We present two children with massive defects of the tibia and an associated active infection who were treated by medial transport of the fibula using the Ilizarov device. The first child had chronic discharging osteomyelitis which affected the whole tibial shaft. The second had sustained bilateral grade-IIIB open tibial fractures in a motor-car accident. The first child was followed up for three years and the second for two years. Both achieved solid union between the proximal and distal stumps of the tibia and the fibula, with hypertrophy of the fibula. The first child had a normal range of movement at the knee, ankle and foot but there was shortening of 1.5 cm. The second had persistent anterior angulation at the proximal tibiofibular junction and the ankle was stiff in equinus

Congenital pseudarthrosis of the tibia (CPT) is a rare but well recognised condition. Obtaining union of the pseudarthrosis in these children is often difficult and may require several surgical procedures. The treatment has changed significantly since the review by Hardinge in 1972, but controversies continue as to the best form of surgical treatment. This paper reviews these controversies.

Cite this article: Bone Joint J 2013;95-B:1027–34.

Aims. Paediatric triplane fractures and adult trimalleolar ankle fractures both arise from a supination external rotation injury. By relating the experience of adult to paediatric fractures, clarification has been sought on the sequence of injury, ligament involvement, and fracture pattern of triplane fractures. This study explores the similarities between triplane and trimalleolar fractures for each stage of the Lauge-Hansen classification, with the aim of aiding reduction and fixation techniques. Methods. Imaging data of 83 paediatric patients with triplane fractures and 100 adult patients with trimalleolar fractures were collected, and their fracture morphology was compared using fracture maps. Visual fracture maps were assessed, classified, and compared with each other, to establish the progression of injury according to the Lauge-Hansen classification. Results. Four stages of injury in triplane fractures, resembling the adult supination external rotation Lauge-Hansen stages, were observed. Stage I consists of rupture of the anterior syndesmosis or small avulsion of the anterolateral tibia in trimalleolar fractures, and the avulsion of a larger Tillaux fragment in triplanes. Stage II is defined as oblique fracturing of the fibula at the level of the syndesmosis, present in all trimalleolar fractures and in 30% (25/83) of triplane fractures. Stage III is the fracturing of the posterior malleolus. In trimalleolar fractures, the different Haraguchi types can be discerned. In triplane fractures, the delineation of the posterior fragment has a wave-like shape, which is part of the characteristic Y-pattern of triplane fractures, originating from the Tillaux fragment. Stage IV represents a fracture of the medial malleolus, which is highly variable in both the trimalleolar and triplane fractures. Conclusion. The paediatric triplane and adult trimalleolar fractures share common features according to the Lauge-Hansen classification. This highlights that the adolescent injury arises from a combination of ligament traction and a growth plate in the process of closing. With this knowledge, a specific sequence of reduction and optimal screw positions are recommended. Cite this article: Bone Joint J 2024;106-B(9):1008–1014

Aims. The aim of this retrospective cohort study was to assess and investigate the safety and efficacy of using a distal tibial osteotomy compared to proximal osteotomy for limb lengthening in children. Methods. In this study, there were 59 consecutive tibial lengthening and deformity corrections in 57 children using a circular frame. All were performed or supervised by the senior author between January 2013 and June 2019. A total of 25 who underwent a distal tibial osteotomy were analyzed and compared to a group of 34 who had a standard proximal tibial osteotomy. For each patient, the primary diagnosis, time in frame, complications, and lengthening achieved were recorded. From these data, the frame index was calculated (days/cm) and analyzed. Results. All patients ended their treatment with successful lengthening and deformity correction. The frame index for proximal versus distal osteotomies showed no significant difference, with a mean 48.5 days/cm (30 to 85) and 48.9 days/cm (28 to 81), respectively (p = 0.896). In the proximal osteotomy group, two patients suffered complications (one refracture after frame removal and one failure of regenerate maturation with subsequent valgus deformity) compared to zero in the distal osteotomy group. Two patients in each group sustained obstacles that required intervention (one necessitated guided growth, one fibula lengthening, and two required change of wires). There was a similar number of problems (pin-site infections) in each group. Conclusion. Our data show that distal tibial osteotomies can be safely employed in limb lengthening for children using a circular frame, which has implications in planning a surgical strategy; for example, when treating a tibia with shortening and distal deformity, a second osteotomy for proximal lengthening is not required. Cite this article: Bone Joint J 2022;104-B(11):1273–1278

Aims. The aim of this study was to utilize a national paediatric inpatient database to determine whether obesity influences the operative management and inpatient outcomes of paediatric limb fractures. Patients and Methods. The Kids’ Inpatient Database (KID) was used to evaluate children between birth and 17 years of age, from 1997 and 2012, who had undergone open and closed treatment of humeral, radial and ulna, femoral, tibial, and ankle fractures. Demographics, hospital charges, lengths of stay (LOS), and complications were analyzed. Results. Obesity was significantly associated with increased rates of open reduction and internal fixation (ORIF) for: distal humeral (odds ratio (OR) = 2.139, 95% confidence interval (CI) 1.92 to 3.44; p < 0.001); distal radius and ulna fractures (OR = 1.436, 95% CI 1.14 to 2.16; p < 0.05); distal femoral (OR = 2.051, 95% CI 1.69 to 3.60; p < 0.05); tibial and fibula shaft (OR = 2.101, 95% CI 2.10 to 3.50; p < 0.001); and ankle (OR = 1.733, 95% CI 1.70 to 2.39; p < 0.001). Older age was significantly associated with ORIF for all fractures (p < 0.05). LOS, hospital charges, and complications were significantly increased in obese patients following ORIF for upper and lower limb fractures (p < 0.05). Conclusion. Obese paediatric patients are more likely to undergo ORIF in both upper and lower limb fractures and have more inpatient complications. These findings may assist in informing obese paediatric fracture patients and their families regarding the increased risk for open operative fixation and associated outcomes. Cite this article: Bone Joint J 2019;101-B:491–496

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Triplane ankle fractures are complex injuries typically occurring in children aged between 12 and 15 years. Classic teaching that closure of the physis dictates the overall fracture pattern, based on studies in the 1960s, has not been challenged. The aim of this paper is to analyze whether these injuries correlate with the advancing closure of the physis with age.

Congenital unilateral anterolateral tibial bowing in combination with a bifid ipsilateral great toe is a very rare deformity which resembles the anterolateral tibial bowing that occurs in association with congenital pseudarthrosis of the tibia. However, spontaneous resolution of the deformity without operative treatment and with a continuously straight fibula has been described in all previously reported cases. We report three additional cases and discuss the options for treatment. We suggest that this is a specific entity within the field of anterolateral bowing of the tibia and conclude that it has a much better prognosis than congenital pseudarthrosis of the tibia, although conservative treatment alone may not be sufficient

We investigated patterns of refracture and their risk factors in patients with congenital pseudarthrosis of the tibia after Ilizarov osteosynthesis. We studied 43 cases in 23 patients. Temporal and spatial patterns of refracture and refracture-free survival were analysed in each case. The refracture-free rate of cumulative survival was 47% at five years and did not change thereafter. Refracture occurred at the previous pseudarthrosis in 16 of 19 cases of refracture. The risk of refracture was significantly higher when osteosynthesis was performed below the age of four years, when the tibial cross-sectional area was narrow, and when associated with persistent fibular pseudarthrosis. Refracture occurs frequently after successful osteosynthesis in these patients. Delaying osteosynthesis, maximising the tibial cross-sectional area and stabilising the fibula may reduce the risk of refracture

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Osteofibrous dysplasia (OFD) is a rare benign lesion predominantly affecting the tibia in children. Its potential link to adamantinoma has influenced management. This international case series reviews the presentation of OFD and management approaches to improve our understanding of OFD.

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The treatment of tibial aplasia is controversial. Amputation represents the gold standard with good functional results, but is frequently refused by the families. In these patients, treatment with reconstructive limb salvage can be considered. Due to the complexity of the deformity, this remains challenging and should be staged. The present study evaluated the role of femoro-pedal distraction using a circular external fixator in reconstructive treatment of tibial aplasia. The purpose of femoro-pedal distraction is to realign the limb and achieve soft tissue lengthening to allow subsequent reconstructive surgery.

We studied 45 children who presented with an inversion injury of the ankle. The clinical signs suggested injury to the distal growth plate of the fibula, but the plain radiographs appeared normal. Ultrasound examination of the joint in 40 patients showed a subperiosteal haematoma consistent with a growth-plate injury in 23 (57.5%). Children who had been treated with a tubular bandage and crutches by random selection had a mean time to return of normal activity of 14.22 days compared with 21.60 days for those treated with a plaster-of-Paris cast (t = 3.60, p = 0.0032; d = 7.38, 95% CI 3.0 to 11.8). We conclude that children with inversion ankle injuries who have clinical signs of injury to the distal fibular growth plate but a normal radiological appearance, should be treated with a tubular bandage and crutches

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Preserving growth following limb-salvage surgery of the upper limb in children remains a challenge. Vascularized autografts may provide rapid biological incorporation with the potential for growth and longevity. In this study, we aimed to describe the outcomes following proximal humeral reconstruction with a vascularized fibular epiphyseal transfer in children with a primary sarcoma of bone. We also aimed to quantify the hypertrophy of the graft and the annual growth, and to determine the functional outcomes of the neoglenofibular joint.

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We wished to examine the effectiveness of tibial lengthening using a two ring Ilizarov frame in skeletally immature patients. This is a potentially biomechanically unstable construct which risks the loss of axial control.

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Following the introduction of national standards in 2009, most major paediatric trauma is now triaged to specialist units offering combined orthopaedic and plastic surgical expertise. We investigated the management of open tibia fractures at a paediatric trauma centre, primarily reporting the risk of infection and rate of union.

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.

Osteofibrous dysplasia is an unusual developmental condition of childhood, which almost exclusively affects the tibia. It is thought to follow a slowly progressive course and to stabilise after skeletal maturity. The possible link with adamantinoma is controversial and some authors believe that they are part of one histological process.

We retrospectively reviewed 16 patients who were diagnosed as having osteofibrous dysplasia initially or on the final histological examination. Their management was diverse, depending on the severity of symptoms and the extent of the lesion. Definitive (extraperiosteal) surgery was localised ‘shark-bite’ excision for small lesions in five patients. Extensive lesions were treated by segmental excision and fibular autograft in six patients, external fixation and bone transport in four and proximal tibial replacement in one. One patient who had a fibular autograft required further excision and bone transport for recurrence. Six initially underwent curettage and all had recurrence. There were no recurrences after localised extraperiosteal excision or bone transport. There were three confirmed cases of adamantinoma.

The relevant literature is reviewed. We recommend extraperiosteal excision in all cases of osteofibrous dysplasia, with segmental excision and reconstruction in more extensive lesions.

The management of chronic osteomyelitis requires the excision of necrotic and infected material followed by the prolonged administration of antibiotics. Sequestrectomy may be required before an involucrum has formed, resulting in a longitudinal bone defect. This can be difficult to fill. Vascularised grafts are complicated by a high rate of recurrent infection and thrombosis.

We have managed defects of long bones in children after sequestrectomy by the use of non-vascularised fibular grafts harvested subperiosteally and held by an intramedullary Kirschner wire. Eight children underwent this procedure. In six the tibia was involved and in one each the humerus and radius. One patient was lost to follow-up. Six grafts united at both ends within 12 weeks. The seventh developed an infected nonunion distally which united after further debridement. One patient required a further sequestrectomy which did not compromise union.

We have found this to be a straightforward technique with reliable results and were able to salvage the limb in all the seven patients who were reviewed.

A percutaneous supramalleolar osteotomy with multiple drill holes and closed osteoclasis was used to correct rotational deformities of the tibia in patients with cerebral palsy. The technique is described and the results in 247 limbs (160 patients) are reported. The mean age at the time of surgery was 10.7 years (4 to 20). The radiographs were analysed for time to union, loss of correction, and angulation at the site of the osteotomy.

Bone healing was obtained in all patients except one in a mean period of seven weeks (5 to 12). Malunion after loss of reduction at the site of the osteotomy developed in one tibia.

Percutaneous supramalleolar osteotomy of the tibia is a safe and simple surgical procedure.

Progressive angular deformity of an extremity due to differential physeal arrest is the most common late orthopaedic sequela following meningococcal septicaemia in childhood. A total of ten patients (14 ankles) with distal tibial physeal arrest as a consequence of meningococcal septicaemia have been reviewed. Radiological analysis of their ankles has demonstrated a distinct pattern of deformity. In 13 of 14 cases the distal fibular physis was unaffected and continued distal fibular growth contributed to a varus deformity. We recommend that surgical management should take account of this consistent finding during the correction of these deformities.