Aim. Although non-union is a devastating and costly consequence of trauma for the child, family and society it is felt to be a rare complication in children. Currently there is no data available in the literature regarding its incidence either per fracture or per head of population. Should we be taking paediatric fracture non-union more seriously regarding research, resource allocation and informed consent? Our aim was to determine the incidence of non-union per child and per fracture. Method. In Scotland Information Services Division (NHS Scotland) records every inpatient admission by ICD-10 diagnosis. As almost all fracture non-unions require intervention ISD provides accurate non-union figures by site and age. However, many fractures are treated as outpatients. Using local data of overall fracture numbers we were able to calculate a ratio of inpatient to total fracture numbers and apply this nationally. Results. Over a 5-year period there were 180 cases of non-union between the ages of 0–14 years, (4.21/100,000pa) and an incidence of 15,335 fractures/100,000pa giving an overall risk of 0.24% non-union per fracture. The risk of non-union per fracture did not change throughout childhood but notably increased in the late teenage years (15–19yrs). Both the incidence of fractures and non-union were far greater in boys, however incidence of non-union per fracture was similar in both sexes in childhood. Non-union per fracture was twice as frequent in the lower than upper limb, this trend reversed in the 15–19 year age group. Conclusion. The annual incidence of fractures in children is 15.3%, more frequent in the upper than lower limb; increasing with age, particularly in boys. The risk of non-union is around 1/400 per upper limb and 1/250 per lower limb fracture in childhood. Fracture non-union is rare in the paediatric population but even so 4.2 cases would be expected per 100,000 population or 240 cases per 100,000 fractures

Purpose. This study aims to report the radiological corrections achieved and complication profile of Peri-Acetabular Osteotomy (PAO) undertaken through the minimally invasive approach. Method. 106 PAOs were performed in 103 patients, by senior author, using a minimally invasive approach from 2007 to 2015. Pre- and post-operative radiographs were reviewed and the degree of acetabular re-orientation was analysed. Case notes were examined retrospectively to identify haemoglobin levels and complications across two sites. Results. 73 female and 30 male patients underwent PAO procedures at a mean age of 25 years (9 – 54 years). Follow-up ranged from 23 to 80 months. 26 patients had concurrent proximal femoral osteotomies. Pre-operatively the average centre edge angle measured −1.6° with the vertical centre edge angle reading −0.2°. Post-operative radiographs confirmed correction of these values to 30° and 25.1° respectively. Sharp's angle also improved from a mean value of 49.5° to 33.3°. Review of the Tönnis angle showed correction from an average of 24.1° to 6.9°. The average drop in haemoglobin was calculated as 39 g/L with around 50 % of the patients requiring a peri-operative blood transfusion. The mean preoperative modified Harris Hip Score was 65.6 (Standard deviation σ=11.6) and the same at follow-up was 84.1(σ=11.5). Our outcome scores were comparable with recent PAO series including that of Gray et al. 10 patients reported lateral cutaneous nerve hypoesthesia and 9 had problematic screws. 2 patients underwent washouts as treatment for haematoma and infection. 4 patients had delayed union of the pubic osteotomy and a further 8 patients had asymptomatic osteotomy non-union. One posterior column non-union necessitated plating. One painful fibrous union of ischium and 3 inferior pubic rami stress fractures. Conclusion. This study shows that minimally invasive approach has favourable outcomes and that it is feasible to achieve adequate correction with results/complication profile comparable to traditional approach

Purpose We report the long term outcome of a minimally invasive technique avoiding the risks associated with open reduction and bone grafting in paediatric lateral condyle fracture non-unions. Methods The Toronto Hospital for Sick Children's radiology database was searched to isolate all those who sustained a lateral condyle elbow fracture and had developed a non-union between the years 1998 and 2008. This identified 16 patients who had undergone percutaneous fixation for the treatment of their non union. Each individuals clinical notes and radiographs were reviewed from presentation to final follow-up. Results Median age at injury was 5.1 (3.2, 7.2) in the successful and 2.8 (2.1, 4.7) in the unsuccessful groups (p=0.18). 11 patients (68.7%) had been initially managed non-operatively. Median time from injury to non-union diagnosis was 15.7 weeks in the successful, and 225.5 weeks in the unsuccessful group (p=0.039). Mean time to union post fixation was 16.2 weeks (+/- 6.74) and mean time to surgery was 5.2 weeks (+/- 4.11). Surgery was successful, defined as radiological and clinical union, in 12 of 16 patients (75%). 43.8% had metalwork removal and no cases of avascular necrosis were reported. Conclusion We have demonstrated this technique to be successful in those non-unions addressed within 16 weeks from initial injury to diagnosis. We had 4 failures, these occurred in patients whose non-unions were diagnosed more than 31 weeks from the time of injury (31; 68; 383; 427 weeks). Each of these failures had been managed non-operatively as part of their primary treatment plan. Percutaneous fixation is feasible and safe. Patients not achieving union were diagnosed significantly later. There was a trend towards successfully treated patients being younger

Purpose of the study is to investigate the outcome of the patients with Perthes disease who have had a surgical dislocation of their hip for the treatment of resultant symptoms from the disease process. Retrospective review of consecutive patients treated with surgical dislocation of the hip for Perthes disease. Review of clinical case notes and radiological imaging. Patient outcome was assessed at follow-up. Between 2010 and 2015, 31 cases of surgical hip dislocation were performed for Perthes disease at our institution by 2 senior surgeons. Age range at time of surgery was 12–33. Male:female ratio was 13:18; right:left ratio was 15:17. Age at the time of Perthes diagnosis was between 3 and 13 years, with 3 diagnosed retrospectively. Mean follow-up was 18months. All patients had an EUA and arthrogram while 61.3%(19/31) had previous surgery for Perthes. 71%(22/31) required a labral repair, 6.5%(2/31) had a peri-acetabular osteotomy at the time of surgery and 3.2%(1/31) required a proximal femoral valgus osteotomy. 22.5%(7/31) required microfracture (femoral head or acetabulum): all of whom had evidence of contained area of degenerative changes on preoperative MRI. 64.5%(20/31) had the trochanteric screws removed. Complications included 1 greater trochanter non-union, 1 pain secondary to suture anchor impinging on psoas tendon, 1 AVN leading to early THR 12 months post-op. Another 2 had further deterioration of degenerative changes and pain leading to THR 18 and 24 months post-op. All 3(9.7%) had microfracture at the time of the dislocation for established degenerative change and also required custom made prostheses. Surgical hip dislocation is an option in treating Perthes patient with resultant symptoms such as impingement. Improved outcome is seen in patients who are younger with a congruent hip joint in contrast to those with established degenerative change evident on MRI / intraoperatively and have an arrow shaped femoral head

We report the radiological outcomes, and short-term clinical results, of 47 periacetabular osteotomies undertaken through both the traditional bikini incision, and a minimally invasive approach. 47 periacetabular osteotomies have been undertaken in 45 patients, by the senior author, between 2005 and 2013. There were 10 male and 35 female patients. The mean age at operation was 28.2 years. Since 2010 surgery has been performed through a 7-cm skin incision (31 hips), an incision coined as minimally invasive by Søballe et al when they described their trans-sartorial approach for acetabular surgery. Clinical data was collected prospectively; primary outcome measures included the young adult hip score and the hip disability and osteoarthritis outcome score. Pre- and post-operative radiographs were analysed for achieved acetabular reorientation. At the time of follow-up the median young adult hip score had improved significantly from pre-operative values. Mean scores were 35.4 pre-operatively, and 64.25 post-operatively. Improvement in the anterior and lateral centre-edge angle was 32 and 32.9 degrees respectively through a traditional incision, and 27.1 and 30 degrees through the minimally invasive approach (p>0.05). No major complications occurred in any patient. Four patients complained of lateral cutaneous nerve hypoaesthesia, in two patients there was delayed union of the pubic osteotomy and in one non-union. Two patients have gone on to total hip replacement. The minimally invasive approach is safe and allows for accurate reorientation of the acetabulum whilst minimizing tissue damage. The scar is cosmetically appealing to patients, especially the predominantly female group treated with this condition. We did not see the evidence of reduced surgical stay that has been reported by other groups utilizing a minimally invasive approach. Level of evidence: II

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

Introduction. Perthes' disease is associated with coxa breva, plana and magna, and a high riding prominent greater trochanter causing abductor shortening and weakness, leg shortening and extra-articular impingement. A trochanteric advancement with an infero-lateralising oblique sliding osteotomy of the proximal femur would lengthen femoral neck, improve abductor length and strength, relieve impingement and improve leg length. We assessed the mid-term outcomes for this procedure. Method. We included patients who underwent the operation by the senior author (JNOH) with more than 2 years follow-up. The osteotomies were performed minimally invasively under image intensifier guidance and fixed with blade plate or locking plates. We assessed functional scores, radiological changes in neck length, Tonnis grading for arthritis and evidence of femoral head avascular necrosis, time interval for conversion to hip arthroplasty and associated complications. Results. Twenty four patients (25 hips) underwent the procedure at mean age of 18.7 years (range:9.3–38.8) with a mean follow-up of 5 years (range:2–13.8). At the last assessment, the mean Oxford Hip Score was 41.6 (range:58–27), Non-Arthritic Hip Score was 53.4 (range:25–77) and UCLA activity score was 4.2 (range:2–6). For changes in neck length, the mean “Head-centre-to-Greater-trochanteric-tip-distance” was 60 mm (range:43–78) compared to 39 mm (range:30–48) pre-operatively and the mean “Head-centre-to-Lesser-trochanteric-tip-distance” was 54 mm (range:47–64) compared to 37 mm (range:31–41) pre-operatively. The mean Tonnis grade was 1.5 (range:1–3) compared to 1.3 (range:1–2) pre-operatively. Two patients underwent arthroplasty conversion at 2 and 13.8 years later. One patient needed head-neck debridement for impingement and 2 patients underwent trochanteric refixation for non-union. There were no cases of avascular necrosis. Discussion. Symptomatic Perthes' hip deformity in adolescents and young adults is difficult to treat with joint preserving surgery. The mid-term clinical, functional and radiological results for double proximal femur osteotomy are encouraging

Aim. To study the results of using recombinant human bone morphogenic protein-2 (rhBMP-2) to achieve bone union in children with complex orthopaedic problems including skeletal dysplasia, congenital limb deficiencies and complex trauma. Materials & Methods. Between November 2006 to April 2010, rhBMP-2 was used to achieve bone healing in a total of 19 children. The indications were delayed union or non-union in 16 long bones where previous surgeries had failed and 4 posterior spinal fusions. All children had underlying complex orthopaedic problems predisposing them to delayed bone healing. The average age at the time of surgery was 13 years and 8 months (Range: From 4 years to 19 years and 4 months). There were 7 boys and 12 girls. Results. Average follow-up period was 9.6 months (Range: From 3 months to 2 years and 2 months). Out of the 16 long bone non-unions treated with rhBMP-2, 13 united without further interventions but 3 required further intervention. The average time for clinical union was 10 weeks (Range: from 6 weeks to 18 weeks). The average time for radiological union was 15 weeks (Range: from 7 weeks to 27 weeks). Two children who underwent instrumented posterior spinal fusion and two children who underwent uninstrumented spinal fusion achieved radiologically evident spinal fusion at an average of 16 weeks. No local or systemic complications attributable to BMP were noted in any of the children. Conclusions. rhBMP-2 can be used successfully to achieve bone healing in long bone nonunion and delayed union and posterior spinal fusion in children with complex orthopaedic problems including skeletal dysplasia, congenital limb deficiencies and complex trauma. Its use in children has shown no unwanted effects in the short term. Significance. rhBMP-2 has been approved by Food and Drug Administration (FDA) as a bone graft substitute in adults. Its use in adults has been widely reported but there are only a few case reports of its use in children. This study shows that rhBMP-2 can be safely

Statement of purpose of study: To determine how effective Flexible Intramedullary Nails are in treating tibial and femoral fractures in adolescents. Summary of Methods used: Retrospective review of consecutive adolescent patients treated over a seven year period with Flexible Intramedullary Nails for tibial and femoral fractures. Statement of Conclusion: We conclude that the higher than expected rates of malunion and delayed union suggest that other treatments should be considered when treating adolescents with unstable tibial or femoral fractures. Introduction Flexible intramedullary nails (FIN) are increasingly used in the management of paediatric tibial and femoral fractures. Recently, concerns have been raised regarding the use of FIN in older children. The aim of this study was to determine how effective FIN's are in treating tibial and femoral fractures in adolescents. Methods Hospital records were used to identify all patients aged 11 years or older under going FIN for tibial and femoral fractures between 2003 and 2009. Radiographs and case notes were reviewed to identify complications. Results 35 consecutive adolescent patients underwent FIN for tibial (n=21) and femoral fractures (n=15) with a mean age of 12.9 years. 2 femoral and 9 tibial fractures were open. Eight patients sustained multiple injuries. Mean radiographic follow up was 29 weeks. 60% (n=9) and 38% (n=9) of femoral and tibial fractures respectively malunited. Fracture severity was associated with increased malunion for both tibial and femoral fractures (P=0.046 and P=0.044 respectively). There were no cases of non-union. 2 femoral fractures took longer than 20 weeks to unite and 7 tibial fractures took longer than 16 weeks to unite. One patient developed post operative compartment syndrome, one patient developed deep infection and two patients were treated with post operative traction for loss of fracture position. Discussion Previous publications from multiple centres, including ours, have demonstrated excellent results of FIN for tibial and femoral fractures in the general paediatric population. However, concerns have recently been raised about the use of FIN in older, heavier children and with unstable fracture patterns. This is the first published series of adolescent patients undergoing FIN. We conclude that the higher than expected rates of malunion and delayed union suggest that other treatments should be considered when treating adolescents with unstable tibial or femoral fractures

Aims

Displaced fractures of the lateral condyle of the humerus are frequently managed surgically with the aim of avoiding nonunion, malunion, disturbances of growth and later arthritis. The ideal method of fixation is however not known, and treatment varies between surgeons and hospitals. The aim of this study was to compare the outcome of two well-established forms of surgical treatment, Kirschner wire (K-wire) and screw fixation.

Osteofibrous dysplasia is an unusual developmental condition of childhood, which almost exclusively affects the tibia. It is thought to follow a slowly progressive course and to stabilise after skeletal maturity. The possible link with adamantinoma is controversial and some authors believe that they are part of one histological process.

We retrospectively reviewed 16 patients who were diagnosed as having osteofibrous dysplasia initially or on the final histological examination. Their management was diverse, depending on the severity of symptoms and the extent of the lesion. Definitive (extraperiosteal) surgery was localised ‘shark-bite’ excision for small lesions in five patients. Extensive lesions were treated by segmental excision and fibular autograft in six patients, external fixation and bone transport in four and proximal tibial replacement in one. One patient who had a fibular autograft required further excision and bone transport for recurrence. Six initially underwent curettage and all had recurrence. There were no recurrences after localised extraperiosteal excision or bone transport. There were three confirmed cases of adamantinoma.

The relevant literature is reviewed. We recommend extraperiosteal excision in all cases of osteofibrous dysplasia, with segmental excision and reconstruction in more extensive lesions.

Between 2005 and 2010 ten consecutive children with high-energy open diaphyseal tibial fractures were treated by early reduction and application of a programmable circular external fixator. They were all male with a mean age of 11.5 years (5.2 to 15.4), and they were followed for a mean of 34.5 months (6 to 77). Full weight-bearing was allowed immediately post-operatively. The mean time from application to removal of the frame was 16 weeks (12 to 21). The mean deformity following removal of the frame was 0.15° (0° to 1.5°) of coronal angulation, 0.2° (0° to 2°) sagittal angulation, 1.1 mm (0 to 10) coronal translation, and 0.5 mm (0 to 2) sagittal translation. All patients achieved consolidated bony union and satisfactory wound healing. There were no cases of delayed or nonunion, compartment syndrome or neurovascular injury. Four patients had a mild superficial pin site infection; all settled with a single course of oral antibiotics. No patient had a deep infection or re-fracture following removal of the frame. The time to union was comparable with, or better than, other published methods of stabilisation for these injuries. The stable fixator configuration not only facilitates management of the accompanying soft-tissue injury but enables anatomical post-injury alignment, which is important in view of the limited remodelling potential of the tibia in children aged > ten years. Where appropriate expertise exists, we recommend this technique for the management of high-energy open tibial fractures in children.

Most surgeons favour removing forearm plates in children. There is, however, no long-term data regarding the complications of retaining a plate. We present a prospective case series of 82 paediatric patients who underwent plating of their forearm fracture over an eight-year period with a minimum follow-up of two years. The study institution does not routinely remove forearm plates. A total of 116 plates were used: 79 one-third tubular plates and 37 dynamic compression plates (DCP). There were 12 complications: six plates (7.3%) were removed for pain or stiffness and there were six (7.3%) implant-related fractures. Overall, survival of the plates was 85% at 10 years. Cox regression analysis identified radial plates (odds ratio (OR) 4.4, p = 0.03) and DCP fixation (OR 3.2, p = 0.02) to be independent risk factors of an implant-related fracture. In contrast ulnar plates were more likely to cause pain or irritation necessitating removal (OR 5.6, p = 0.04).

The complications associated with retaining a plate are different, but do not occur more frequently than the complications following removal of a plate in children.

Nonunion of the humerus with bone loss and shortening due to osteomyelitis is rare but difficult to treat. We describe our experience with a callus distraction technique using a monolateral external fixator for the treatment of this condition.

Between October 1994 and January 2004, 11 patients were treated. There were seven males and four females, with a mean age of 14 years (10 to 17). The mean bone loss was 1.9 cm (1 to 2.7) and the mean length discrepancy in the upper limb was 5.6 cm (3.5 to 8.0).

The mean follow-up was for 106 months (54 to 166). The mean external fixation index was 34.8 days/cm (29.8 to 40.5). The mean lengthening was 9.5 cm (5.5 to 13.4). There were seven excellent results, three good and one poor. There were nine excellent functional results and two good.

The treatment of humeral nonunion with bone loss and shortening due to osteomyelitis by callus distraction is a safe and effective means of improving function and cosmesis.

We investigated patterns of refracture and their risk factors in patients with congenital pseudarthrosis of the tibia after Ilizarov osteosynthesis. We studied 43 cases in 23 patients. Temporal and spatial patterns of refracture and refracture-free survival were analysed in each case. The refracture-free rate of cumulative survival was 47% at five years and did not change thereafter. Refracture occurred at the previous pseudarthrosis in 16 of 19 cases of refracture. The risk of refracture was significantly higher when osteosynthesis was performed below the age of four years, when the tibial cross-sectional area was narrow, and when associated with persistent fibular pseudarthrosis. Refracture occurs frequently after successful osteosynthesis in these patients. Delaying osteosynthesis, maximising the tibial cross-sectional area and stabilising the fibula may reduce the risk of refracture.