Introduction. Osteochondral defects of the knee may occur following patella dislocation or following direct trauma or twisting injuries to the knee in adolescents. Often a diagnostic and therapeutic challenge, if these lesions are left, posttraumatic osteoarthritis may occur. This retrospective single centre study presents the short-term results following operative fixation of osteochondral fragments of the knee using Omnitech ® screws. Method. All skeletally immature patients presenting with an osteochondral fracture of their femur or patella confirmed on xray and MRI were identified. Arthroscopic evaluation of the osteochondral defect was performed followed by open reduction and internal fixation of the osteochondral fragment using Omnitech ® screws. A standard postoperative rehabilitation protocol was followed. Patients were evaluated at follow-up using a Knee Injury and Osteoarthritis Outcome Score (KOOS). Results. Eight patients were identified. The mean age at time of injury was 15 years (range 14–16) for two girls and 14.4 years (range 13–16) for six boys. The lateral femoral condyle was involved in six cases and patella in two cases. At mean follow up of 14 months (range 1–38) there was no revision for failure and no postoperative complications. The KOOS score (out of 100) at final follow up was subdivided as follows; Pain, 93 (range 81–100), other symptoms, 77 (range 36–100), function in daily living (ADL), 97 (range 84–100), function in sport and recreation, 84 (range 55–100) and knee related quality of life, 79 (range 44–100). Discussion. The short-term results of using Omnitech® screws are promising. Subchondral screw placement with adequate compression of the osteochondral fragment is achievable with Omnitech ® screws. Seven patients are back to their pre-injury sporting activity and one patient is currently undergoing postoperative rehabilitation, one month following surgery

Aims. Spinal fusion remains the gold standard in the treatment of idiopathic scoliosis. However, anterior vertebral body tethering (AVBT) is gaining widespread interest, despite the limited data on its efficacy. The aim of our study was to determine the clinical efficacy of AVBT in skeletally immature patients with idiopathic scoliosis. Methods. All consecutive skeletally immature patients with idiopathic scoliosis treated with AVBT enrolled in a longitudinal, multicentre, prospective database between 2013 and 2016 were analyzed. All patients were treated by one of two surgeons working at two independent centres. Data were collected prospectively in a multicentre database and supplemented retrospectively where necessary. Patients with a minimum follow-up of two years were included in the analysis. Clinical success was set a priori as a major coronal Cobb angle of < 35° at the most recent follow-up. Results. A total of 57 patients were included in the study. Their mean age was 12.7 years (SD 1.5; 8.2 to 16.7), with 95% being female. The mean preoperative Sanders score and Risser grade was 3.3 (SD 1.2), and 0.05 (0 to 3), respectively. The majority were thoracic tethers (96.5%) and the mean follow-up was 40.4 months (SD 9.3). The mean preoperative major curve of 51° (SD 10.9°; 31° to 81°) was significantly improved to a mean of 24.6° (SD 11.8°; 0° to 57°) at the first postoperative visit (45.6% (SD 17.6%; 7% to 107%); p < 0.001)) with further significant correction to a mean of 16.3° (SD 12.8°; -12 to 55; p < 0.001) at one year and a significant correction to a mean of 23° (SD 15.4°; -18° to 57°) at the final follow-up (42.9% (-16% to 147%); p < 0.001). Clinical success was achieved in 44 patients (77%). Most patients reached skeletal maturity, with a mean Risser score of 4.3 (SD 1.02), at final follow-up. The complication rate was 28.1% with a 15.8% rate of unplanned revision procedures. Conclusion. AVBT is associated with satisfactory correction of deformity and an acceptable complication rate when used in skeletally immature patients with idiopathic scoliosis. Improved patient selection and better implant technology may improve the 15.8% rate of revision surgery in these patients. Further scrutiny of the true effectiveness and long-term risks of this technique remains critical. Cite this article: Bone Joint J 2020;102-B(12):1703–1708

Abstract. Introduction. The paediatric population present unique challenges to the knee surgeon, particularly when treating recurrent patellofemoral instability(PFI), the management of which is poorly standardised. Through the EPPIC BASK National Trainee Collaborative, we aimed to identify which procedures (and in which combination) are being used to surgically manage recurrent PFI in skeletally immature patients across the UK. Methods. A retrospective national service evaluation via a trainee collaborative analysing local trust data between 1st January 2014 and 31st December 2019. Data from institutions registered for EPPIC was compiled and compared to the national guidelines for adults. Results. A total of 333 patients were classified as skeletally immature(radiologically open physes) across 28 hospitals. Mean age was 14.1 years(+/- 4.5) with 64.9% being female. Mean number of procedures performed was 11.9 (+/-16.4). Isolated medial patellofemoral ligament reconstruction (MPFLR) was the most common procedure, performed in 65.8% of patients. Combined MPFLR and TTO was undertaken in 13.2% of patients. Proximal realignment surgery was performed in 5.1% of patients. Lateral releases were performed in 18.3% of patients with 8.4% performed in isolation. Conclusion. This study highlights the national variation in surgical treatment of PFI in skeletally immature patients. The guidance for adults cannot be applied universally to the skeletally immature, and it not always acceptable to delay treatment until physes close. This lack of standardisation within the UK in the management of recurrent PFI in skeletally immature patients highlights the need for a national consensus in appropriate surgical management of this patient population

Abstract. Introduction. There is currently very little evidence which can be used to guide surgeons treating skeletally immature patients with suspected meniscal injury. The aim of our modified Delphi study was to develop comprehensive recommendations for the management of isolated meniscal tears in skeletally immature children. Methodology. An international, two round, modified Delphi consensus was completed. Included ‘experts’ were identified as having an established adult and/or paediatric knee practice and either: 1) Faculty at the international kid's knee meeting, 2) Active member of the complex national paediatric MDT group, or 3) faculty on recognised national course aimed at teaching knee surgeons regarding the management of meniscal lesions. A threshold of 70% was used to identify consensus. Results. A total of 43 experts (Round 1) and 41 experts (Round 2) took part in the Delphi study. Surgeons from the UK, Europe, USA and South America took part. 34 statements were identified exploring 4 main domains – clinical diagnosis, investigation, management and specialist tears. Following round 1 consensus was reached on 17 (50%) statements, subsequently after completion of round 2 consensus was reached on 28 (82%) statements, leaving 6 (18%) with no consensus. Conclusions. This is the first modified delphi consensus which provides evidence for surgeons treating skeletally immature children with isolated meniscal tears. Further studies are required to provide evidence for the areas where no consensus was reached

Introduction. Coronal malalignment and leg length discrepancies (LLD) are frequently associated. Temporary hemiepiphysiodesis (tHED) is commonly employed for the correction of limb malalignment in skeletally immature patients. For treatment of LLD greater than 2 cm, lengthening with intramedullary legnthening nails is a safe and reliable technique. However, the combined application of these approaches in skeletally immature patients has not yet been investigated. Materials & Methods. Retrospective radiological and clinical analysis of 25 patients (14 females, 11 males) who underwent intramedullary femoral lengthening with an antegrade PRECICE® lengthening nail as well as tHED of the distal femur and / or proximal tibia between 2014 and 2019. tHED was conducted by implantation of flexible staples (FlexTack™) either prior (n = 11), simultaneously (n = 10), or subsequently (n = 4) to femoral lengthening. The mean follow-up period was 3.7 years (±1.4). Results. The median initial LLD was 39.0 mm (35.0–45.0). 21 patients (84%) presented valgus and 4 (16%) showed varus malalignment. Leg length equalization was achieved in 13 patients at skeletal maturity (62%). The median LLD of patients with a residual LLD > 10 mm was 15.5 mm (12.8–21.8). Limb realignment was obtained in nine of seventeen skeletally mature patients (53%) in the valgus group, and in one of four patients (25%) in the varus group. Conclusions. The combination of antegrade femoral lengthening and tHED can efficiently correct LLD and coronal limb malalignment in skeletally immature patients. Nevertheless, achieving limb length equalization and realignment may render difficult in cases of severe LLD and angular deformity. Furthermore, the reported techniques ought to be thoroughly planned and executed and require regular clinical and radiological examinations until skeletal maturity to avoid - or timely detect and manage - adverse events such as overcorrection and rebound of deformity

Anterior vertebral body tethering (AVBT) is a growth modulating procedure used to manage idiopathic scoliosis by applying a flexible tether to the convex surface of the spine in skeletally immature patients. The purpose of this study is to determine the preliminary clinical outcomes for an adolescent patient cohort. 18 patients with scoliosis were selected using a narrow selection criteria to undergo AVBT. Of this cohort, 11 had reached a minimum follow up of 2 years, 4 had reached 18 months, and 3 had reached 6 months. These patients all demonstrated a primary thoracic deformity that was too severe for bracing, were skeletally immature, and were analysed in this preliminary study of coronal plane deformity correction. Using open-source image analysis software (ImageJ, NIH) PA radiographs taken pre-operatively and at regular follow-up visits post-operatively were used to measure the coronal plane deformity of the major and compensatory curves. Pre-operatively, the mean age was 12.0 years (S.D. 10.7 – 13.3), mean Sanders score 2.6 (S.D. 1.8-3.4), all Risser 0 and pre-menarchal, with mean main thoracic Cobb angle of 52° (S.D. 44.2-59.8°). Post-operatively the mean angle decreased to 26.4° (S.D. 18.4-32°) at 1 week, 30.4° (S.D. 21.3-39.6°) at 2 months, 25.7° (S.D. 18.7-32.8°) at 6 months, 27.9° (S.D. 16.2-39.6°) at 12 months, and 36.8° (S.D. 22.6– 51.0°) at 18 months and 38.2° (S.D. 27.6-48.7°) at 2 years. The change in curve at 2 years post-operative was statistically significant (P=0.004). There were 4 tether breakages identified that did not require return to theatre as yet, one patient underwent a posterior spinal instrumented fusion due to curve progression. AVBT is a promising new growth modulation technique for skeletally immature patients with progressive idiopathic scoliosis. This study has demonstrated a reduction in scoliosis severity

Introduction. Genu valgum is a common presentation in paediatric patients with congenital limb deformities. The aim of this study is to assess the outcome of guided growth surgery in paediatric patients referred via our physiotherapy pathway with isolated genu valgum and associated patellar instability. Materials & Methods. Patients were identified from our prospective patellar instability database. Inclusion criteria was acquired or congenital genu valgum associated with patellar instability in skeletally immature patients. The mechanical lateral-distal femoral angle was assessed on long leg alignment radiographs (mLDFA <85 degrees). Surgical treatment was the placement of a guided growth plate (PediPlate, OrthoPediatrics, USA) on the medial distal femoral physis (hemi-epiphysiodesis). KOOS-child scores were collected pre-operatively and post-operatively (minimum at 6 months). Results. Eleven patients (seven female) with mean age of 12(range 5–15) were identified. Five patients had congenital talipes equinovarus(CTEV), one fibular hemimelia, one di-George syndrome, one septic growth arrest and three had idiopathic genu valgum. Pre- and post-operative KOOS-child scores showed overall improvement: 58(range 36–68) to 88(65–99) and knee symptoms subscores: 64(43–71) to 96(68–100) p<0.01, t-test. Mean follow-up was 10 months (range 3–23). No subsequent dislocations/subluxations occurred during follow-up. Conclusions. Guided growth surgery is an effective way of treating symptomatic patellar instability in skeletally immature patients with genu valgum in the absence of other structural pathology. It was most common in our cohort in patients with unilateral CTEV. We would recommend to screen syndromic and congenital limb deformity patients for patellar instability symptoms in the presence of genu valgum

Aims. The ulna is an extremely rare location for primary bone tumours of the elbow in paediatrics. Although several reconstruction options are available, the optimal reconstruction method is still unknown due to the rarity of proximal ulna tumours. In this study, we report the outcomes of osteoarticular ulna allograft for the reconstruction of proximal ulna tumours. Methods. Medical profiles of 13 patients, who between March 2004 and November 2021 underwent osteoarticular ulna allograft reconstruction after the resection of the proximal ulna tumour, were retrospectively reviewed. The outcomes were measured clinically by the assessment of elbow range of motion (ROM), stability, and function, and radiologically by the assessment of allograft-host junction union, recurrence, and joint degeneration. The elbow function was assessed objectively by the Musculoskeletal Tumor Society (MSTS) score and subjectively by the Toronto Extremity Salvage Score (TESS) and Mayo Elbow Performance Score (MEPS) questionnaire. Results. The mean follow-up of patients was 60.3 months (SD 28.5). The mean elbow flexion-extension ROM was 95.8° (SD 21). The mean MSTS of the patients was 84.4 (SD 8.2), the mean TESS was 83.8 (SD 6.7), and the mean MEPS was 79.2 (SD 11.5). All the patients had radiological union at the osteotomy site. Symptomatic osteoarthritic change was observed in three patients (23%), one of whom ended up with elbow joint fusion. Two patients (15.4%) had recurrence during the follow-up period. Surgical complications included two allograft fractures, two plate fractures, three medial instabilities, and two infections. Conclusion. Osteoarticular ulna allograft reconstruction provides acceptable functional outcomes. Despite a high rate of complications, it is still a valuable reconstruction method, particularly in skeletally immature patients who need their distal humerus physis for the rest of hand growth. Cite this article: Bone Jt Open 2024;5(9):749–757

Recent concerns regarding the prospective growth disruption of the olecranon apophysis in skeletally immature patients with intramedullary nail fixation for ulnar fractures has been documented. This retrospective review investigated the long-term functional and radiological outcomes of intramedullary nail fixation through the olecranon apophysis in skeletally immature patients. Intramedullary nail fixation through the olecranon apophysis in skeletally immature patients is an effective, efficient procedure with excellent functional outcomes and without radiographic evidence of growth disruption at maturity. To investigate the long-term radiological and functional outcomes on the olecranon apophysis after intra-medullary nail fixation in skeletally immature ulnar fractures. Retrospective review of patients who where skeletally immature at the time of intramedullary nail fixation through the olecranon apophysis. Patients were excluded if they had previous forearms fractures or fracture of the contralateral forearm. Functional measures included the “Activities Scale for Kids (ASK)”, “Disabilities of the Arm, Shoulder and Hand (DASH)” and “Elbow Assessment Form (EAF)” questionnaires. Radiological outcomes where independently evaluated for ulnar, olecranon, coronoid and trochlear notch proportions at follow-up and initial post-op radiographic data. All patients had a clinical exam and the injured forearm outcomes were compared to the contralateral forearm. Nineteen patients were assessed. The average age at surgical intervention was 10.8 years (range, 1.6–15.9) with a mean follow up time of 3.4 years (range, 1.2–7.2). We outlined the demographics, clinical outcomes and functional questionnaire outcomes for the study cohort. Detailed radiographic measurements for ulnar, olecranon, coronoid and trochlear notch proportions are outlined also. Intramedullary nail fixation through the olecranon apophysis in skeletally immature patients is an effective, efficient procedure with excellent functional outcomes and without radiographic evidence of growth disruption at maturity. When skeletally immature ulnar fractures require an intramedullary nail fixation, disrupting the olecranon apophysis has not been shown to affect the long-term functional and radiological outcomes. Please contact author for tables and/or diagrams

Aims. Vertebral body tethering (VBT) is a non-fusion technique to correct scoliosis. It allows correction of scoliosis through growth modulation (GM) by tethering the convex side to allow concave unrestricted growth similar to the hemiepiphysiodesis concept. The other modality is anterior scoliosis correction (ASC) where the tether is able to perform most of the correction immediately where limited growth is expected. Methods. We conducted a retrospective analysis of clinical and radiological data of 20 patients aged between 9 and 17 years old, (with a 19 female: 1 male ratio) between January 2014 to December 2016 with a mean five-year follow-up (4 to 7). Results. There were ten patients in each group with a total of 23 curves operated on. VBT-GM mean age was 12.5 years (9 to 14) with a mean Risser classification of 0.63 (0 to 2) and VBT-ASC was 14.9 years (13 to 17) with a mean Risser classification of 3.66 (3 to 5). Mean preoperative VBT-GM Cobb was 47.4° (40° to 58°) with a Fulcrum unbend of 17.4 (1° to 41°), compared to VBT-ASC 56.5° (40° to 79°) with 30.6 (2° to 69°)unbend. Postoperative VBT-GM was 20.3° and VBT-ASC Cobb angle was 11.2°. The early postoperative correction rate was 54.3% versus 81% whereas Fulcrum Bending Correction Index (FBCI) was 93.1% vs 146.6%. The last Cobb angle on radiograph at mean five years’ follow-up was 19.4° (VBT-GM) and 16.5° (VBT-ASC). Patients with open triradiate cartilage (TRC) had three over-corrections. Overall, 5% of patients required fusion. This one patient alone had a over-correction, a second-stage tether release, and final conversion to fusion. Conclusion. We show a high success rate (95%) in helping children avoid fusion at five years post-surgery. VBT is a safe technique for correction of scoliosis in the skeletally immature patient. This is the first report at five years that shows two methods of VBT can be employed depending on the skeletal maturity of the patient: GM and ASC. Cite this article: Bone Jt Open 2022;3(2):123–129

Subtrochanteric femoral fractures are uncommon in children, consequently there are no good treatment guidelines in the literature. This series reviewed all subtrochanteric femur fractures in skeletally immature adolescents older than ten years treated at a pediatric trauma center. There were fifteen adolescents with open growth plates. Treatment was non-operative in four and operative in eleven. Each of the adolescents treated non-operatively developed an unsatisfactory result, while eight of the eleven who were treated operatively experienced a satisfactory result. These results suggest improved outcome with operative treatment in this patient population. It was the purpose of this study to describe treatment options and make recommendations for management of subtrochanteric femur fractures among skeletally immature adolescents older than ten years of age. This series consisted of a retrospective review of all cases of subtrochanteric fractures in adolescents with open growth plates. The outcome was classified on the basis of radiographic criteria. There were fifteen adolescents with an average age of thirteen years and one month. The average length of follow-up was two years and nine months. Treatment was non-operative in four and operative in eleven, utilizing a variety of fixation devices. There was fracture union in each case, although there was one delayed union. Complications included limb length discrepancy in three, each of which were treated non-operatively, one transient peroneal nerve palsy and asymptomatic heterotopic ossification. One adolescent, treated with a rigid intramedullary rod, developed avascular necrosis of the femoral head. The result was unsatisfactory in each of the non-operative cases, while eight of the eleven treated operatively developed satisfactory results. Children less than ten years of age may be treated non-operatively. However, in skeletally immature adolescents, operative treatment resulted in improved outcomes. Rigid intramedullary fixation is contraindicated in skeletally immature adolescents due to the risk of avascular necrosis of the femoral head. This series is the first to emphasize treatment and make management recommendations regarding subtrochanteric fractures in this age group. Internal fixation is more effective than non-operative treatment for subtrochanteric femur fractures in skeletally immature adolescents, however the ideal method of fixation requires further study

To evaluate the functional outcome of open humerus diaphyseal fractures treated with the Three-stitch technique of antegrade humerus nailing. This is a retrospective study conducted at the Department of Orthopaedics in D. Y. Patil University, School of Medicine, Navi Mumbai, India. The study included 25 patients who were operated on from January 2019 to April 2021 and follow-ups done till May 2022. Inclusion criteria were adult patients with open humerus diaphyseal fractures (Gustilo-Anderson Classification). All patients with closed fractures, skeletally immature patients, and patients with associated head injury were excluded from the study. All patients were operated on with a minimally invasive Three-stitch technique for antegrade humerus nailing. All patients were evaluated based on DASH score. Out of the 25 patients included in the study, all patients showed complete union. The mean age of the patients was 40.4 years (range 23–66 years). The average period for consolidation of fracture was 10.56 weeks (range 8–14 weeks). The DASH score ranged from 0 to 15.8 with an average score of 2.96. Five patients reported complications with three patients of post-operative infection and delayed wound healing and two patients with screw loosening. All complications were resolved with proper wound care and the complete union was noted. None of the patients had an iatrogenic neurovascular injury. Three-stitch antegrade nailing technique is a novel method to treat diaphyseal humerus fractures and provides excellent results. It has various advantages such as minimal invasiveness, minimal injury to the rotator cuff, fewer infection rates, minimal iatrogenic injuries, and good functional outcomes. Therefore, this treatment modality can be effectively used for open humerus diaphyseal fractures

Introduction. Epiphysiodesis, defined as the process of closing the growth plate (physis), have been used for several years as a treatment option of cases where the predicted leg-length discrepancy (LLD) falls between 2 to 5 cm. The aim of this study was to systematically review the existing literature on the effectiveness of three different epiphysiodesis techniques with implant usage for the treatment of leg-length discrepancy in the pediatric population. The secondary aim was to address the reported complications of staples, tension-band plates (TBP) and percutaneous epiphysiodesis screws (PETS). Method. This systematic review was performed according to PRISMA guidelines. We searched MEDLINE (PubMed), Embase, Cochrane Library, Web of Science and Scopus for studies on skeletally immature patients with LLD treated with epiphysiodesis with an implant. The extracted outcome categories were effectiveness of epiphysiodesis (LLD measurements pre/post-operatively, successful/unsuccessful) and complications that were graded on severity. Result. Forty-four studies (2184 patients) were included, from whom 578 underwent TBP, 455 PETS and 1048 staples. From pooled analysis of the studies reporting success rate, 64% (150/234) successful TBP surgeries (10 studies), 78% (222/284) successful PETS (9 studies) and 52% (212/407) successful Blount staples (8 studies). Severe complications rate was 7% for PETS, 17% for TBP and 16% for Blount staples. TBP had 43 cases of angular deformity (10%), Blount staples 184 (17%) while PETS only 18 cases (4%). Conclusion. Our results highlighted that PETS seems to be the most successful type of epiphysiodesis surgery with an implant, with higher success rate and lower severe complications than TBP or Blount staples

Osteomyelitis and septic arthritis are common pathologies in young children. Because of their skeletal immaturity, children are particularly vulnerable to orthopaedic complications, including limb-length discrepancies, angular deformities, chondrolysis, etc. The primary objective of this study was to review the clinical follow up and outcomes of paediatric patients diagnosed with osteoarticular infections. The secondary purpose was to look for significant differences in the clinical characteristics between the one with and without complications. Patients' medical charts, hospitalised between 2010 and 2016, were retrospectively reviewed. The inclusion criteria were: patients (1) aged of less than 10 years old (2) treated and followed for osteomyelitis of long bones of upper and lower extremities and/or septic arthritis (3) with at least one year of radiological follow up. The exclusion criterion was: (1) any concomitant chronic diseases. The information collected included demographic and clinical data. A late sequela was defined as a limb-length discrepancy superior to 5 mm or an abnormal articular angulation of more than 5°, or a symptomatic chondropathy. Patients were separated in two groups: with and without complications. Chi-square tests were used for categorical variables and Mann-Whitney U tests for continuous data in order to establish significant differences between both groups. Of the 401 patients with osteomyelitis and/or septic arthritis treated in our tertiary paediatric hospital over 7 years, 50 met the inclusion criteria. There were 24 girls and 26 boys. The etiological agent was identified in 56% of the cases. Staphylococcus aureus was the predominant causal pathogen (50%), followed by Kingella kingae (19.2%). The mean follow up was 780 days. Six out of 50 (12%) patients had physeal or chondrolytic complications at the latest follow-up. The only significant difference between the 2 groups was the delay between onset of symptoms and initiation of antibiotic therapy (P = 0.039). Only 12.5% of the patients were followed up at least one year. In the population of 50 skeletally immature patients without comorbidities, 12% had a sequela. The delay in initiating antibiotic treatment was significantly longer in the group with the presence of sequelae. The results of this study reveal that there were low rates of outpatient follow-up reaching more than a year after an osteoarticular infection, thus raising the question about the importance of a follow up after such a diagnosis. Twelve percent of the patients had a growth or chondrolysis complication and this might be related to the delay before initiating antibiotic treatment

This study aimed to investigate the outcomes of open tibia shaft fractures at a level one trauma center in a developing world setting. Specific objectives were to determine the association of time delay to antibiotic administration, surgical debridement, definitive skeletal stabilisation and soft tissue reconstruction, and the development of fracture-related infection (FRI). A retrospective cohort study included all adult patients with open tibia shaft fractures from July 2014 to June 2016 and January 2018 to December 2019. Patients who were skeletally immature at the time of injury, those with pathological fractures and who did not complete follow-up of at least three months were excluded. Patients were identified from hospital records. Data was captured in Microsoft Excel and analysed using STATISTICA. A Chi-squared was used to detect significant differences between groups. No association between infection and antibiotic administration was observed when patients were treated within or after 3 hours (p=0.625) or if patients had their first surgical debridement in theatre before or after 24 hours (p=0.259). Patients who waited more than five days for definitive skeletal fixation or soft tissue reconstruction had a significant increase in FRI (OR 4.7, 95% CI 2.0 – 10.9 and OR 4.7, 95% CI 2.0 – 11.0, respectively). Patients who underwent more than two formal debridements had a higher risk of developing FRI (OR 15.6, 95% CI 5.8 – 41.6). Whilst administration of antibiotics within 3 hours of presentation to the emergency unit had no impact on the development of FRI, time delays in managing open tibia shaft fractures are associated with an increased risk for FRI. Definitive soft tissue reconstruction and skeletal stabilization should not be delayed for more than five days

Introduction. A subset of patients in cast awaiting fixation of ankle fractures require conversion to delayed external fixation (dEF). We aimed to evaluate the effect of delayed versus planned external fixation (pEF), then identify objective characteristics contributing to need for conversion. Method. We extracted data from our booking system to identify all ankle external fixation procedures between 2010 to 2022. Exclusions included open fractures, the skeletally immature, and pilon or talus fractures. Fractures were classified using the AO/OTA classification, then a matched cohort was identified based on fracture classification. We compared the planned, delayed and matched cohorts for demographics, posterior malleolar fragment (PMF) ratio, and degree of displacement at presentation. Results. We identified 25 pEF, 42 dEF, and 67 matched patients. Ankles with dEF had a 3.8 day longer time to ORIF from presentation than those who had pEF, and had an infection rate of 9.5%, compared to 4% in the pEF group. Two patients in the dEF group required further operative intervention. There were no infections or reoperations required in the pEF or matched groups. The dEF group were more likely to have ≥2 reductions (OR 4.13), a PMF ratio of >0.23 (OR 5.07), and have increased displacement at time of injury on lateral (32% vs 19%) and AP (62% vs 36%) radiographs. Discussion. Our retrospective study highlights the longer time to operation and increased infection rates of patients who do not get timely external fixation. We propose a series of objective parameters that predict failure of cast treatment and guide the surgeon to consider planned external fixation in some ankle

Background: A recent study found that after median term follow-up disability correlated with pain rather than the limited residual impairments in motion and strength. We studied impairment and disability an average of twenty-one years after injury in a cohort of Dutch patient, with the hypothesis that both impairment and disability would be lower in patients that were skeletally immature at the time of injury. Methods: Seventy-one patients were evaluated an average of 21 years after injury. The majority of the 35 skeletally immature patients were treated conservatively with closed reduction and cast immobilization and the majority of the 36 skeletally mature patients were treated with plate and screw fixation. Objective evaluation included radiographs and measurements of range of motion and grip strength. Questionnaires were used to measure arm-specific disability (Disabilities of the Arm, Shoulder and Hand: DASH), misinterpretation or over interpretation of pain (Pain Catastrophizing Scale-PCS-), and depression (CES-D). Multivariable analysis of variance and multiple linear regression were used to compare patients that were skeletally mature and immature at the time of injury and to identify predictors of arm-specific disability (SPSS 17.0, SPSS inc., Chicago). Results: There were 44 men and 27 women with a an average age of forty-one at time of follow-up (range, 20 to 81). Fractures were classified as AO/OTA-type A3 in 46 patients (simple), B3 in 18 (including wedge fragment) and C fractures in 7 patients (comminuted). The average DASH score was 8 points (0 to 54) and 73% reported no pain. Both rotation and wrist flexion/extension were 91% of the uninjured side; grip strength was 94%. There were small, but significant differences in rotation (151 versus 169 degrees, p=0.004) and wrist flexion/extension (123 versus 142 degrees, p=0.002), but not disability between skeletally mature and immature patients. The best predictors of DASH score were nerve damage, pain and grip strength, explaining 56% of the variation in DASH scores. Disability did not correlate with depression or misconceptions about pain. Conclusions: Twenty-one years after initial fracture, both skeletally immature and mature patients have limited impairment (averaging over 90% motion and grip strength) and disability after non operative and operative treatment respectively. Patients that were skeletally immature at the time of injury had better motion, but comparable disability. Disability correlated with pain rather than motion, but did not correlate with psychosocial measures

Abstract. Aims. Vertebral body tethering (VBT) is a non-fusion technique to correct scoliosis allowing correction of scoliosis through growth modulation (GM) by tethering the convex side to allow concave unrestricted growth similar to the hemiepiphysiodesis concept. The other modality is anterior scoliosis correction (ASC) where the tether is able to perform most of the correction immediately where limited growth is expected. Methods. A retrospective analysis of 20 patients (M:F=19:1 – 9–17 years) between January 2014 to December 2016 with a mean five-year follow-up (4 to 7). Results. There were ten patients in each group with a total of 23 curves operated upon. VBT-GM mean age −12.5 years (9 to 14), mean Risser of 0.63 (0 to 2) and VBT-ASC was 14.9 years (13 to 17) and mean Risser of 3.66 (3 to 5). Mean preoperative VBT-GM Cobb was 47.4° (40°–58°) compared to VBT-ASC 56.5° (40°–79°). Postoperative VBT-GM Cobb was 20.3° and VBT-ASC was 11.2°. The early postoperative correction rate was 54.3% versus 81% whereas Fulcrum Bending Correction Index (FBCI) was 93.1% vs 146.6%. Latest Cobb angle at mean five years' follow-up was 19.4° (VBT-GM) and 16.5° (VBT-ASC). Overall, 5% of patients required fusion. Conclusion. We show a high success rate (95%) in helping children avoid fusion at five years post-surgery. VBT is a safe technique for scoliosis correction in the skeletally immature patient. This is the first report at five years showing two possible options of VBT depending on the skeletal maturity of the patient: GM and ASC

Introduction and Aims: The treatment of femoral shaft fractures in skeletally immature patients has changed dramatically over the past 30 years. This is due in part to the advances in intramedullary nail outcomes pioneered in the adult orthopaedic trauma literature. We examined the results of reamed, locked nails in a pediatric population. Method: The medical records of 224 children with femoral shaft fractures treated with reamed, locked intramedullary nails (RLIMN) at our institution between 1987 and 2000 were reviewed (largest series in the literature). Patients were treated with nails placed through the greater trochanter. Of those patients, 72 patients had long-term clinical (> 24 months) and radiographic (AP pelvis and leg length CT scanogram) follow-up. Functional status and radiographic parameters (femoral neck-shaft angle, leg length, presence of osteonecrosis) were recorded. Patients lacking two-year clinical and radiographic follow-up were evaluated via telephone follow-up. Results: At our institution, over 200 skeletally immature patients have successfully undergone reamed, locked, intramedullary nailing of femur fractures. Average age at the time of treatment was 10.3 years. No case of osteonecrosis of the femoral head occurred. All fractures united after treatment with RLIMN at an average of 71 days. No patient manifested a gait abnormality after healing. Complications included delayed union in two patients, (one patient was treated with exchange IMN and one patient healed after dynamisation) superficial wound infection in one patient, (treated with oral antibiotics) and coxa valga in one patient. The patient that developed coxa valga was 7.7 years old at the time of intramedullary nailing. The only other procedures performed were removal of hardware in patients who remained skeletally immature at the time of healing. All patients returned to pre-injury activity level. The average leg length difference was 0.6cm (longer on the injured extremity). Average articulo-trochanteric distance was 0.28cm (longer on injured extremity). Conclusion: Our results demonstrate that femoral shaft fractures in skeletally immature patients can be safely treated with reamed, locked intramedullary nails placed through the greater trochanter. We recommend careful placement of the nail through the greater trochanter to avoid damage to the blood supply of the femoral head

Tibial eminence fractures were historically thought of as a condition of skeletal immaturity. Increasingly this injury has been recognized in adults. The aim was to report on the demographics, mechanism, treatment and outcomes of this injury in adult and paediatric patients. A retrospective review of all patients presenting to Dunedin Hospital, for management of a displaced tibial eminence fracture, between 1989 and 2009. 19 cases were identified, 10 skeletally mature and 9 skeletally immature. Alpine skiing with a forced flexion and rotation injury accounted for 7 cases, primarily adult females (5 cases). A hyper-extension and rotation injury accounted for 7 cases, primarily in skeletally immature males (4 cases), while direct trauma accounted for 5 cases, primarily males (4 cases). Associated injuries were more commonly seen in adults and those with high energy trauma. Stiffness was the most common complication (10 cases). Tibial spine fractures are more common in adults than previously thought. Female skiers appear to be a group at particular risk. Our most common complication was stiffness. Early range of motion is essential to reduce the problem of stiffness and extension impingement. Laxity is an infrequent problem in adults and children