End caps are intended to prevent nail migration (push-out) in elastic stable intramedullary nailing. The aim of this study was to investigate the force at failure with and without end caps, and whether different insertion angles of nails and end caps would alter that force at failure. Simulated oblique fractures of the diaphysis were created in 15 artificial paediatric femurs. Titanium Elastic Nails with end caps were inserted at angles of 45°, 55° and 65° in five specimens for each angle to create three study groups. Biomechanical testing was performed with axial compression until failure. An identical fracture was created in four small adult cadaveric femurs harvested from two donors (both female, aged 81 and 85 years, height 149 cm and 156 cm, respectively). All femurs were tested without and subsequently with end caps inserted at 45°. In the artificial femurs, maximum force was not significantly different between the three groups (p = 0.613). Push-out force was significantly higher in the cadaveric specimens with the use of end caps by an up to sixfold load increase (830 N, standard deviation (SD) 280 vs 150 N, SD 120, respectively; p = 0.007). These results indicate that the nail and end cap insertion angle can be varied within 20° without altering construct stability and that the risk of elastic stable intramedullary nailing push–out can be effectively reduced by the use of end caps. Cite this article: Bone Joint J 2015;97-B:558–63

We reviewed the radiological and clinical long-term results after the nailing in situ of slipped upper femoral epiphysis in 59 hips in 43 patients. The displacement of the epiphysis had been measured as the ‘slipping angle’ before operation and related to the results at follow-up at a mean of 30.9 years (27 to 34). The mean age at follow-up was 44.2 years (39 to 50). Radiographic re-examination of 41 hips with slipping angles of ≤30° at the time of operation showed that eight (20%) had developed mild osteoarthritis and one had severe changes. For 18 hips with slipping angles ranging from 31 to 50° at surgery six (33%) had mild osteoarthritis and three had severe changes. The differences did not quite achieve statistical significance (p = 0.09). Clinical re-examination of the 41 hips with slipping angles of ≤30° showed fair or poor results (Harris hip score < 90) in three (7%). In the 18 hips with slipping of 31 to 50°, four had fair or poor results (22%) (p= 0.13). We conclude that nailing in situ for slipping of ≤30°, using one thin nail, can give excellent long-term results. At present we recommend that hips with slips ranging from 31 to 50° should also be nailed in situ, but further long-term studies are required, especially on the choice between nailing in situ and corrective osteotomy for slips in excess of 50°

We identified 25 children (10 girls and 15 boys) who had been treated with single bone intramedullary fixation for diaphyseal fractures of both forearm bones. Their mean age was 10.75 years (4.6 to 15.9). All had a good functional outcome. We conclude that in selected children, single bone intramedullary nailing is a suitable method of treatment for diaphyseal fractures of both bones of the forearm.

Aims. Current American Academy of Orthopaedic Surgeons (AAOS) guidelines for treating femoral fractures in children aged two to six years recommend early spica casting although some individuals have recommended intramedullary stabilization in this age group. The purpose of this study was to compare the treatment and family burden of care of spica casting and flexible intramedullary nailing in this age group. Methods. Patients aged two to six years old with acute, non-pathological femur fractures were prospectively enrolled at one of three tertiary children’s hospitals. Either early closed reduction with spica cast application or flexible intramedullary nailing was accomplished under general anaesthesia. The treatment method was selected after discussion of the options by the surgeon with the family. Data were prospectively collected on patient demographics, fracture characteristics, complications, pain medication, and union. The Impact on Family Scale was obtained at the six-week follow-up visit. In all, 75 patients were included in the study: 39 in the spica group and 36 in the nailing group. The mean age of the spica group was 2.71 (2.0 to 6.9) years and the mean age of the nailing group was 3.16 (2.0 to 6.9) years. Results. All fractures healed without evidence of malunion or more than 2.0 cm of shortening. The mean Impact on Family score was 70.2 for the spica group and 63.2 (55 to 99) for the nailing group, a statistically significant difference (p = 0.024) in a univariate analysis suggesting less impairment of the family in the intramedullary nailing group. There was no significant difference between pain medication requirements in the first 24 hours postoperatively. Two patients in the spica group and one patient in the intramedullary nailing group required additional treatment under anaesthesia. Conclusion. Both early spica casting and intramedullary nailing were effective methods for treating femoral fractures in children two to six years of age. Intramedullary stabilization provides an option in this age group that may be advantageous in some social situations that depend on the child’s mobility. Fracture treatment should be individualized based on factors that extend beyond anatomical and biological factors. Cite this article: Bone Joint J 2020;102-B(8):1056–1061

Elastic stable intramedullary nailing (ESIN) is generally acknowledged to be the treatment of choice for displaced diaphyseal femoral fractures in children over the age of three years, although complication rates of up to 50% are described. Pre-bending the nails is recommended, but there are no published data to support this. Using synthetic bones and a standardised simulated fracture, we performed biomechanical testing to determine the influence on the stability of the fracture of pre-bending the nails before implantation. Standard ESIN was performed on 24 synthetic femoral models with a spiral fracture. In eight cases the nails were inserted without any pre-bending, in a further eight cases they were pre-bent to 30° and in the last group of eight cases they were pre-bent to 60°. Mechanical testing revealed that pre-bending to 60° produced a significant increase in the stiffness or stability of the fracture. Pre-bending to 60° showed a significant positive influence on the stiffness compared with unbent nails. Pre-bending to 30° improved stiffness only slightly. These findings validate the recommendations for pre-bending, but the degree of pre-bend should exceed 30°. Adopting higher degrees of pre-bending should improve stability in spiral fractures and reduce the complications of varus deformity and shortening

Aims

We aimed to assess the cumulative risk of total hip arthroplasty (THA) from in situ fixation for slipped capital femoral epiphysis (SCFE) after a follow-up of almost 50 years.

Aims

The aim of this study is to evaluate the surgical treatment with the best healing rate for patients with proximal femoral unicameral bone cysts (UBCs) after initial surgery, and to determine which procedure has the lowest adverse event burden during follow-up.

Aim. The purpose of this study was to quantify the number of children treated with ESIN (elastic stable intra-medullary nails) at our institution and to determine what proportion of these nails have been removed and the time and difficulty taken to do so. Methods. Patients treated with ESIN between 2000 and 2005 were identified by database search. Their notes were reviewed to record patient and initial nailing details, and timing, difficulty and length of metalwork removal procedures. Complications leading to premature removal or following nail extraction were noted. Results. Eighty-seven patients were identified who fitted our study criteria (68% male, 32% female). Mean age was 10.9 years (4.7–15.9 years). Twelve of the procedures were for open fractures. Seventy-nine patients underwent nail removal at our institution. Four were followed up elsewhere and a decision to leave the nails in was made in another four patients (usually underlying bone pathology). Four patients had surgery earlier than planned to deal with implant problems: 3 to address prominent nails and 1 for re-fracture. The nails were removed at a mean of 8 months after insertion. Mean time taken to remove the metalwork was 25 minutes (10 to 75 minutes). Eight of the 79 removal procedures were graded as difficult, with one being extremely difficult: this was not predictable from pre-operative radiographs. There were 2 complications following metalwork removal. One was a re-fracture through a unicortical bone cyst 2 years after removal, which was successfully treated with ESIN again. The other was a superficial wound infection, which settled with antibiotics. Conclusion. It is routine policy at our institution to remove ESIN after fracture healing, but it should be noted that removal procedures can be difficult and lengthy. There is, however, a low complication rate following removal, and routine follow-up may not be necessary

The aim of this retrospective study was to review the outcome of patients treated with Fassier-Duval (FD) rods and highlight some of the complications found during treatment. Between April 2006 and August 2010 we inserted 24 FD rods in 13 patients. 17 rods for osteogenesis imperfecta (OI), 2 for fractures and deformity associated with cerebral palsy, 1 for fracture associated with muscular dystrophy, 1 for fibrous dysplasia and 3 for centralisation of single bone forearms. In the upper limb one patient required revision for proximal migration of the male component and another patient is waiting for revision for the same problem. In the lower limb, a tibial nail was revised because of proximal migration of the male component. A femoral nail was adjusted because of loss of the proximal fixation. One of the OI patients fell, fractured the femur and bent a femoral nail. This awaits revision at a later date. A second OI patient fell on 2 separate occasions bending both a tibial and a femoral nail respectively. These were both revised to trigen intramedullary nails. In all the other cases there were no complications. In summary the Fassier Duval system provides a versatile way of providing intramedullary stabilisation for growing bones through a single entry point. However in our experience we have a 33% complication rate most notably bending of the rods. We advocate careful patient selection and using as high a diameter nail as is feasible

Purpose of the Study. A cooled, side cutting burr designed for use in adult foot surgery has been used as a primary bone cutting device in children to facilitate a truly percutaneous method of performing osteotomies. Stabilisation of the femur was using a percutaneous locked nail and for the tibia percutaneous K-wires. The author describes the advantages and disadvantages of this method with results from the first cohort of patients treated. Method. Patients under going osteotomy of the femur, tibia and fibula using a 2 mm × 20 mm side cutting burr were followed prospectively and assessed for scar size, bone healing time and complications. Results. Thirty six osteotomies were performed in the femur and tibia in 25 patients. A fibula osteotomy was always performed with a tibial osteotomy. Scar size for the femoral osteotomy was <15 mm and for the nail insertion <25 mm. For the tibia & fibula the scar size was <10 mm. Healing time was by 6 weeks in the tibia and in the femur was within 16 weeks in non-lengthening cases in all but 1 case of non-union (associated with Vitamin D insufficiency). Three burr bits broke during the learning curve including 2 in tibial osteotomies and 1 in the femur. Cortical thickness and slow burr speeds were associated with burr breakage. All wounds healed without infection. The optimum speed for the burr at 50 Nm of torque was established as 200 rpm in children under the age of 13 yrs. The initial recommended speed of 300 rpm increases healing time when performing osteotomies in children. Conclusion. Truly percutaneous surgery can be performed to osteotomise the femur and tibia using a cooled, side cutting burr with a locked femoral nail and crossed tibial wires with excellent cosmetic results and minimal complications. Level of Evidence IV

Aims

Osteofibrous dysplasia (OFD) is a rare benign lesion predominantly affecting the tibia in children. Its potential link to adamantinoma has influenced management. This international case series reviews the presentation of OFD and management approaches to improve our understanding of OFD.

Flexible intramedullary nailing is gaining popularity as an effective method of treating long-bone fractures in children. We retrospectively reviewed the records and radiographs of 56 unstable fractures of the tibia in 54 children treated between March 1997 and May 2005. All were followed up for at least two months after the removal of the nails. Of the 56 tibial fractures, 13 were open. There were no nonunions. The mean time to clinical and radiological union was ten weeks. Complications included residual angulation of the tibia, leg-length discrepancy, deep infection and failures of fixation. All achieved an excellent functional outcome. We conclude that flexible intramedullary fixation is an easy and effective method of management of both open and closed unstable fractures of the tibia in children

This study compares the initial outcomes of minimally invasive techniques for single-event multi-level surgery with conventional single-event multi-level surgery. The minimally invasive techniques included derotation osteotomies using closed corticotomy and fixation with titanium elastic nails and percutaneous lengthening of muscles where possible. A prospective cohort study of two matched groups was undertaken. Ten children with diplegic cerebral palsy with a mean age of ten years six months (7.11 to 13.9) had multi-level minimally invasive surgery and were matched for ambulatory level and compared with ten children with a mean age of 11 years four months (7.9 to 14.4) who had conventional single-event multi-level surgery. Gait kinematics, the Gillette Gait Index, isometric muscle strength and gross motor function were assessed before and 12 months after operation. The minimally invasive group had significantly reduced operation time and blood loss with a significantly improved time to mobilisation. There were no complications intra-operatively or during hospitalisation in either group. There was significant improvement in gait kinematics and the Gillette Gait Index in both groups with no difference between them. There was a trend to improved muscle strength in the multi-level group. There was no significant difference in gross motor function between the groups. We consider that minimally invasive single-event multi-level surgery can be achieved safely and effectively with significant advantages over conventional techniques in children with diplegic cerebral palsy

Aims

Open tibial fractures are limb-threatening injuries. While limb loss is rare in children, deep infection and nonunion rates of up to 15% and 8% are reported, respectively. We manage these injuries in a similar manner to those in adults, with a combined orthoplastic approach, often involving the use of vascularised free flaps. We report the orthopaedic and plastic surgical outcomes of a consecutive series of patients over a five-year period, which includes the largest cohort of free flaps for trauma in children to date.

Aims

This observational study examines the effect of the COVID-19 pandemic upon the paediatric trauma burden of a district general hospital. We aim to compare the nature and volume of the paediatric trauma during the first 2020 UK lockdown period with the same period in 2019.

A femoral fracture in an adolescent is a significant injury. It is generally agreed that operative fixation is the treatment of choice and rigid intramedullary nailing is a surgical treatment option. We present on experience of treating adolescent femoral fractures using a lateral entry intramedullary nail. We reviewed 15 femoral fractures in 13 children who we treated in our unit between 2011 and 2014. Two patients had bilateral fractures (non-simultaneous). Data collected included patient demographics, mechanism of injury, type of fracture, associated injuries, size of nail, time to unite and complications. The mean age of the patients at time of surgery was 12 years (range 10–15). There were 7 male and 6 female. 10 fractures were caused by a fall whilst 5 were due to road traffic collisions (RTC). 8 fractures involved the middle third, 2 of theses were open fractures and were caused by a RTC. The remaining 7 involved the proximal third of the femur. The mean time to radiological union was 3.4 months (range 2.5–5) in 14 fractures. One patient had a delayed union that required bone grafting and united fully at 7.5 months post injury. The only other complications were a broken proximal locking screw in one patient and an undisplaced femoral neck fracture in another patient. These complications did not compromise the outcome. No patients had infection or developed avascular necroses at the latest follow up. Intramedullary nailing of adolescent femoral fractures using the lateral entry point is safe and effective

Aims

The Fassier Duval (FD) rod is a third-generation telescopic implant for children with osteogenesis imperfecta (OI). Threaded fixation enables proximal insertion without opening the knee or ankle joint. We have reviewed our combined two-centre experience with this implant.

Purpose of the study. We report on the clinical, radiographic and functional outcomes after salvage arthrodesis for complex ankle and hindfoot problems the Portsmouth experience with the Ilizarov ring fixator. Methods and results. We report on 10 patients who underwent ankle and hindfoot (tibio-calcaneal) arthrodeses using an Ilizarov ring fixator between 2006 and 2010. The indications included failed fusion after primary arthrodesis, sepsis complicating internal fixation of fractures, talar avascular necrosis and failed total ankle arthroplasty (TAR). All patients had undergone multiple previous surgeries which had failed. There were 7 males and 3 females in this group. Average age of the patients was 60 (47 years–77 years) Mean follow up was 32 months (6–56 months) BMP 2 (Inductos) was used in three cases. The procedure was combined with a proximal corticotomy and lengthening in 2 patients who had undergone a talectomy and tibio-calcaneal fusion. There were no major complications apart from minor pin site infections requiring oral antibiotics. There were no deep infections, thromo-embolic issues, CRPS, or functional problems on account of limb shortening. Patients were assessed clinically, radiologically and using functional outcome scores EQ50 and AOFAS. Solid arthrodesis was achieved in all but one patient who was subsequently revised with a hindfoot nail. All patients were satisfied with their overall improvement in pain and function. Conclusion. We conclude that this is an effective salvage technique for complex ankle and hindfoot problems in patients with impaired healing potential, insufficient bone stock and progressive deformity

Aims

Slipped capital femoral epiphysis (SCFE) is one of the most common hip diseases of adolescence that can cause marked disability, yet there is little robust evidence to guide treatment. Fundamental aspects of the disease, such as frequency, are unknown and consequently the desire of clinicians to undertake robust intervention studies is somewhat prohibited by a lack of fundamental knowledge.

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The aim of this study was to report the clinical, functional and radiological outcomes of children and adolescents with tibial fractures treated using the Ilizarov method.