Purpose: Wrist fractures are often seen in elderly subjects who cannot generally tolerate aggressive fixation of unstable fractures. Percutaneous intra-focal pinning (Kapandji) is usually employed. The purpose of this study was to compare the classical treatment of unstable extra-articular fractures of the lower quarter of the radius with posterior displacement with a modified pinning technique.

Material and methods: This prospective radiological study concerned two groups of randomised patients aged 30 – 70 years who were hospitalised for surgical treatment of Pouteau-Colles fractures. In the first group, all patients were treated by the classical intra-focal technique using one or two dorsal pins and one lateral pin (group K). In the second group, all patients were treated by fixation with one or two infrafocal dorsal pins and a third pin inserted transfocally (group KM). Preoperative care, anaesthesia, and postoperative care (21 days immobilisation, pin removal at 45 days) were the same in both groups. The following anatomic measurements were made on the radiographs at day 1, 21, 45, and last follow-up: radial inclination on the lateral and AP views, bistyloid line.

Results: Group K included 49 patients, mean age 45 years. Group KM included 46 patients, mean age 54 years. There was no statistical difference between groups for age, gender, side, type of fracture. Radial inclination on the AP view was 19.2 (10–27 in group KM and 23.2 (19-30) in group. On the lateral view, radial inclination was 0 (−11 to 20) in group KM and −5.7 (−25 to 2) in group K. The proportion of bistyloid lines considered satisfactory was not different between groups.

Discussion: Infra-focal pinning can have limitations for maintaining reduction to bone healing. The Kapandji technique modified by use of a third transstyloid pin appears to provide better stabilisation of unstable fractures of the lower extremity of the radius, particularly in older subjects who cannot tolerate aggressive surgery. This preliminary study should be completed by a radio-clinical analysis in a larger number of patients to confirm these results.

Augmented reality simulators offer opportunities for practice of orthopaedic procedures outside of theatre environments. We developed an augmented reality simulator that allows trainees to practice pinning of paediatric supracondylar humeral fractures (SCHF) in a radiation-free environment at no extra risk to patients. The simulator is composed of a tangible child's elbow model, and simulated fluoroscopy on a tablet device. The treatment of these fractures is likely one of the first procedures involving X-ray guided wire insertion that trainee orthopaedic surgeons will encounter. This study aims to examine the extent of improvement simulator training provides to real-world operating theatre performance.

This multi-centre study will involve four cohorts of New Zealand orthopaedic trainees in their SET1 year. Trainees with no simulator exposure in 2019 - 2021 will form the comparator cohort. Trainees in 2022 will receive additional, regular simulator training as the intervention cohort. The comparator cohort's performance in paediatric SCHF surgery will be retrospectively audited using routinely collected operative outcomes and parameters over a six-month period. The performance of the intervention cohorts will be collected in the same way over a comparable period. The data collected for both groups will be used to examine whether additional training with an augmented reality simulator shows improved real-world surgical outcomes compared to traditional surgical training. This protocol has been approved by the University of Otago Health Ethics committee, and the study is due for completion in 2024.

This study is the first nation-wide transfer validity study of a surgical simulator in New Zealand. As of September 2022, all trainees in the intervention cohort have been recruited along with eight retrospective trainees via email. We present this protocol to maintain transparency of the prespecified research plans and ensure robust scientific methods. This protocol may also assist other researchers conducting similar studies within small populations.

Purpose of the study: Appropriate treatment for fractures of the distal radius with dorsal displacement remains a subject of debate. Intrafocal pinning is the most widely used technique in France. Plate fixation has been developed to avoid secondary displacement and stiffness sometimes observed after pinning. We compared three osteosynthesis techniques for the same type of fracture (extra-articular with dorsal displacement). Material and methods: Sixty-two consecutive patients underwent osteosynthesis using the following techniques successively: posterior plates [20 patients mean age 59.9 years (range 25–87 years)], intra and extra-focal pînning [22 patients mean age 55.6 years (range17–83 years)], the anterior plate [20 patients mean age 57.1 years (range 17–78 years)]. An independent operator evaluated all patients using the Herzberg, Gartland and Werley and Dash scores. The radial slope in the frontal plane, sagittal tilt, and ulnar variance were measured and compared between the preoperative and last follow-up values. Kruskall-Wallis or ANOVA were applied as appropriate for continuous variables and the chi-square test for non-continuous variables. P< 0.05 was considered significant. Results: Mean operative time was equivalent for the two plate fixation techniques and twice as long as for pinning. There were more complications in the posterior plating group (32%) and less satisfactory function score despite a two-fold longer follow-up and a smaller number of operators. The best results were obtained with the anterior plating group in terms of range of motion (flexion-extension), Dash, preservation of ulnar variance and presence of a largest number of excellent and very good outcomes according to Gartland. The pinning group provided the best results in terms of sagittal slope. The pinning and anterior plating groups had equivalent range of motion for supination pronation and the same rate of complications (5%). Irrespective of the treatment arm, the Herzberg scores and the Gartland and Dash scores were better: in men, in patients aged less than 30 years, in patients with an associated fracture of the apex of the ulnar syloid process rather than its base. Discussion: While posterior plate fixation is logical (approach on the side of the injury), the technique is difficult and can lead to nerve and tendon complications. For these extra-articular fractures, pinning like anterior plating can provide good functional results. Pinning is a rapid procedure and anterior plates do not have to be removed, allowing more rapid recovery of total independence

Prophylactic pinning of the contralateral hip in unilateral Slipped Upper Femoral Epiphysis (SUFE) persists as a source of debate with the majority of surgeons selecting this option in a proportion of patients whom they regard as at increased risk of a subsequent slip.

Universal prophylactic pinning was introduced in our region in 2005 after an audit of ten years local practice identified 25% of unilateral cases presented with a subsequent slip. This study reports our experience between 2005 and 2020.

In this prospective study, 44 patients presented with 55 affected hips compared with 60 patients with 67 affected hips in the original study. Two patients were excluded as their initial slip had not been treated in our unit. Of the 42 hips seven were bilateral, 34 of the 35 unilateral hips underwent prophylactic pinning. The one exception subsequently underwent prophylactic pinning due to developing pain.

Consistent with our original series, at a minimum follow up of 13 months there have been no complications of infection, fracture, chondrolysis or avascular necrosis subsequent to prophylactic pinning.

Over 25 years 70 patients have undergone prophylactic pinning without complication. On the premise that 25% of our unpinned hips presented with subsequent slips before instituting our policy we estimate that we have prevented 17 subsequent slips over 25 years including the consequences which can be significant. We continue to advocate universal prophylactic pinning as an effective and safe practice in the management of SUFE.

Prophylactic fixation of the contralateral hip in cases of unilateral slipped capital femoral epiphysis (SCFE) remains contentious. Our senior author reported a 10 year series in 2006 that identified a rate of subsequent contralateral slip of 25percnt; when prophylactic fixation was not performed. This led to a change in local practice and employment of prophylactic fixation as standard. We report the 10 year outcomes following this change in practice.

A prospective study of all patients who presented with diagnosis of SCFE between 2004 and 2014 in our region. Intra-operative complication and post-operative complication were the primary outcomes. 31 patients presented during the study period: 16 male patients and 15 female patients. The mean age was 12.16 (8–16, SD 2.07). 25 patients had stable SCFE and 5 had unstable SCFE. Stability was uncertain in 1 patient. 25 patients had unilateral SCFE and 6 had bilateral SCFE. 24 patients who had unilateral SUFE had contralateral pinning performed. 1 unilateral SCFE did not have contralateral pinning performed as there was partial fusion of physis on contralateral side.

In the hips fixed prophylactically there was 1 cases of transient intraoperative screw penetration into the joint and 1 case of minor wound dehiscence. There were no cases or chondrolysis or AVN. There were no further contralateral slips. This change in practice has been adopted with minimal complication. The fixation of the contralateral side is not without risk but by adopting this model the risk of subsequent slip has been reduced from 25percnt; to 0percnt;.

Femoral neck fractures in the elderly has a devastating impact on health and resources. Past trends suggest pinning un-displaced fractures in the more active elderly patients and resorting to arthroplasty in those less active. In our study the failure rate for un-displaced fractures (18.4%) was greater than that quoted in the literature and greater than the failure rate of fractures treated with arthroplasty (7.4%). Failures consisted of AVN (5), nonunion/malunion (1) and loss of fixation (1). This data suggests that arthroplasty would decrease the failure rate in our study group.

To evaluate the outcome of ORIF for un-displaced femoral neck fractures in the elderly at a tertiary care teaching hospital.

ORIF of femoral neck fractures in the elderly at our institution resulted in higher failure rates than quoted in the literature. A large multi-center randomized controlled trial is warranted to establish clear guidelines in the management of these injuries.

In our study the failure rate for undisplaced fractures was greater than fractures treated with arthroplasty. The clinical relevance of this data suggests that not all un-displaced fractures go on to uneventful union.

Of the forty-five patients that met the inclusion criteria for un-displaced femoral neck fracture, seven of which were originally treated at our institution failed, resulting in 18.4% failure rate. In comparison, our complication rates for displaced femoral neck fractures treated with arthroplasty results in a 7.4% failure rate. Failures consisted of AVN (5), nonunion/malunion (1) and loss of fixation (1).

Retrospective study. Patients sixty-five to eighty years of age with un-displaced femoral neck fractures repaired by cannulated screw fixation from 1995 to 2001. X-ray confirmation was done when fracture was not described in the chart. Failure of pinning was defined as requiring re-operation or arthroplasty.

Recent studies argue in favor of arthroplasty for most displaced femoral neck fractures. Despite the limitations of our study, the failure rate of the un-displaced femoral neck fracture is higher than that quoted in the literature, and suggests that arthroplasty would decrease the failures in our study group.

Purpose: The purpose of this study was to evaluate centromedullary pinning for bone lengthening. We studied an animal model to discover the details of bone regeneration and assess the advantages of the technique. We present our early clinical results.

Material and methods: Progressive lengthenings of the tibia by centromedullary pinning were performed in eleven dogs. Distraction began on day 5 and lasted 28 days. Arteriograms were obtained after sacrifice.We also analysed 17 cases of limb lengthening in patients: one arm, two forearms, nine femurs, five tibias. Mean patient age was 14 years. Mean gain in bone length was 6.2 cm.

Results: The experimental work demonstrated that intensive bone regeneration requires faster distraction. Early bone union was observed in four dogs. Bone healing was complete at about 15 days in all dogs. The centromedullary pins were left in place in three dogs after removing the external fixator. There was no secondary deformation. The arteriogram showed that the nourishing artery was not ruptured. In our patients, delay to healing was shorter. The radiograms demonstrated intensive bone regeneration. Endosteal regeneration was significant and was never inhibited. Significant periosteal reaction was observed. The planned gain in length was achieved in all patients. We did not have any complications.

Discussion: Bone lengthening methods using a centromedullary nail provide absolute stability while avoiding external fixation but at the cost of complete destruction of the centromedullary vascular supply. Our animal experiments and clinical experience prove that elastic centromedullary pins do not inhibit endosteal regeneration but, on the contrary, partial destruction of the marrow with intact vascularisation stimulates bone regeneration. For bone lengthenings, centromedullary pinning is the only method of internal fixation allowing optimal conditions for bone regneration.

Conclusion: The progressive distraction of the elastic centromedullary pin during the lengthening period stimulates the regenerative processes. The biological effect of the vascular “displacement” from the centre to the periphery of the bone fragments leads to significant periosteal reaction. Elastic centromedullary pinning adds stability to the bone fragments. Associating the two methods allows removal of the external fixator leaving the centromedullary pins in place. By strengthening the regenerated bone, the pins provide a certain degree of additional stability.

Introduction: The purpose of this retrospective study was to evaluate the results of retrograde pinning, according to Hacketal procedure, for unstable fractures of the humeral neck with particular attention to three and four part fractures.

Materials and Methods: Between 7/1990 and 4/2001, we treated 44 patients (26 females and 18 males) ranging in age from 16 to 92 years (mean: 59/5 years). 75% of the cases followed a domestic trauma. Using Neer classification there were 30 two part fractures, 12 three part and 2 four part fractures. After closed reduction was performed under biplane image intensification, a small incision was made to expose the distal humerus by blount dissection. A 5 mm hole was drilled. Three to five prebend Kirschner (25 cases) or Metaizeau pins (19 cases) were introduced retrograde achieving a ‘bouquet’-type fixation within the humeral head. Post operatively, the arm was immobilized in a Mayo-type sling for 2–3 weeks. Then mobilization was started in all directions except rotation, who was cautiously done later. The results were evaluated according to consolidation, pain and range of motion. Complications associated with the treatment were recorded. We considered as excellent results, asymptomatic shoulder with full motion, good results patients with slight pain or reduction of motion and bad results, those with any pain, valuable restriction of motion and functional handicap.

Results: The mean follow up was 21/7 months. Two patients died before callus formation. All patients were re-examined or contacted by phone. No patient was lost to follow-up. The mean hospitalization range was 6.4 days. Two patients had loss of fixation. Fractures united with callus formation in 4 to 8 week. Patients regained a full range of motion in 64% of the cases, 88% were free of pain. No avascular necrosis was noted in that series.

The functional outcome was excellent in 64% of the cases, good in 21.5% of the cases. Pins removal was almost necessary for proximal pins migration in 45% of the cases and distal migration in 7.5% of the cases.

Discussion: The overall finding of good results in this series compares favorably with results of other operative treatment. We believe that our technique offers distinct advantages: few displacement, no osteonecrosis but our follow-up can be considered as insufficient. Migrations of the pins remain a matter of concern.

Conclusion: Retrograde pinning by the olcranon fossea is a demanding technique which makes sense biologically from the stand point of respect of vascularity. It is a useful alternative to open reduction and internal fixation. In three or four part fractures, it has to be tested before primary hemiarthroplasty.

A prospective study to examine the outcome of closed fixation technique in managing the unstable, intra-articular fractures of the distal radius by using k-wires only is undertaken.

Sixty-two wrists with unstable distal radius fractures were treated with closed manipulation and closed pinning of the fracture. Ten are between fifty-one and eighty-one years old and fifty-two are below fifty years of age. Both readial styloid and the dorsal cortex of the distal fragment provided the entry points. All fractures were reduced with fingfer trap traction. Tran osseous and intra-medulaary pinning was carried out in all the fractures. In this two step technique, first the radial articular surface is stabilised. Then, axial stability is provided by trans-epiphyseal intramedullary nails. Emphasis was laid on the reduction, complications and fracture healing.

All fractures healed. A ‘concentric’ collapse varying from 1 to 3 mm was seen in twenty-six cases. No loss of reduction was seen. Surprisingly, no cutaneous radial nerve injuries, no tendon related complications were seen. Five pins in three patients were loose and were removed betweeen seven to thirty days. None had repeat surgeries.

Sound technique is key to success. The longer the collective length of the intra- medullary pins the greater remained the stability of the fracture construct. Ulnar bone provides as a pillar to assemble the distal radius. Fracture of the distal ulna (not merely a fracure of the ulnar styloid) required an additional support in the form of an external fixator in only two patients. Since the follow-up is not very long (mean six months), the author contends to say that the short term results are rewarding with this technique. The unsatisfactory results reported in literature from the closed pinning is largely from inadequate fixations used. When proper technique is applied the radial articular surface is held on the distal shaft to permit only a minimal collapse that is concentric; and compression at the fracture site promoting excellent healing is the rewarding result.

Aim: To compare 2 methods of osteosynthesis (pinning and plate and screws) in displaced intraarticular fractures of the calcaneus

Material and method: Between 2001 and 2005, 82 displaced intraarticular fractures of the calcaneus were surgically treated in our department. Fractures were classified according to Bohler’s classification: 18 Bohler type II and 64 Bohler type III fractures.

Open reduction and reconstruction with osseous grafts (autologous grafts in 22 cases and heterologous grafts in 52 cases) were used in 74 cases. In 8 cases (all of Bohler II type) grafts weren’t used. Osteosynthesis with plate and screws was performed in 26 cases and with pins in 56. The 2 groups were similar in what concerns age, sex ratio, BMI, degree of comminution. The surgical procedure was delayed in both groups (average − 6 days). Pins were removed at 6 weeks and the plates at 12 months.

Results: A number of clinical parameters (pain evolution, moment of partial and full weight bearing, achievement of clinical and radiological union, ankle and forefoot mobility, etc.) were similar in both groups. Skin complications were more frequent in the plate group even if similar lateral surgical approaches were used. Pain along peroneal tendons was much more frequent in the plate group.

Conclusions: Even if theoretically osteosynthesis with plate and screws assures a better fixation, in practice it has similar clinical results with the pinning. The number of complications is higher after plate osteosynthesis. The pins can be extracted with local anesthesia, while plate extraction requires lumbar or general anesthesia and a full extent surgical procedure.

Arthroscopic debridement and pinning is not considered to be effective in dynamic scapholunate (SL) instability treated more than three months post injury; open procedures (capsulodesis, tenondesis, SL ligament reconstruction, intercarpal fusions) are preferred for these patients. The best procedure for this problem is yet to be determined. A restrospective review of the senior author’s records produced thirteen patients with late presenting dynamic SL instability who were unwilling to undergo an open procedure and were treated initially with aggressive arthroscopic debridement and pinning. The mid-term results of this approach are presented.

Eleven of the initial thirteen patients were available for follow-up. Their mean age was 36 years (range 23–50) and the mean time elapsed from injury was 7 months (range 4.5–10). The diagnosis of dynamic SL instability was based on a positive Watson’s test, SL gapping on grip view radiographs and arthroscopic findings of a Geissler type III (in 5 patients) or type IV (in 6 patients) SL tear. The SL angle was under 550 in all patients. The procedure included aggressive arthroscopic debridement of the torn portion of the SL ligament to bleeding bone in an effort to induce scar formation in the SL interval. The SL interval was subsequently reduced and pinned (with 2 pins through the SL and one pin in the scaphocapitate joint) under fluoroscopy. The pins were removed at a mean of 9.6 weeks (range 8–14).

The mean follow-up was 36 months (range 12–76). Three patients were re-operated at 9, 10 and 11 months after the initial procedure. Re-operations included a dorsal capsulodesis, a four-corner fusion and a wrist arthrodesis. The eight remaining patients achieved two excellent, four good, one fair and one poor result with the Mayo wrist score. Patients diagnosed with Geissler III tears were found to be younger and achieved better final wrist score (mean 86 points versus 76 points in patients with Geissler IV tears). Two pin track infections were treated conservatively.

Late (more than three months post injury) arthroscopic debridement and pinning was found to be only moderately successful for dynamic SL instability (6 out of 11 patients achieved a good or excellent result without re-operation). This approach, however, does not preclude subsequent open surgery. It is best suited for patients with Geissler type III tears (not a gross drive through sign) who are unwilling to undergo an extensive open procedure provided they understand the risks and benefits of this approach.

In an effort to determine if severe degrees of SCFE can be successfully treated with in situ pinning an anatomical study was undertaken to determine the relationship between severity of SCFE, the level of the metaphysis in relation to epiphysis on AP x-ray of the hip, the position of entry on the femoral neck and impaction/inclusion.

A dry bone specimen of a young adult without bony pathology was used to create a severe SCFE of varying degrees between 30 and 90 degrees. Standard x-rays AP pelvis and frog lateral were taken to determine the degree of SCFE. A titanium pin marker was inserted in the femoral neck to be centrally directed and placed in the femoral head for each degree of SCFE studied. The position of the pin was inspected as well as assessed with x-rays and CT. Computer model was then used to determine values for younger patients as well as the role that screw diameter will play.

Twelve degrees of SCFE were studied namely from 30 to 90 degrees. Varus and external rotation were simulated as well according to the tables of Rab. The results show that severe SCFE of more than 60 degrees pinning in situ as a method of management is associated with risk. SCFE of 70 degrees is pinned midway up the femoral neck. The screw penetrates the posterior neck and in younger children will penetrate in lesser degrees. Impaction is present in mild degrees of SCFE and demonstrated to contribute to failure of fixation.

The study illustrates that severe SCFE is difficult to pin in situ, associated with inclusion and impaction that will result in coxarthrosis and biomechanically not secure. If the level of the femoral neck metaphysis is proximal or at the same level as the epiphysis, the SCFE is of such a degree that the neck may be reconstructed given the limits of subtrochanteric and intertrochanteric osteotomies.

Purpose of the study: The role of injectable phosphocalcium cements for the treatment of fractures of the osteoporotic distal radius is poorly defined. Simple adjunction of a phosphocalcium cement to infrafocl pinning has not proven its efficacy. To improve this percutaneous technique, the purpose of this work was to study the contribution of prior metaphysodiaphyseal preparation by drilling to increase the quantity of cement injected and to improve is distribution on either side of the fracture line, with the hope of limiting the progressive degradation of the radioulnar index.

Material and methods: Sixteen patients aged 76.5 years on average (range 65–92 years) were treated starting in 2004 for fractures of the distal radius with posterior displacement and very porotic bone. After orthopedic reduction with external manoeuvres, three n°18 pins were introduced into the fracture focus percutaneously. After pin insertion, a fourth stab incision was made at the apex of the radial styloid process for insertion of a n°11 trocar which was advanced to the medial cortex without perforating it. The trocar was then removed to allow insertion of a curved pin for the purpose of drilling out the remaining bony network to the distal part of the shaft through to the subchondral bone. 20 mg Cementek LV® was then injected under fluoroscopic control. The postoperative protocol was as usual with an orthesis for six weeks and pin removal at six weeks.

Results: Mean follow-up was nine months. There were five complications which resolved (reflex dystrophy). On average, 4.6 ml was injected. There were eight cases of cement leakage which was «milked out» as much as possible via the skin incision. Leaks resorbed in a few months and did not have any clinical impact. At follow-up, clinical outcome (pain, strength, mobility, DASH), and radiological indices were satisfactory. Loss of the distal radioulnar index was 1 mm on average.

Discussion: This technique for drilling, cementing, pinning, appears to limit secondary displacements of distal radial fractures with osteoporotic bone. Cement leakage is not sufficient to contraindicate this method since all observed leaks resorbed spontaneously with no sequelae. Longer follow-up will be necessary to confirm these encouraging results.

Prophylactic pinning of the contralateral hip in the treatment of slipped upper femoral epiphysis has been shown to be safer than continued observation of the contralateral hip. This treatment remains controversial due to the potential for harm caused to an apparently unaffected hip. There is evidence that pinning of an already slipped epiphysis causes growth disturbance of the proximal femur, however Hagglund showed that there is not necessarily growth arrest at the physis after pinning, as the slip occurs at the hypertrophic layer of the growth plate with no damage to the germative layer. This was confirmed by Guzzanti who confirmed that a single screw provided epiphyseal stability and preserved potential for growth. We conducted a pilot study to determine whether prophylactic pinning affects subsequent growth of the unaffected hip.

In order to determine the effect of prophylactic pinning we compared radiographs skeletally mature patients who had either undergone the procedure (group 1), not undergone the procedure but had pinning of the affected side (group 2), and adults with no history of SUFE (group 3). We measured the articulo-trochanteric distance and calculated the ratio of the trochanteric-trochanteric distance to articulo-trochanteric distance. These measures have been used in previous studies and shown to be reliable indicators of disturbed proximal femoral growth. As this was a pilot study we recruited 8 to each group.

The absolute sum of the ATDs were 219mm (average 27.3mm) Group 1, 213mm (average 26.6mm) Group2 and 258mm (average 32.5mm). The average trochanter-trochanter: ATD ratio in group 1 was 2.7 (1.9 - 3.8) compared to 2.7 (2.3 - 3.2) and 2.3 (1.9 - 2.7) in groups 2 and 3 respectively.

Our results suggest no difference in subsequent growth between hips that are prophylactically pinned and those that are not. They also show that unpinned hips go on to grow abnormally when compared to normal hips suggesting perhaps sub-clinical SUFE.

These results have prompted expansion of the study to include much a higher number of patients.

This purpose of this study was to investigate whether prophylactic pinning of the contralateral hip in unilateral slipped upper femoral epiphysis affects subsequent femoral morphology.

To determine the effect of prophylactic pinning on growth we compared contralateral hip radiographs of 24 proximal femora prophylactically pinned with 26 cases observed, in a cohort of patients with unilateral SUFE. Validated measurements were used to determine hip morphology; the articulo-trochanteric distance (ATD) and the ratio of the trochanteric-trochanteric distance (TTD) to articulo-trochanteric distance (TTD:ATD) in addition to direct measurement of the femoral neck length. Post-operative radiographs were compared to radiographs taken at a 12–84 months follow-up.

Comparing pinned and unpinned hips the neck length was shorter (mean 5.1 mm vs 11.1 mm) and the ATD was lower (p=0.048). The difference between initial and final radiograph TTD:ATD ratio for each case was calculated. The average was 0.63 in the prophylactically pinned group and 0.25 in the unpinned group (p=0.07).

When hips of the same patient were compared on final radiographs, there was a smaller difference in TTD:ATD between the two sides when the patient had been prophylactically pinned (0.7) as opposed to observed (1.47). This was not statistically significant (p=0.14).

Universal prophylactic pinning of the contralateral hip in slipped upper femoral epiphysis is controversial and alteration of the proximal femoral morphology is one reason for this.

Our results show that prophylactic pinning does not stop growth but does alter subsequent proximal femoral morphology by causing a degree of coxa vara and breva. Some loss of growth in the prophylactically pinned hip contributes to reduction in leg length inequality at skeletal maturity which is advantageous.

No iatrogenic complications were observed with single cannulated screw fixation. Prophylactic pinning prevents the potential catastrophe of a subsequent slip, is safe and the effect on growth is, if anything, beneficial.

Level of evidence: III

Purpose: Biomechanical studies have shown that fixation by two lateral pins of supracondylar fractures in children provide less stability than crossed pin fixation from lateral and medial sides. However, closed percutaneous medial pin fixation may be associated with ulnar nerve injury. Soft tissue edema or excessive mobility of ulnar nerve may be predisposing factors for iatrogenic ulnar nerve injury. We present our experience with the use of nerve stimulator in preventing such complications during surgery.

Material and Methods: During the last two years 22 children with supracondylar fractures (20- extension type; 2- flexion type) underwent surgery by closed reduction and percutaneous crossed KW fixation. The average age was 5.3 years (range 3–9 years). Detection of the ulnar nerve location was made possible by continuous intraoperative use of nerve stimulator, connected to the medial pin during its insertion. In 4/22 Pts irritation of ulnar nerve during pin insertion was observed by the appearance of clear contractions of forearm and hand muscles, and therefore, the location of the medial pin was immediately changed.

Results: In all cases anatomic reduction was achieved. No cases of nerve or vascular injury were observed. No cases of secondary fracture displacement were noted.

Conclusions: Based on this study it seems that the use of intraoperative nerve stimulator, during percutaneous crossed pin fixation of supracondylar fractures in children, may assist in localizing the nerve and prevent its injury during medial pin insertion. Changes in original setting of the standard anesthesiology nerve stimulator may be performed easily in order to allow such monitoring. The use of nerve stimulator during such procedures is very simple, even in cases of emergency. Monitoring of ulnar nerve by nerve stimulator is reliable and enables safe pin placement, decreasing the risk of nerve injury.

Introduction: To compare olecranon screw traction with percutaneous pinning for the treatment of Gartland III supracondylar fractures in children.

Methods: This was a retrospective study of 151 patients between 1986 and 1996 treated with olecranon screw traction and 92 patients between 1996 and 2002 treated with percutaneous pinning. Both sets of patients were followed up clinically and radiologically following their injuries until there was evidence of fracture union and the child could demonstrate a satisfactory range of movement. Data recorded included demographics, fracture information, neurovascular injury, operation details, length of stay, length of follow up and clinical outcome. Radiographs were used to measure initial and final Baumann angles to give an indication of outcomes of distal humerus alignment.

Results: Results are shown for the percutaneous pinning group with the olecranon screw traction results in brackets for comparison.

The percutaneous pinning study included 54 (88) males and 38 (63) females with 63% (63%) left and 37% (37%) right elbow fractures. 46% (29%) of fractures occurred at home, 46% (56%) sustained the injury whilst playing and 7% (7%) occurred at school/nursery. The mean age was 6.0 (6.8) years with a range of 21–165 (12–168) months. The radial pulse was absent in 12% (13%). None of the fractures were open (compared with 5%). There were neurological deficits in 20% (17%). The median time to surgery was 5 hours. The fracture needed to be opened in 12% of cases as satisfactory reduction could not be achieved closed. The median stay length was 1 day (compared to a median stay on traction of 14 days). Mean follow up was 15.2 weeks. (Compared to 38.0 weeks). 2 % (3%) had cubitus varus detectable clinically. Median time to recovery for neurological deficit was 24 weeks (18 weeks). Mean initial Baumann’s angle was 74.6 degrees (73.7degrees). Mean final Baumann’s angle was 75.3 degrees (76.0 degrees)

Discussion: Outcomes achieved from percutaneous pinning of displaced supracondylar fractures are similar to those from olecranon screw traction. The advantage of percutaneous pinning to both patient and provider is the reduced hospital stay and duration of follow up. Olecranon screw traction remains a possible treatment option for the management of this injury.

Purpose

We share our experience in management of failed in-situ pinning in severe unstable Slipped Capital Femoral Epiphysis (SCFE) by surgical dislocation approach.

Introduction and Aims: Practice standards vary considerably for prophylactic pinning the contralateral hip opposite a scfe. This work provides a data-driven framework with which to analyse the risks, benefits, and costs of two modes of treatment: prophylactic pinning the normal side contralateral to a scfe versus observation; and pinning of subsequent slips.

Method: A decision analysis model was constructed using the English language literature to estimate SCFE incidence and severity. The model framework assumes that if a hip is pinned prophylactically it will not slip. The benefits of prophylactic pinning are therefore determined by identifying the percentage of contralateral hips that will subsequently slip and then develop early osteoarthritis requiring total hip arthroplasty at a young age. In our cost analysis model, the cost of diagnosis, treatment, and follow-up was developed for the two treatment modes using actual hospital costs and standardised medicare reimbursement schedules for professional fees.

Results: If a hip is not pinned prophylactically, there is a 7% risk of requiring a total hip arthroplasty in the contralateral hip at an early age due to osteoarthritis. This 7% is a combination of patients whose contralateral femoral epiphysis slipped moderately or severely and was pinned in a non-anatomic position (1.5% of the initial population) and patients whose substantial slip was not detected (5.5%). The risk of prophylactic pinning appears to be associated with a 0.3% chance of developing avascular necrosis. Other risks would include chances of infection or chondrolysis, although these have not been reported to date.

If every patient is managed by the prophylactic pinning protocol, the total cost per patient, not including lost time at work or school, for pinning a slipped capital femoral epiphysis, prophylactically pinning the contra lateral side, and post-operative follow-up is $6266. Conversely, the total cost per patient for the second mode, pinning a slipped capital femoral epiphysis, post-operative follow-up and pinning of subsequent contralateral slips that are detected is $6864. Costs of later hip arthroplasty were not included. This analysis suggests that costs to a national health care system for treatment of SCFE would not increase by prophylactic contralateral pinning.

Conclusions: Prophylactic pinning of the contralateral side is merited on the basis of both risk/benefit and cost-effectiveness analyses. Ultimately, the decision must incorporate the physician’s assessment of patient risk factors including: age, weight, co-morbidities, sports activities, the likelihood and feasibility of regular follow-up, and the patient’s and parents’ acceptance of prophylactic surgery.

Slipped capital femoral epiphysis (SCFE) is the most common pediatric hip disorder. The most devastating complication is development of avascular necrosis of the femoral head. In order to reduce the potential for this complication occurring following delayed contralateral SCFE, there has been consideration in the literature of prophylactic pinning of the contralateral hip. The objective of this study was to determine the cost-effectiveness of this treatment strategy.

The outcome probabilities and utilities utilised in a decision analysis of prophylactic pinning of the contralateral hip in SCFE, reported by Kocher et al, were used in this study. Costing data, reported in 2005 Canadian dollars, was obtained from our institution. Using this data, an economic evaluation was performed. The time horizon was four years, so as to follow the adolescents to skeletal maturity. Discounting was performed at 3% per year. Sensitivity analyses were conducted to determine the effect of variation of the outcome probabilities and utilities.

In all analyses, prophylactic pinning resulted in cost savings but lower utility, compared to the currently accepted strategy of observation of the contralateral hip. The results were most sensitive to an increase in the probability of a delayed contralateral SCFE to 27%. Using the base case analysis, the incremental cost-effectiveness ratio was $7856.12 per utility gained. Using the most sensitive probability of a delayed contralateral SCFE of 27%, the incremental cost-effectiveness ratio was $27,252.92 per utility gained.

The results of this study demonstrated overall cost savings with prophylactic treatment, however the utility was lower than the standard treatment of observation. For both the base case and sensitivity analysis, the incremental cost-effectiveness ratio was less than the accepted threshold of $50,000 per quality adjusted life year gained. It should be noted that the use of a four year time horizon excluded consideration of the costs related to total hip arthroplasty for the sequelae of AVN. A prospective, randomised controlled trial, with an accompanying economic evaluation, is required to definitively answer the question of the cost-effectiveness of this treatment. On the basis of this cost-effectiveness analysis, prophylactic pinning of the contralateral hip in SCFE cannot be recommended. A prospective, randomised controlled trial, with an accompanying economic evaluation, is required to definitively answer the question of the cost-effectiveness of this treatment.