was lower in adjuvant groups (DEX, 40.0 ± 77.0 µg/kg; DEM, 46.7 ± 73.0 µg/kg) compared with placebo (123.3 ± 62.6 µg/kg). FLACC scores were significantly reduced at 6, 8, and 12 hours in both adjuvant groups. NLR at 48 hours was significantly lower in the dexamethasone group (p=0.0136). No nerve injuries or hemodynamic complications occurred. Conclusions Both adjuvants prolonged analgesia and reduced opioid requirements. Although DEX produced slightly longer analgesia than DEM, the clinical significance of this difference may be limited. Larger studies are needed to confirm safety. Trial registration number ClinicalTrials.gov Identifier: NCT06233565.

Purpose: Management of ankle deformity and instability remains a challenge in patients with severe fibular hemimelia (FH). This study aims to evaluate the long-term effectiveness of lateral malleus reconstruction using the fibular anlage in correcting ankle malalignment and preventing the recurrence of deformity following leg lengthening. Methods: Ten patients (age: 3.3 years, 0.8–7.7) with a severe FH, equino-valgus foot deformity, ankle instability, and tibial bowing underwent tibia and ankle realignment and lateral malleolus reconstruction. Afterward, all patients underwent tibial lengthening, and the mean lengthening was 9.9 cm (5.0–16.5). Foot and ankle alignment was evaluated clinically and radiographically before surgery, postoperatively, and at a follow-up (10.0 years, 9.2–11.7). Recurrences, additional procedures, and complications were analyzed. Quality of life was assessed using the Limb Deformity-Scoliosis Research Society (LD-SRS) questionnaire. Results: At the last follow-up, all patients present neutral heel position or slight valgus (three patients 5° and one patient 10°). No additional procedures were performed except medial malleus temporary epiphysiodesis in two patients. The foot was plantigrade in six patients, presented equinus 10° in two and 20° in two, due to equinus, supra-malleolar osteotomy was performed in three patients. Significant improvement of radiological alignment was found and maintained in all parameters. The mean LD-SRS score was 3.78 at follow-up. Conclusion: Lateral malleolus reconstruction provided good clinical, radiological, and functional outcomes. Due to the tendency for recurrence, additional procedures may be necessary. Level of Evidence: IV