Background: Fractures of the distal femur include metadiaphyseal fractures and physeal injuries. Treatment with cast alone is often excluded because of the inability to achieve and maintain reduction, polytrauma, and pathological fractures. Furthermore, operative treatment can also be challenging as the physis is still open and can be damaged by the fracture itself or by the fixation device, the metaphyseal fragment is short and problematic to fixate, and some of the fractures are intraarticular.

The goal of the study was to review the pattern of these fractures and report the midterm outcomes of various treatment options.

Study design: Inclusion criteria for this retrospective study were: age 9–16 years, fracture in the distal third of the femur treated surgically, growth plates open and availability to follow-up. From 2003–2006, fourteen children (mean age 11.5 years) met inclusion criteria. Over the same period, a search based on ICD-9 codes identified 49 patients with femur fractures that had undergone surgery.

Patient charts and radiographs were reviewed and the children were evaluated by an orthopedic surgeon not involved in the patient management. Parameters recorded included: time to union, time to achieve 0–110° knee range of motion (ROM), and emergency surgery, limited knee ROM and premature physeal arrest.

Results: Fractures of the distal femur were frequent among teenagers accounting for 28% of all femoral fractures. a) Injury was related to sport activities (n=10), motor vehicle accidents (n=3) and blast injury (n=1). b) Fracture types: Salter-Harris physeal injuries (n=6) and metaphyseal fractures (n=8). Three of the meta-diaphyseal fractures were pathological fractures through bone cysts.

Treatment: The following methods were employed: a) external fixators (n=2), b) screws, pins and cast (n=6), c) Plates (n=5), and d) Titanium elastic nails (n=1). The mean follow-up was 16 months (range 3–38 months). d) There were no major complications. The knee ROM at 6 weeks was 35° after pins and cast, and 80° after other methods. The knee ROM was at least 110° at 3 months after plate fixation and at six months after pins and cast.

Conclusions: We identified two main subgroups of treatment in teenagers: plates in 5, and screws or Kirschner wires with cast augmentation in 6. The teenagers treated with plates had better short-term outcomes but, at 6 months, there was no difference between the groups. It appears that, if fracture configuration allows, the percutaneous locking plates should be the first treatment option. Bone cysts appear to be a significant risk factor in this age group. The midterm outcome of distal femur fractures was overall good without physeal arrest or malalignment.

Introduction: Fracture of the lateral condyle of distal humerus in the pediatric population is a common problem. In children less than 13 year the distal humerus is only partially ossified and it is sometimes impossible to assess whether a fracture extends to the articular surface of distal humerus and whether or not there is a step off. Classic recommendations were to perform an open reduction in order to ensure perfect reduction. There are sporadic reports on use of arthrography or MRI studies

Aim of the Study: Retrospective study- intended to evaluate the clinical and radiographic outcome in children in whom the articular surface of distal humerus was evaluated by arthrography . Uppon arthrography results undisplaced fractures were percutaneously pinned and displaced fractures underwent formal open reduction and internal fixation.

Patients and Methods: 11 children mean age 7.8 (1.5–15) were enrolled in the study. Inclusion criteria was a fracture of lateral condyle of humerus suspected to be type II according to Jakob (the fracture is complete but is not diplaced out of the elbow joint). The mean follow up was 2.4y (13m-5.2y). Range of motion. Carrying angle were and neurovascular status were noted and compared with controlateral elbow. Actual X-rays were reviewed.

Results: The patient sample represent around 8% of the whole number of children treated in our Institution during 2000–2005. In 7 patients we were able to avoid open reduction and still to achieve excellent results. In 4 cases that were finally managed by open reduction the intraoperative findings fitted the arthrographic findings.

In Conclusion: Arthrography may prevent unnecessary open reductions for lateral condyle fractures in children.

With advances in surgical technique and instrumentation, the anterior approach to the thoracolumbar spine becomes more popular. Anterior approach is considered particularly when ventral decompression of neural structures is needed, providing optional stability by fusing the involved segment with instruments specially designated for that purpose. The usual approach is done through a 10th or 11th rib thoracotomy, opening of the pleural cavity and a semilunar cut at the periphery of the diaphragm, in order to expose the anterolateral aspect of the vertebral column. This technique involves the risk of phrenic nerve injury and diaphragmatic paralysis combined with morbidity of the chest tube. A variant of that technique is the retrodiaphragmatic approach, which provides the surgeon with the advantages of ventral exposure, potentially avoiding the morbidity of the standard transpleural thoracotomy.

Methods: During a three-year period, all patients with major anterior pathology at the T11, T12 or Ll level, were operated using the retrodiaphragmatic anterior approach. This involved an 10th or 11th rib thoracotomy with the patient in a lateral decubitus position. Following rib resection, blunt dissection of the diaphragm from the chest wall was performed without its surgical incision. The parietal pleural was mobilized medially and left intact and the thoracolumbar spine was exposed for the procedure. In case of a major pleural defect, a chest drain was inserted.

Results: Fifteen patients (10 males and 5 females, mean age: 32.6y) made up by study group. This included six patients who had a thoracolumbar fracture, five patients who were diagnosed as having idiopathic scoliosis and four patients who presented with metastatic disease in the thoracolumbar region. Adequate decompression was achieved in all patients as well as stable fixation of the involved segment. Mean operating time was 4.5 hours, average hospitalization length was six days. Three patients (20%) required a chest drain following the procedure. The drain was removed within three postoperative days of the operation. In five cases (40%) blood transfusion was required. Mainly for the underlying disease. The average decrease in the hemoglobin values, in the patient subgroup not requiring blood transfusion, was 3mg% at discharge comparing to the preoperative level. No intra-operative complications related to the surgical technique or instrumentation, were noted, nor any case of mortality. Complications such as respiratory distress, neurological damage, infection, hardware loosening or failure, pseudoarthrosis or hernia in scar were not observed during the post operative follow-up.

Conclusion: The retrodiaphragmatic approach to the thoracolumbar spine is safe and technically easy to apply in cases where ventral exposure of the spine is needed. This technique spares the need for diaphragmatic incision and in most cases, leaves the pleural cavity intact.

Antibiotic polymethylmethacrylate (PMMA) beads are known as an effective drug delivery system for local antibiotic therapy in bone and soft tissue infections. Over the years it has become an efficient method to treat osteomyelitis and other infections in orthopaedic surgery. Whilst this method has gained popularity primarily in infected arthroplasty, trauma and chronic osteomyelitis, its application in spine surgery is less known.

Methods: From 1997 to 2000 we have followed prospectively all patients who developed severe purulent wound infection following various types of instrumented spine fusion. Any patient, who had the typical presentation of surgical wound infection was enrolled into the study. Revision consisted of radical debridement of all necrotic tissue from the surgical wound, jet irrigation with saline and application of antibiotic contained PMMA beads. Primary closure over a suction drain was done in all cases and the patient was treated with parenteral antibiotic therapy. Following first revision, patients were treated with broad-spectrum parenteral antibiotic therapy, which was converted to culture-sensitive antibiotic. Suction drains were removed when the output was less than 50cc/24hr. Patients were returned for a second revision when local and systemic parameters showed no evidence of active infection.

This revision consisted of PMMA bead removal, debridement as necessary and irrigation. Primary closure over a suction drain was performed in all cases. No hardware removal was done in any of the cases. Follow up studies included radiographs and gallium bone scan.

Results: There were five patients in the study group. Of these, two had posterior spinal fusion for trauma; the remaining three had fusion for a various etiologies (tumor, corrective osteotomy in ankylosing spondylitis and lumbar instability). Causative organism was staphylococcus aureous (2 patients) and MRSA (3 patients). Mean interval from primary surgery to the first revision was 12 days and 19 days until the second revision. None of the patients had a third revision. There was no evidence for exacerbation of the infectious disease during follow up nor any pain or other signs which could mark the beginning of chronic osteomyelitis. No systemic or local complications related to the surgical technique or the PMMA beads were noted during the period between revisions. Galium scan was performed in only three of the five patients for a different reason. Scan results were negative in all three.

Conclusion: Two-stage revision surgery with PMMA antibiotic beads in a purulent surgical wound infection following spinal fusion, is a highly efficient method. This approach can assure proper healing of the surgical wound with no need for instrumentation removal or prolonged secondary healing of the surgical