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PubMed2000

[Tendon transfers in postoperative hallux varus. Apropos of 12 cases].

PURPOSE OF THE STUDY: Iatrogenic hallux varus deformity after bunion surgery is a post-operative condition in which the great toe is oriented in medial deviation in relation to the first metatarsal head. This overcorrection can be a disabling complication with poor cosmetic appearance. A review of the surgical literature showed a reported hallux varus incidence range of 2 p. 100 to 13 p. 100. Various surgical interventions to treat hallux varus are described in the literature and we present here our experience in operative management of acquired hallux varus based on the results of surgical repair with the Johnson (extensor hallucis longus tendon) EHLT transfer procedure and the Hawkins (abductor hallucis tendon) procedure in 12 patients. MATERIAL AND METHODS: All of the patients suffered from painful iatrogenic hallux varus and conservative treatment was unsuccessful in all cases. The mean duration of follow-up was 42 months (range 8-96). The average age was 37 years (range: 17 to 58). The index procedure in eleven patients was a Mc Bride bunionectomy and in one case a Petersen procedure. On physical examination, a claw deformity of the hallux characterized by extension of the metatarsophalangeal joint and flexion of the interphalangeal joint was noted in all feet. Eight transfers of the abductor hallucis tendon and four complete transfers of the extensor hallucis longus tendon with interphalangeal joint fusion were done. At the time of the final follow-up, patients were interviewed and graded using a standardized questionnaire based on pain, metatarso-phalangeal range of motion, alignment of the hallux, footwear requirements, walking capabilities and first ray rest. RESULTS: Eleven patients reported satisfactory results and one patient a fair result. Overcorrection was a potential complication and in this retrospective study, one bunion deformity recurred but was asymptomatic. On radiographic evaluation the hallux abductus angle was improved by a mean 26.6 degrees and the average first intermetatarsal angle was 7 degrees (range: 3 degrees to 12 degrees ). A narrowing of the metatarso-phalangeal joint was observed in four cases (2 Johnson and 2 Hawkins). DISCUSSION: The addition of a tendon transfer to the medial soft tissue release is recommanded in most cases of hallux varus in active patients without osteoarthritis of the metatarso-phalangeal joint. Our experience with the EHLT transfer or the abductor hallucis tendon transfer demonstrated excellent correction of the hallux varus deformity; however metatarso-phalangeal joint stiffness was frequently observed. As originally described by Johnson et Spiegl, the entire extensor hallucis longus tendon was used in conjunction with an interphalangeal joint arthrodesis in the presence of a fixed and painful deformity of the hallux interphalangeal joint. If no fixed claw deformity was present an abductor hallucis tendon transfer was preferred. Onset of degenerative disease involving the metatarso-phalangeal joint in four cases may jeopardize long term survival of these surgical results.

Adolescent↗

PubMed2004

[Epidemiology of pes varus and/or equinus one year after a first cerebral hemisphere stroke: apropos of a cohort of 86 patients].

OBJECTIVE: To determine the frequency and the functional consequences of varus equinus in stabilized vascular hemiplegia. METHODS: Prospective cohort study of 86 hemiplegic patients. All patients consecutively admitted for a first hemispheral stroke between July 2001 and January 2002 were included. The evaluation consisted in a clinical examination and a descriptive study of gait. The functional capacity of patients with and without varus equinus were compared using the Barthel index, the New Functional Ambulation Classification (NFAC), the confortable ten meters gait speed and gait perimeter. RESULTS: The incidence of varus equinus was 18%. There was no difference in gait speed (0.8 m/s), NFAC or Barthel index between patients with or without varus equinus. Patients with varus equinus had had more specialized, intensive and prolonged rehabilitation. The only prognostic factor that could be identified was the motor impairment and the existence of spasticity. DISCUSSION: The mechanism of varus equinus is thought to be mainly the over-activity of gastrocnemius and solaris compared to that of the tibialis anterior, associated to the weakness of fibular muscles. The role of tibialis posterior is thought to be less important. The frequency of varus equinus after a first hemispheral stroke was low and the consequences were limited. This could be in part explained by the access of these patients to early, specialized and prolonged rehabilitation care.

Aged↗

PubMed2007

Proximally placed alignment control strap for ankle varus deformity: a case report.

Ankle varus is a commonly encountered deformity in patients with neurologic or musculoskeletal disorders. It impedes stability during the stance phase of gait and often causes skin lesions on the lateral ankle area. Plastic or conventional ankle-foot orthoses (AFOs) with supplementary features such as a T-strap or increased contact area of the lateral flange have been used for correctable varus deformities. These supplementary modifications, however, have limitations as effective tools for varus control, and ankle varus may persist despite their use. We are revisiting the concept of a proximally placed alignment control strap for ankle varus, which may overcome the limitations of currently available modifications. This alignment control strap is designed to provide a medially directed force on the tibia and fibula against the force of varus deformation of the ankle. This modification can be easily added to various types of existing AFOs with acceptable aesthetic appearance. We describe 2 cases of manually correctable but persistent varus deformities of the ankle that were successfully controlled by utilization of the proximally placed alignment control strap.

Adult↗

PubMed1997

Valgus-varus motion of the knee in normal level walking and stair climbing.

OBJECTIVE: The knee valgus-varus moment and the knee angles were compared between normal level walking and stair climbing. DESIGN: Ten healthy subjects were tested for ascent, descent, and level walking. BACKGROUND: An understanding of the normal valgus-varus motion of the knee during stair climbing is needed to apply biomechanical analysis of stair climbing as a evaluation tool for knee osteoarthritis patients. METHODS: A motion analysis system, three force plates, and a flight of stairs were used to collect kinematic and kinetic data. The knee angles and moments were calculated from the collected kinematic and kinetic data. RESULTS: The knee varus angle for the maximum knee valgus moments in stair climbing was significantly greater than that in level walking. The knee valgus moment was significantly correlated to ground reaction forces and knee valgus-varus angle during stair climbing and level walking. CONCLUSIONS: There is a coupling between the knee valgus-varus motion and flexion-extension motion. Ground reaction forces are the major contributors to the within-subject variation in the knee valgus-varus moment during stair climbing and level walking. The knee valgus-varus angle is a major contributor to the between-subject variation in the knee valgus moment during stair climbing and level walking.

Journal Article↗

PubMed1997

Finite element analysis of human knee joint in varus-valgus.

OBJECTIVE: The overall response, load transmission, role of ligaments, and state of stress in various components under varus-valgus moments in the intact and collateral-deficient tibiofemoral joint are investigated. DESIGN: A non-linear finite element model consisting of bony structures (tibia and femur), their articular cartilage layers, medial and lateral menisci and four primary ligaments (cruciates and collaterals) is utilized. BACKGROUND: Valgus and varus stresses are among the primary mechanisms of injury to knee ligaments. Several in vitro studies have investigated the role of ligaments in resisting such loads and on the way deficiency in either collateral may affect the response. METHODS: Cartilage layers are isotropic while menisci are non-homogeneous composite. The articulation of cartilage layers with each other and with the intervening menisci and the wrapping of the medial collateral ligament around the tibial edge are treated as large displacement frictionless contact problems. The non-linear elastostatic response of the joint at full extension is computed under varus-valgus moments applied to the femur with the tibia fixed. Cases simulating deficiency in collaterals and constraint on femoral axial rotation are also studied. RESULTS: The response is non-linear with large coupled axial rotations, internal in varus and external in valgus. In intact and collateral-deficient states, the joint shows varus or valgus openings so that the articulation occurs at one plateau only, medial in varus and lateral in valgus. Large tensile forces in cruciates in collateral-cut models generate higher compression penalty on the loaded plateau. CONCLUSIONS: Collaterals are the primary load-bearing structures; their absence would substantially increase primary laxities, coupled axial rotations, forces in cruciates, and articular contact forces. Good agreement with measurements is found. RELEVANCE: Detailed knowledge of joint biomechanics is essential in the diagnosis, prevention and treatment of observed disorders. Absence of collateral ligaments increases the loads in cruciates and contact stresses transmitted through cartilage layers and menisci, and thus places the affected components at more risk, especially when varus-valgus is accompanied by other modes of loading as well.

Journal Article↗

PubMedDate not supplied

Three-dimensional corrective osteotomy for treatment of cubitus varus after supracondylar fracture of the humerus in children.

Cubitus varus deformity after supracondylar fracture of the humerus in children generally includes deformities of varus, hyperextension, and internal rotation. Presently almost all corrective osteotomies for treatment of cubitus varus deformity have been limited to correction of only the varus or of the varus and hyperextension deformity. Electromyographic study and stick picture motion analysis have revealed unphysiological joint motion and muscle activity around the joint in elbows with cubitus varus, hyperextension, and internal rotation deformity. On this basis we have successfully attempted simultaneous correction of all three deformities. The end results in 41 elbows have been satisfactory. In conclusion, we recommend simultaneous correction of the three elements of cubitus varus deformity to restore anatomic alignment of the elbow joint.

Adolescent↗

PubMed2006

Influence of shoulder abduction and lateral trunk tilt on peak elbow varus torque for college baseball pitchers during simulated pitching.

Elbow varus torque is a primary factor in the risk of elbow injury during pitching. To examine the effects of shoulder abduction and lateral trunk tilt angles on elbow varus torque, we conducted simulation and regression analyses on 33 college baseball pitchers. Motion data were used for computer simulations in which two angles-shoulder abduction and lateral trunk tilt-were systematically altered. Forty-two simulated motions were generated for each pitcher, and the peak elbow varus torque for each simulated motion was calculated. A two-way analysis of variance was performed to analyze the effects of shoulder abduction and trunk tilt on elbow varus torque. Regression analyses of a simple regression model, second-order regression model, and multiple regression model were also performed. Although regression analyses did not show any significant relationship, computer simulation indicated that the peak elbow varus torque was affected by both angles, and the interaction of those angles was also significant. As trunk tilt to the contralateral side increased, the shoulder abduction angle producing the minimum peak elbow varus torque decreased. It is suggested that shoulder abduction and lateral trunk tilt may be only two of several determinants of peak elbow varus torque.

Abdomen↗

PubMed1987

Pathomechanics of congenital and acquired hallux varus: a clinical and anatomical study.

Hallux varus was observed in 69 feet among patients from a rural Indian population. This included three types of congenital hallux varus. The congenital "primary" type was the commonest and was not associated with any other foot deformity. Among the acquired forms was idiopathic hallux varus of middle age, which developed spontaneously in unshod persons and progressed gradually. Hallux varus following chronic arthritis was part of a consistent pattern of foot deformities in which the first ray collapsed in a zig-zag manner in two planes. Although the development of hallux varus is often due to intrinsic muscle imbalance, hallux varus secondary to chronic arthritis seems to occur as a result of both intrinsic and extrinsic muscle imbalance associated with midtarsal and subtalar arthritis. Muscular factors contribute to progression of the deformity also. No anatomical basis for a racial predilection for the deformity was noted. Failure to use footwear could account for the higher incidence of hallux varus in India.

Adolescent↗

PubMed1990

Influence of the varus-valgus instability on the contact of the femoro-tibial joint.

The varus-valgus instability of the knee joint is mainly due to ruptured or lax collateral ligaments. The purpose of this investigation was to study the influence of the varus-valgus instability on the contact pressures of the femoro-tibial joint. Six fresh knee specimens of human cadavers were tested to measure the contact pressure on the tibia plateau of the knee joint at varus or valgus alignment under various loads and at full extension. Pressure transducers and Bourdon tube pressure gauges were used simultaneously for recording pressure. At neutral alignment of the knee with the menisci intact, the peak pressure increased linearly with forces up to 4 MPa. With increasing varus alignment, the peak contact pressure on the medial plateau not covered by the menisci increased up to a maximum of 7.3 MPa at 5 degrees varus, and at 5 degrees valgus, the peak pressure on the lateral plateau was 7.8 MPa. After total meniscectomy, the contact pressure increased up to a maximum of 7.4 MPa at a force of 2700 N. With increasing varus alignment, the contact pressure on the medial plateau increased to 8.1 MPa at 5 degrees varus and on the lateral plateau 9.2 MPa at 5 degrees valgus.

Cartilage, Articular↗

PubMed2002

Varus inclination of the distal femur and high tibial osteotomy.

We have analysed retrospectively the relationship between the axial parameters of alignment of the lower limb and the recurrence of varus deformity after high tibial osteotomy. We studied 29 patients (37 knees) with a mean age at surgery of 66 years. The mean follow-up was for 7.4 years (5 to 10.5). Recurrence of varus deformity was defined as an increase in the femorotibial angle of 3 degrees or more, compared with that obtained six months after the operation. There were four patients (four knees) with recurrence of varus deformity. They had a greater varus inclination of the distal femur than those without varus recurrence. An association between varus inclination of the distal femur and horizontal obliquity of the joint surface was observed. Excessive obliquity prevents the shift of weight-bearing to the lateral compartment, and may cause a recurrence of varus deformity after high tibial osteotomy.

Aged↗

PubMed2003

Total knee arthroplasty after varus osteotomy of the distal part of the femur.

BACKGROUND: There is little information in the literature regarding the outcome of total knee arthroplasty following distal femoral varus osteotomy. The purpose of the present study was to evaluate the intermediate-term results of total knee arthroplasty following distal femoral varus osteotomy. METHODS: The study group consisted of nine consecutive patients (eleven knees) who had had a total knee arthroplasty following varus osteotomy of the distal part of the femur. The average age of the patients was forty-four years (range, fifteen to seventy years) at the time of the arthroplasty. The results were evaluated with use of the Knee Society score preoperatively and after a mean duration of follow-up of 5.1 years. Radiographs made preoperatively and at the time of follow-up were evaluated for alignment in the coronal plane. RESULTS: The mean Knee Society knee score was 35 points before the arthroplasty and 84 points after the arthroplasty. The mean Knee Society function score was 49 points before the arthroplasty and 68 points after the arthroplasty. The mean interval between the femoral osteotomy and the total knee replacement was fourteen years (range, two to thirty-two years). A constrained prosthesis was required in five of the eleven knees. Two knees had an excellent result, five had a good result, and four had a fair result. The mean arc of motion improved from 81.8 degrees to 105.9 degrees. The mean radiographic alignment was 3.6 degrees of valgus (range, 7 degrees of varus to 18 degrees of valgus) before the arthroplasty and 3.3 degrees of valgus (range, 1 degrees of valgus to 6 degrees of valgus) at the time of the latest follow-up. There were no infections or wound complications. CONCLUSION: Total knee arthroplasty following distal femoral varus osteotomy decreases pain and improves knee function, but the procedure is technically demanding and is associated with inferior results when compared with those of primary arthroplasty performed in a patient without a prior femoral osteotomy. In the present series, the use of an intramedullary femoral alignment guide increased the tendency to place the femoral component in relative varus angulation (that is, in <5 degrees of valgus). We recommend checking the alignment of the femoral component with an extramedullary guide in knees that have had a previous distal femoral varus osteotomy.

Adolescent↗

PubMedDate not supplied

Femoral varus derotation osteotomy with or without acetabuloplasty for unstable hips in cerebral palsy.

We reviewed 39 children with cerebral palsy who had surgery for hip subluxation or dislocation. Of 55 treated hips, 31 had a varus derotation osteotomy alone, and 24 had a combination of varus derotation osteotomy and an acetabular procedure. There was no significant difference in the ages of the two groups. There was no difference in the preoperative acetabular indices of the two groups, but the average percentage of preoperative uncoverage of the femoral head was 56% in the group with varus derotation osteotomy and 63% in the group with combined varus derotation osteotomy with an acetabular procedure. The incidence of resubluxation or redislocation (24%) after varus derotation osteotomy alone was higher than that after varus derotation osteotomy with an acetabular procedure (13%). The incidence of postoperative hip instability was higher in the patients who had preoperative uncoverage of the femoral head ranging from 70 to 100%. This was in comparison with the patients who had preoperative uncoverage of the femoral head ranging from 30 to 70%. These results suggest that a combination of varus derotation osteotomy and an acetabular procedure decreases the incidence of resubluxation or redislocation, and that unstable hips with > 70% uncoverage of the femoral head should undergo the combined procedure.

Acetabulum↗

PubMed1998

Femoral condyle geometry in the normal and varus knee.

Femoral condyle geometry was evaluated in 30 normal and 30 varus knees using magnetic resonance imaging. In the sagittal view, the distal part of the medial condyle was deformed in the varus knees, but there was no significant difference in the posterior part of the medial condyle between the normal and varus knees. In the transverse view, the transepicondylar axis (a reliable rotational landmark) showed approximately 6 degrees external rotation relative to the posterior condylar axis in the varus knees and the normal knees. The results of this study suggest that no hypoplasia exists at the posterior part of the medial condyle in varus knees. In addition, the posterior condylar axis may be a reliable rotational landmark but is in relative internal rotation in varus knees when total knee arthroplasty is performed.

Aged↗

PubMed2005

Rotational deformity in varus osteoarthritis of the knee: analysis with computed tomography.

UNLABELLED: Rotational deformities in varus osteoarthritis of the knee were evaluated with computed tomography. Preoperative computed tomography scans of 150 knees (114 patients) having total knee arthroplasty and 31 control knees (20 patients) were included. The femorotibial rotation was quantified using the clinical epicondylar axis of the femur and the tibial tuberosity (patella tendon) as the references. The knees with osteoarthritis were divided into three groups according to the femorotibial angle (Group 1, 0 degrees -9 degrees varus, n = 87; Group 2, 10 degrees -19 degrees varus, n = 51; Group 3, 20 degrees or greater varus, n = 12) and statistically analyzed. Rotational deformities (external rotation of the tibia) existed in knees with osteoarthritis and were larger in knees with increased varus deformities (mean +/- standard deviation, -2.24 degrees +/- 4.19 degrees in Group 1; 0.33 degrees +/- 4.14 degrees in Group 2; and 5.33 degrees +/- 5.71 degrees in Group 3). When the femorotibial rotation of each knee was stratified by the corresponding femorotibial angle, we found a correlation. The information should help minimize the rotational mismatch between the femoral and the tibial components in total knee arthroplasty and elucidate the pathogenesis of varus osteoarthritis of the knee. LEVEL OF EVIDENCE: Diagnostic study, Level III-1 (study of nonconsecutive patients--no consistently applied reference gold standard). See the Guidelines for Authors for a complete description of levels of evidence.

Aged↗

PubMed2003

Measurement of forefoot varus angle by laser technology in people with flexible flatfoot.

OBJECTIVE: The purpose of this study was to measure the forefoot varus angles in subjects with and without flexible flatfoot (FF) by using laser foot-scanning technology. DESIGN: In the rehabilitation laboratory of a tertiary medical center, 70 subjects with FF, ranging in age from 10 to 50 yr, were recruited. The control group consisted of 30 volunteers without clinical evidence of FF. A total of 100 positive casts were obtained by having their subtalar joints kept in a neutral position. The plantar surface of the positive cast was scanned by a Yeti 3D Foot Scanner. A straight line was drawn between the first and fifth metatarsophalangeal joints. The forefoot varus angle was measured from this line in relation to the line parallel to the ground. RESULTS: The mean forefoot varus angle was calculated to be 5.01 +/- 4.51 degrees in our FF subjects, and 1.23 +/- 1.96 degrees in the control group. Significant statistical difference in forefoot varus angle was noted between these two groups. CONCLUSIONS: The laser foot-scanning technique offers fast and accurate measurement of the forefoot varus angles. An average forefoot varus angle of approximately 5 degrees was observed in subjects with FF, which was significantly greater than the subjects without FF. Therefore, we recommend the concept of incorporating adequate forefoot posting at the medial forefoot area of an insole in treating people with FF.

Adolescent↗

PubMedDate not supplied

Cubitus varus: significant factors.

For better understanding of the etiology of "post-supracondylar fracture cubitus varus," an in vitro anatomic experiment was performed. Elbow models were precisely photographed in 256 combinations of 10 degrees increments of varus angulation, posterior angulation, internal rotation, and/or flexion contracture. Varus angulation was the most important single factor contributing to deformity. Addition of flexion contracture or posterior angulation to a given varus angulation decreased apparent deformity, whereas addition of internal rotation worsened the deformity. Control of varus angulation in the clinical setting, by whatever method, should minimize post-supracondylar fracture cubitus varus.

Fractures, Bone↗

PubMed1996

Varus malalignment of the talar neck. Its effect on the position of the foot and on subtalar motion.

We performed an in vitro study on twelve specimens of the foot and ankle from cadavera to determine whether varus malalignment of the talar neck alters the position of the foot and subtalar motion. An osteotomy of the talar neck was performed, and the specimens were studied with and without removal of a medially based wedge of bone. Removal of the wedge produced an average varus malalignment of the talar neck of 17.1 +/- 2.4 degrees (range, 12.5 to 21.0 degrees). In the coronal plane, the average arc of motion of the subtalar joint decreased from 17.2 +/- 3.3 degrees before the osteotomy to 11.7 +/- 2.9 degrees after the osteotomy and removal of the wedge. In the transverse plane, it decreased from 17.5 +/- 2.9 degrees to 11.9 +/- 2.4 degrees. In the sagittal plane, it decreased from 8.9 +/- 2.4 degrees to 6.8 +/- 2.3 degrees. The decrease in subtalar motion was characterized by an inability to evert the foot; inversion was not limited, however. The malalignment produced an average of 4.8 +/- 1.2 degrees of varus deformity and 8.7 +/- 2.3 degrees of internal rotation of the hindfoot and an average of 5.5 +/- 2.0 degrees of varus deformity and 11.5 +/- 2.4 degrees of adduction of the forefoot. A linear correlation analysis was used to compare the change in subtalar motion and the position of the foot with the degree of varus malalignment at the talar neck. The correlation coefficient was 0.90 (p < 0.01) for subtalar motion, 0.76 (p < 0.01) for internal rotation of the calcaneus, and 0.81 (p < 0.01) for adduction of the forefoot. This indicated a direct correlation between the degree of varus malalignment at the talar neck and the change in the position of the foot and in subtalar motion.

Ankle Joint↗

PubMed1999

The effect of bracing on varus gonarthrosis.

BACKGROUND: The purpose of this study was to compare a custom-made valgus-producing functional knee (unloader) brace, a neoprene sleeve, and medical treatment only (control group) with regard to their ability to improve the disease-specific quality of life and the functional status of patients who had osteoarthritis in association with a varus deformity of the knee (varus gonarthrosis). METHODS: The study design was a prospective, parallel-group, randomized clinical trial. Patients who had varus gonarthrosis were screened for eligibility. The criteria for exclusion included arthritides other than osteoarthritis; an operation on the knee within the previous six months; symptomatic disease of the hip, ankle, or foot; a previous fracture of the tibia or femur; morbid obesity (a body-mass index of more than thirty-five kilograms per square meter); skin disease; peripheral vascular disease or varicose veins that would preclude use of a brace; a severe cardiovascular deficit; blindness; poor English-language skills; and an inability to apply a brace because of physical limitations such as arthritis in the hand or an inability to bend over. Treatment was assigned on the basis of a computer-generated block method of randomization with use of sealed envelopes. The patients were stratified according to age (less than fifty years or at least fifty years), deformity (the mechanical axis in less than 5 degrees of varus or in at least 5 degrees of varus), and the status of the anterior cruciate ligament (torn or intact). The patients were randomly assigned to one of three treatment groups: medical treatment only (control group), medical treatment and use of a neoprene sleeve, or medical treatment and use of an unloader brace. The disease-specific quality of life was measured with use of the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and the McMaster-Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR), and function was assessed with use of the six-minute walking and thirty-second stair-climbing tests. The primary outcome measure consisted of an analysis of covariance of the change in scores between the baseline and six-month evaluations. RESULTS: One hundred and nineteen patients were randomized. The control group consisted of forty patients (thirty-one men and nine women; mean age, 60.9 years); the neoprene-sleeve group, of thirty-eight patients (twenty-seven men and eleven women; mean age, 58.2 years); and the unloader-brace group, of forty-one patients (twenty-eight men and thirteen women; mean age, 59.5 years). Nine patients withdrew from the study. At the six-month follow-up evaluation, there was a significant improvement in the disease-specific quality of life (p = 0.001) and in function (p< or =0.001) in both the neoprene-sleeve group and the unloader-brace group compared with the control group. There was a significant difference between the unloader-brace group and the neoprene-sleeve group with regard to pain after both the six-minute walking test (p = 0.021) and the thirty-second stair-climbing test (p = 0.016). There was a strong trend toward a significant difference between the unloader-brace group and the neoprene-sleeve group with regard to the change in the WOMAC aggregate (p = 0.062) and WOMAC physical function scores (p = 0.081). CONCLUSIONS: The results indicate that patients who have varus gonarthrosis may benefit significantly from use of a knee brace in addition to standard medical treatment. The unloader brace was, on the average, more effective than the neoprene sleeve. The ideal candidates for each of these bracing options remain to be identified.

Bone Diseases, Developmental↗