Aims. 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. Methods. Between January 2013 and December 2016, 138 patients (22 children, 116 adolescents) with genu valgum or genu varum were treated with 285 flexible staples. The minimum follow-up was 24 months. These results were compared with 98 patients treated with 205 two-hole plates and 92 patients treated with 535 Blount staples. In long-standing anteroposterior radiographs, mechanical axis deviations (MADs) were measured before and during treatment to analyze treatment efficiency. The evaluation of the new flexible staple was performed according to the idea, development, evaluation, assessment, long-term (IDEAL) study framework (Stage 2a). Results. Overall, 79% (109/138) of patients treated with flexible staples achieved sufficient deformity correction. The median treatment duration was 16 months (interquartile range (IQR) 8 to 21). The flexible staples achieved a median MAD correction of 1.2 mm/month/HED site (IQR 0.6 to 2.0) in valgus deformities and 0.6 mm/month/HED site (IQR 0.2 to 1.5) in varus deformities. Wound infections occurred in 1%, haematomas and joint effusions in 4%, and implant-associated complications in 1% of patients treated with flexible staples. Valgus AD were corrected faster using flexible staples than two-hole plates and Blount staples. Furthermore, the median MAD after treatment was lower in varus and valgus AD, fewer implant-associated complications were detected, and reduced implantation times were recorded using flexible staples. Conclusion. The flexible staple seems to be a viable option for guided growth, showing comparable or possibly better results regarding correction speed and reducing implant-associated complications. Further comparative studies are required to substantiate these findings. Cite this article: Bone Joint J 2023;105-B(3):331–340

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. Methods. Data were extracted from medical records and databases for patients with an open tibial fracture aged < 16 years who presented between 1 May 2014 and 30 April 2019. Patients who were transferred from elsewhere were excluded, yielding 44 open fractures in 43 patients, with a minimum follow-up of one year. Management was reviewed from the time of injury to discharge. Primary outcome measures were the rate of deep infection, time to union, and the Modified Enneking score. Results. The mean age of the patients was 9.9 years (2.8 to 15.8), and 28 were male (64%). A total of 30 fractures (68%) involved a motor vehicle collision, and 34 (77%) were classified as Gustilo Anderson (GA) grade 3B. There were 17 (50%) GA grade 3B fractures, which were treated with a definitive hexapod fixator, and 33 fractures (75%) were treated with a free flap, of which 30 (91%) were scapular/parascapular or anterolateral thigh (ALT) flaps. All fractures united at a median of 12.3 weeks (interquartile range (IQR) 9.6 to 18.1), with increasing age being significantly associated with a longer time to union (p = 0.005). There were no deep infections, one superficial wound infection, and the use of 20 fixators (20%) was associated with a pin site infection. The median Enneking score was 90% (IQR 87.5% to 95%). Three patients had a bony complication requiring further surgery. There were no flap failures, and eight patients underwent further plastic surgery. Conclusion. The timely and comprehensive orthoplastic care of open tibial fractures in this series of patiemts aged < 16 years resulted in 100% union and 0% deep infection, with excellent patient-reported functional outcomes. Cite this article: Bone Joint J 2021;103-B(6):1160–1167

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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.

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Paediatric fractures are highly prevalent and are most often treated with plaster. The application and removal of plaster is often an anxiety-inducing experience for children. Decreasing the anxiety level may improve the patients’ satisfaction and the quality of healthcare. Virtual reality (VR) has proven to effectively distract children and reduce their anxiety in other clinical settings, and it seems to have a similar effect during plaster treatment. This study aims to further investigate the effect of VR on the anxiety level of children with fractures who undergo plaster removal or replacement in the plaster room.

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Children with spinal dysraphism can develop various musculoskeletal deformities, necessitating a range of orthopaedic interventions, causing significant morbidity, and making considerable demands on resources. This systematic review aimed to identify what outcome measures have been reported in the literature for children with spinal dysraphism who undergo orthopaedic interventions involving the lower limbs.

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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.

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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.

Aims. Following the introduction of national standards in 2009, most major paediatric trauma is now triaged to specialist units offering combined orthopaedic and plastic surgical expertise. We investigated the management of open tibia fractures at a paediatric trauma centre, primarily reporting the risk of infection and rate of union. Patients and Methods. A retrospective review was performed on 61 children who between 2007 and 2015 presented with an open tibia fracture. Their mean age was nine years (2 to 16) and the median follow-up was ten months (interquartile range 5 to 18). Management involved IV antibiotics, early debridement and combined treatment of the skeletal and soft-tissue injuries in line with standards proposed by the British Orthopaedic Association. Results. There were 36 diaphyseal fractures and 25 distal tibial fractures. Of the distal fractures, eight involved the physis. Motor vehicle collisions accounted for two thirds of the injuries and 38 patients (62%) arrived outside of normal working hours. The initial method of stabilisation comprised: casting in nine cases (15%); elastic nailing in 19 (31%); Kirschner (K)-wiring in 13 (21%); intramedullary nailing in one (2%); open reduction and plate fixation in four (7%); and external fixation in 15 (25%). Wound management comprised: primary wound closure in 24 (39%), delayed primary closure in 11 (18%), split skin graft (SSG) in eight (13%), local flap with SSG in 17 (28%) and a free flap in one. A total of 43 fractures (70%) were Gustilo-Anderson grade III. There were four superficial (6.6%) and three (4.9%) deep infections. Two deep infections occurred following open reduction and plate fixation and the third after K-wire fixation of a distal fracture. No patient who underwent primary wound closure developed an infection. All the fractures united, although nine patients required revision of a mono-lateral to circular frame for delayed union (two) or for altered alignment or length (seven). The mean time to union was two weeks longer in diaphyseal fractures than in distal fractures (13 weeks versus 10.8 weeks, p = 0.016). Children aged > 12 years had a significantly longer time to union than those aged < 12 years (16.3 weeks versus 11.4 weeks, p = 0.045). The length of stay in hospital for patients with a Gustilo-Anderson grade IIIB fracture was twice as long as for less severe injuries. . Conclusion. Fractures in children heal better than those in adults. Based on our experience of deep infection we discourage the use of internal fixation with a plate for open tibial fractures in children. We advocate aggressive initial wound debridement in theatre with early definitive combined orthopaedic and plastic surgery in order to obtain skeletal stabilisation and soft-tissue cover. Cite this article: Bone Joint J 2017;99-B:544–53

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To examine the long-term outcome of arthrodesis of the hip undertaken in a paediatric population in treating painful arthritis of the hip. In our patient population, most of whom live rurally in hilly terrain and have limited healthcare access and resources, hip arthrodesis has been an important surgical option for the monoarticular painful hip in a child.

Our aim was to review the efficacy of the wound vacuum-assisted closure (VAC) system in the treatment of deep infection after extensive instrumentation and fusion for spinal deformity in children and adolescents. A total of 14 patients with early deep spinal infection were treated using this technique. Of these, 12 had neuromuscular or syndromic problems. Clinical and laboratory data were reviewed. The mean follow-up was 44 months (24 to 72). All wounds healed. Two patients required plastic surgery to speed up the process. In no patient was the hardware removed and there was no loss of correction or recurrent infection. We believe that the wound VAC system is a useful tool in the armamentarium of the spinal surgeon dealing with patients susceptible to wound infections, especially those with neuromuscular diseases. It allows for the retention of the instrumentation and the maintenance of spinal correction. It is reliable and easy to use

Between 1988 and 1995, we studied 91 club feet from a series of 120 recalcitrant feet in 86 patients requiring surgical treatment. There were 48 boys and 20 girls. The mean age at operation was 8.9 months. Surgery consisted of an initial plantar medial release followed two weeks later by a posterolateral release. This strategy was adopted specifically to address the problems of wound healing associated with single-stage surgery and to ascertain the rate of relapse after a two-stage procedure. Immobilisation in plaster was used for three months followed by night splintage. The feet were classified preoperatively and prospectively into four grades according to the system suggested by Dimeglio et al. Grade-1 feet were postural and did not require surgery. All wounds were closed primarily. One superficial wound infection occurred in a grade-4 foot and there were no cases of wound breakdown. The rate of relapse was 20.4% in grade-3 and 65.4% in grade-4 feet. Two-stage surgery for the treatment of club foot seems to be effective in the reduction of wound problems but does not appear to give significantly better results in terms of relapse when performed for more severe deformities

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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.

Purpose. To document the incidence and nature of complications associated with hemiepiphysiodesis using a screw and plate device (8-plate, Orthofix). Methods. We reviewed case notes and radiographs of 71 children (130 segments) with lower limb deformities treated with temporary hemiepiphyseal arrest using the 8-plate. 96% of deformities were in the coronal plane, 4% sagittal. 72% of coronal deformities demonstrated valgus malalignment. We defined three types of complications:. early (perioperative) complications eg infection and/or wound breakdown, bleeding, neurological impairment. implant related complications such as soft tissue irritation, plate breakage or migration,. complications involving the growth plate including rebound deformity, early physeal closure or iatrogenic deformity. Complications were related to variables of patient age, gender, diagnosis, location of deformity and associated surgery. Results. The average age at surgery was 10 years (range 3-16). There were 41 boys, 30 girls. 3/70 patients were treated for an idiopathic deformity: the remainder were affected by a wide range of pathologies (20% skeletal dysplasia, 20% metabolic bone disease). Full correction has occurred in 38% of patients. The remaining 45 children are all showing improvement in their deformity. 10 patients (14%) have had a complication: 3 patients had early complications (wound infection, wound breakdown and intra-operative hypotensive crisis) and 2 patients have had implant related complications (irritation and migration). In a further 5 patients there have been physis related problems: 1 over-correction, 1 recurrence and 3 cases in which the timing of the procedure or the ill-health of the physis did not allow correction to occur. Conclusion. The 8-plate is an effective device in the management of deformity secondary to pathological conditions. 10% of patients had complications: the majority were minor but care should be taken regarding the timing of the procedure related to the growth potential of the pathological physis

We describe the technique and results of medial submuscular plating of the femur in paediatric patients and discuss its indications and limitations. Specifically, the technique is used as part of a plate-after-lengthening strategy, where the period of external fixation is reduced and the plate introduced by avoiding direct contact with the lateral entry wounds of the external fixator pins. The technique emphasises that vastus medialis is interposed between the plate and the vascular structures. . A total of 16 patients (11 male and five female, mean age 9.6 years (5 to 17)), had medial submuscular plating of the femur. All underwent distraction osteogenesis of the femur with a mean lengthening of 4.99 cm (3.2 to 12) prior to plating. All patients achieved consolidation of the regenerate without deformity. The mean follow-up was 10.5 months (7 to 15) after plating for those with plates still in situ, and 16.3 months (1 to 39) for those who subsequently had their plates removed. None developed a deep infection. In two patients a proximal screw fractured without loss of alignment; one patient sustained a traumatic fracture six months after removal of the plate. . Placing the plate on the medial side is advantageous when the external fixator is present on the lateral side, and is biomechanically optimal in the presence of a femoral defect. We conclude that medial femoral submuscular plating is a useful technique for specific indications and can be performed safely with a prior understanding of the regional anatomy. Cite this article: Bone Joint J 2014;96-B:137–42

The purpose of the study was to investigate the incidence of surgical site infection following elective paediatric orthopaedic surgery. A pro forma adopted from a pilot study was filled out preoperatively for each elective operation performed during the study period. Each patient was then followed up for six weeks postoperatively to record any SSI that developed. Data collected included patient demographics, type of operation, grade of Surgeon, type of procedure, wound length, skin preparations, use of tourniquet, any antibiotic prophylaxis and length of operation. This study collated data on 334 operations with 410 procedural sites over a six month period. Infection were recorded in 19 sites equivalent to a SSI rate of 4.63%. None of the patients developed long-term complications. The mean age of the participants in the study was 11 years (range 0.5 to 17 years), 57% were males and 43% were females. The infection were detected between 1 and 38 days after surgery. The outcome was not compromised in any of the patients as none of them required long-term treatment. Statistical analysis was undertaken. The study proves that the surgical site infection after elective paediatric orthopaedic surgery is low and serve as a bases for consenting patients for surgery

Aims

The study was undertaken to compare the efficacy of Woodcast splints and plaster-of-Paris casts in maintaining correction following sequential manipulation of idiopathic clubfeet.

We present the results of 90 consecutive children with displaced fractures of the forearm treated by elastic stable intramedullary nailing with a mean follow-up of 6.6 months (2.0 to 17.6). Eight (9%) had open fractures and 77 (86%) had sustained a fracture of both bones. The operations were performed by orthopaedic trainees in 78 patients (86%). All fractures healed at a mean of 2.9 months (1.1 to 8.7). There was one case of delayed union of an ulnar fracture. An excellent or good functional outcome was achieved in 76 patients (84%). There was no statistical difference detected when the grade of operating surgeon, age of the patient and the diaphyseal level of the fracture were correlated with the outcome. A limited open reduction was required in 40 fractures (44%). Complications included seven cases of problematic wounds, two transient palsies of the superficial radial nerve and one case each of malunion and a post-operative compartment syndrome. At final follow-up, all children were pain-free and without limitation of sport and play activities. Our findings indicate that the functional outcome following paediatric fractures of the forearm treated by elastic stable intramedullary nailing is good, without the need for anatomical restoration of the radial bow

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

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

Purpose of Study. A description of a procedure to stabilize symptomatic complete discoid menisci with medium term results. Methods and Results. Children with mechanical symptoms of lateral meniscal instability were assessed by MRI scan. In those with a lateral discoid meniscus an arthroscopic examination was performed to identify the presence of tears and confirm the radiological diagnosis. No incomplete or Wrisberg variant types were encountered. An antero-lateral arthrotomy was performed. The anterior horn of the meniscus was mobilized and traction sutures inserted. Flexion and extension of the knee whilst traction was applied led to delivery of the anterior horn into the wound. After confirmation of position with image intensifier a groove was fashioned in the anterior aspect of the cartilaginous portion of the proximal tibial epiphysis. Typically three titanium bone anchors with non absorbable sutures were placed in the base of the groove. The anterior horn of the meniscus was drawn into the groove and anchored with sutures. Active range of motion exercises were encouraged but a canvas knee immobilizer was employed whilst walking for the first six weeks. Four boys and three girls underwent meniscopexy performed at a mean age of 9.4 years (range 5.7 to 12.4 years). Follow up was at a mean of 4.9 years. At last follow up no patient reported symptoms of locking or pain. No patient has required revision surgery but one girl had a subsequent meniscopexy procedure on the opposite knee. Five of the children have had Lysholm scores performed at last follow up averaging 93.5 (80 to 100 points). Conclusion. Complete lateral discoid menisci in children can be rendered asymptomatic in the medium term by re-tensioning the anterior horn