Aims. Management of displaced paediatric supracondylar elbow fractures remains widely debated and actual practice is unclear. This national trainee collaboration aimed to evaluate surgical and postoperative management of these injuries across the UK. Methods. This study was led by the South West Orthopaedic Research Division (SWORD) and performed by the Supra Man Collaborative. Displaced paediatric supracondylar elbow fractures undergoing surgery between 1 January 2019 and 31 December 2019 were retrospectively identified and their anonymized data were collected via Research Electronic Data Capture (REDCap). Results. A total of 972 patients were identified across 41 hospitals. Mean age at injury was 6.3 years (1 to 15), 504 were male (52%), 583 involved the left side (60%), and 538 were Gartland type 3 fractures (55%). Median time from injury to theatre was 16 hours (interquartile range (IQR) 6.6 to 22), 300 patients (31%) underwent surgery on the day of injury, and 91 (9%) underwent surgery between 10:00 pm and 8:00 am. Overall, 910 patients (94%) had Kirschner (K)-wire) fixation and these were left percutaneous in 869 (95%), while 62 patients (6%) had manipulation under anaesthetic (MUA) and casting. Crossed K-wire configuration was used as fixation in 544 cases (59.5%). Overall, 208 of the fixation cases (61%) performed or supervised by a paediatric orthopaedic consultant underwent lateral-only fixation, whereas 153 (27%) of the fixation cases performed or supervised by a non-paediatric orthopaedic consultant used lateral-only fixation. In total, 129 percutaneous wires (16%) were removed in theatre. Of the 341 percutaneous wire fixations performed or supervised by a paediatric orthopaedic consultant, 11 (3%) underwent wire removal in theatre, whereas 118 (22%) of the 528 percutaneous wire fixation cases performed or supervised by a non-paediatric orthopaedic consultant underwent wire removal in theatre. Four MUA patients (6%) and seven K-wire fixation patients (0.8%) required revision surgery within 30 days for displacement. Conclusion. The treatment of supracondylar elbow fractures in children varies across the UK. Patient cases where a paediatric orthopaedic consultant was involved had an increased tendency for lateral only K-wire fixation and for wire removal in clinic. Low rates of displacement requiring revision surgery were identified in all fixation configurations. Cite this article: Bone Joint J 2023;105-B(1):82–87

We describe a method of pinning extension supracondylar fractures of the humerus in children. Following closed reduction, a posterior intrafocal wire is inserted and a second lateral wire added when needed for rotational stability. Between May 2002 and November 2005 we performed this technique in 69 consecutive patients. A single posterior wire was used in 29 cases, and two wires in 40. The mean follow-up was two years (21 to 30 months). The results were assessed according to Flynn’s criteria. In the single-wire group there were 21 excellent, five good and one poor result. Two patients were lost to follow-up. In the two-wire group there were 32 excellent, two good and three poor results. Three were lost to follow-up. The poor results were due to a failure to achieve adequate reduction, fixation or both. We conclude that the intact posterior periosteal hinge can be used successfully in the clinical situation, giving results that compare well with other techniques of pinning. The posterior route offers an attractive alternative method for fixation of supracondylar fractures of the humerus in children

Purpose of the study. The aim of this mechanical study was to investigate the ability of cannulated fixation bolts to stop wire slippage in Ilizarov circular external fixators. Methods and Results. Three types of cannulated fixation bolts (Smith and Nephew, Orthofix and one designed by the authors) were tested on Ilizarov rings to compare their performance. Three levels of bolt torques were applied and the wires were pulled to measure the load at which the wire will start to slip or fail. It was revealed that the initial resistance to slippage is due to plastic deformation of the wire under the clamp and is in fact governed by the size of this deformation. The slippage was found to occur in a slip/stick fashion, as the plastic deformation was propagated along the wire. Conclusion. The more the plastic deformation caused by the bolt on the wire the higher the initial resistance to loading

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The aim of this retrospective cohort study was to assess and investigate the safety and efficacy of using a distal tibial osteotomy compared to proximal osteotomy for limb lengthening in children.

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Temporary hemiepiphysiodesis (HED) is applied to children and adolescents to correct angular deformities (ADs) in long bones through guided growth. Traditional Blount staples or two-hole plates are mainly used for this indication. Despite precise surgical techniques and attentive postoperative follow-up, implant-associated complications are frequently described. To address these pitfalls, a flexible staple was developed to combine the advantages of the established implants. This study provides the first results of guided growth using the new implant and compares these with the established two-hole plates and Blount staples.

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The aim of this study was to explore parents’ experience of their child’s recovery, and their thoughts about their decision to enrol their child in a randomized controlled trial (RCT) of surgery versus non-surgical casting for a displaced distal radius fracture.

Conventional surgical treatment of relapsed or neglected club foot deformities is not always successful or easy to apply. The presence of shortened neurovascular structures and unhealthy skin may preclude the surgical interference. Bone resection in severe deformities results in short foot which is not satisfactory functionally and cosmetically. Objectives. In this study we evaluate the use of the bloodless technique for management of relapsed or neglected club foot deformities. Methods. From Jan 2000–2006, 64 cases older than 2 years with relapsed or neglected club foot deformities were referred to our center. Four cases were excluded because of inadequate follow up data. This thesis based on 60 consecutive cases (67 feet). The patients average age was 8 years and 4 months (range, 2–16 years). Seven cases were bilateral, 20 Left sides, and 34 Right sides. There were 57 relapsed club foot (5 bilateral), and 3 cases were neglected (2 bilateral). Patients with relapsed club foot had average 3 previous operations (range, 1–8 operations). There was no preoperative assembling of the apparatus. The construct was designed according to the condition of deformity: equinus, varus forefoot etc. Additional procedures, elongation of tendoachilis was done concomitantly with the original procedure in 10 cases. The patients were discharged from the hospital the same day of the operation. Results. The range of operative time was 1–3 hours with an average of 1.5 hours. Average time in the fixator was 19.6 weeks (range, 10 weeks–38 weeks). After fixator removal cast was applied for 2 months, followed by night splint and special shoes for their daily activities. The average follow-up period was 30.6 months (range, 12–84 months) after fixator removal. The results were good in 55 feet, fair in 9, bad in 3. Complications. All cases suffered from some sort of pin tract inflammation. For 8 cases: one of the wires had to be removed without anaesthesia due to persistent infection. For 3 cases: replacement of wires under general anaesthesia was performed. Oedema developed in the leg and dorsum of the foot or the ankle in 34cases. Frame adjustment under general anaesthesia in 3 cases. There are others such as: migration of the calcanean wire, 2 cases; over correction with valgus heel, two cases; flatfoot, 4 cases; talar subluxationin, 2 cases; talonavicular subluxation, one case; first metatarsophalangeal subluxation, 2 cases; flat topped talus, one case; broken wire, 2 cases and recurrence in 2 cases. Discussion. It seems logic that osteotomy of the tarsus must be carried out whenever skeletal growth of the foot is at such an advanced stage that correction can not be established by means of articular repositioning and remodeling. However, equinovarus deformity of the foot in 65 adults (38 feet) was treated by external fixator without open procedure (Oganesyan et al, 1996). After an average follow-up 10 years, satisfactory results were obtained in all feet except four. Conclusion. Ilizarov Treatment is lengthy, difficult, fraught with complications, and a technically demanding procedure. However, the complications did not affect the final outcome too much. Ilizarov method also offers the advantage of performing many additional procedures for other associated lower limb deformity. We believe that the bloodless technique using Ilizarov external fixator is an effective method in treating relapsed or neglected club foot deformities

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Medial humeral epicondyle fractures (MHEFs) are common elbow fractures in children. Open reduction should be performed in patients with MHEF who have entrapped intra-articular fragments as well as displacement. However, following open reduction, transposition of the ulnar nerve is disputed. The aim of this study is to evaluate the need for ulnar nerve exploration and transposition.

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The management of fractures of the medial epicondyle is one of the greatest controversies in paediatric fracture care, with uncertainty concerning the need for surgery. The British Society of Children’s Orthopaedic Surgery prioritized this as their most important research question in paediatric trauma. This is the protocol for a randomized controlled, multicentre, prospective superiority trial of operative fixation versus nonoperative treatment for displaced medial epicondyle fractures: the Surgery or Cast of the EpicoNdyle in Children’s Elbows (SCIENCE) trial.

The traditional techniques involving an oblique tunnel or triangular wedge resection to approach a central or mixed-type physeal bar are hindered by poor visualisation of the bar. This may be overcome by a complete transverse osteotomy at the metaphysis near the growth plate or a direct vertical approach to the bar. Ilizarov external fixation using small wires allows firm fixation of the short physis-bearing fragment, and can also correct an associated angular deformity and permit limb lengthening. . We accurately approached and successfully excised ten central- or mixed-type bars; six in the distal femur, two in the proximal tibia and two in the distal tibia, without damaging the uninvolved physis, and corrected the associated angular deformity and leg-length discrepancy. Callus formation was slightly delayed because of periosteal elevation and stretching during resection of the bar. The resultant resection of the bar was satisfactory in seven patients and fair in three as assessed using a by a modified Williamson–Staheli classification. Cite this article: Bone Joint J 2015;97-B:1726–31

Of 48 consecutive children with Gartland III supracondylar fractures, 11 (23%) had evidence of vascular injury, with an absent radial pulse. The hand was pink and warm in eight and white and cold in the other three patients. They underwent colour-coded duplex scanning (CCDS) and ultrasound velocimetry (UV) to investigate the patency of the brachial artery and arterial blood flow. In seven patients with a pink pulseless hand, CCDS showed a displaced, kinked and spastic brachial artery and a thrombosis was present in the other. In all cases UV showed reduced blood flow in the hand. In three patients with a white pulseless hand, scanning demonstrated a laceration in the brachial artery and/or thrombosis. In all cases, the fracture was reduced under general anaesthesia and fixed with Kirschner wires. Of the seven patients with a pink pulseless hand without thrombosis, the radial pulse returned after reduction in four cases. The remaining three underwent exploration, along with the patients with laceration in the brachial artery and/or thrombosis. We believe that the traditional strategy of watchful waiting in children in whom the radial pulse remains absent in spite of good peripheral perfusion should be revisited. Vascular investigation using these non-invasive techniques that are quick and reliable is recommended in the management of these patients. Cite this article: Bone Joint J 2013;95-B:694–98

In a prospective, randomised controlled trial, 68 children who had a completely displaced metaphyseal fracture of the distal radius were treated either by manipulation (MUA) and application of an above-elbow cast alone or by the additional insertion of a percutaneous Kirschner (K-) wire. Full radiological follow-up to union was obtained in 65 children and 56 returned for clinical evaluation three months after injury. Maintenance of reduction was significantly better in the K-wire group and fewer follow-up radiographs were required. There was no significant difference in the clinical outcome measured three months after injury. Seven of 33 patients in the MUA group had to undergo a second procedure because of an unacceptable position compared with none of the 35 in the K-wire group (chi-squared test, p < 0.01). One patient in the K-wire group required exploration for recovery of a migrated wire. We conclude that the use of a percutaneous K-wire to augment the reduction of the fracture in children who have a completely displaced metaphyseal fracture of the distal radius is a safe and reliable way of maintaining alignment of the fracture

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Temporary epiphysiodesis (ED) is commonly applied in children and adolescents to treat leg length discrepancies (LLDs) and tall stature. Traditional Blount staples or modern two-hole plates are used in clinical practice. However, they require accurate planning, precise surgical techniques, and attentive follow-up to achieve the desired outcome without complications. This study reports the results of ED using a novel rigid staple (RigidTack) incorporating safety, as well as technical and procedural success according to the idea, development, evaluation, assessment, long-term (IDEAL) study framework.

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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.

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To compare changes in gait kinematics and walking speed 24 months after conventional (C-MLS) and minimally invasive (MI-MLS) multilevel surgery for children with diplegic cerebral palsy (CP).

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Guided growth has been used to treat coxa valga for cerebral palsy (CP) children. However, there has been no study on the optimal position of screw application. In this paper we have investigated the influence of screw position on the outcomes of guided growth.

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

Background. CRUS is difficult to treat. Many techniques have been tried in an effort to restore forearm rotation; however, they have not been successful. It is inadvisable by many authors to perform any operation with the hope of obtaining pronation and supination. Patients and Methods. Eleven children; 3 - 8 years old with CRUS, Wilkie type I, with fixed full pronation deformity were managed by the new ALLAM'S OPERATION which is a one stage intervention including separation of the bony fusion, special cementation technique of the ulnar (or radial) side of the osteotomy, double osteotomy of the radius and a single osteotomy of the ulna (all of the 3 osteotomies were done percutaneously) with intramedullary K. wire fixation of osteotomies at the mid-prone position and above elbow cast application for 6 weeks. Results. Excellent significant functional range of forearm rotation was obtained with no significant complications after a follow-up period of 3 – 4 y. (average: 3.2 m). Summary. The new ALLAM'S OPERATION is a one stage intervention for CRUS, (Wilkie type I, with fixed full pronation deformity) with significant obtained active functional range of forearm rotation with no significant complications after an average follow-up period of more than 3 years

Aim. Since 2008 we have been using third generation Fassier Duval (FD) telescopic rods for children with complex and severe osteogenesis imperfecta (sOI). We present our experience with the technique. Method. 8 children with sOI have undergone rodding of 16 lower limb long bones; 6 tibial, 10 femoral. 3 were revision procedures, exchanging previous Sheffield rods that had been implanted with the female portion only. Indications were recurrent fracture and/or progressive deformity. Age range and follow up are 2–12 and 0.4–4.75 years respectively. All but one of the procedures were performed by a single surgeon. Results. There have been 3 re-fractures at 3–5 years with bending of the implant at the rod-tip interface and one re-fracture around a well-positioned implant without bending, all requiring revision. Some female femoral rods have migrated distally (3/10) leading in one case to re-fracture above the implant, which was also revised. All rods have initially telescoped well but we have experienced high pull out rates of the threads in the distal tibia (3/6) at an average 18 months post implantation (range 14–20 months). None has yet required revision for this. Proximal migration of the femoral female component has not occurred except in one revision case, which responded well to interference wire fixation. We have one case of coxa vara that developed in a child whose femur was rodded at 2 years of age. Conclusion. The FD implants have functioned well and enabled us to avoid opening the ankle joint for tibial roddings. Nonetheless the re-fracture rates remain high in this group of severely affected children and are comparable to older generation implants. Proximal femoral and distal tibial anchoring points remain common sites of failure though rarely require early re-operation

Purpose. Analyze the results of reconstruction of post osteomyelitic bone defect using non-vascularised fibula graft in children and correlation of results with magnitude of defect. Methods. 11 boys and 15 girls (mean age 6.8±2.33 years) were prospectively enrolled in the study. All had primary acute hematogeneous osteomyelitis with diaphyseal sequestration and active discharging sinuses. 7 femur, 12 tibia, 3 humerus, 3 radius and 1 ulna were the bone involved. As first step a radical debridement and sequestrectomy was performed. Second step was considered after a ‘dry’ period judged clinically and by normalized CRP. A subperiosteal resection of fibula was done and used as graft to fill in the diaphyseal defect. Graft was stabilized using intramedullary ‘K’ wires and supported by post-operative casts. Weight-bearing was started on radiological evidence of union. Results. mean follow up was 3.02±0.74 years with mean union time of 38.76±12.02 weeks. Delayed union (n=4) was seen at sites with large discrepancy between diameter of native bone and graft (like proximal tibial metaphysis). These cases united with plate fixation and bone grafting. There was weak positive correlation between union time and preoperative bone defect (+0.699). Subgroup analysis showed that there no significant difference between union times of patients with defect <4cms (mean of 31.7±11.5 weeks) and defect >4<6cms (mean 36.6±9 weeks), however the union time of patients with defect >6cms was significantly more (51±6.7 weeks). Conclusion. Non-vascularised fibula graft gives predictable results in children with post-osteomyelitic bone defects. Delayed unions are expected if the size of bone defect is >6cms or there is large discrepancy between the diameters of native and grafted bone