Aims. The main objective of this study is to analyze the penetration of bone cement in four different full cementation techniques of the tibial tray. Methods. In order to determine the best tibial tray cementation technique, we applied cement to 40 cryopreserved donor tibiae by four different techniques: 1) double-layer cementation of the tibial component and tibial bone with bone restrictor; 2) metallic cementation of the tibial component without bone restrictor; 3) bone cementation of the tibia with bone restrictor; and 4) superficial bone cementation of the tibia and metallic keel cementation of the tibial component without bone restrictor. We performed CT exams of all 40 subjects, and measured cement layer thickness at both levels of the resected surface of the epiphysis and the endomedular metaphyseal level. Results. At the epiphyseal level, Technique 2 gave the greatest depth compared to the other investigated techniques. At the endomedular metaphyseal level, Technique 1 showed greater cement penetration than the other techniques. Conclusion. The best metaphyseal cementation technique of the tibial component is bone cementation with cement restrictor. Additionally, if full tibial component cementation is to be done, the cement volume used should be about 40 g of cement, and not the usual 20 g. Cite this article: Bone Joint Res 2021;10(8):467–473

Aims. Our purpose was to describe an unusual series of 21 patients with fungal osteomyelitis after an anterior cruciate ligament reconstruction (ACL-R). Methods. We present a case-series of consecutive patients treated at our institution due to a severe fungal osteomyelitis after an arthroscopic ACL-R from November 2005 to March 2015. Patients were referred to our institution from different areas of our country. We evaluated the amount of bone resection required, type of final reconstructive procedure performed, and Musculoskeletal Tumor Society (MSTS) functional score. Results. A total of 21 consecutive patients were included in the study; 19 were male with median age of 28 years (IQR 25 to 32). All ACL-R were performed with hamstrings autografts with different fixation techniques. An oncological-type debridement was needed to control persistent infection symptoms. There were no recurrences of fungal infection after median of four surgical debridements (IQR 3 to 6). Five patients underwent an extensive curettage due to the presence of large cavitary lesions and were reconstructed with hemicylindrical intercalary allografts (HIAs), preserving the epiphysis. An open surgical debridement was performed resecting the affected epiphysis in 15 patients, with a median bone loss of 11 cm (IQR 11.5 to 15.6). From these 15 cases, eight patients were reconstructed with allograft prosthesis composites (APC); six with tumour-type prosthesis (TTP) and one required a femoral TTP in combination with a tibial APC. One underwent an above-the-knee amputation. The median MSTS functional score was 20 points at a median of seven years (IQR 5 to 9) of follow-up. Conclusion. This study suggests that mucormycosis infection after an ACL-R is a serious complication. Diagnosis is usually delayed until major bone destructive lesions are present. This may originate additional massive reconstructive surgeries with severe functional limitations for the patients. Level of evidence: IV. Cite this article: Bone Joint Open 2020;2(1):3–8

Objectives. Legg–Calvé–Perthes’ disease (LCP) is an idiopathic osteonecrosis of the femoral head that is most common in children between four and eight years old. The factors that lead to the onset of LCP are still unclear; however, it is believed that interruption of the blood supply to the developing epiphysis is an important factor in the development of the condition. Methods. Finite element analysis modelling of the blood supply to the juvenile epiphysis was investigated to understand under which circumstances the blood vessels supplying the femoral epiphysis could become obstructed. The identification of these conditions is likely to be important in understanding the biomechanics of LCP. Results. The results support the hypothesis that vascular obstruction to the epiphysis may arise when there is delayed ossification and when articular cartilage has reduced stiffness under compression. Conclusion. The findings support the theory of vascular occlusion as being important in the pathophysiology of Perthes disease. Cite this article: M. Pinheiro, C. A. Dobson, D. Perry, M. J. Fagan. New insights into the biomechanics of Legg-Calvé-Perthes’ disease: The Role of Epiphyseal Skeletal Immaturity in Vascular Obstruction. Bone Joint Res 2018;7:148–156. DOI: 10.1302/2046-3758.72.BJR-2017-0191.R1

Introduction. Fibula contributes to weight bearing and serves as a lateral buttress to the talus. Fibular shortening leads to ankle valgus, distal tibial epiphyseal wedging and ankle instability. Trauma, infection and skeletal dyplasias are the common causes of fibular shortening in children. Aim was to review this cohort who underwent fibular lengthening and ankle reconstruction. Materials and Methods. Retrospective review from a prospective database of clinical and radiographic data of all children who underwent fibular lengthening for correction of ankle valgus. Distraction osteogenesis with external fixator was performed for all cases. Results. Eight children with 10 fibulae (average age: 10 years) were followed up for an average of 75.6 months. In older children, corrective tibial osteotomy was performed in addition to fibular lengthening. TSF frame mounted with mini-rail fixator was used in seven children who required adjuvant tibial correction and mini-rail was used for bilateral fibular lengthening in one. Remodelling of the wedged distal tibial epiphysis was noted in 75%. Talar tilt and mLDTA improved in 66.7% and fibular station in 85.7% limbs. Seven year old girl required re-lengthening. Two children developed fibular non-union. Proximal fibular migration was observed in one child, in whom the tibial wire did not engage the fibula. Conclusions. Restoration of tibial mechanical axis and lateral talar buttress is necessary to correct ankle valgus. Stabilisation of fibula to the tibia is prudent during distraction. Younger children may require re-lengthening. Remodelling of the triangular tibial epiphysis can be achieved when done early

Os acromiale is a developmental defect caused by failure of fusion of the anterior epiphysis of the acromion between the ages of 22 and 25. The prevalence of os acromiale in the general population ranges from 1.4% to 15%. Os acromiale has been reported as a contributory factor to shoulder impingement symptoms and rotator cuff injuries, despite being a common incidental observation. In this retrospective study, we examined the prevalence of os acromiale in black African patients with shoulder pain. We retrospectively reviewed the clinical records, radiographs, and magnetic resonance imaging (MRI) scans of 119 patients who presented with atraumatic and minor traumatic shoulder pain at a single institution over a one-year period. Anteroposterior, scapula Y-view, and axillary view plain images were initially evaluated for the presence of os acromiale, and this was corroborated with axial MRI image findings. Patients with verified os acromiale had their medical records reviewed to determine their first complaint and the results of their clinical examination and imaging examination. Radiographs and MRI on 24 patients (20%) revealed an osacromiale. This cohort had a mean age of 59.2 years, and there were significantly more females (65%) than males. Meso-acromion was identified as the most prevalent type (n=11), followed by pre-os acromion (n=7). All patients underwent bilateral shoulder x-rays, and 45 percent of patients were found to have bilateral meso- acromion. Most patients (70%) were reported to have unstable os acromiale with subacromial impingement symptoms, and nine patients (36%) had confirmed rotator cuff tears based on clinical and Mri findings. Surgery was necessary for 47% of the 24 patients with confirmed Os acromiale (arthroscopic surgery, n=7; open surgery, n=1) in order to treat their symptoms. The prevalence of os acromiale in our African patients with atraumatic shoulder symptoms is greater than that reported in the general population. Os acromiale is a rare condition that should always be considered when evaluating shoulder pain patients

Articular cartilage is a multi-zonal tissue that coats the epiphysis of long bones and avoids its wear during motion. An unusual friction could micro-fracture this connective membrane and progress into an osteochondral defect (OD), where the affected cartilage suffers inflammation, fibrillation, and forfeiture of its anisotropic structure. Clinical treatment for ODs has been focused on micro-fracture techniques, where the defect area is removed and small incisions are performed in the subchondral bone, which allows the exudation of mesenchymal stem cells (hMSCs) to the abraded zone. However, hMSCs represent less than 0.01% of the total cell population and are not able to self-organise coherently, so the treatments fail in the long term. To select, support and steer hMSCs from the bone marrow into a specific differentiation stage, and recreate the cartilage anisotropic microenvironment, multilayer dual-porosity 3D-printed scaffolds were developed. Dual-porosity scaffolds were printed using prepared inks, containing specific ratios of poly-(d,l)lactide-co-caprolactone copolymer and gelatine microspheres of different diameters, which acted as sacrificial micro-pore templates and were leached after printing. The cell adhesion capability was investigated showing an increased cell number in dual-porosity scaffolds as compared to non-porous ones. To mimic the stiffness of the three cartilage zones, several patterns were designed, printed, and checked by dynamic-mechanical analysis under compression at 37 ºC. Three patterns with specific formulations were chosen as candidates to recreate the mechanical properties of the cartilage layers. Differentiation studies in the selected scaffolds showed the formation of mature cartilage by gene expression, protein deposition and biomolecular analysis. Given the obtained results, designed scaffolds were able to guide hMSC behaviour. In conclusion, biocompatible, multilayer and dual-porosity scaffolds with cell entrapment capability were manufactured. These anisotropic scaffolds were able to recreate the physical microenvironment of the natural cartilage, which in turn stimulated cell differentiation and the formation of mature cartilage. Acknowledgments: This work was supported by the EMAKIKER grant

Aims. Our retrospective analysis reports the outcome of patients operated for slipped capital femoral epiphysis using the modified Dunn procedure. Results, complications, and the need for revision surgery are compared with the recent literature. Methods. We retrospectively evaluated 17 patients (18 hips) who underwent the modified Dunn procedure for the treatment of slipped capital femoral epiphysis. Outcome measurement included standardized scores. Clinical assessment included ambulation, leg length discrepancy, and hip mobility. Radiographically, the quality of epiphyseal reduction was evaluated using the Southwick and Alpha-angles. Avascular necrosis, heterotopic ossifications, and osteoarthritis were documented at follow-up. Results. At a mean follow-up of more than nine years, the mean modified Harris Hip score was 88.7 points, the Hip Disability and Osteoarthritis Outcome Score (HOOS) 87.4 , the Merle d’Aubigné Score 16.5 points, and the UCLA Activity Score 8.4. One patient developed a partial avascular necrosis of the femoral head, and one patient already had an avascular necrosis at the time of delayed diagnosis. Two hips developed osteoarthritic signs at 14 and 16 years after the index operation. Six patients needed a total of nine revision surgeries. One operation was needed for postoperative hip subluxation, one for secondary displacement and implant failure, two for late femoroacetabular impingement, one for femoroacetabular impingement of the opposite hip, and four for implant removal. Conclusion. Our series shows good results and is comparable to previous published studies. The modified Dunn procedure allows the anatomic repositioning of the slipped epiphysis. Long-term results with subjective and objective hip function are superior, avascular necrosis and development of osteoarthritis inferior to other reported treatment modalities. Nevertheless, the procedure is technically demanding and revision surgery for secondary femoroacetabular impingement and implant removal are frequent. Cite this article: 2020;1-4:80–87

Introduction. Fibrous dysplasia is a pathological condition, where normal medullary bone is replaced by fibrous tissue and small, woven specules of bone. Fibrous dysplasia can occur in epiphysis, metaphysis or diaphysis. Occationally, biopsy is necessary to establish the diagnosis. We present a review of operative treatment using the Ilizarov technique. The management of tibial fibrous dysplasia in children are curettage or subperiosteal resection to extra periosteal wide resection followed by bone transport. Materials and Methods. A total of 18 patients were treated between 2010 – 2020; 12 patients came with pain and 6 with pain and deformity. All patients were treated by Ilizarov technique. Age ranges from 4–14 years. 12 patients by enbloc excision and bone transportation and 6 patients were treated by osteotomy at the true apex of the deformity by introducing the k/wires in the medullary cavity with stable fixation by Ilizarov device. The longest duration for bone transport was 16 weeks (14–20 weeks) for application, after deformity correction was 20 weeks. We have never used any kind of bone grafts. Results. All the 18 patients were treated successfully by Ilizarov compression distraction device. The patients with localized tibial pathology with deformity had the shortest period on the Ilizarov apparatus, 14 weeks. Conclusions. Preservation and bone regeneration by distraction histogenesis constitutes a highly conservative limb saving surgery. Patients with bone defects of <10 cm, a great deal of preserved healthy tissue and good prognosis are good candidates for these methods

Abstract. Objective. A higher prevalence of cam morphology has been reported in the athletic population but the development of the cam morphology is not fully understood. The purpose of this systematic review is to establish the timing of development of the cam morphology in athletes, the proximal femoral morphologies associated with its development, and other associated factors. Methods. Embase, MEDLINE and the Cochrane Library were searched for articles related to development of the cam morphology, and PRISMA guidelines were followed. Data was pooled using random effects meta-analysis. Study quality was assessed using the Downs and Black criteria and evidence quality using the GRADE framework. Results. This search identified 16 articles involving 2,028 participants. In males, alpha angle was higher in athletes with closed physes than open physes (SMD 0.71; 95% CI 0.23, 1.19). Prevalence of cam morphology was associated with age during adolescence when measured per hip (β 0.055; 95% CI 0.020, 0.091) and per individual (β 0.049; 95% CI 0.034, 0.064). Lateral extension of the epiphysis was associated with an increased alpha angle (r 0.68; 95% CI 0.63, 0.73). A dose-response relationship was frequently reported between sporting frequency and cam morphology. There was a paucity of data regarding the development of cam morphology in females. Conclusions. Very low and low quality evidence suggests that in the majority of adolescent male athletes’ osseous cam morphology developed during skeletal immaturity, and that prevalence increases with age. Very low quality evidence suggests that osseous cam morphology development was related to lateral extension of the proximal femoral epiphysis

Aim. Vascularized fibula flap is one of the available options in the management of bone loss that can follow cases of severe haematogenous osteomyelitis. The aim of this study was to evaluate the outcomes of this procedure in a pediatric population in a Sub-saharan setting. Method. The retrospective study focuses on the procedures done in the period between October 2013 and December 2016. Twenty-eight patients, 18 males and 10 females, were enrolled. The youngest was 2 years old, the oldest 13. The bones involved were tibia (13), femur (7), radius (5) and humerus (3). In 5 cases the fibula was harvested with its proximal epiphysis, whereas in 17 cases the flap was osteocutaneous and osseous in 6 cases. In most cases, operations for eradication of the infection were carried out prior to the graft. The flap was stabilized mainly with external fixators, rarely with Kirschner's wires or mini plate. No graft augmentation was used. Results. Graft integration was achieved in 24 cases. Three cases of early flap failure required the removal, while in one case complete reabsorption of the flap was noted a few months after the procedure. The follow-up period ranged from a minimum of 2 and half to a maximum of 6 years. Integration of the graft was obtained in a period of 4 months on average. The fibular flap with epiphysis had good functional outcomes with reconstruction of articular end. Early and delayed complications were observed. All grafts underwent a process of remarkable remodeling. No major problems were observed in the donor site, except for a transitory foot drop that resolved spontaneously. Conclusions. Reconstruction of segmental bone defects secondary to hematogenous osteomyelitis with vascularized fibula flap is a viable option that salvages and restores limb function. It can be safely used even in early childhood. The fibula can be harvested as required by the local conditions. When harvested with a skin island, bone loss and poor soft tissues envelope may be addressed concurrently. The procedure is long and difficult but rewarding. When surgical skills and facilities are available, it can be carried out even in settings located in low resources countries

Introduction. We report 3 cases from different centres of infantile tibia vara in which the deformity was due to slippage of the proximal tibial epiphysis on the metaphysis; the aim of this study was to define the features of this previously unreported condition, and their implications for management. Method. Three cases of tibia vara secondary to atraumatic slippage of the upper tibial epiphysis on the metaphysis were identified from three different centres. The case notes and imaging studies were retrospectively reviewed to distinguish common clinical and radiographic features. Results. There were one male and two females, all of non-Caucasian origin, (age 3–7 years). All patients' weights were above the 97th centile for age. In all cases there was an infero-medial subluxation of the tibial epiphysis over a dome shaped proximal tibial metaphysis, with disruption of continuity between their lateral borders. The height of the medial tibial plateau was preserved in all cases. New bone formation suggests this is a chronic process. The evolution of one case indicates that pathogenesis is shared with infantile Blount's disease. A gradual deformity correction was performed in all cases using circular external fixation, with the proximal ring secured to both the proximal epiphysis and metaphysis. Conclusion. Slipped upper tibial epiphysis is an uncommon but distinct cause of tibia vara. The radiological features are completely different from those previously described for infantile tibia vara and not encompassed by the existing classification. The unusual morphology has consequences for treatment. Management is analogous to a slipped upper femoral epiphysis – the physis has to be stabilized to the metaphysis and an osteotomy performed to restore the mechanical axis. We believe this is best achieved with a circular external fixator because this permits multiaxial correction including translation and rotation

Aim. Segmental bone defects following osteomyelitis in pediatric age group may require specifically designed surgical options. Clinical and radiographic elements dictate the option. Different elements play a role on the surgeon's choice. Among them, the size of the defect, the size and the quality of the bone stock available, the status of the skin envelope, the involvement of the adjacent joint. When conditions occur, vascularized fibula flap may represent a solution in managing defects of the long bones even during the early years of life. Method. A retrospective study, covering the period between October 2013 and September 2015, was done. Fourteen patients, nine males, five females, aged 2–13 years, with mean skeletal defect of 8.6 cm (range, 5 to 14 cm), were treated; the mean graft length was of 8.3 cm. The bones involved were femur (4), radius (4), tibia (3) and humerus (3). In 5 cases fibula with its epiphysis was used, in 5 cases the flap was osteocutaneous and in the remaining 4 cases only fibula shaft was utilized. After an average time of 8 months from eradication of infection, the procedure was carried out and the flap was stabilized with external fixators, Kirschner's wires or mini-plate. No graft augmentation was used. Results. Total limb reconstruction was achieved in 13 of 14 cases. The average integration period was 3.5 months. The mean follow-up period was 20.7 months (range 22–43). Mean time for full weight bearing in reconstructed lower limb was 5.8 months. All patients were walking pain-free and none with a supportive device. The fibular flap with epiphysis had good functional outcomes. A few early and delayed complications were observed. Lengthening through one graft on the forearm was achieved and the radial length restored. Conclusions. In low resource setting, provided that the technical skills and the right equipment are available, reconstruction of segmental bone defects secondary to hematogenous osteomyelitis in children using vascularized fibula flap is a viable option that salvages and restores limb function

Aim. To investigate the effect of the eight plate position in sagittal plane on tibial slope in temporary epiphysiodesis technique applied to the proximal tibia and whether there is a rebound effect after removing the plate. Method. Forty New Zealand rabbits (6 weeks old) were divided into four groups. In all groups, two 1.3 mm mini plates and cortical screws implantation were placed on both medial and lateral side of the proximal epiphysis of the right tibia. In Group 1 and 3, the plates were placed on anterior of the proximal tibial anatomical axis in the sagittal plane, and placed posteriorly in Group 2 and 4. The left tibia was examined as control in all groups. Group 1 and Group 2 were sacrificed after four week-follow-up. In Group 3 and Group 4, the implants were removed four weeks after index surgery and the rabbits were followed four more weeks to investigate the rebound effect. The tibial slope was measured on lateral X-rays every two weeks. Both medial and lateral plateau slopes were evaluated on photos of the dissected tibia. Results. In Group 1, right MTPA (medial tibial plateau angle) and left MTPA, right LTPA (lateral tibial plateau angle) and left LTPA, and right 4wTPPA (the tibial proximal posterior angle at 4th week) and left 4wTPPA values were compared with each other. There was a significant difference in MTPA, LTPA, and 4wTPPA in Group 1 (p: 0.003, 0.006, 0.004). In Group 1, the medial and lateral slope significantly decreased after 4 weeks. There was no significant difference in MTPA, LTP and 4wTPPA measurements in Group 2 (p= 0.719, 0.306, 0.446, respectively). In Group 2, the slope did not change in four weeks. There was a significant difference in MTPA, LTPA, 4wTPPA, and 8wTPPA (tibial proximal posterior angle at 8th week) in Group 3 (p= 0.005, 0.002, <0.001, <0.001, respectively). In Group 3, the slope decreased at 4th week and remained stabile during the next four week-follow up and no rebound effect was observed. There was no significant difference in MTPA, LTPA, 4wTPPA, and 8wTPPA measurements in Group 4 (p= 0.791, 0.116, 0.232, 0.924), respectively. In group 4, slope did not change at 4th week of index surgery and no rebound effect was observed in the next four week-follow up. Conclusion. If eight plates were placed on anterior of lateral proximal tibia axis on both medial and lateral side, the tibial slope would reduce, and remain stabile after implant removal. Care should be taken to place the plates on the line of proximal tibial axis in sagittal plane in temporary epiphysiodesis technique performed due to angular knee deformities. Changing the slope due to plate placement can be used as a secondary gain for patients who will benefit from slope change, such as adolescent ACL surgery

Aim of study: Finding the differences between classic distal humeral physeal injuries as radial condylar phy-seal injury, intercondylar fractures or apophyseal injuries and separations of the entire distal humeral epiphysis. To identify a classification of this serious injury according to the age. Material: Children treated in the Regional Paediatric Trauma Centre, Thomayer Teaching Hospital, Prague during the period of last ten years (1992 – 2001): 14.708 patients with fractures; 1.249 from them with humeral fractures, 875 with distal humeral fractures and 29 with separation of distal humeral epiphysis. Methods: Retrospective study of all cases with separation of the entire distal humeral epiphysis, diagnostic imaging, methods of treatment and results. Especially pitfalls and their reasons are followed. Results: Eight fracture-separations were misdiagnosed or not recognised. One half of injuries was operated on either by miniinvasive or open surgery. In all misdiag-nosed cases serious sequels were recorded. Conclusions: Separation of the entire distal humeral epiphysis has several forms according to ossification of the humerus. The most difficult diagnosis is in young children with cartilaginous periarticular skeleton invisible on X-rays. Stress investigation in general anaesthesia with the use of an image Intensifier or ultrasound imaging can be helpful. However, the knowledge of this type of skeletal injury is not welll known and due to frequent complications can be considered as one of most dangerous fractures in children

Purpose: To evaluate the vascularisation of the femoral head in children with slipped capital femoral epiphysis (SCFE) before and after surgery with use of contrast-enhanced MRI. Methods and Materials: 20 consecutive children, 13 boys and 7 girls, aged 9–15 years, with slipped capital femoral epiphysis, were included into the study. The classification of SCFE was performed traditionally due to the patient’s history, physical examination and findings of the radiographs. There were no pre-slips, 9 children had acute, 5 children had acute-on-chronic and 6 children had chronic SCFE. The MRI-examinations were performed in a 1.5 Tesla MR-scanner with use of the body coil and all postoperative MR-examinations were carried out within 4 weeks after surgery. The examination protocol included a coronal fat-suppressed STIR-sequence, a coronal contrast-enhanced T1-weighted spin-echo sequence and a sagittal 3D-gradient-echo (FFE) sequence. Morphology, signal intensities and contrast-enhancement of the femoral head were assessed retrospectively by two experienced radiologists in consensus. Results: Morphologic distortion of the physis, bone marrow edema in the metaphysis and epiphysis and joint effusion were the preoperative MRI-findings of slipped capital femoral epiphysis in each child. In 17 children, who underwent in situ-fixation with a single screw, and in one child, who underwent open reduction of the epiphysis, the vascularisation of the femoral head before and after surgery was normal. An avascular zone in the posterior-lateral aspect of the epiphysis was visible preoperatively in one child, which completely revascularized after open reduction and internal fixation of the epiphysis with two screws. One child with severe SCFE developed avascular necrosis of the femoral head after open reduction and corrective osteotomy through the physis. Conclusion: MRI allows for accurate evaluation of the femoral head vascularisation before and after surgery in children with slipped capital femoral epiphysis

The April 2013 Oncology Roundup. 360 . looks at: the margin for error; new money for old risks; hindquarter amputation; custom tumour jigs; preserving the tibial epiphysis; how long is long enough?; genomics and radiation-induced bone tumours; and India ink

Purpose of Study:. In situ fixation with cannulated screws, is the most common surgical management of Slipped Capital Femoral Epiphysis. Surgeons are wary of the consequences to the epiphysis with any manipulation of the hip. The purpose of this study, was to evaluate the use of a single cannulated screw, inserted with imaging done in the standard AP position, and gentle positioning for a frog lateral X-ray, and the risk of slip progression. Description:. A retrospective radiological review was done on 18 patients between the ages of 9–14 treated for unstable slips from 2006–2014. All patients were treated with a single partially threaded, cannulated screw inserted from the anterior aspect of the neck perpendicular to the epiphysis. Intraoperative imaging included an AP image, and thereafter the hip was gently abducted and externally rotated for a frog lateral view. Radiological comparison of the preoperative, postoperative and subsequent follow up X-rays was done. Follow up ranged from 6 months to 8 years. Results:. Radiographs showed no significant slip progression post op. Conclusion:. Gentle positioning for a frog lateral image during screw placement, and a single screw technique appears to be a safe in the management of unstable slips in Slipped Capital Femoral Epiphysis

The August 2013 Children’s orthopaedics Roundup. 360 . looks at: a multilevel approach to equinus gait; whether screening leads to needless intervention; salvage of subcapital slipped epiphysis; growing prostheses for children’s oncology; flexible nailing revisited; ultrasound and the pink pulseless hand; and slipping forearm fractures

Introduction: The study of appearance and development of the different ossification nuclei of the skeleton in the diverse segments of the locomotor apparatus is relevant for fields of medicine, such as Human Anatomy, Paediatry, Endocrinology, Forensic Medicine, Traumatology and Orthopaedic Surgery, among others. A number of studies show significant differences regarding their results due to the heterogeneity of methods and scientific and geographic fields originating each series. The present study is intended to show the age of appearance and complete fusion of the different ossification nuclei of the first radio of the foot in a present Mediterranean sample of children and its relation with several morphometric and clinical parameters. Material and Methods: We report a retrospective study where 971 x-ray dorso-plantar images from 225 patients were analysed. A descriptive and qualitative assessment allowed us to determine the existence or lack of each ossification nucleus of the first radio of the foot. Risser’s scale, adapted by us, was applied in the following way: 0, lack; I, rudimentary nucleus; II, well formed nucleus; III, partial fusion to diaphysis; IV, complete fusion. Likewise, a statistical analysis was performed relating the ages of appearance and fusion of each nucleus with the forefoot morphology (digital and metatarsal formulae) and the main pathologies motivating the x-ray examination (traumatism, our control group; flatfoot; hallux valgus; clubfoot). Results: Data about the age of appearance and fusion of each nucleus of the first radio of the foot were quantified. As a general rule, the age of appearance of each nucleus was earlier in girls. A delay in the age of appearance of the proximal metatarsal epiphysis in clubfoot patients (3.33 years) was observed in comparison with the control group (1.96 years). In general, there was no relation between sex and the fusion (partial and total) of each nucleus of the first radio of the foot. The exception was the age of appearance of the distal metatarsal epiphysis (when this incostant nucleus was present), earlier in boys (9.49 years) than girls (11.21 years). A delay in the age of fusion of the proximal and distal metatarsal epiphyses and the proximal phalanx epiphysis was observed in hallux valgus patients. In patients with egyptian foot, there seems to be a delay in the age of fusion of the distal metatarsal and distal phalanx epiphyses. Conclusions: The different ages of appearance and partial and total fusion of each ossification secondary nucleus of the first radio of the foot are detailed in the present comunication. A delay in the age of fusion of the secondary nucleus of the first radio of the foot would contribute to determine significantly forefoot morphology (egyptian formula) and even its pathology (hallux valgus)

The aim of this paper is to present our experience from the surgical treatment of lower limb fractures in the developing skeleton with the use of bio-absorbable PLLA implants as a means of internal fixation. From 1997 until 2002, twenty-three patients (15 boys and 8 girls, ages ranging from 7 to 15 years old, mean of 12 years) who had suffered from 30 lower limb fractures were operated on in our department, with the use of PLLA screws as a means of internal fixation that followed the standard open reduction procedure. We surgically treated 20 tibial fractures (distal metaphysis:1,medial malleolar:6,distal epiphysis lesions:9,tibial spine:2, lateral tibial condyle:1, tibial shaft:1), 8 fibular fractures (distal metaphysis:2, distal epiphysis lesions:5, fibular shaft:1), one transtrochanteric fracture and 1 patellar fracture. All patients were operated on under constant radiographic control. A cast was applied, post-operatively, to all patients, for a period of 3–4 weeks. Gradual and assisted weight-bearing and ambulation, was commencing immediately after the cast removal. All patient’s (with the exception of 1 case of delayed callus formation) post-operative period was completely normal. However, follow-up revealed the development of osteolytic lesions (bone absorption cysts) in 3 of our patients. All lesions were located in the border between epiphysis and metaphysis, at the exact position were the PLLA screws had been placed. The use of PLLA implants in the treatment of fractures renders unnecessary a second operation for the removal of the osteosynthesis’ material. Nevertheless, we should be quite reluctant when deciding to use the PLLA screws in the treatment of these fractures in the developing skeleton, especially of the lower limbs, were the applied weight bearing forces are quite powerful