The purpose of this study was to establish whether exploration and neurolysis is an effective method of treating neuropathic pain in patients with a sciatic nerve palsy after total hip replacement (THR). A total of 56 patients who had undergone this surgery at our hospital between September 1999 and September 2010 were retrospectively identified. There were 42 women and 14 men with a mean age at exploration of 61.2 years (28 to 80). The sciatic nerve palsy had been sustained by 46 of the patients during a primary THR, five during a revision THR and five patients during hip resurfacing. The mean pre-operative visual analogue scale (VAS) pain score was 7.59 (2 to 10), the mean post-operative VAS was 3.77 (0 to 10), with a resulting mean improvement of 3.82 (0 to 10). The pre- and post-neurolysis VAS scores were significantly different (p < 0.001). Based on the findings of our study, we recommend this form of surgery over conservative management in patients with neuropathic pain associated with a sciatic nerve palsy after THR. Cite this article: Bone Joint J 2013;95-B:20–2

Aims. Medial humeral epicondyle fractures (MHEFs) are common elbow fractures in children. Open reduction should be performed in patients with MHEF who have entrapped intra-articular fragments as well as displacement. However, following open reduction, transposition of the ulnar nerve is disputed. The aim of this study is to evaluate the need for ulnar nerve exploration and transposition. Methods. This was a retrospective cohort study. The clinical data of patients who underwent surgical treatment of MHEF in our hospital from January 2015 to January 2022 were collected. The patients were allocated to either transposition or non-transposition groups. Data for sex, age, cause of fracture, duration of follow-up, Papavasiliou and Crawford classification, injury-to-surgery time, preoperative ulnar nerve symptoms, intraoperative exploration of ulnar nerve injury, surgical incision length, intraoperative blood loss, postoperative ulnar nerve symptoms, complications, persistent ulnar neuropathy, and elbow joint function were analyzed. Binary logistic regression analysis was used for statistical analysis. Results. A total of 124 patients were followed up, 50 in the ulnar nerve transposition group and 74 in the non-transposition group. There were significant differences in ulnar nerve injury (p = 0.009), incision length (p < 0.001), and blood loss (p = 0.003) between the two groups. Binary logistic regression analysis revealed that preoperative ulnar nerve symptoms (p = 0.012) were risk factors for postoperative ulnar nerve symptoms. In addition, ulnar nerve transposition did not affect the occurrence of postoperative ulnar nerve symptoms (p = 0.468). Conclusion. Ulnar nerve transposition did not improve clinical outcomes. It is recommended that the ulnar nerve should not be transposed when treating MHEF operatively. Cite this article: Bone Joint J 2024;106-B(2):212–218

Purpose of the study: The cervicobrachial outlet syndrome is an anatomic and clinical entity related to intermittent or permanent compression of the brachial plexus trunks, and/or the subclavian artery and vein as they pass through six successive spaces in the thoracic cervicobrachial outlet, including the intercostoscalenic space. The purpose of this work was to evaluate the feasibility of endoscopic exploration of the infra-clavicular portion of the outlet and the options for therapeutic interscalenic release. Material and methods: Cadaver study of 12 shoulders: 3 male, 3 female. dissection of the supra and infra-clavicular region (n=3) to identify zones of potential impingement and determine the structures constituting the outlet;. dissections (n=2) centred on the different zones considered as potential endoscopic portals;. endoscopies (n=2) via a supra-lateral clavicular approach followed by dissection;. endoscopies (n=2) via a supra-lateral clavicular approach followed by dissection with insertion of landmarks then a new endoscopy;. Endoscopies (n=3) via a supra-lateral clavicular approach to achieve intercalenic release followed by control dissection. Results: The medial and lateral clavicular approaches identified two zones of less risk considering the proximity of the neck vessels and the phrenic and suprascapular nerves. A first, it was difficult to localize the brachial plexus endoscopically. This was achieved after dissection and insertion of landmarks. Five endoscopic procedures had to be performed to localize the plexus and starte the interscalenic release. Minute identification of the entry points for the trocars, as a perfect orientation of the instruments was necessary to achieve the procedure. The control dissections did not identify any vessel or nerve injury. Discussion: Few data in the literature examine the question of endoscopic interscalenic release. Unlike Krishnan and Pinzer, we found that endoscopic exploration of the outlet at possible, but difficult, procedure. Use of an arthropump remains to be evaluated because of the distension and impregnation of the tissues. Insufflations with CO2 might be an alternative. Conclusion: To our knowledge, a supra-clavicular approach for endoscopic exploration of the brachial plexus has not been described. Exploration of the outlet via this approach might be a less invasive procedure than conventional surgery. Complementary research is necessary to evaluate the morbidity of the different techniques

Hamstring muscle strain is a common sports related injury. It has been reported in a variety of sports, following acceleration or deceleration while running or jumping. Injury may vary from simple muscle strains to partial or complete rupture of the hamstring origin. Avulsion fracture of the ischial tuberosity has also been described. Simple hamstring muscle strains are treated conservatively. Surgical exploration and repair is currently advocated for partial or complete rupture of the hamstring origin. A few case series exists in literature suggesting the benefits of early intervention. We report a series of 8 athletes who presented between 2002 and 2006 with complete tear of their hamstring origin. Avulsion of the ischial tuberosity was excluded in these cases. After confirming the diagnosis, early surgical exploration and repair or reattachment was performed. The patients were braced for 8 weeks. This was followed by specialist physiotherapy and a supervised rehabilitation programme over 6 months. All patients were followed up to monitor return to normal activities and sports. The sciatic nerve was scarred to the avulsed tendon in three cases. Neurolysis led to a rapid relief of symptoms. Cases where the hamstring origin had retracted more than 3 cm required a figure 7 incision. There were no major complications including nerve palsies. An excellent functional outcome was noted by 12 months in all 8 patients. 7 of them returned to their previous level within 6-9 months of injury. One person despite a very good recovery, opted out of sports. No other complications were seen as a result of the surgical procedure. In conclusion, a tear of the origin of hamstring muscles is a significant injury. Early surgical repair and physiotherapy is associated with a good outcome and enables an early return to high level sports

Purpose of the study: Ankle sprains constitute a serious public health problem with nearly 6000 consultations daily in France. The prognosis is generally good if a precise clinical diagnosis can be established and appropriate treatment undertaken. The purpose of this study was to ascertain the pertinence of the initial physical examination which determines the treatment by correlating it with the results of a high-resolution ultrasound examination. Material and methods: This prospective study included 23 patients, mean age 30.7 years, who were followed regularly for three months. A total of 154 ultrasound explorations were performed. The initial treatment for these patients who consulted a hospital emergency room for ankle trauma was established on the basis of the Ottawa criteria. The ankles were examined by a senior physician and an ultrasonographic exploration was performed 3.9 days on average after the first consultation in the emergency room. Standard protocols were used for the physical examination and for the ultrasonography. Results: The initial results confirmed a lesion of the lateral collateral ligament in 91% of cases with an initial tear of the anterior talofibular ligament in half of the cases and a injury to the calcaneofibular ligament in one out of five cases. One quarter of the patients had an isolated lesion. One out of ten presented a lesion of the syndesmosis and one out of three lesions of the fibular tendons. The standard ankle examination performed by the senior physician established correct diagnosis of the precise lesion in 80% of the cases. Discussion: Lesions of the mid food and of the syndesmosis are diagnosed clinically, ultrasonography is not contributive. The stage of the initial lesion was compared with the stage at three months: in 7 out of 10 cases, the anterior talofibular and the calcaneofibular ligaments had healed correctly. Physical examination is essential but ultrasonography provides certain complementary information at a time when the physical examination can be hindered by the pain and potentially the lesser experience of emergency room examinators. Conclusion: In light of the evidence provided by this study, it can be confirmed that the initial diagnosis of ankle sprain established in an emergency room setting can be corrected by a physical examination performed by an experienced clinician. At the present time, it is not possible to demonstrate the specific contribution of ultrasonography for the management of ankle sprains. This would require a prospective study over a longer period and should be designed to demonstrate the relationship between injury of the fibular tendons and ankle stability

Non-operative management has frequently been adopted for closed injuries of the infraclavicular brachial plexus and its branches in the belief that spontaneous recovery is likely to occur, and surgical exploration is performed only if recovery has not occurred in the expected time. This paper correlates the clinical and electrophysiological features with the operative findings in six patients with such injuries. The axillary nerve was ruptured in all six patients, the musculocutaneous nerve in two and the radial nerve in two. When the muscles supplied by a branch of the plexus were denervated, the differentiation between rupture of that branch and a lesion in continuity could only be made by surgical exploration, which should be performed as soon as other injuries permit

Generally, the sacroiliac joint is not considered accessible for arthroscopy under physiological conditions. The non-injured joint is not large enough for introduction of even the smallest arthroscope into the joint space. After traumatic injury however, or in the event of an inflammatory condition or tumour formation, it is theoretically possible to position an endoscope in the joint space. Study of the anatomy of the sacroiliac joint and knowledge of the anatomic relations, particularly the vascular and nervous relations, is a prerequisite for arthroscopic exploration of the sacroiliac joint space. The posterior approach must account for the bone configuration of the iliac wing and the orientation of the sacroiliac joint line. A cadaver study confirmed the feasibility of endoscopic exploration of the sacroiliac joint via a posterior percutaneous access. Based on this anatomic experience, we positioned an arthroscope in an injured sacroiliac joint and report the different phases. A technique for obtaining a biopsy of the anterior aspect under endoscopic control has already been described, but to our knowledge, there is no arthroscopic description of the sacroiliac joint via a posterior access. Indications for arthroscopy of the sacroiliac joint remain very limited. This technique can be used to remove osteocartilaginous fragments or foreign bodies incarcerated in the joint and to obtain biopsy material, drain collections and, in the near future, should allow avivement of the cartilage surfaces with the objective of a percutaneous arthrodesis

Purpose and Background

Work-related musculoskeletal disorders (WRMSD) can affect 56–80% of physiotherapists. Patient handling is reported as a significant risk factor for developing WRMSD with the back most frequently injured. Physiotherapists perform therapeutic handling to manually assist and facilitate patients’ movement to aid rehabilitation, which can increase physiotherapists risk of experiencing high forces during patient handling.

A Core Outcome Set (COS) for treatment of adolescent idiopathic scoliosis (AIS) is essential to ensure that the most meaningful outcomes are evaluated and used consistently. Measuring the same outcomes ensures evidence from clinical trials and routine clinical practice of different treatments can be more easily compared and combined, therefore increasing the quality of the evidence base. The SPINE-COS-AYA project aims to develop a gold standard COS which can be used internationally in research and routine clinical practice to evaluate the treatment (surgical and bracing) of AIS.

In this qualitative study, the views of adolescents and young adults with AIS (10-25 years of age), their family members and healthcare professionals in a UK region were sought, via interviews, on treatment outcomes. Participants were purposively recruited from a variety of sources including NHS outpatient clinics and social media. Semi-structured interviews were analysed using thematic analysis.

Key findings will be presented, to include potential core outcome domains identified by the different subgroups.

The core outcome domains identified in this research programme will subsequently form part of an international consensus survey to agree a COS. In future, if the COS is used by healthcare staff and researchers, it will be easier for everyone, including patients and their families, to assess which treatment works best.

Pain and disability following wrist trauma are highly prevalent, however the mechanisms underlying painare highly unknown. Recent studies in the knee have demonstrated that altered joint contact may induce changes to the subchondral bone density and associated pain following trauma, due to the vascularity of the subchondral bone. In order to examine these changes, a depth-specific imaging technique using quantitative computed tomography (QCT) has been used. We've demonstrated the utility of QCT in measuring vBMD according to static jointcontact and found differences invBMD between healthy and previously injured wrists. However, analyzing a static joint in a neutral position is not necessarily indicative of higher or lower vBMD. Therefore, the purposeof this study is to explore the relationship between subchondral vBMDand kinematic joint contact using the same imaging technique.

To demonstrate the relationship between kinematic joint contact and subchondral vBMDusing QCT, we analyzed the wrists of n = 10 participants (n = 5 healthy and n = 5 with previous wrist trauma). Participantsunderwent 4DCT scans while performing flexion to extension to estimate radiocarpal (specifically the radiolunate (RL) and radioscaphoid (RS)) joint contact area (JCa) between the articulating surfaces. The participantsalso underwent a static CT scan accompanied by a calibration phantom with known material densities that was used to estimate subchondral vBMDof the distal radius. Joint contact is measured by calculatinginter-bone distances (mm2) using a previously validated algorithm. Subchondral vBMD is presented using mean vBMD (mg/K2HPO4) at three normalized depths from the subchondral surface (0 to 2.5, 2.5 to 5 and 5 to 7.5 mm) of the distal radius.

The participants in the healthy cohort demonstrated a larger JCa in the RS joint during both extension and flexion, while the trauma cohort demonstrated a larger JCa in the RL during extension and flexion. With regards to vBMD, the healthy cohort demonstrated a higher vBMD for all three normalized depths from the subchondral surface when compared to the trauma cohort.

Results from our preliminary analysis demonstrate that in the RL joint specifically, a larger JCa throughout flexion and extension was associated with an overall lower vBMD across all three normalized layers. Potential reasoning behind this association could be that following wrist trauma, altered joint contact mechanics due to pathological changes (for example, musculoskeletal trauma), has led to overloading in the RL region. The overloading on this specific region may have led to a decrease in the underlying vBMD when compared to a healthy wrist. However, we are unable to conclude if this is a momentary decrease in vBMD that could be associated with the acute healing phase following trauma given that our analysis is cross-sectional. Therefore, future work should aim to analyze kinematic JCa and vBMD longitudinally to better understand how changes in kinematic JCa over time, and how the healing process following wrist trauma, impacts the underlying subchondral bone in the acute and longitudinal phases of recovery.

In 2019, Lin et al. published a proof-of-concept study of electrical impedance spectroscopy as a simple and low-cost method to characterize progression of fracture repair (Lin et al., Sci Rep 2019). However, the electrical impedance sensors were placed in the fracture site which may impair the transfer to clinical use. To further explore the concept of monitoring fracture healing by electrical impedance spectroscopy, we established a tibial fracture model in the rabbit where sensors are positioned in proximity to the fracture site but without being placed in the fracture site. The aim of this pilot study was to explore whether distinct patterns of electrical impedance would evolve as tibial fractures in rabbits were evaluated until radiographic signs of healing.

Approval was granted from the Inspectorate of the Animal Experimentation under the Danish Ministry of Justice. Four rabbits were anaesthetized, and in each rabbit a tibial osteotomy was made and stabilized by an external fixator. Electrical impedance was measured immediately postoperative and hereafter daily until euthanization after 3 weeks. Recordings were obtained within a wide frequency range (10 Hz to 1 MHz) from an inner electrode placed into the medullary canal and an outer electrode placed extracortical on the lateral with a distance of 3 mm to the defect.

A similar pattern of electrical impedance over time was observed in the four rabbits. During the very early stages of fracture healing, an initial fluctuation in electrical impedance occurred. However, after 10 days the curves revealed a steady daily increase in electrical impedance. The first radiological signs of bone healing were detected after 14 days and progressed in all four rabbits in accordance with increments in the electrical impedance until termination of the pilot study after 21 days.

Consistent electrical impedance patterns were detected during bone healing in a pilot study of four rabbits. Further research is needed to explore whether the presented method of electrical impedance measurements can be used to monitor bone healing over time.

Achilles tendinopathy is classically defined as a tendinosis devoid of an inflammatory cell population. However, recent literature suggests inflammation as a mediator in the pathogenesis. These finding were mainly based on semi-quantative immunohistochemistry. We therefore used flow cytometry to obatain a more accurate identification and quantification of the different cell types involved. Thirty-two samples were obtained from twelve patients with chronic tendinopathic lesions undergoing Achilles tendon surgery. Samples obtained from three patients with hemiplegia requiring surgical release due to spastic Achilles tendons served as control. We used two panels to identify the myeloid and lymphoid population targeting the following markers: CD45, CD3, CD8, CD4, CD19, CD11b, CD56, CD14, CD16, Vα7.2, 6b11, CD161, TCRγδ. To assess the presence of fibroblasts CD90 was targeted. The mean count of CD45+ hematopoietic cells in the tendinopathic samples was significantly higher than in the control samples, respectively 13.27% and 3.24% of the total cell count (P<0.001). The mean fraction of CD3+ cells present in the complete cell population was significantly higher in pathological samples than in control samples, respectively 1.70% and 0.37% (P<0.05). Presence of CD19+ B cells was not reported. The mean fraction of γδ T cells was significantly higher in tendinopathic samples compared to blood samples of the same patient and consisted of 12.9% and 5.8% γδ T cells respectively (P<0.05). These findings support an inflammatory cell infiltration in midportion Achilles tendinopathy that show similarities to enthesitis in SpA. This implies a potential target to investigate in novel treatment modalities.

Purpose

Clinical guidelines identify a clear role for managing back pain with structured exercise. Pilates is a commonly recommended modality, however, Pilates-specific research is limited. Research suggests the patient-practitioner relationship may be important in managing persistent low back pain, although further research is needed to evaluate its impact on outcomes. The purpose of this study was to identify the components of the relationship between Pilates teachers and clients with persistent low back pain.

Purpose of study

Cauda Equina Syndrome (CES) is a surgical emergency. With Physiotherapists increasingly taking on first-contact and spinal triage roles, screening for CES must be as thorough and effective as possible. This study explores whether Physiotherapists are asking the correct questions, in the correct way and investigates their experiences when screening for this serious condition.

Introduction

The purpose of this study was to evaluate the outcome of vascularized iliac bone grafting for idiopathic osteonecrosis of the femoral head.

Introduction: The surgical correction of idiopathic scoliosis is a technically complex procedure that requires significant surgical expertise and highly specialized support. The current study examines practice patterns for the surgical treatment of scoliosis over a 5-year period in the State of California, with particular attention to the effect of payer status on surgical outcomes. Given the significant disparity in reimbursement for scoliosis surgery between patients with different payment sources (i.e. Medicaid versus private insurance), the potential exists for different management of disease and patient outcomes.

Methods: Using the California Office of Statewide Health Planning and Development (OSHPD) hospital discharge database, data for all surgical discharges between 1993 and 1997 for children ages 10–18 years old with a primary diagnosis of idiopathic scoliosis were reviewed. 1614 children were discharged from 99 hospitals over this period, and form the basis for this report. Outcomes of interest included length of stay (LOS), readmission, death, and need for surgical reoperation. Results: The mean age at admission of patients was 13.97 years (SD=1.89). The mean LOS was 7.38 days (SD=5.63) and mean readmission rate was 4.5%. Death (n=2) and reoperation (n=4) were extremely uncommon, making it impossible to use these as primary endpoints. Patients insured by Medi-Cal did not have significantly higher readmission rates, but did have a significantly longer length of hospital stay than patients with other payment sources (p< 0.001) and had a greater proportion of cases of extreme severity (p< 0.05), according to DRG severity code. Patients insured by Medi-Cal also incurred significantly higher hospital charges than patients with other sources of payment (p< 0.001).

Discussion and conclusions: The current study highlights the significant disparity in reimbursement rates for scoliosis surgery for patient insured by Medicaid versus private insurance in California. While this study does not address the issue of “unmet need” among the underinsured segment of the population, review of administrative data suggests that patients with Medicaid are more likely to have a higher severity of illness when presenting for surgery, and perhaps as a result, a longer length of stay. Future investigations will seek to reanalyze this dataset in patients with neurogenic scoliosis, where higher mortality and morbidity may allow for a more sensitive analysis of predictors of outcome.

Purpose – Improve health professionals’ knowledge and understanding of patients’ perspectives of a randomised controlled trial of accelerated discharge following elective orthopaedic surgery.

Methods/Design – A qualitative study using purposive sampling and in-depth, semi-structured interviews was carried out with 16 patients who were approached about taking part in a randomised controlled trial comparing accelerated discharge within 24 hours with conventional management. Nine patients who consented and seven who declined the trial were interviewed; the interviews were tape recorded, transcribed and analysed thematically.

Main results – Patients who entered the trial did so because they were attracted by the possibility of early discharge and for altruistic reasons of helping medical research. Those who refused did so because they worried that they would not have the required domestic assistance at home.

Conclusions – Most people who took part in this trial expressed satisfaction. The accelerated discharge option was not seen to be disadvantageous. Those who refused did so for social rather than medical reasons. With the increase in early discharge schemes this social concern will have to be addressed if patients’ wishes are to be met. The large number of refusals (17 out of 58) may have implications in the planning of RCTs, in that sufficient time needs to be allocated for recruitment.

Hip-spine relationships should be better investigated in THP as lumbo-sacral orientation in the sagittal plane plays a critical role in the function of the hip joints. Lateral X-rays showing spine and hips together in standing, sitting or squatting positions characterize the adaptations of the sagittal balance and the functionnal interactions between hips and spine.

Acetabular cup implantation has to be planned for frontal inclination, axial anteversion, and sagittal orientation. The later refers to the sacro-acetabular angle, key-point in the spine – hip relationships, and that is redefined by the surgeon at the time of implantation.

Usual standard CT-sections are biased for evaluating acetabular anteversion. The conventional CT procedure does not refer to the pelvic bony frame and. the measured anteversion is a projected angle on a transverse plane, depending on the pelvic adaptation in lying position. This measured angle is often considered as anatomical anteversion, leading to some confusion. Therefore this angle is only a “functional” supine anteversion, reflecting the anterior opening angle of the acetabulum in a specific position. According to the sagittal orientation of the pelvis, the true functional acetabular orientation can virtually be assessed in various postures from adjusted CT-scan sections.

The EOS^™ low irradiation 2D-3D X-ray scanner is an innovative technology already used for global evaluation of the spine. This technology allows simultaneously “full body” frontal and lateral X-rays with the patient in standing, sitting or squatting positions; a tridimensionnal patient specific bone recontruction can be performed and the cup anteversion can be directly assessed according to the position.

We investigated the lumbo-pelvic parameters influencing the tridimensionnal orientation of the acetabulum. We compared the data obtained for real postural situations using the EOS^™ system and the measures from plane X Rays and classical CT scan cuts replicating standing, and sitting positions.368 patients with cementless THP were involved in a prospective follow-up protocol. Sacral slope and pelvic tilt, incidence angle, acetabular frontal and sagittal inclination were evaluated on AP and lateral standard XRays. Functionnal anteversion of the cup has been measured using a previously described protocol with CTscan cuts oriented according to standing and sitting sacral slope. The mean difference between CTscan and EOS^™ system was 4,4° with comparable accuracy and reproductibility.

Sacral slope decrease in sitting position was linked to anteversion increase (38,8° SD 5,4°). Sacral slope increase in standing position was linked to lower ante-version (31,7° SD 5,6°). The anatomical acetabular anteversion, the frontal inclination, and the sagittal inclination were functional parameter which significantly varied between the standing, sitting, and lying positions. We noticed that the acetabular parameters in lying position highly correlated to the one in standing position, while poorly correlated with the one in sitting position. The difference between the lying and the sitting positions was about 10°, 25°, and 15° for the cup anteversion (CA) and the frontal and sagittal inclinations (FI,SI) respectively. The poor correlation between the lying and sitting positions suggests that the usual CT scan protocol is biased and not fully appropriate for investigating the cases of posterior THP dislocation and subluxation, which happen in sitting position. On the contrary, a strong correlation was observed between lying and standing measurements with all the acetabular parameters (CA,FI, SI), suggesting that the classical CT assessment of the cup anteversion remains an interesting source of information in case of anterior THP

Each patient is characterized by a morphological parameter, the incidence angle. High incidence angle is linked to low acetabular anteversion, increasing the instability risk and anterior impingement in sitting and squatting position; higher anteversion angles are observed in low incidence angle patients, leading to more internal rotation of the hip in any position.

Lumbo-sacral orientation in the sagittal plane influences the tridimensionnal orientation of the acetabulum, especially for anteversion. Aging of the hip-spine complex is linked to progressive pelvic posterior extension. Impingement phenomenons, orientation of stripe wear zones and some instability situations can be interpreted according to those data.

This study points out the opportunity to adjust the CT scan sections to the sacral slope in functional position for properly investigating the orientation of the acetabular cup, mainly in case of posterior dislocation.

In addition, the mobility of the lumbo-sacral junction could be a crucial parameter in the mechanical functioning and the stability of a THP due to its impact on sacral slope and pelvic tilt. Therefore we also recommend doing dynamic lateral radiographs of the lumbo sacral junction in standing and sitting position for planning a THP implantation in order to detect stiff lumbosacral junction or sagittal pelvic malposition.

The June 2024 Children’s orthopaedics Roundup. 360. looks at: Proximal femoral unicameral bone cysts: is ESIN the answer?; Hybrid-mesh casts in the conservative management of paediatric supracondylar humeral fractures: a randomized controlled trial; Rate and risk factors for contralateral slippage in adolescents treated for slipped capital femoral epiphysis; CRP predicts the need to escalate care after initial debridement for musculoskeletal infection; Genu valgum in paediatric patients presenting with patellofemoral instability; Nusinersen therapy changed the natural course of spinal muscular atrophy type 1: what about spine and hip?; The necessity of ulnar nerve exploration and translocation in open reduction of medial humeral epicondyle fractures in children