Aims. There is ambiguity surrounding the degree of scaphoid union required to safely allow mobilization following scaphoid waist fracture. Premature mobilization could lead to refracture, but late mobilization may cause stiffness and delay return to normal function. This study aims to explore the risk of refracture at different stages of scaphoid waist fracture union in three common fracture patterns, using a novel finite element method. Methods. The most common anatomical variant of the scaphoid was modelled from a CT scan of a healthy hand and wrist using 3D Slicer freeware. This model was uploaded into COMSOL Multiphysics software to enable the application of physiological enhancements. Three common waist fracture patterns were produced following the Russe classification. Each fracture had differing stages of healing, ranging from 10% to 90% partial union, with increments of 10% union assessed. A physiological force of 100 N acting on the distal pole was applied, with the risk of refracture assessed using the Von Mises stress. Results. Overall, 90% to 30% fracture unions demonstrated a small, gradual increase in the Von Mises stress of all fracture patterns (16.0 MPa to 240.5 MPa). All fracture patterns showed a greater increase in Von Mises stress from 30% to 10% partial union (680.8 MPa to 6,288.6 MPa). Conclusion. Previous studies have suggested 25%, 50%, and 75% partial union as sufficient for resuming hand and wrist mobilization. This study shows that 30% union is sufficient to return to normal hand and wrist function in all three fracture patterns. Both 50% and 75% union are unnecessary and increase the risk of post-fracture stiffness. This study has also demonstrated the feasibility of finite element analysis (FEA) in scaphoid waist fracture research. FEA is a sustainable method which does not require the use of finite scaphoid cadavers, hence increasing accessibility into future scaphoid waist fracture-related research. Cite this article: Bone Jt Open 2023;4(8):612–620

Aims. The timing of when to remove a circular frame is crucial; early removal results in refracture or deformity, while late removal increases the patient morbidity and delay in return to work. This study was designed to assess the effectiveness of a staged reloading protocol. We report the incidence of mechanical failure following both single-stage and two stage reloading protocols and analyze the associated risk factors. Methods. We identified consecutive patients from our departmental database. Both trauma and elective cases were included, of all ages, frame types, and pathologies who underwent circular frame treatment. Our protocol is either a single-stage or two-stage process implemented by defunctioning the frame, in order to progressively increase the weightbearing load through the bone, and promote full loading prior to frame removal. Before progression, through the process we monitor patients for any increase in pain and assess radiographs for deformity or refracture. Results. There were 244 frames (230 patients) included in the analyses, of which 90 were Ilizarov type frames and 154 were hexapods. There were 149 frames which underwent single-stage reloading and 95 frames which underwent a two-stage reloading protocol. Mechanical failure occurred after frame removal in 13 frames (5%), which suffered refracture. There were no cases of change in alignment. There was no difference between refracture patients who underwent single-stage or two-stage reloading protocols (p = 0.772). In all, 14 patients had failure prevented through identification with the reloading protocol. Conclusion. Our reloading protocol is a simple and effective way to confirm the timing of frame removal and minimize the rate of mechanical failure. Similar failure rates occurred between patients undergoing single-stage and two-stage reloading protocols. If the surgeon is confident with clinical and radiological assessment, it may be possible to progress directly to stage two and decrease frame time and patient morbidity. Cite this article: Bone Jt Open 2022;3(5):359–366

Aim

In previous small series, some authors have suggested a difference between re-fractures through immature callus and remodelled bone. We aimed to determine whether different fracture patterns occur in early and late re-fractures of paediatric forearm bones.

A novel, validated three dimensional finite element model of the femur was used to characterize the stress concentration in the bone at the proximal end of a fracture fixation plate. A supracondylar fracture of the distal femur fixed with a plate was modeled utilizing physiologic load patterns simulating several phases of a cycle of gait. The relative maginitude and length of the zone of increased stress was characterized. The effects of varying plate geometry and material in the attempt to decrease stress concentration at the end of the plated were investigated.

The exact nature and distribution of stresses around femoral fracture fixation plates remains unclear making it difficult to determine how close to existing hardware a distal femoral plate can be implanted. Our objective was to use a novel, validated finite element (FE) model to examine the stress distribution at the proximal end of the plate.

The von Mises element stresses in the bone without the implant were compared to those with the implant. Additionally, we determined the effect of metal (titanium versus stainless steel), and plate taper (ten, thirty and forty-five degrees) on stresses at the proximal end of the plate.

The peak von Mises stress in the plated bone occurred below the corners of the plate, and was approximately four times that in the un-plated case (thirty-eight MPa versus nine MPa). We identified a distance of 34 mm (approximately one bone diameter) beyond the edge of the plate before stresses returned to within 1% of the un-plated control. The choice of metal did not affect the state of stress distribution in the bone beyond the proximal edge of the plate. In addition, the stress concentrations decreased proportionally as the taper angle decreased from forty-five to ten.

Utilizing this FE model we report the following:

Stresses are concentrated at the end of plates and return to within normal limits approximately one bone diameter beyond the edge of the plate.

Funding: The authors gratefully acknowledge the financial support of Materials and Manufacturing Ontario (MMO) and the Dean’s New Faculty Seed Grant at Ryerson University.

Aims. Congenital pseudarthrosis of the tibia (CPT) has traditionally been a difficult condition to treat, with high complication rates, including nonunion, refractures, malalignment, and leg length discrepancy. Surgical approaches to treatment of CPT include intramedullary rodding, external fixation, combined intramedullary rodding and external fixation, vascularized fibular graft, and most recently cross-union. The current study aims to compare the outcomes and complication rates of cross-union versus other surgical approaches as an index surgery for the management of CPT. Our hypothesis was that a good index surgery for CPT achieves union and minimizes complications such as refractures and limb length discrepancy. Methods. A multicentre study was conducted involving two institutions in Singapore and China. All patients with CPT who were surgically managed between January 2009 and December 2021 were included. The patients were divided based on their index surgery. Group 1 included patients who underwent excision of hamartoma, cross-union of the tibia and fibula, autogenic iliac bone grafting, and internal fixation for their index surgery. Group 2 included patients who underwent all other surgical procedures for their index surgery, including excision of hamartoma, intramedullary rodding, and/or external fixation, without cross-union of the tibia and fibula. Comparisons of the rates of union, refracture, limb length discrepancy, reoperations, and other complications were performed between the two groups. Results. A total of 36 patients were included in the study. Group 1 comprised 13 patients, while Group 2 comprised 23 patients. The mean age at index surgery was four years (1 to 13). The mean duration of follow-up was 4.85 years (1.75 to 14). All patients in Group 1 achieved bony union at a mean of three months (1.5 to 4), but ten of 23 patients in Group 2 had nonunion of the pseudarthrosis (p = 0.006). None of the patients in Group 1 had a refracture, while seven of 13 patients who achieved bony union in Group 2 suffered a refracture (p = 0.005). None of the patients in Group 1 had a limb length discrepancy of more than 2 cm, while ten of 23 patients in Group 2 have a limb length discrepancy of more than 2 cm (p = 0.006). In Group 1, four of 13 patients had a complication, while 16 of 23 patients in Group 2 had a complication (p = 0.004). Excluding removal of implants, four of 13 patients in Group 1 had to undergo additional surgery, while 18 of 23 patients in Group 2 had to undergo additional surgery following the index surgery (p = 0.011). Conclusion. A good index surgery of excision of hamartoma, cross-union of the tibia and fibula, autogenic iliac bone grafting, and internal fixation for CPT achieves union and minimizes complications such as refractures, limb length discrepancy, and need for additional surgeries

Our study seeks to determine whether characteristics of radiographs taken post-reduction of a forearm fracture can indicate future risk of refracture or loss of reduction. We hypothesize that reducing forearm fractures too precisely may be counterproductive and provide less benefit than reductions left slightly offset prior to cast immobilization. We conducted a retrospective review of 1079 pediatric patients treated for forearm fractures between January 2014 and September 2021 in a 327 bed regional medical center. Percent fracture displacement, location, orientation, comminution, fracture line visibility and angle of angulation were determined by AP and lateral radiographs. Percent fracture displacement was derived by: (Displacement of Bone Shafts / Diameter) x 100% = %Fracture Displacement. Patients treated with closed reduction were reduced from a mean displacement of 29.26±36.18% at an angulation of 22.67±16.57 degrees to 7.88±9.07% displacement and 3.89±6.68 degrees angulation post-reduction. Patients developing complications including a loss of reduction or refracture were found to have post-operative radiographs with a lower percent displacement (0.50±1.12) than those not developing complications (8.65±9.21)(p=0.0580). Post-reduction angulation (p=1.000), average reduction in angulation (p=1.000) and average reduction in displacement percent(p=0.2102) were not significantly associated with development of complications. Percent displacement of radial shafts was seen to be the most important metric to monitor in post-operative radiographs for patients undergoing closed reduction of a forearm fracture. We theorize a slight displacement provides greater surface area for osteoblastic expansion and callus formation leading to a decreased risk of refracture or loss of reduction. While our sample size precludes our ability to measure the ideal amount of post-reduction displacement for optimal healing, our results demonstrate that some degree of shaft displacement is required for optimal healing conditions

This study was conducted to investigate the characteristics, complications, radiologic features and clinical course of patients undergoing reduction of forearm fractures in order to better inform patient prognosis and postoperative management. We conducted a retrospective cohort study of 1079 pediatric patients treated for forearm fractures between January 2014 and September 2021 in a 327 bed regional medical center. A preoperative radiological assessment and chart review was performed. Percent fracture displacement, location, orientation, comonution, fracture line visibility and angle of angulation were determined by AP and lateral radiographs. Percent fracture displacement was derived by: (Displacement of Bone Shafts / Diameter) x 100% = %Fracture Displacement. Angle of angulation and percent fracture displacement were calculated by averaging AP and lateral radiograph measurements. 80 cases, averaging 13.5±8.3 years, were identified as having a complete fracture of the radius and/or ulna with 69 receiving closed reduction and 11 receiving fixation via an intramedullary device or percutaneous pinning. Eight patients (10%) experienced complications with four resulting in a refracture and four resulting in significant loss of reduction (LOR) without refracture. Fractures in the proximal ⅔s of the radius were associated with a significant increase in complications compared to fractures in the distal ⅓ of the radius (31.6% vs 3.4%) (P=.000428). Likewise, a higher percent fracture displacement was associated with a decreased risk of complications (28.7% vs 5.9% displacement)(P=0.0403). No elevated risk of complications was found based on fracture orientation, angulation, fracture line visibility, forearm bone(s) fractured, sex, age or arm affected. Our result highlights radius fracture location and percent fracture displacement as markers with prognostic value following forearm fracture. These measurements are simply calculated via pre-reduction radiographs, providing an efficient method of informing risk of complications following forearm fracture

Introduction. This is a report of the outcome of management of congenital pseudoarthrosis of the tibia (CPT) at skeletal maturity. Materials and Methods. Retrospective study. Inclusion criteria:. CPT Crawford IV. Skeletally maturity. Availability of radiographs and medical records. Outcome: union rate, healing time, residual deformities, ablation and refracture. Results. 23 patients who reached maturity were analysed. Time to union was 7.6 months. Union rate 70%. External fixation group: 7 patients, age 6.1 years, all united, 1 needed Bone graft. Average union time 8.2 months, no residual mal-alignment, no amputations, 2/7 needed corrective osteotomies and residual LLD in 2/7 < 1 cm. Numbers of surgery was 3. Vascularized fibular graft was done in 3 cases; all had failed previous attempts. Union time was 7 months. 2/3 united, 1 had amputation due to extensive disease. All patients had residual mal-alignment. Rodding group included 13 patients, age 3.2 years, union rate 61%, union time 8.3 months. Average LLD 1 cm with 1 patient LLD > 2 cm. Residual knee mal-alignment in 2/13, 4 had procurvatum and 55% of patients had ankle valgus. Fibula pseudoarthrosis. Refracture was reported in 53% of the rodding group. The causes of refracture were mal-alignment in 3, traumatic in 2 and idiopathic in 2. Total surgeries no 5. 2 patients had amputations after an unsuccessful 1. st. attempt. Our current trend of treatment was applied on 8 patients. They are not skeletally mature yet. the treatment combined excision of hamartoma, tibial rodding, wrapped periosteal graft with/out neutralization frame, and fibular fixation. Average age 3.8 years, union time was 10 months, Union rate 80%, no residual deformities. Conclusions. Our study shows the evolution of the treatment of CPT with increasing union rate, fewer residual deformities, and numbers of surgeries with more recent techniques

The aim of this study was to define the long-term outcome following adolescent clavicle fracture. We retrospectively reviewed all adolescent fractures presenting to our region (13–17years) over a 10-year period. Patient reported outcomes were undertaken at a minimum of 4 years post-injury (QuickDASH and EQ-5D) in completely displaced midshaft fractures (Edinburgh 2B, >2cm displacement, n=50) and angulated midshaft fractures (Edinburgh 2A2, >30 degrees angulation, n=32). 677 clavicle fractures were analysed. The median age was 14.8 (IQR 14.0–15.7) and 89% were male. The majority were midshaft (n=606, 89.5%) with either angulation (39.8%) or simple fully displaced (39.1%). Only 3% of midshaft fractures underwent acute fixation (n=18/606), all of which were fully displaced. The incidence of refracture following non-operative management of midshaft fractures was 3.2% (n=19/588), all united with non-operative management. Fracture type, severity of angulation or displacement was not associated with risk of refracture. There was one case of non-union encountered following non-operative management of all displaced midshaft fractures (0.4%, n=1/245). At a mean of 7.6 years following injury, non-operative management of both displaced and angulated fractures had a median QuickDASH was 0.0 (IQR 0.0–2.3), EQ-5D was 1.0 (IQR 1.0–1.0). 97% of angulated fractures and 94% of displaced fractures were satisfied with their final shoulder function. We conclude that Non-operative management of adolescent midshaft clavicle fractures result in excellent functional outcomes with a low rate of complications at long-term follow up. The relative indications for surgical intervention for clavicle fractures in adults do not appear to be applicable to adolescents

Acute metatarsal fractures are a common extremity injury. While surgery may be recommended to reduce the risk of nonunion or symptomatic malunion, most fractures are treated with nonoperative management. However, there is significant variability between practitioners with no consensus among clinicians on the most effective nonoperative protocol, despite how common the form of treatment. This systematic review identified published conservative treatment modalities for acute metatarsal fractures and compares their non-union rate, chronic pain, and length of recovery, with the objective of identifying a best-practices algorithm. Searches of CINAHL, EMBASE, MEDLINE, and CENTRAL identified clinical studies, level IV or greater in LOE, addressing non-operative management strategies for metatarsal fractures. Two reviewers independently screened the titles, abstracts, and full texts, extracting data from eligible studies. Reported outcome measures and complications were descriptively analyzed. Studies were excluded if a rehabilitation program outlining length of immobilization, weight-bearing and/or strengthening approaches was not reported. A total of 12 studies (8 RCTs and 4 PCs), from the 2411 studies that were eligible for title screening, satisfied inclusion criteria. They comprised a total of 610 patients with acute metatarsal fractures, with a mean age of 40.2 years (range, 15 – 82). There were 6 studies that investigated avulsion fractures, 2 studies on true Jones fractures, and 4 studies with mixed fracture types. Studies assessed a variety of treatment modalities including: WB and NWB casts, elasticated support bandages, hard-sole shoes, plaster slippers, metatarsal shoe casts, and air cast boots. Most studies investigated the outcomes of NWB casts and elasticated support bandages. The NWB short leg cast had no reported non-unions, delayed-unions, or refractures for avulsion fractures. In true Jones fractures, there was an average non-union rate of 23.6% (range, 5.6 – 27.8%), delayed-union rate of 11.8% (range, 5.6 – 18.8%), and refracture rate of 3% (range, 0 – 5.6%). Overall, the average AOFAS score was 87.2 (range, 84 – 91.7) and the average VAS score was 83.7 (range, 75 – 93). The elasticated support bandage had an average non-union rate of 3.4% (range, 0 – 12%), and delayed-union rate of 3.8% for acute avulsion fractures, with no reported refractures. No included study arm investigated outcomes of elasticated support bandages for the true Jones fracture. The average AOFAS score for elasticated support bandages was 93.5 (range, 90 – 100). The average VAS score was 88.9 (range, 90 – 100). Most acute metatarsal fractures heal well, with good-to-excellent functional outcomes and moderate-to-high patient satisfaction. Conservative strategies for avulsion fractures are highly successful and based on this data the authors recommend patients undergo a schedule that involves 3 – 4 weeks in an elasticated support bandage, short leg cast, or equivalent, and WB thereafter as tolerated, with return-to-activity after clinical union. Despite poorer conservative outcomes for true Jones fractures, patients should undergo 8 weeks in a NWB short leg cast, followed by a walking cast or hard-sole shoe for an additional 4 – 6 weeks, or until clinical union. However, surgical consultation is recommended

Introduction. Traditionally, radiological union of fractures treated with an Ilizarov frame is confirmed by a period of dynamization - destabilisation of the frame for a period prior to removal. Reduced clinic availability during the COVID-19 pandemic caused a shift to selective dynamisation in our department, whereby lower risk patients had their frames removed on the same day as destabilisation. This study investigates the effects of this change in practice on outcomes and complication rates. Materials & Methods. Adult patients treated with circular frames between April 2020 and February 2022 were identified from our Ilizarov database. Patients were divided into 2 groups: - “dynamised” if their frame was destabilised for a period to confirm union prior to removal; or “not dynamised” if the decision was taken to remove the frame without a period of dynamisation, other than a short period in the clinic. A retrospective review of clinical notes was conducted to determine outcome. Results. 175 patients were included in the final analysis, 70 in the dynamised and 103 in the not dynamised groups, median follow-up was 33 months. 3 patients in the dynamised group failed dynamisation and had their period of fixation extended, subsequently having their frames removed without complication. Two patients suffered a refracture or non-union after frame removal in the dynamised group and none in the not dynamised group, this difference was not statistically significant. Conclusions. In our practice, selective frame removal without a period of dynamisation appears safe. This has the potential to shorten frame time and reduce the number of clinic appointments and radiographic investigations for these patients. Some patients find the period of dynamisation uncomfortable and associated with pin site infection, which can be avoided. We plan to continue this practice and collect further data to confirm these findings in a larger dataset

The Femoral Neck System (FNS) was introduced as an alternative device for the fixation of neck of femur fractures (NOFFs). The purported advantages include superior angular and rotatory stability compared to multiple cancellous screws, via a minimally invasive instrumentation that is simpler than conventional fixed angle devices. There were limited clinical studies regarding the utility of this device. We aimed to study the outcomes of NOFFs fixed with the FNS. This was a single-institution, retrospective review of all undisplaced elderly (≥60 years old) undisplaced young, and displaced young NOFFs fixed with the FNS. Demographics, surgical parameters, radiographic parameters, and clinical outcomes including complications were reviewed. Thirty-six subjects with a median age of 75 [44,89] years old, had NOFF fixation using the FNS. Thirty-one (86.1%) had undisplaced fractures. There were 6 (16.7%), 26 (72.2%), and 4 (11.1%) subjects with Pauwels types 1, 2, and 3 respectively. Thirty-two (88.9%) had posterior tilt of <20º. The mean duration of surgery was 71±18 minutes. Excluding 4 patients whom required revision surgery, 2 patients whom demised, and 10 patients whom defaulted reviews, the mean follow-up duration was 55±13 weeks. Four complications were recorded, namely implant cut out at the femoral head at week 8, breaking of the locking screw at the run-off region at week 22, avascular necrosis at week 25, and a refracture following near fall, causing the fracture to fail in varus at week 7 postoperation. While reasonably fast to instrument, failures still occur and it is likely multifactorial. However, the rate of reoperation is lower than what has been reported for NOFFs fixed with the a fixed-angle device or 3 cancellous screws. In conclusion, the FNS is a reasonably safe instrument to use. Surgeons’ discretion is still needed in patient selection, keeping in mind the need for satisfactory radiological parameters

Recurrent fracture risk after kyphoplasty is inferior to vertebroplasty, but the risk is still eminent. The reduction of kyphosis is strongly related to the age of the fracture, therefore the reduction and the correction of the kyphosis varies. We investigated the indication of a prophylactic kyphoplasty of adjacent levels to the fracture site in order to decrease the postoperative refracture risk. Study design: Prospective randomized clinical study, 2 groups: monosegmental kyphoplasty versus bi- or multi-segmental kyphoplasty with prophylactic level superior to the fracture. F/U 6 months with X-rays. Results: Group 1: monosegmental stabilisation: (20 pat. 4 male, 16 female, 27 levels). 5 refractures. 3 refractures adjacent to the kyphoplasty, 2 cases not related to the primary stabilisation. In 2 cases cement leakage was seen as direct cause of the refracture. Group 2: prophylactic stabilisation (28 pat. 4 male, 24 female, 63 levels, 29 prophylactic levels). 8 refractures, all adjacent to kyphoplasty. In 3 cases cement leakage as cause of recurrent fracture. Conclusion: Refracture rates are in both groups similar (group 1: 25% refracture risk, group 2: 28% refracture risk). Therefore we do not see the need for a generalised prophylactic stabilisation of adjacent levels with kyphoplasty. It is crucial to avoid any leakage, which has a direct impact on the fracture rate, only in those cases we advise a prophylactic stabilisation at the leakage site. In general kyphoplasty is preferable to vertebroplasty due to the decreased leakage and embolism rate

Purpose: After vertebroplasty and kyphoplasty the recurrent fracture risk after kyphoplasty is inferior to vertebroplasty, but the risk is still eminent. The reduction of kyphosis is strongly related to the age of the fracture, therefore the reduction and the correction of the kyphosis varies. We investigated the indication of a prophylactic kyphoplasty of adjacent levels to the fracture site in order to decrease the postoperative refracture risk. Methods: Prospective randomized clinical study, 2 groups: monosegmental kyphoplasty versus bi- or mul-tisegmental kyphoplasty with prophylactic level superior to the fracture. F/U 6 months with X-rays. Results: Group 1: monosegmental stabilization: (23 pat. 4 male, 19 female, 23 levels). 5 refractures. 3 refractures adjacent to the kyphoplasty, 2 cases not related to the primary stabilization. In 3 cases cement leakage was seen as direct cause of the refracture. |Group 2: pro-phylactic stabilization (27 pat. - 4 male, 23 female, 27 prophylactic levels). 7 refractures, all adjacent to kypho-plasty. In 3 cases cement leakage as cause of recurrent fracture. No statistical difference between both groups was found, however in 6 out of 12 recurrent fractures we found intradiscal cement leakage as the direct cause of the fracture.|. Conclusions: No statistical difference between both groups (group 1: 22% refracture risk, group 2: 26% refracture risk, p=1). Therefore we do not see the need for a generalized prophylactic stabilization of adjacent levels with kyphoplasty. However, we conclude that it is crucial to avoid any leakage, which has a direct impact on the fracture rate, only in those cases we advise a prophylactic stabilization at the leakage site. In general kyphoplasty is preferable to vertebroplasty due to generally decreased leakage and embolism rate

Aims. To investigate a treatment algorithm of various Ilizarov methods in managing infected tibial non-union. Patients and Methods. A consecutive series of 76 patients with infected tibial non-union were treated with one of four Ilizarov protocols, consisting of; monofocal distraction (25 cases), monofocal compression (18), bifocal compression/distraction (16) and bone transport (17). Median duration of non-union was 10.5 months (range 2–546 months). All patients underwent at least one previous operation, 36 had associated limb deformity and 49 had non-viable non-unions. Twenty-six cases had a new muscle flap at the time of Ilizarov surgery and 24 others had pre-existing flaps. Results. Infection was eradicated in 74 cases (96.1%) at a mean follow-up of 42 months (range 8–131). Both infection recurrences were in the monofocal compression group. Union was achieved in 66 cases (86.8%) with the initial Ilizarov method alone. Union was highest amongst the monofocal distraction and bifocal compression/distraction groups, 96% and 93.8% respectively. Monofocal compression was successful in only 77.8% of mobile non-unions. Bone transport secured initial union in 76.5% with a 47% unplanned reoperation rate. However, following further treatment union was 100% in the bone transport group compared to 88.9% in the monofocal compression group. Six cases sustained a refracture, with 5/6 occurring in the monofocal compression group, representing a 27.7% refracture rate. ASAMI scores were also significantly lower for the monofocal compression group. Conclusion. We do not recommend monofocal compression in the treatment of infected, mobile non-unions. Distraction (monofocal or bifocal) was more effective achieving higher rates of infection clearance, lower refracture rates and better ASAMI scores

The December 2015 Children’s orthopaedics Roundup. 360 . looks at: Paediatric femoral fractures: a single incision nailing?; Lateral condylar fractures: open or percutaneous?; . Forearm refracture: the risks; Tibial spine fractures; The child’s knee in MRI; The mechanics of SUFE; Idiopathic clubfoot

Introduction. Correction of multiplanar bone deformities in children is indicated for prevention of secondary orthopaedic complications. Different problems related to surgical intervention were reported: non-union, delayed union, recurrent deformity, refracture, nerve palsy and pin tract infection. The aim of this study was to show the results of children femur and tibia bowing deformities by Ilizarov technique. Materials and Methods. We analysed 27 cases of children femur and tibia bowing deformities under the age of 13 yrs. Simultaneous deformity correction in femur and tibia was done with Ilizarov device in ipsilateral side. Contralateral side was operated after 14 days. Results. The duration of Ilizarov fixation was 130 days on an average. The deformity correction was achieved with a proper alignment in all the cases. Conclusions. Bowing of femur and tibia can be corrected simultaneously by Ilizarov fixation with minimum complications. There were no recurrent deformities in our cases

Introduction: Aim of this study is to evaluate the results of the treatment using the technique of dual cortical graft. Material and Methods: Twenty-one patients (13 boys, 8 girls, age 3–8 years) were treated in period 1996–2008 in our institution. In seventeen patients, dual cortical graft harvested from tibia of parents was used for reconstruction of pseudarthrosis. NF type I was the cause of pseudarthrosis in 13 patients. After resection of the hamartomatous fibrous tissue, sclerotic bone ends and periosteum and reduction of angulations, the cortical grafts are placed on lateral and medial side of the tibia and are fixed thru the tibia proximally and distally with conventional screws. Cast immobilization follows for 9–12 weeks. In concomitant fibular pseudarthrosis, intra-medullary fixation and cancelous bone grafting treat the pseudarthrosis. In 11 patients, this technique represented the 1st surgical procedure, whereas in 6 cases (including 2 failed vascularised fibular transfers), 1–15 previous surgical procedures were used in treatment. Further surgical procedures followed for correction of the leg length discrepancy and deformity of the ankle. Results: The fusion of non-union was achieved in 16 patients. 12 patients reached skeletal maturity (59%) whereas 4 patients (24%) did not finished the growth and are still in treatment. 10 patients use the protection brace and intramedullar nail was used in 2 patients to prevent refracture. One patient refused further treatment and amputation followed in another institution. Concerning functional outcome, 14 patients walk unlimited, 2 patients walk more then 1 hour and 1 patient walks less then 1 hour. 13 patients did not use the walking aid, 2 patients use 1 cane a 2 patients the crutches. The complication rate of this method is similar to the other methods, mainly due to the refractures. Only in one patient, the pseudarthrosis primarily fused after single procedure. In 3 patients, second procedure was necessary. In remaining 12 patients, 3–6 further surgical procedures were used for the healing of pseudarthrosis due the delayed-union of grafts or refracture of the tibia. In these cases, cancelous bone grafting and various techniques of fixation were used to achieve the union. Discussion: and conclusion: The results of the dual cortical grafting technique are comparable to other effective methods like Ilizarov method and the method is useful also after previous failed procedures. The complication rate is similar to other methods. The prevention of the refracture by bracing or rodding is recommended in all patients. This surgical procedure should be delayed until 4 years of age. Significance: The method of dual cortical grafting represents still effective method of treatment of CPT

Bone transport/limb lengthening with circular external fixation has been associated with a prolonged period of time in the frame and a significant major complication rate following frame removal. We examined the results of bone transport in fifty-one limbs using the “monorail” technique and found a dramatically improved lengthening index (24.5 days/cm. – time in frame /cm. of length gained) and an absence of refracture or angulatory deformity following fixator removal. This technique is our treatment of choice for limb lengthening/bone transport. We sought to determine patient oriented outcome and complication rates following b one transport using an external fixator placed over an intramedullary nail (the “monorail” technique). Bone transport using the monorail technique is associated with a dramatically improved lengthening index and a lower major complication rate than traditional ring fixator methods. Patient satisfaction with the procedure was high. Our study confirms the significant advantages of the monorail technique for bone transport/limb lengthening. The time in the fixator is dramatically reduced, and complications associated with earlier techniques such as angulatory deformity or refracture were not seen. We identified forty-nine patients (fifty-one limbs) who had undergone bone transport using the monorail technique (external fixator placed over an intramedullary nail). There were thirty-five men and fourteen women with a mean age of thirty-five years (range 17–50). Pre-operative diagnoses included post traumatic length discrepancy/bone defect (forty-one), congenital short stature (six) and other (four). All patients had a unilateral fixator placed over an implanted intramedullary nail. Once length correction was achieved, the fixator was removed and the nail “locked”. The mean amount of lengthening was 5.5 cm. (range 2 – 18 cm.). The lengthening index was 24.5 days /cm. (duration of external fixation/cm. bone length gained), with a range from ten to fifty days /cm. There were nineteen complications (thirty-seven percent): nine premature consolidations, four infected pin sites, two hardware failures, two osteomyelitis, one DVT, one nonunion. There were no refractures, angulatory deformities or cases of intramedullary sepsis

Ten RCTs published between 2000 and 2013 support treating distal radius buckle fractures and other low-risk distal radius fractures with a removable splint and with no orthopaedic follow-up. Application of this evidence has been shown to be variable and suboptimal resulting in unnecessary costs to a strained healthcare system. The Canadian evidence on this topic has been generated by subspecialist physicians working in paediatric hospitals. It is unclear what factors affect the dissemination of this information. We investigated the association of hospital type and physician type with the application of best-evidence treatment for low-risk distal radius fractures in children with the goal of improving our understanding of evidence diffusion in Ontario for this common injury. We performed a retrospective population-based cohort study using linked health care administrative data. We identified all children aged 2–14 treated in Ontario emergency departments from 2003–2015 with distal radius fractures with no reduction and no operation within a six week period. We excluded refractures and children with comorbidities. We evaluated the followup received – orthopaedic, general practitioner, or none. We examined the data for trends over time. Multivariable log binomial regression was used to quantify associations between hospital and physician type and best-evidence treatment. We adjusted for patient-related variables including age, sex, rural or urban location, and socioeconomic status. 70,801 fractures were analyzed. Best-evidence treatment was more likely to occur in a small (RR 1.86, 95%CI 1.72–2.01), paediatric (RR 1.16, 95%CI 1.07–1.26), or community (RR 1.13, 95%CI 1.06–1.20) hospital compared with treatment in a teaching hospital. Best-evidence treatment was more likely if initial management was by a paediatrician with additional emergency medicine training (RR 1.73, 95%CI 1.56–1.92) or paediatrician (RR 1.22, 95%CI 1.11–1.34). Paediatric and teaching hospitals have improved their use of best-evidence over time while other hospital types have stagnated or deteriorated. Paediatricians, paediatricians with additional emergency medicine training, and emergency medicine residency trained physicians have improved their use of best-evidence over time, while other physician types have stagnated or deteriorated. Overall, only 20% of patients received best-evidence treatment and 70% had orthopaedic follow-up. Significant over-utilization of resources for low-risk distal radius fractures continues decades after the first randomized trials showed it to be unnecessary. Physician type and hospital rurality are most strongly associated with best-evidence treatment. Physician types involved in generating, presenting, and publishing best-evidence for this fracture type are successfully implementing it, while others have failed to change their practices. Rural hospitals are excellent resource stewards by necessity, but are deteriorating over time. Our results strongly indicate the need for targeted implementation strategies to explicitly apply clinical evidence in clinical practice Canada-wide, with the goal of providing more cost-effective care for common children's fractures