Aims

Temporary epiphysiodesis (ED) is commonly applied in children and adolescents to treat leg length discrepancies (LLDs) and tall stature. Traditional Blount staples or modern two-hole plates are used in clinical practice. However, they require accurate planning, precise surgical techniques, and attentive follow-up to achieve the desired outcome without complications. This study reports the results of ED using a novel rigid staple (RigidTack) incorporating safety, as well as technical and procedural success according to the idea, development, evaluation, assessment, long-term (IDEAL) study framework.

We report a case of spontaneous physeal growth arrest of the distal femur in a nine-year-old child with Ewing’s sarcoma of the proximal femur treated with chemotherapy and endoprosthetic replacement. Owing to the extent of disuse osteoporosis at the time of surgery, the entire intramedullary canal up to the distal femoral physis was filled with cement. Three years later, the femur remained at its pre-operative length of 19 cm. Pre-operative calculations of further growth failed to account for the growth arrest, and the initial expandable growing prosthesis inserted has been revised to a longer one in order to address the leg-length discrepancy. To our knowledge, this is the only reported case of distal femoral physeal growth arrest following cemented endoprosthetic replacement of the proximal femur

A review is presented of 13 young patients with congenital scoliosis who were treated by epiphysiodesis of part of the vertebral bodies combined with posterior fusion, both on the convex side; the plan was to arrest growth on the convexity which, combined with growth of the concave side, would result in progressive correction of the curve. The first patient was operated on at the age of four years and has now reached skeletal maturity with complete correction of her curve. Several others, still growing, are showing progressive correction. Only three curves, in which kyphosis was more severe than scoliosis, have deteriorated since operation. Although full assessment must await skeletal maturity of all the patients, this approach appears to have sufficient potential to justify an early report

We reviewed 13 children with partial growth plate arrest who had been treated by epiphyseolysis. Eight were followed to skeletal maturity and five for at least four years. In three cases the affected limb was restored to normal and in five the operation was successful in improving angular deformity and leg length discrepancy such that further surgery was not necessary. In the five failures, angular deformity had progressed or limb length discrepancy had increased. There were no significant complications and the procedure did not prevent subsequent osteotomy or limb length equalisation. Epiphyseolysis was most effective for small bars and those affecting only the central area of the plate

Salter-Harris II fractures of the distal tibia affect children frequently, and when they are displaced present a treatment dilemma. Treatment primarily aims to restore alignment and prevent premature physeal closure, as this can lead to angular deformity, limb length difference, or both. Current literature is of poor methodological quality and is contradictory as to whether conservative or surgical management is superior in avoiding complications and adverse outcomes. A state of clinical equipoise exists regarding whether displaced distal tibial Salter-Harris II fractures in children should be treated with surgery to achieve anatomical reduction, or whether cast treatment alone will lead to a satisfactory outcome. Systematic review and meta-analysis has concluded that high-quality prospective multicentre research is needed to answer this question. The Outcomes of Displaced Distal tibial fractures: Surgery Or Casts in KidS (ODD SOCKS) trial, funded by the National Institute for Health and Care Research, aims to provide this high-quality research in order to answer this question, which has been identified as a top-five research priority by the British Society for Children’s Orthopaedic Surgery.

Cite this article: Bone Joint J 2023;105-B(5):471–473.

We report two cases of deformity of the ankle caused by physeal damage secondary to extravasation of an intravenous infusion in infancy. The possible mechanisms of injury to the physis are discussed.

McFarland fractures of the medial malleolus in children, also classified as Salter–Harris Type III and IV fractures, are associated with a high incidence of premature growth plate arrest. In order to identify prognostic factors for the development of complications we reviewed 20 children with a McFarland fracture that was treated surgically, at a mean follow-up of 8.9 years (3.5 to 17.4). Seven children (35%) developed premature growth arrest with angular deformity. The mean American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale for all patients was 98.3 (87 to 100) and the mean modified Weber protocol was 1.15 (0 to 5). There was a significant correlation between initial displacement (p = 0.004) and operative delay (p = 0.007) with premature growth arrest. Both risk factors act independently and additively, such that all children with both risk factors developed premature arrest whereas children with no risk factor did not. We recommend that fractures of the medial malleolus in children should be treated by anatomical reduction and screw fixation within one day of injury. Cite this article: Bone Joint J 2013;95-B:419–23

Septicaemia resulting from meningococcal infection is a devastating illness affecting children. Those who survive can develop late orthopaedic sequelae from growth plate arrests, with resultant complex deformities. Our aim in this study was to review the case histories of a series of patients with late orthopaedic sequelae, all treated by the senior author (CFB). We also describe a treatment strategy to address the multiple deformities that may occur in these patients. Between 1997 and 2009, ten patients (seven girls and three boys) were treated for late orthopaedic sequelae following meningococcal septicaemia. All had involvement of the lower limbs, and one also had involvement of the upper limbs. Each patient had a median of three operations (one to nine). Methods of treatment included a combination of angular deformity correction, limb lengthening and epiphysiodesis. All patients were skeletally mature at the final follow-up. One patient with bilateral below-knee amputations had satisfactory correction of her right amputation stump deformity, and has complete ablation of both her proximal tibial growth plates. In eight patients length discrepancy in the lower limb was corrected to within 1 cm, with normalisation of the mechanical axis of the lower limb. Meningococcal septicaemia can lead to late orthopaedic sequelae due to growth plate arrests. Central growth plate arrests lead to limb-length discrepancy and the need for lengthening procedures, and peripheral growth plate arrests lead to angular deformities requiring corrective osteotomies and ablation of the damaged physis. In addition, limb amputations may be necessary and there may be altered growth of the stump requiring further surgery. Long-term follow-up of these patients is essential to recognise and treat any recurrence of deformity

Distal femoral physeal fractures in children have a high incidence of physeal arrest, occurring in a mean of 40% of cases. The underlying nature of the distal femoral physis may be the primary cause, but other factors have been postulated to contribute to the formation of a physeal bar. The purpose of this study was to assess the significance of contributing factors to physeal bar formation, in particular the use of percutaneous pins across the physis. We reviewed 55 patients with a median age of ten years (3 to 13), who had sustained displaced distal femoral physeal fractures. Most (40 of 55) were treated with percutaneous pinning after reduction, four were treated with screws and 11 with plaster. A total of 40 patients were assessed clinically and radiologically after skeletal maturity or at the time of formation of a bar. The remaining 15 were followed up for a minimum of two years. Formation of a physeal bar occurred in 12 (21.8%) patients, with the rate rising to 30.6% in patients with high-energy injuries compared with 5.3% in those with low-energy injuries. There was a significant trend for physeal arrest according to increasing severity using the Salter-Harris classification. Percutaneous smooth pins across the physis were not statistically associated with growth arrest

The management of spinal deformity in children with univentricular cardiac pathology poses significant challenges to the surgical and anaesthetic teams. To date, only posterior instrumented fusion techniques have been used in these children and these are associated with a high rate of complications. We reviewed our experience of both growing rod instrumentation and posterior instrumented fusion in children with a univentricular circulation. Six children underwent spinal corrective surgery, two with cavopulmonary shunts and four following completion of a Fontan procedure. Three underwent growing rod instrumentation, two had a posterior fusion and one had spinal growth arrest. There were no complications following surgery, and the children undergoing growing rod instrumentation were successfully lengthened. We noted a trend for greater blood loss and haemodynamic instability in those whose surgery was undertaken following completion of a Fontan procedure. At a median follow-up of 87.6 months (interquartile range (IQR) 62.9 to 96.5) the median correction of deformity was 24.2% (64.5° (IQR 46° to 80°) vs 50.5° (IQR 36° to 63°)). We believe that early surgical intervention with growing rod instrumentation systems allows staged correction of the spinal deformity and reduces the haemodynamic insult to these physiologically compromised children. Due to the haemodynamic changes that occur with the completed Fontan circulation, the initial scoliosis surgery should ideally be undertaken when in the cavopulmonary shunt stage. Cite this article: Bone Joint J 2014;96-B:94–9

Permanent growth arrest of the longer bone is an option in the treatment of minor leg-length discrepancies. The use of a tension band plating technique to produce a temporary epiphysiodesis is appealing as it avoids the need for accurate timing of the procedure in relation to remaining growth. We performed an animal study to establish if control of growth in a long bone is possible with tension band plating. Animals (pigs) were randomised to temporary epiphysiodesis on either the right or left tibia. Implants were removed after ten weeks. Both tibiae were examined using MRI at baseline, and after ten and 15 weeks. The median interphyseal distance was significantly shorter on the treated tibiae after both ten weeks (p = 0.04) and 15 weeks (p = 0.04). On T. 1. -weighted images the metaphyseal water content was significantly reduced after ten weeks on the treated side (p = 0.04) but returned to values comparable with the untreated side at 15 weeks (p = 0.14). Return of growth was observed in all animals after removal of implants. Temporary epiphysiodesis can be obtained using tension band plating. The technique is not yet in common clinical practice but might avoid the need for the accurate timing of epiphysiodesis. Cite this article: Bone Joint J 2013;95-B:855–60

Between 1990 and 2001, 24 children aged between 15 months and 11 years presented with late orthopaedic sequelae after meningococcal septicaemia. The median time to presentation was 32 months (12 to 119) after the acute phase of the disease. The reasons for referral included angular deformity, limb-length discrepancy, joint contracture and problems with prosthetic fitting. Angular deformity with or without limb-length discrepancy was the most common presentation. Partial growth arrest was the cause of the angular deformity. Multiple growth-plate involvement occurred in 14 children. The lower limbs were affected much more often than the upper. Twenty-three children underwent operations for realignment of the mechanical axis and limb-length equalisation. In 15 patients with angular deformity around the knee the deformity recurred. As a result we recommend performing a realignment procedure with epiphysiodesis of the remaining growth plate when correcting angular deformities

Patellar instability most frequently presents during adolescence. Congenital and infantile dislocation of the patella is a distinct entity from adolescent instability and measurable abnormalities may be present at birth. In the normal patellofemoral joint an increase in quadriceps angle and patellar height are matched by an increase in trochlear depth as the joint matures. Adolescent instability may herald a lifelong condition leading to chronic disability and arthritis. Restoring normal anatomy by trochleoplasty, tibial tubercle transfer or medial patellofemoral ligament (MPFL) reconstruction in the young adult prevents further instability. Although these techniques are proven in the young adult, they may cause growth arrest and deformity where the physis is open. A vigorous non-operative strategy may permit delay of surgery until growth is complete. Where non-operative treatment has failed a modified MPFL reconstruction may be performed to maintain stability until physeal closure permits anatomical reconstruction. If significant growth remains an extraosseous reconstruction of the MPFL may impart the lowest risk to the physis. If minor growth remains image intensifier guided placement of femoral intraosseous fixation may impart a small, but acceptable, risk to the physis. This paper presents and discusses the literature relating to adolescent instability and provides a framework for management of these patients. Cite this article: Bone Joint J 2017;99-B:159–70

The potential harm to the growth plate following reconstruction of the anterior cruciate ligament in skeletally-immature patients is well documented, but we are not aware of literature on the subject of the fate of the graft itself. We have reviewed five adolescent males who underwent reconstruction of the ligament with four-strand hamstring grafts using MR images taken at a mean of 34.6 months (18 to 58) from the time of operation. The changes in dimension of the graft were measured and compared with those taken at the original operation. No growth arrest was seen on radiological or clinical measurement of leg-length discrepancy, nor was there any soft-tissue contracture. All the patients regained their pre-injury level of activity, including elite-level sport in three. The patients grew by a mean of 17.3 cm (14 to 24). The diameter of the grafts did not change despite large increases in length (mean 42%; 33% to 57%). Most of the gain in length was on the femoral side. Large changes in the length of the grafts were seen. There is a considerable increase in the size of the graft, so some neogenesis must occur; the graft must grow

Although supracondylar fracture is a very common elbow injury in childhood, there is no consensus on the timing of surgery, approach for open reduction and positioning of fixation wires. We report our ten-year experience between 1993 and 2003 in 291 children. Most fractures (285; 98%) were extension injuries, mainly Gartland types II (73; 25%) and III (163; 56%). Six (2%) were open fractures and a neurovascular deficit was seen in 12 (4%) patients. Of the 236 children (81%) who required an operation, 181 (77%) were taken to theatre on the day of admission. Most (177; 75%) of the operations were performed by specialist registrars. Fixation was by crossed Kirschner wires in 158 of 186 (85%) patients and open reduction was necessary in 52 (22%). A post-operative neurological deficit was seen in nine patients (4%) and three (1%) required exploration of the ulnar nerve. Only 22 (4%) patients had a long-term deformity, nine (3%) from malreduction and three (1%) because of growth arrest, but corrective surgery for functional limitation was required in only three (1%) patients

Severe kypho-scoliosis, lateral curvature and lordo-scoliosis are ultimately caused by disturbance of vertebral growth. The results of treatment by destroying the growth potential opposite the area of growth inhibition have been encouraging. When the operation has been adequate further deterioration has been prevented; in younger children there has been improvement with further growth. It is important that the growth arrest should be at the right site and that it should be sufficiently extensive. Accurate pre-operative diagnosis of the type and extent of the curve is important

We report our results in 24 children with malignant primary bone tumours of the distal femur treated with a Stanmore extendible endoprosthesis (SEER). This consists of a femoral component that can be lengthened, a constrained knee and an uncemented sliding tibial component which crosses the proximal tibial physeal plate perpendicularly. The average age of the patients at diagnosis was ten years and the mean follow-up was 4.7 years (2.5 to 7.9). The mean growth of the affected tibia was 76% (18 to 136) and of the fibula 83% (15 to 750) of the growth of the unaffected limb. Measurement of growth arrest lines showed that the mean growth of the proximal tibial physis on the affected side was 69% (43 to 100) of that of the normal side. The great variability in the growth of the physis cannot yet be explained

We report the ulnar impingement syndrome, which is caused by a shortened ulna impinging on the distal radius and causing a painful, disabling pseudarthrosis. Of the 11 cases reported, 10 were due to excision of the distal ulna after injury to the wrist; the other was a result of a growth arrest after a fracture of the distal ulna in a child. The symptoms are a painful, clicking wrist and a weak grip; clinical examination reveals a narrow wrist with pain on compression of the radius and ulna and on forced supination. Radiographs in the majority of cases show scalloping of the distal radius corresponding to the site of impingement. The mechanism by which ulnar impingement occurs after radio-ulnar convergence is illustrated. The plan of management for the young patient with traumatic dysfunction of the distal radio-ulnar joint is discussed; excision of the lower end of the ulna is not advised in such patients

Distal tibial physeal fractures are the second most common growth plate injury and the most common cause of growth arrest and deformity. This study assesses the accuracy of pre-operative planning for placement of the screws in these fractures using either standard radiographs or CT scans. We studied 62 consecutive physeal fractures over a period of four years. An outline of a single cut of the CT scan was used for each patient. An ideal position for the screw was determined as being perpendicular to and at the midpoint of the fracture. The difference in entry point and direction of the screw between the ideal and the observers’ assessments were compared using the paired Student’s t-test. There was a statistically significant improvement (p < 0.0001) in the accuracy of the point of insertion and the direction of the screw on the pre-operative plan when CT scans were used rather than plain radiographs. We would, therefore, recommend that CT scans are routinely used in the pre-operative assessment and treatment of distal tibial physeal fractures

Torsional deformities of the tibia are common in children, but in the majority both the torsion and the associated disturbance of gait resolve without intervention. There are, however, a significant number of children and adults with neuromuscular disease who present with pathological tibial torsion, which may require surgical correction. We conducted a prospective study in two centres, to investigate the outcome of supramalleolar derotation osteotomy of the tibia, using internal fixation with the AO-ASIF T plate. A range of outcome variables was collected, prospectively, for 57 patients (91 osteotomies), including thigh foot angle, foot progression angle, post-operative complications and serial radiographs. Correction of thigh foot angle and foot progression angle was satisfactory in all patients. Three major complications were recorded; one aseptic nonunion, one fracture through the osteotomy site after removal of the plate and one distal tibial growth arrest. We found that supramalleolar derotation osteotomy of the tibia, with AO-ASIF T plate fixation is an effective method for the correction of torsional deformities of the tibia and the associated disturbances of gait in children and adults with neuromuscular disease, with a 5.3% risk of major complications