Background and Objectives: Monteggia fracture-dislocations are rare but critical injuries in children. Accurate early diagnosis is essential to avoid long-term complications; however, such injuries are frequently missed. Therefore, this study aimed to assess the diagnostic accuracy of Monteggia fractures among physicians of varying specialties and experience levels and to identify factors influencing diagnostic performance. Materials and Methods: This retrospective study analyzed the radiographic interpretations of pediatric elbow and forearm injuries by six physician groups: orthopedic residents, general orthopedic surgeons, pediatric orthopedic surgeons, general radiologists, and subspecialized musculoskeletal radiologists. The final diagnosis established by pediatric radiology experts served as the reference standard. Influential variables, such as image quality, splint application, and age-related ossification, were evaluated. Results: In total, 120 patients were included, 40 (33.3%) of whom were diagnosed with Monteggia fractures and 80 (66.7%) with other fracture types. The diagnostic accuracy of Monteggia fractures varied significantly according to the physician’s experience. First-year residents and non-subspecialty radiologists had the highest rate of missed diagnoses. While other fracture types were occasionally influenced by technical factors, most missed Monteggia fracture cases stemmed from recognition failure. Subtle imaging features, plastic deformation of the ulna, and the omission of dedicated elbow views contributed to the misdiagnosis. Awareness and training improved performance, and a high index of suspicion was identified as crucial. Early follow-ups and standardized imaging protocols were identified as effective safeguards. Conclusions: Experience level, awareness, and imaging protocol quality were identified as being central to the accurate diagnosis of pediatric Monteggia fractures. Implementing educational strategies, promoting systematic imaging reviews, and reinforcing team-based approaches may reduce the rate of missed diagnoses.

Rationale: Excessive distal clavicle resection can result in severe bone loss and disruption of the coracoclavicular (CC) ligament attachment, leading to significant vertical instability of the acromioclavicular joint. The optimal surgical approach in such cases remains controversial due to the technical challenges associated with achieving anatomical fixation. Patient concerns: A 40-year-old male construction worker presented with persistent shoulder pain, limited range of motion, and visible clavicular prominence 1 year and 7months after undergoing distal clavicle resection at an outside hospital following a traumatic fracture. Diagnoses: Radiography and physical examination revealed substantial bone loss in the distal clavicle and vertical instability, with a CC distance of 15.16 mm, confirming CC ligament insufficiency. Interventions: The patient underwent a single-tunnel arthroscopically assisted CC ligament reconstruction with allograft augmentation using the TightRope system and a peroneus brevis tendon allograft. Outcomes: At the 60-month follow-up, radiographs demonstrated maintained joint stability. The CC distance was reduced to 6.01 mm immediately postoperatively and was 9.30 mm at the final follow-up. Clinical scores significantly improved (Visual Analog Scale: 6→1, American Shoulder and Elbow Surgeons: 13→95, and University of California at Los Angeles: 9→35), and the patient returned to heavy manual labor 6 months postoperatively, maintaining full function. Lessons: In patients with severe distal clavicle bone loss, single-tunnel arthroscopically assisted CC ligament reconstruction with allograft augmentation can yield excellent long-term clinical and radiological outcomes, serving as a viable and effective treatment option.

When positioning the acetabular component for total hip arthroplasty (THA) in patients with sequelae of Legg-Calvé-Perthes disease (LCPD), elevating the center of rotation (COR) of the hip is often unavoidable. We aimed to compare the outcomes between the preserved and elevated COR groups in patients with sequelae of LCPD. We enrolled 53 patients who underwent primary THA for sequelae of LCPD between 2006 and 2019. Patients were divided into 2 groups based on the postoperative COR position: 19 in the preserved COR group and 34 in the elevated COR group. The mean elevation of COR was 2.7 mm (range, 0–5.0 mm) in the preserved COR group and 8.1 mm (range, 6.0–12.0 mm) in the elevated COR group. Radiological outcomes, such as osteolysis and implant loosening, were evaluated. Additionally, reoperation, perioperative complications, limping gait, pelvic obliquity, and the modified Harris hip score (mHHS) were assessed. There were no significant differences in radiological or clinical outcomes between the 2 groups. Neither osteolysis nor implant loosening was observed, and no reoperations were required. Intraoperative periprosthetic femoral fractures occurred in 3 cases (6%), but no cases of sciatic nerve palsy were observed. Residual limping gait was noted in 10 patients (19%), and pelvic obliquity persisted in 8 patients (15%). At the last follow-up, the mean mHHS was 89.2. The 5–17-year follow-up results of primary cementless THA in patients with sequelae of LCPD were satisfactory. Furthermore, a moderate elevation of the COR, with a mean of 8.1 mm (range, 6.0–12.0 mm), did not significantly affect the outcomes of THA in these patients. Therefore, a moderate elevation of the COR can be considered an acceptable option for patients undergoing THA with sequelae of LCPD.

The failure cases of peritrochanteric fractures are occasionally encountered due to poor bone stock. For proximal humeral fractures, a strategy using a segment of the fibular allograft (FA) placed endosteally was introduced. Several studies have demonstrated favorable outcomes with FA. Inspired by this, a fixation strategy using FA with a locking plate was performed in patients with unfavorable bone stock conditions. Ten patients with poor bone stock and nonunion of peritrochanteric fractures were treated with FA and a locking plate at a tertiary hospital between 2016 and 2022. We analyzed the bone union status, the time taken for union, and postoperative complications. Bone union was achieved in all cases following average time of 9.6 months (range 6–14 months). There was no complication related to allograft such as infection. The use of FA in conjunction with a locking plate for fixation in nonunion of peritrochanteric fractures with poor bone stock or cortical bone defects demonstrated successful outcomes in our study. Ongoing observations and reporting are essential for comprehensive validation and addressing potential complications.

Background/Objectives: Valgus alignment shifts load toward the lateral compartment, and even a mild shift may matter when that compartment already contains a torn meniscus and an osteochondral lesion. We describe a skeletally immature knee in which a torn discoid lateral meniscus (DLM), an osteochondral lesion of the lateral femoral condyle and mild valgus coexisted. Case Presentation: A 14-year-old boy presented with longstanding right knee pain, lateral joint line tenderness and a positive McMurray test. The hip–knee–ankle (HKA) axis showed 4° of valgus (contralateral 0.5°), with a mechanical lateral distal femoral angle (mLDFA) of 84.6°, a medial proximal tibial angle (mMPTA) of 90.0° and mechanical axis deviation (MAD) 10.78 mm lateral. Imaging and arthroscopy showed a torn, centrally shifted DLM and a 1.4 × 1.6 cm ICRS grade 4 lesion of the lateral femoral condyle. Saucerization with repair, microfracture, and temporary hemiepiphysiodesis of the medial distal femoral and proximal tibial physes were performed in one stage. Results: At five months, the HKA was 0.7° varus (mLDFA, 87.2°; mMPTA, 88.3°) and the screws were removed; the repaired meniscus measured 9 mm in width without extrusion. At two years, the HKA was neutral (mLDFA, 87.0°; mMPTA, 87.7°; MAD, 0 mm) without rebound, and the patient was asymptomatic; no validated patient-reported outcome measure was collected. Conclusions: As a short-term result in a single patient, this case illustrates the feasibility of incorporating temporary hemiepiphysiodesis into a joint-preserving strategy in a selected skeletally immature knee. It is not evidence of efficacy; longer-term follow-up is needed to judge joint preservation.