Surgical treatment of congenital pseudoarthrosis of the clavicle: Our 22-year, single-center experience

Join Diseases and Rela ed Su ge y J Dis Rela Su g 2021;32(1):224-229 CASE SERIES Recei ed: No embe 03, 2020 Accep ed: Decembe 02, 2020 Published online: Janua y 06, 2021 Co espondence: Ca men Ma ínez-Azna , MD. O hopedic and T auma Su ge y Se ice, Miguel Se e Uni e si y Hospi al, Paseo de Isabel la Ca ólica, 50009 Za agoza. Spain. E-mail: cma inezazna @gmail.com Doi: 10.5606/ehc.2021.79576 Congeni al pseuda h osis o he cla icle (CPC) is a a e en i y. I was i s epo ed by Fi zwilliams[1] in 1910 and i is di icul o know he ue incidence wi h a ound 200 cases published in he li e a u e. The exac e iology is s ill unknown. The mos accep ed heo y s a es ha i is a ailu e o usion o he wo diaphyseal memb anous ossi ica ion cen e s in he six h in au e ine week o ges a ion[2] and seconda y o ana omic abno mali ies which a ec he subcla ian a e y, as in he p esence o a p ominen i s ib.[3,4] I explains ha mos pa ien s p esen igh -sided CPC, and cases o le -sided a e associa ed o dex oca dia. Bila e al cases a e excep ional.[5] I seems o be mo e common in emales. Congeni al pseuda h osis o he cla icle can be diagnosed a bi h o la e in childhood, as a swelling in he middle- hi d cla icle bu which is no mally painless (Figu e 1), being necessa y o es ablish a di e en ial diagnosis wi h Objec i es: This s udy epo s he su gical ou comes in a pa ien coho wi h congeni al pseuda h osis o he cla icle (CPC). Pa ien s and me hods: A o al o nine pedia ic pa ien s (5 males, 4 emales; mean age: 4.43 yea s; ange, 2 o 12 yea s) who we e diagnosed wi h CPC and ea ed su gically wi h a minimum one-yea ollow-up be ween Janua y 1996 and Decembe 2018 we e e ospec i ely analyzed. The pa ien s we e di ided in o wo g oups acco ding o he ixa ion me hod as he Ki schne wi e (K-wi e; G oup A, n=2) o s abiliza ion wi h a pla e (G oup B, n=7). The physical unc ion and symp oms we e e alua ed using he Quick Disabili ies o he A m, Shoulde and Hand (QuickDASH) scale. Resul s: The mean age a he ime o diagnosis was 2.95 ( ange, 0 o 12) yea s. Six cases we e a ophic pseuda h osis and h ee cases we e hype ophic. Radiog aphic consolida ion occu ed in all cases wi h a mean du a ion o 103.8±39.1 days, indica ing no signi ican di e ence be ween he g oups (p>0.05). Complica ions egis e ed we e a K-wi e b eakage in a pa ien in G oup A and an in e nal ixa ion pla e loosening in a pa ien in G oup B. The mean pos ope a i e ollow-up was 2.98±1.82 yea s. The QuickDASH sco e was 0 poin s in all pa ien s. Conclusion: The ea ly su gical indica ion based on e eshmen o he pseuda h osis ocus, wi h bone au og a in e posi ion when a ailu e exis s o es o e adequa e cla icula leng h, and ixa ion a e eliable al e na i es wi h a o able clinical and adiological esul s in he mid- and long- e m wi h ewe complica ions. Keywo ds: Cla icle, congeni al pseuda h osis o cla icle, quick disabili ies o he a m, shoulde and hand, su gical p ocedu es. ABSTRACT Su gical ea men o congeni al pseudoa h osis o he cla icle: Ou 22-yea , single-cen e expe ience Ca men Ma ínez-Azna , MD1, Isabel Pa ada-A endaño, MD1, Vic o ia E Gómez-Palacio, MD, PhD1, Sand a Abando-Ruiz, MD1, Jo ge Gil-Alba o a, MD, PhD1,2 1O hopedic and T auma Su ge y Se ice, Miguel Se e Uni e si y Hospi al, Za agoza, Spain 2Depa men o Su ge y, Facul y o Medicine, Uni e si y o Za agoza, Za agoza, Spain. obs e ic ac u es, pos - auma ic nonunion, neu o ib oma osis o cleidoc anial dysos osis.[6,7] I is possible ha symp oms appea due o g ow h o inc eased ac i i y.[8] In a e cases, ho acic ou le synd ome o b achial plexus ne e comp ession a e desc ibed.[9] The e is no clea consensus on he op imal ea men o his en i y, a wha age o wha su gical echnique should be pe o med. Some au ho s ha e ad oca ed o a mo e conse a i e Ci a ion: Ma ínez-Azna C, Pa ada-A endaño I, Gómez- Palacio VE, Abando-Ruiz S, Gil-Alba o a J. Su gical ea men o congeni al pseudoa h osis o he cla icle: Ou 22-yea , single- cen e expe ience. J Dis Rela Su g 2021;32(1):224-229. This is an open access a icle unde he e ms o he C ea i e Commons A ibu ion-NonComme cial License, which pe mi s use, dis ibu ion and ep oduc ion in any medium, p o ided he o iginal wo k is p ope ly ci ed and is no used o comme cial pu poses (h p://c ea i ecommons.o g/licenses/by-nc/4.0/). ©2021 All igh ese ed by he Tu kish Join Diseases Founda ion Su gical ea men o congeni al pseudoa h osis o he cla icle 225 ea men , con ending ha he di icul y o achie e a bony union and he ac ha pa ien s do no achie e be e unc ional esul s wi h su ge y.[10,11] Howe e , a su gical in e en ion is now widely accep ed. Some au ho s who a gue in a o o su ge y conclude good unc ional ou comes in pa ien s wi h e iden de o mi y and/o ela ed symp oma ology.[12] In he p esen s udy, we aimed o e alua e he su gical ou comes in a pa ien coho wi h CPC ea ed in ou cen e . PATIENTS AND METHODS This single-cen e , e ospec i e s udy was conduc ed a O hopedic and T auma Su ge y Se ice, Miguel Se e Uni e si y Hospi al, Za agoza, Spain be ween Janua y 1996 and Decembe 2018. All child en diagnosed wi h CPC and ea ed su gically using one o wo ixa ion echniques, namely Ki schne wi e (K-wi e) o pla e ixa ion,[13] and ollowed o minimum one yea a e su ge y we e included. Those ha ing associa ed o he pa hologies (i.e., obs e ic o auma ic ac u es o he cla icle, neu omuscula diso de s o cleidoc anial dysplasia) we e excluded. A o al o 13 pa ien s we e diagnosed wi h CPC in ou cen e ; howe e , only nine o hem (5 males, 4 emales; mean age: 4.43 yea s; ange, 2 o 12 yea s) ul illed he inclusion c i e ia. Two pa ien s did no unde go su ge y due o associa ed ce eb al palsy and majo neu osenso y disabili y. The o he wo pa ien s we e admi ed o ou cen e a he age o h ee mon hs and eigh mon hs, espec i ely. The da a we e ex ac ed om an ins i u ional da abase and a w i en in o med consen was ob ained om each pa en and/o legal gua dian o he su ge y. The s udy was conduc ed in acco dance wi h he p inciples o he Decla a ion o Helsinki. Two me hods o ixa ion du ing su ge y we e pe o med: The K-wi e (G oup A, n=2) o ixa ion wi h a pla e (G oup B, n=7). Fixa ion was pe o med wi h a K-wi e in he wo oldes cases, while he mos common echnique was a pla e wi h 4 o 6 co ices on each side o he ocus (Figu e 2). Da a we e collec ed om medical eco ds and adiological es s a he ime o diagnosis and a six weeks, a h ee mon hs, FIGURE 1. Clinical aspec o congeni al pseuda h osis o he cla icle. FIGURE 2. (a) An in aope a i e image o congeni al pseuda h osis o he cla icle. (b) Focus o pseuda h osis a e e eshmen and in amedulla y d illing. (c) Fixa ion wi h a econs uc ion pla e. (a) (b) (c) J Dis Rela Su g226 and a one yea a e su ge y and a e emo al o he os eosyn hesis ma e ial. Demog aphic and clinical cha ac e is ics o he pa ien s such as sex, age a he ime o diagnosis, a ec ed side, symp oms, ype o pseuda h osis, age a he ime o in e en ion, ype o su gical ea men , adiog aphic bone healing ime, esul s, complica ions, implan emo al ime, and ollow-up we e eco ded. In o de o measu e he esul s o physical unc ion and symp oms, we used he Quick Disabili ies o he A m, Shoulde and Hand (QuickDASH) scale du ing he pos ope a i e isi , wo o h ee mon hs a e emo al o he ma e ial.[14] The policy o ou hospi al a he ime o his s udy was o o e su gical managemen o all pa ien s wi h CPC who me inclusion c i e ia. The minimum age o he child en a he ime o ope a ion was wo yea s old and he easons we e cosme ic in all o hem and/o discom o wi h he backpack in he cla icula a ea in olde pa ien s. No pa ien p esen ed pain a he ime o diagnosis. All pa ien s p esen ed a swelling in he cla icula egion a o soon a e bi h. Radiog aphically, we classi ied hem as a ophic o hype ophic pseuda h osis. The echnique consis ed o a longi udinal incision o e he supe io su ace o he cla icle, ollowed by e eshmen he ocus o pseuda h osis and d illing he in amedulla y canal in all cases. An au og a was used only in he a ophic pa ien s a he bony edges and/o a gap a e excision o he non-union. Pos ope a i e ca e was simila in all pa ien s; a sling was kep o an a e age o ou weeks, allowing ac i e shoulde mobiliza ion a e wa ds, wi hou eques ing physio he apy. Spo s ac i i y was no allowed o h ee mon hs. All pa ien s unde wen a scheduled ex ac ion o he os eosyn hesis ma e ial. S a is ical analysis S a is ical analysis was pe o med using he IBM SPSS e sion 19.0 so wa e (IBM Co p., A monk, NY, USA). Con inuous a iables we e exp essed in mean ± s anda d de ia ion (SD), median (min-max), while ca ego ical a iables we e exp essed in numbe and equency. The Kolmogo o -Smi no es , wi h Lillie o s co ec ion, was pe o med o assess he no mali y dis ibu ion. The Fishe ’s exac es and he non-pa ame ic Mann-Whi ney U es we e used o compa e he g oups o non-no mally dis ibu ed a iables. A p alue o <0.05 was conside ed s a is ically signi ican . RESULTS Baseline demog aphic and clinical cha ac e is ics o he pa ien s a e shown in Table I. TAbLE I Baseline demog aphic and clinical cha ac e is ics o pa ien s Pa ien No. 1 2345 6 789 Sex F M M M F M M F F Age a diagnosis 12 days 2 yea s 25 days 3 yea s 12 yea s 1 mon h 2 yea s 4 yea s 22 mon hs Side R RRRR R RRR Age a su ge y (yea s) 4 2 2 4 12 3 3 4 4 Type o pseudoa h osis H A A A A A H A H Fixa ion K-wi e K-wi e PPP P PPP Complica ions K-wi e b oken No No No No Sc ew mobiliza ion+pla e ailu e+delayed union No No No Radiological healing (days) 150 105 92 46 96 180 85 97 84 Ma e ial emo al (mon hs) 12 18 10 20 22 14 14 11 13 Follow-up (yea s) 41,75 71,9 24,3 2,6 21,3 Ou come (QuickDASH) (%) 0 0000 0 000 F: Female; M: Male; R: Righ ; H: Hype ophic; A: A ophic; K-wi e: Ki schne wi e; P: Pla e. Su gical ea men o congeni al pseudoa h osis o he cla icle 227 In all pa ien s, he igh side was a ec ed. The mean age a he ime o diagnosis was 2.95 ( ange, 0 o 12) yea s. On physical examina ion, all pa ien s had a isible de o mi y o e he midcla icula line and we e neu o ascula ly in ac . Hype ophic pseuda h osis was desc ibed in se en pa ien s (53.84%), h ee o whom we e ope a ed. The emaining six child en (46.15%) had a ophic cha ac e is ics and all we e ope a ed (Figu e 3). In all o hem, we used local au og a and allog a . Consolida ion occu ed in all pa ien s wi h no signi ican di e ences ega ding he ime o achie e i (p>0.05). In G oup A, one pa ien p esen ed a complica ion due o needle b eakage one mon h a e he in e en ion, which equi ed ea ly eope a ion (Figu e 4). In G oup B, he e we e se en cases, one o which, wi h a ophic CPC, su e ed om mobiliza ion o he sc ews ha had an impac on consolida ion. This case unde wen ein e en ion wi hin wo mon hs h ough an open educ ion, ocus e eshmen , and a new pla e ixa ion wi h he addi ional co icocancellous iliac c es bone g a ing. The esul was sa is ac o y wi h a subsequen union. No dono si e mo bidi y was obse ed. Two pa ien s p esen ing wi h complica ions wi h he ma e ial had a adiog aphic delay in FIGURE 3. (a) A ophic CPC; (b) Hype ophic CPC. CPC: Congeni al pseuda h osis o he cla icle. (a) (b) FIGURE 4. (a) Fixa ion wi h Ki schne wi e; (b) Ki schne wi e b eak; (c) Rein e en ion wi h ocus e eshmen and ixa ion wi h a pla e adding co icocancellous iliac c es au og a ; (d) One-yea ollow-up esul s. (a) (c) (b) (d) J Dis Rela Su g228 consolida ion, eaching a mean o 165±21.2 ( ange, 150 o 180) days. Good adiological consolida ion was achie ed in he es o pa ien s on 86.4±19.2 ( ange, 46 o 105) days wi h no s a is ically signi ican di e ences be ween he g oups. Rega ding sex, he e we e no signi ican di e ences in consolida ion (p=0.858), as well as in he ype o pseuda h osis (p=0.43). The mean pos ope a i e ollow-up was 2.98±1.82 yea s. The QuickDASH sco e was 0 poin s in all pa ien s. Taking in o accoun he i s eigh i ems abou he abili y o do ac i i ies, all pa ien s p esen ed comple e shoulde mobili y and abili y o do hem. None o he pa ien s had pain. The emo al o he ma e ial in G oup A occu ed a a mean du a ion o ou ( ange, 3 o 5) weeks, while he pa ien s e u ned o he ope a ing oom a a mean du a ion o 14.88 ( ange, 10 o 22) mon hs in G oup B, as long as bone healing was obse ed on X- ay. The unc ional and quali y o li e esul s du ing ollow-up we e also sa is ac o y. DISCUSSION Congeni al pseuda h osis o he cla icle has a e y low incidence. In he li e a u e, he e a e ew s udies wi h long- e m se ies[12,15,16] and he a icle by Kim e al.[15] is one o hem wi h he longes ollow-up in 47 cases. Cu en ly, he e is no consensus on he mos op imal me hod and iming o ea men . Some au ho s ha e sugges ed a conse a i e ea men , i he e a e no symp oms,[10,11] while o he s ecommend su ge y, ega dless o he absence o symp oms.[17,18] Su gical ea men can be es ablished o cosme ic appea ance, d ooping o he shoulde , discom o in he a ea, pain o unc ional symp oms[7] o o a oid ho acic ou le synd ome o o he ascula pa hologies.[19] In gene al, in all s udies, he pa ien - epo ed su ge y ou comes a e a o able. The mean age o in e en ion may be delayed in some cases due o he pa en ’s decision who a e unwilling o an ea ly su gical ea men (<6 yea s o age) o hei asymp oma ic child en;[18] howe e , o e all, many au ho s ecommend pe o ming he ope a ion a he age o h ee o six yea s.[4,7,8,15,20,21] In ou s udy, he mean age was 4.43 yea s, consis en wi h p e ious indings.[2-12] One o he easons o his is he low a e o nonunion in his g oup o age, compa ed o child en 18 mon hs o olde .[15] The e a e di e en ixa ion me hods used in he ea men including p ese a ion o he pe ios al slee e and ixa ion wi h non-abso bable su u e alone in child en unde 18 mon hs o age,[15] sc ews alone o ully h eaded pins.[22] Howe e , pla es ( econs uc ion, comp ession o ana omical) and K-wi es a e he mos equen ly used me hods. Al hough he e a e se e al epo s ad oca ing K-wi e ixa ion,[8,12,17] many o hem we e w i en be o e he mos common use o ana omical and locking pla es. Complica ions wi h K-wi es ixa ion include pin- ac in ec ions, b eakages, delayed unions[12] and mig a ion aking in o accoun he p oximi y o subcla ian a e y and b achial plexus.[22] The e a e no published cases in which he subcla ian a e y o b achial plexus ha e been inju ed wi h he use o pla e ixa ion. The use o bone g a is conside ed impo an in he ea men o CPC o inc ease he union a e.[16,21] The use o allogenic g a has been desc ibed,[12,18] and a combina ion o local au og a and allog a has been epo ed, as well.[22] Howe e , i is p e e ed au ologous iliac c es bone hanks o i s g ea e biological bene i s,[1,16] aking in o accoun a emained and p olonged pain in he dono a ea. To sol e his complica ion, Abdellaoui e al.[23] p oposed a modi ied Masquele echnique, as an al e na i e, o ob ain comple e union o he ocus wi hou g a in e posi ion and wi h minimal aes he ic de ec . In ou s udy, he adiological e idence o consolida ion was ob ained a a mean du a ion o 103.8±39.1 days, consis en wi h he s udies o Chand an e al.[20] and E l e al.[24] Sal age p ocedu es a e su gical ea men complica ions consis in mos o he cases o e ision su ge y, epea ing esec ion o he pseuda h osis, and placemen o bone g a and in e nal ixa ion; howe e , he e a e some epo s using ascula ized bone g a ing[25] o ascula ized medial emo al condyle lap,[26] al hough hey can ne e be conside ed he i s choice in he managemen o CPC. The main limi a ion o ou s udy lies in i s e ospec i e design wi h Le el o E idence IV, wi hou a con ol g oup o conse a i e ea men . In addi ion, he small sample size did no allow o many s a is ical compa isons o subg oup analyses. Despi e hese limi a ions, he cu en s udy de ails ea men op ions o hese pa ien s and imp o es ou unde s anding o he esul s o su gical ea men . Ou case se ies is also compa able wi h p e ious published s udies. As a esul o ou expe ience and he li e a u e e iew, we sugges ha he e is no clinical di e ence be ween ea lie e sus la e ope a ion; howe e , we ad ise an ea ly su gical ea men pe o ming a Su gical ea men o congeni al pseudoa h osis o he cla icle 229 e eshmen o he pseuda h osis ocus, using always au ologous bone g a in a ophic CPC o when a gap appea s be ween he agmen s, and s able ixa ion. Be ween ou o six yea s o age, i seems o be easonable o achie e a good ixa ion and adap a ion o a pla e acco ding o he size o he cla icle. I can also a oid di icul ies which may occu in olde child en wi h a la ge size o he gap and a possible longe ime o heal. This app oach may p e en he p oblems associa ed wi h an abno mal ana omy o he cla icle. Rega ding ixa ion, based on ou small coho , i is di icul o each a i m conclusion; howe e , ou p ac ice has changed om he K-wi es o pla e ixa ion as he i s choice o ea men . In conclusion, he scheduled ea ly su gical indica ion (<6 yea s o age) based on e eshmen o he pseuda h osis ocus, wi h bone au og a in e posi ion when a gap exis s, and ixa ion a e eliable al e na i es wi h a o able clinical and adiological esul s in he mid- and long- e m. I also yields minimal complica ions and imp o es aes he ics, a oiding possible u u e p oblems. We ecommend su gical ea men as o ou yea s o age using pla e ixa ion as he i s op ion. Decla a ion o con lic ing in e es s The au ho s decla ed no con lic s o in e es wi h espec o he au ho ship and/o publica ion o his a icle. Funding The au ho s ecei ed no inancial suppo o he esea ch and/o au ho ship o his a icle. REFERENCES 1. Fi zwilliams DCL. He edi a y c anio-cleido-dysos osis. Lance 1910;2:1466-75. 2. Fawce . The De elopmen and Ossi ica ion o he Human Cla icle. J Ana Physiol 1913;47:225-34. 3. Lloyd-Robe s GC, Apley AG, Owen R. Re lec ions upon he ae iology o congeni al pseuda h osis o he cla icle. Wi h a no e on c anio-cleido dysos osis. J Bone Join Su g [B ] 1975;57:24-9. 4. Gomez-B ouche A, Sales de Gauzy J, Accadbled F, Abid A, Delisle MB, Cahuzac JP. Congeni al pseuda h osis o he cla icle: a his opa hological s udy in i e pa ien s. J Pedia O hop B 2004;13:399-401. 5. Nie o Gil A, Gómez Na alón A, Zo illa Ribo P. Bila e al congeni al seuda h osis o he cla icle. A clinical case. Re Esp Ci O op T auma ol 2016;60:397-9. 6. Chal an JS, Sanchez TR. Congeni al Cla icula Pseudoa hosis-How o Di e en ia e I F om he Mo e Common Cla icula F ac u es. Pedia Eme g Ca e 2019;35:e37-e39. 7. Pe siani P, Molayem I, Villani C, Cadilhac C, Glo ion C. Su gical ea men o congeni al pseuda h osis o he cla icle: a epo on 17 cases. Ac a O hop Belg 2008;74:161-6. 8. Gibson DA, Ca oll N. Congeni al pseuda h osis o he cla icle. J Bone Join Su g [B ] 1970;52:629-43. 9. Wa son HI, Hoppe GP, Ko acs P. Congeni al pseuda h osis o he cla icle causing ho acic ou le synd ome. BMJ Case Rep 2013;2013:bc 2013010437. 10. O’Lea y E, Elsayed S, Mukhe jee A, Tay on K. Familial pseuda h osis o he cla icle: does i need ea men ? Ac a O hop Belg 2008;74:437-40. 11. Shalom A, Khe mosh O, Wien oub S. The na u al his o y o congeni al pseuda h osis o he cla icle. J Bone Join Su g [B ] 1994;76:846-7. 12. Di Genna o GL, C a ino M, Ma inelli A, Be a di E, Rao A, S illi S, e al. Congeni al pseuda h osis o he cla icle: a epo on 27 cases. J Shoulde Elbow Su g 2017;26:e65-e70. 13. A ik OŞ. Is he e some hing new and in e es ing in my a icle? Eklem Has alik Ce ahisi 2019;30:69. 14. Kennedy CA, Bea on DE, Smi h P, Van Ee d D, Tang K, In ig T, e al. Measu emen p ope ies o he QuickDASH (disabili ies o he a m, shoulde and hand) ou come measu e and c oss-cul u al adap a ions o he QuickDASH: a sys ema ic e iew. Qual Li e Res 2013;22:2509-47. 15. Kim AE, Vuille min CB, Bae DS, Samo a JB, Wa e s PM, Baue AS. Congeni al pseuda h osis o he cla icle: su gical decision making and ou comes. J Shoulde Elbow Su g 2020;29:302-7. 16. Owen R. Congeni al pseuda h osis o he cla icle. J Bone Join Su g [B ] 1970;52:644-52. 17. Lo en e Mol o FJ, Bone e Lluch DJ, Ga ido IM. Congeni al pseuda h osis o he cla icle: a p oposal o ea ly su gical ea men . J Pedia O hop 2001;21:689-93. 18. S ude K, Bake MP, K ieg AH. Ope a i e ea men o congeni al pseuda h osis o he cla icle: a single-cen e expe ience. J Pedia O hop B 2017;26:245-49. 19. Cu a ino G, He ing JA. Congeni al pseuda h osis o he cla icle. Pedia Radiol 2009;39:1343-9. 20. Chand an P, Geo ge H, James LA. Congeni al cla icula pseuda h osis: compa ison o wo ea men me hods. J Child O hop 2011;5:1-4. 21. Cadilhac C, Fenoll B, Pe e i A, Pado ani JP, Pouliquen JC, Rigaul P. Congeni al pseuda h osis o he cla icle: 25 childhood cases. Re Chi O hop Repa a ice Appa Mo 2000;86:575-80. 22. Toledo LC, MacEwen GD. Se e e complica ion o su gical ea men o congeni al pseuda h osis o he cla icle. Clin O hop Rela Res 1979;(139):64-7. 23. Abdellaoui H, A a a K, Cha e L, A i i MA. Congeni al pseuda h osis o he cla icle ea ed by Masquele echnique. BMJ Case Rep 2017;2017:bc 2017221557. 24. E l V, Wild A, K auspe R, Raab P. Su gical ea men o congeni al pseuda h osis o he cla icle: a epo o h ee cases and e iew o he li e a u e. Eu J Pedia Su g 2005;15:56-60. 25. Glo zbecke MP, Shin EK, Chen NC, Labow BI, Wa e s PM. Sal age econs uc ion o congeni al pseuda h osis o he cla icle wi h ascula ized ibula g a a e ailed ope a i e ea men : a case epo . J Pedia O hop 2009;29:411-5. 26. Mu ai A, Tada K, Nakada M, Ma su a M, Hayashi K, Tsuchiya H. Use o a ee ascula ized medial emo al condyle lap o e ision su ge y in a pedia ic pa ien wi h congeni al pseuda h osis o he cla icle. Case Rep O hop 2020;2020:8872934.