We describe the technique and results of medial submuscular plating of the femur in paediatric patients and discuss its indications and limitations. Specifically, the technique is used as part of a plate-after-lengthening strategy, where the period of external fixation is reduced and the plate introduced by avoiding direct contact with the lateral entry wounds of the external fixator pins. The technique emphasises that vastus medialis is interposed between the plate and the vascular structures.

A total of 16 patients (11 male and five female, mean age 9.6 years (5 to 17)), had medial submuscular plating of the femur. All underwent distraction osteogenesis of the femur with a mean lengthening of 4.99 cm (3.2 to 12) prior to plating. All patients achieved consolidation of the regenerate without deformity. The mean follow-up was 10.5 months (7 to 15) after plating for those with plates still in situ, and 16.3 months (1 to 39) for those who subsequently had their plates removed. None developed a deep infection. In two patients a proximal screw fractured without loss of alignment; one patient sustained a traumatic fracture six months after removal of the plate.

Placing the plate on the medial side is advantageous when the external fixator is present on the lateral side, and is biomechanically optimal in the presence of a femoral defect. We conclude that medial femoral submuscular plating is a useful technique for specific indications and can be performed safely with a prior understanding of the regional anatomy.

Cite this article: Bone Joint J 2014;96-B:137–42.

Talipes equinovarus is one of the more common congenital abnormalities affecting the lower limb and can be challenging to manage. This review provides a comprehensive update on idiopathic congenital talipes equinovarus with emphasis on the initial treatment. Current management is moving away from operative towards a more conservative treatment using the Ponseti regime. The long-term results of surgical correction and the recent results of conservative treatment will be discussed.

We performed a systematic review of the literature to evaluate the use and interpretation of generic and disease-specific functional outcome instruments in the reporting of outcome after the surgical treatment of disruptions of the pelvic ring. A total of 28 papers met our inclusion criteria, with eight reporting only generic outcome instruments, 13 reporting only pelvis-specific outcome instruments, and six reporting both. The Short-Form 36 (SF-36) was by far the most commonly used generic outcome instrument, used in 12 papers, with widely variable reporting of scores. The pelvis-specific outcome instruments were used in 19 studies; the Majeed score in ten, Iowa pelvic score in six, Hannover pelvic score in two and the Orlando pelvic score in one. Four sets of authors, all testing construct validity based on correlation with the SF-36, performed psychometric testing of three pelvis-specific instruments (Majeed, IPS and Orlando scores). No testing of responsiveness, content validity, criterion validity, internal consistency or reproducibility was performed.

The existing literature in this area is inadequate to inform surgeons or patients in a meaningful way about the functional outcomes of these fractures after fixation.

We describe a method of pinning extension supracondylar fractures of the humerus in children. Following closed reduction, a posterior intrafocal wire is inserted and a second lateral wire added when needed for rotational stability. Between May 2002 and November 2005 we performed this technique in 69 consecutive patients. A single posterior wire was used in 29 cases, and two wires in 40. The mean follow-up was two years (21 to 30 months). The results were assessed according to Flynn’s criteria. In the single-wire group there were 21 excellent, five good and one poor result. Two patients were lost to follow-up. In the two-wire group there were 32 excellent, two good and three poor results. Three were lost to follow-up. The poor results were due to a failure to achieve adequate reduction, fixation or both.

We conclude that the intact posterior periosteal hinge can be used successfully in the clinical situation, giving results that compare well with other techniques of pinning. The posterior route offers an attractive alternative method for fixation of supracondylar fractures of the humerus in children.

Recurrence of back or leg pain after discectomy is a well-recognised problem with an incidence of up to 28%. Once conservative measures have failed, several surgical options are available and have been tried with varying degrees of success. In this study, 42 patients with recurrent symptoms after discectomy underwent less invasive posterior lumbar interbody fusion (LI-PLIF). Clinical outcome was measured using the Oswestry Disability Index (ODI), Short Form 36 (SF-36) questionnaires and visual analogue scales for back (VAS-BP) and leg pain (VAS-LP). There was a statistically significant improvement in all outcome measures (p < 0.001). The debate around which procedure is the most effective for these patients remains controversial.

Our results show that LI-PLIF is as effective as any other surgical procedure. However, given that it is less invasive, we feel that it should be considered as the preferred option.

The October 2013 Knee Roundup³⁶⁰ looks at: Make it easy, release the MCL; Do patients remember clinical information in day surgery?; Osteoarthritis and arthroscopy?; How best to double your bundles; When to operate for infection; Cementless unicompartment knee replacement?; Tibial tubercle-trochlear groove confusion; Tarts, cherries and osteoarthritis

The aim of this retrospective multicentre study was to report the continued occurrence of compartment syndrome secondary to paediatric supracondylar humeral fractures in the period 1995 to 2005. The inclusion criteria were children with a closed, low-energy supracondylar fracture with no associated fractures or vascular compromise, who subsequently developed compartment syndrome. There were 11 patients (seven girls and four boys) identified from eight hospitals in three countries. Ten patients with severe elbow swelling documented at presentation had a mean delay before surgery of 22 hours (6 to 64). One patient without severe swelling documented at presentation suffered arterial entrapment following reduction, with a subsequent compartment syndrome requiring fasciotomy 25 hours after the index procedure.

This series is noteworthy, as all patients had low-energy injuries and presented with an intact radial pulse. Significant swelling at presentation and delay in fracture reduction may be important warning signs for the development of a compartment syndrome in children with supracondylar fractures of the humerus.

The October 2013 Trauma Roundup³⁶⁰ looks at: Radiological, electromagnetic or just leave it out altogether?: distal locking in intramedullary nailing; Internal fixation of radiation-induced pathological fractures of the femur has a high rate of failure; Obesity and trauma; Short and sweet?: antibiotics in open fractures; Extremity injuries more important than previously thought?; Cement nails tiptop for osteomyelitis; Oxygen measurements for compartment syndrome?

The August 2013 Children’s orthopaedics Roundup³⁶⁰ 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.

The August 2013 Trauma Roundup³⁶⁰ looks at: reverse oblique fractures do better with a cephalomedullary device; locking screws confer no advantage in tibial plateau fractures; it’s all about the radius of curvature; radius of curvature revisited; radial head replacement in complex elbow reconstruction; stem cells in early fracture haematoma; heterotrophic ossification in forearms; and Boston in perspective.

Several techniques are available for the treatment of displaced fractures of the neck of the radius in children. We report our experience in 14 children treated by indirect reduction and fixation using an elastic stable intramedullary nail. The patients were followed up for a mean of 28 months. One developed asymptomatic avascular necrosis. The rest had excellent results. One had a neuropraxia of the posterior interosseous nerve, which recovered within six weeks. We advocate elastic stable intramedullary nailing for the closed reduction and fixation of these fractures in children.

Failure of bone repair is a challenging problem in the management of fractures. There is a limited supply of autologous bone grafts for treating nonunions, with associated morbidity after harvesting. There is need for a better source of cells for repair. Mesenchymal stem cells (MSCs) hold promise for healing of bone because of their capacity to differentiate into osteoblasts and their availability from a wide variety of sources. Our review aims to evaluate the available clinical evidence and recent progress in strategies which attempt to use autologous and heterologous MSCs in clinical practice, including genetically-modified MSCs and those grown on scaffolds. We have compared various procedures for isolating and expanding a sufficient number of MSCs for use in a clinical setting.

There are now a number of clinical studies which have shown that implantation of MSCs is an effective, safe and durable method for aiding the repair and regeneration of bone.

The June 2013 Children’s orthopaedics Roundup³⁶⁰ looks at: whether reaching a diagnosis is more difficult than previously thought; adolescent and paediatric DDH; the A-frame orthosis and Legg-Calvé-Perthes’ disease; failure of hip surgery in patients with cerebral palsy; adolescent rotator cuff injuries; paediatric peripheral nerve injuries; predicting residual deformity following Ponseti treatment; and the Dunn procedure.

There are unacceptable delays in the management of pelvic trauma in the United Kingdom. In 2003 this became a political issue after TV and radio coverage. Changes to the service were introduced, including trauma coordinators and a special tariff, but has it made a difference?

The purpose of this study was to evaluate treatment results following arthroscopic triangular fibrocartilage complex (TFCC) debridement for recalcitrant ulnar wrist pain. According to the treatment algorithm, 66 patients (36 men and 30 women with a mean age of 38.1 years (15 to 67)) with recalcitrant ulnar wrist pain were allocated to undergo ulnar shortening osteotomy (USO; n = 24), arthroscopic TFCC repair (n = 15), arthroscopic TFCC debridement (n = 14) or prolonged conservative treatment (n = 13). The mean follow-up was 36.0 months (15 to 54). Significant differences in Hand20 score at 18 months were evident between the USO group and TFCC debridement group (p = 0.003), and between the TFCC repair group and TFCC debridement group (p = 0.029). Within-group comparisons showed that Hand20 score at five months or later and pain score at two months or later were significantly decreased in the USO/TFCC repair groups. In contrast, scores in the TFCC debridement/conservative groups did not decrease significantly. Grip strength at 18 months was significantly improved in the USO/TFCC repair groups, but not in the TFCC debridement/conservative groups. TFCC debridement shows little benefit on the clinical course of recalcitrant ulnar wrist pain even after excluding patients with ulnocarpal abutment or TFCC detachment from the fovea from the indications for arthroscopic TFCC debridement.

Cite this article: Bone Joint J 2013;95-B:1687–96.

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 T₁-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.

A total of 80 patients with an acute rupture of tendo Achillis were randomised to operative repair using an open technique (39 patients) or non-operative treatment in a cast (41 patients). Patients were followed up for one year. Outcome measures included clinical complications, range of movement of the ankle, the Short Musculoskeletal Function Assessment (SMFA), and muscle function dynamometry evaluating dorsiflexion and plantar flexion of the ankle. The primary outcome measure was muscle dynamometry.

Re-rupture occurred in two of 37 patients (5%) in the operative group and four of 39 (10%) in the non-operative group, which was not statistically significant (p = 0.68). There was a slightly greater range of plantar flexion and dorsiflexion of the ankle in the operative group at three months which was not statistically significant, but at four and six months the range of dorsiflexion was better in the non-operative group, although this did not reach statistically significance either. After 12 weeks the peak torque difference of plantar flexion compared with the normal side was less in the operative than the non-operative group (47% vs 61%, respectively, p < 0.005). The difference declined to 26% and 30% at 26 weeks and 20% and 25% at 52 weeks, respectively. The difference in dorsiflexion peak torque from the normal side was less than 10% by 26 weeks in both groups, with no significant differences. The mean SMFA scores were significantly better in the operative group than the non-operative group at three months (15 vs 20, respectively, p < 0.03). No significant differences were observed after this, and at one year the scores were similar in both groups.

We were unable to show a convincing functional benefit from surgery for patients with an acute rupture of the tendo Achillis compared with conservative treatment in plaster.