Aims. The aim of this study is to evaluate the surgical treatment with the best healing rate for patients with proximal femoral unicameral bone cysts (UBCs) after initial surgery, and to determine which procedure has the lowest adverse event burden during follow-up. Methods. This multicentre retrospective study was conducted in 20 tertiary paediatric hospitals in France, Belgium, and Switzerland, and included patients aged < 16 years admitted for UBC treatment in the proximal femur from January 1995 to December 2017. UBCs were divided into seven groups based on the index treatment, which included elastic stable intramedullary nail (ESIN) insertion with or without percutaneous injection or grafting, percutaneous injection alone, curettage and grafting alone, and insertion of other orthopaedic hardware with or without curettage. Results. A total of 201 patients were included in the study. The mean age at diagnosis was 8.7 years (SD 3.9); 77% (n = 156) were male. The mean follow-up was 9.4 years (SD 3.9). ESIN insertion without complementary procedure had a 67% UBC healing rate after the first operation (vs 30% with percutaneous injection alone (p = 0.027), 43% with curettage and grafting (p = 0.064), and 21% with insertion of other hardware combined with curettage (p < 0.001) or 36% alone (p = 0.014)). ESIN insertion with percutaneous injection presented a 79% healing rate, higher than percutaneous injection alone (p = 0.017), curettage and grafting (p = 0.028), and insertion of other hardware combined with curettage (p < 0.001) or alone (p = 0.014). Patients who underwent ESIN insertion with curettage had a 53% healing rate, higher than insertion of other hardware combined with curettage (p = 0.009). The overall rate of postoperative complications was 25% and did not differ between groups (p = 0.228). A total of 32 limb length discrepancies were identified. Conclusion. ESIN insertion, either alone or combined with percutaneous injection or curettage and grafting, may offer higher healing rates than other operative procedures. Limb length discrepancy remains a major concern, and might be partly explained by the cyst’s location and the consequence of surgery. Therefore, providing information about this risk is crucial. Cite this article: Bone Joint J 2024;106-B(5):508–514

Aims. The Fassier Duval (FD) rod is a third-generation telescopic implant for children with osteogenesis imperfecta (OI). Threaded fixation enables proximal insertion without opening the knee or ankle joint. We have reviewed our combined two-centre experience with this implant. Methods. In total, 34 children with a mean age of five years (1 to 14) with severe OI have undergone rodding of 72 lower limb long bones (27 tibial, 45 femoral) for recurrent fractures with progressive deformity despite optimized bone health and bisphosphonate therapy. Data were collected prospectively, with 1.5 to 11 years follow-up. Results. A total of 24 patients (33%) required exchange of implants (14 femora and ten tibiae) including 11 rods bending with refracture. Four (5%) required reoperation with implant retention. Loss of proximal fixation in the femur and distal fixation in the tibia were common. Four patients developed coxa vara requiring surgical correction. In total, 13 patients experienced further fractures without rod bending; eight required implant revision. There was one deep infection. The five-year survival rate, with rod revision as the endpoint, was 63% (95% confidence interval (CI) 44% to 77%) for femoral rods, with a mean age at implantation of 4.8 years (1.3 to 14.8), and 64% (95% CI 36% to 82%) for tibial rods, with a mean age at implantation of 5.2 years (2.0 to 13.8). Conclusion. FD rods are easier to implant but do not improve on the revision rates reported for second generation T-piece rods. Proximal femoral fixation is problematic in younger children with a partially ossified greater trochanter. Distal tibial fixation typically fails after two years. Future generation implants should address proximal femoral and distal tibial fixation to avoid the majority of complications in this series. Cite this article: Bone Joint J 2020;102-B(8):1048–1055

Aims

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.

Aims

Temporary hemiepiphysiodesis (HED) is applied to children and adolescents to correct angular deformities (ADs) in long bones through guided growth. Traditional Blount staples or two-hole plates are mainly used for this indication. Despite precise surgical techniques and attentive postoperative follow-up, implant-associated complications are frequently described. To address these pitfalls, a flexible staple was developed to combine the advantages of the established implants. This study provides the first results of guided growth using the new implant and compares these with the established two-hole plates and Blount staples.

End caps are intended to prevent nail migration (push-out) in elastic stable intramedullary nailing. The aim of this study was to investigate the force at failure with and without end caps, and whether different insertion angles of nails and end caps would alter that force at failure. Simulated oblique fractures of the diaphysis were created in 15 artificial paediatric femurs. Titanium Elastic Nails with end caps were inserted at angles of 45°, 55° and 65° in five specimens for each angle to create three study groups. Biomechanical testing was performed with axial compression until failure. An identical fracture was created in four small adult cadaveric femurs harvested from two donors (both female, aged 81 and 85 years, height 149 cm and 156 cm, respectively). All femurs were tested without and subsequently with end caps inserted at 45°. In the artificial femurs, maximum force was not significantly different between the three groups (p = 0.613). Push-out force was significantly higher in the cadaveric specimens with the use of end caps by an up to sixfold load increase (830 N, standard deviation (SD) 280 vs 150 N, SD 120, respectively; p = 0.007). These results indicate that the nail and end cap insertion angle can be varied within 20° without altering construct stability and that the risk of elastic stable intramedullary nailing push–out can be effectively reduced by the use of end caps. Cite this article: Bone Joint J 2015;97-B:558–63

Aims

Fixation techniques used in the treatment of slipped capital femoral epiphysis (SCFE) that allow continued growth of the femoral neck, rather than inducing epiphyseal fusion in situ, have the advantage of allowing remodelling of the deformity. The aims of this study were threefold: to assess whether the Free-Gliding (FG) SCFE screw prevents further slip; to establish whether, in practice, it enables lengthening and gliding; and to determine whether the age of the patient influences the extent of glide.

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.

Aims

The management of fractures of the medial epicondyle is one of the greatest controversies in paediatric fracture care, with uncertainty concerning the need for surgery. The British Society of Children’s Orthopaedic Surgery prioritized this as their most important research question in paediatric trauma. This is the protocol for a randomized controlled, multicentre, prospective superiority trial of operative fixation versus nonoperative treatment for displaced medial epicondyle fractures: the Surgery or Cast of the EpicoNdyle in Children’s Elbows (SCIENCE) trial.

Aims

Multiple secondary surgical procedures of the shoulder, such as soft-tissue releases, tendon transfers, and osteotomies, are described in brachial plexus birth palsy (BPBP) patients. The long-term functional outcomes of these procedures described in the literature are inconclusive. We aimed to analyze the literature looking for a consensus on treatment options.

Aims

To examine the long-term outcome of arthrodesis of the hip undertaken in a paediatric population in treating painful arthritis of the hip. In our patient population, most of whom live rurally in hilly terrain and have limited healthcare access and resources, hip arthrodesis has been an important surgical option for the monoarticular painful hip in a child.

We have reviewed our experience of the removal of deep extremity orthopaedic implants in children to establish the nature, rate and risk of complications associated with this procedure. A retrospective review was performed of 801 children who had 1223 implants inserted and subsequently removed over a period of 17 years. Bivariate analysis of possible predictors including clinical factors, complications associated with implant insertion and indications for removal and the complications encountered at removal was performed. A logistical regression model was then constructed using those predictors which were significantly associated with surgical complications from the bivariate analyses. Odds ratios estimated in the logistical regression models were converted to risk ratios. The overall rate of complications after removal of the implant was 12.5% (100 complications in 801 patients), with 48 (6.0%) major and 52 (6.5%) minor. Children with a complication after insertion of the initial implant or with a non-elective indication for removal, a neuromuscular disease associated with a seizure disorder or a neuromuscular disease in those unable to walk, had a significantly greater chance of having a major complication after removal of the implant. Children with all four of these predictors were 14.6 times more likely to have a major complication

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.

The role of heritable thrombophilic risk factors in the pathogenesis of the Perthes’ disease is controversial. The clinical and radiological findings of Perthes’ disease may be indistinguishable from those of Gaucher’s disease, and the most common Jewish N370S Gaucher mutation is threefold greater in patients with Perthes’ disease. Familial osteonecrosis of the femoral head is associated with variant mutations of collagen type II (COL2A1 mutations). We therefore studied the potential role of genetic thrombophilia and the Gaucher and COL2A1 mutations in children with Perthes’ disease. Genomic DNA of 119 children with radiologically-confirmed Perthes’ disease diagnosed between 1986 and 2005 was analysed for the thrombophilic polymorphisms Factor V Leiden, 677T-MTHFR and FIIG20210A. The results were compared with those of a group of 276 children without Perthes’ disease. DNA was also analysed for the Gaucher mutations N370S, G insertion (84GG), L444P, Intron 2 (IVS2+1G> A) and R496H. Enzymic assays confirmed the Gaucher disease status. Collagen (COL2A1) mutations of the 12q13 gene were also analysed. The prevalence of thrombophilic markers was similar among the 119 patients with Perthes’ disease and the 276 control subjects. The prevalence of the Gaucher mutation was consistent with Israeli population carriership data and did not confirm an earlier-claimed association with Perthes’ disease. All 199 patients were negative for the studied COL2A1 mutations. We found no genetic association between Perthes’ disease and either Gaucher’s disease or COL2A1 mutations or increased genetic thrombophilia among our patients compared with the control group. A systematic review of case-control studies suggested that there was a positive association between Perthes’ disease and Factor V Leiden. The impact of this association upon the disease, although not consistent across the studies, remains unclear

Aims

To describe and analyze the mid-term functional outcomes of a large series of patients who underwent the Hoffer procedure for brachial plexus birth palsy (BPBP).

We investigated the clinical outcome of a reconstructive procedure of the medial patellofemoral ligament for the treatment of habitual or recurrent dislocation of the patella in four children (6 knees), with a minimum follow-up of four years. The technique involves transfer of the tendon of semitendinosus to the patella using the posterior one-third of the femoral insertion of the medial collateral ligament as a pulley. There was no recurrence of dislocation after surgery. The mean Kujala score at follow-up was 96.3 points. Radiological assessment showed that the congruence angle, the tilt angle and the lateral shift radio were restored to normal. The lateral and medial stress shift ratios and the Insall-Salvati ratio remained abnormal. We conclude that this technique can be recommended for the treatment of habitual or recurrent patellar dislocation in children, although hypermobility and patella alta are not fully corrected

In a prospective, randomised controlled trial, 68 children who had a completely displaced metaphyseal fracture of the distal radius were treated either by manipulation (MUA) and application of an above-elbow cast alone or by the additional insertion of a percutaneous Kirschner (K-) wire. Full radiological follow-up to union was obtained in 65 children and 56 returned for clinical evaluation three months after injury. Maintenance of reduction was significantly better in the K-wire group and fewer follow-up radiographs were required. There was no significant difference in the clinical outcome measured three months after injury. Seven of 33 patients in the MUA group had to undergo a second procedure because of an unacceptable position compared with none of the 35 in the K-wire group (chi-squared test, p < 0.01). One patient in the K-wire group required exploration for recovery of a migrated wire. We conclude that the use of a percutaneous K-wire to augment the reduction of the fracture in children who have a completely displaced metaphyseal fracture of the distal radius is a safe and reliable way of maintaining alignment of the fracture

Aims

The aims of this study were to evaluate the abductor function in moderate and severe slipped capital femoral epiphysis (SCFE), comparing the results of a corrective osteotomy at the base of the femoral neck and osteoplasty with 1) in situ epiphysiodesis for mild SCFE, 2) contralateral unaffected hips, and 3) hips from healthy individuals.

Aims

Our aim was to describe the mid-term appearances of the repair process of the Achilles tendon after tenotomy in children with a clubfoot treated using the Ponseti method.

Aims

To compare the structural durability of hydroxyapatite-tricalcium phosphate (HATCP) to autologous iliac crest bone graft in calcaneal lengthening osteotomy (CLO) for pes planovalgus in childhood.

A retrospective study was performed in 18 patients with achondroplasia, who underwent bilateral humeral lengthening between 2001 and 2013, using monorail external fixators. The mean age was ten years (six to 15) and the mean follow-up was 40 months (12 to 104).

The mean disabilities of the arm, shoulder and hand (DASH) score fell from 32.3 (20 to 40) pre-operatively to 9.4 (6 to 14) post-operatively (p = 0.037). A mean lengthening of 60% (40% to 95%) was required to reach the goal of independent perineal hygiene. One patient developed early consolidation, and fractures occurred in the regenerate bone of four humeri in three patients. There were three transient radial nerve palsies.

Humeral lengthening increases the independence of people with achondroplasia and is not just a cosmetic procedure.

Cite this article: Bone Joint J 2015;97-B:1577–81.

Aims

Extendible endoprostheses have been available for more than 30 years and have become more sophisticated with time. The latest generation is ‘non-invasive’ and can be lengthened with an external magnetic force. Early results have shown a worryingly high rate of complications such as infection. This study investigates the incidence of complications and the need for further surgery in a cohort of patients with a non-invasive growing endoprosthesis.

Aims

This study analysed the clinical and radiological outcome of anatomical reduction of a moderate or severe stable slipped capital femoral epiphysis (SCFE) treated by subcapital osteotomy (a modified Dunn osteotomy) through the surgical approach described by Ganz.

Aims

Our aim was to investigate the predictive factors for the development of a rebound phenomenon after temporary hemiepiphysiodesis in children with genu valgum.

Aims

Although atlantoaxial rotatory fixation (AARF) is a common cause of torticollis in children, the diagnosis may be delayed. The condition is characterised by a lack of rotation at the atlantoaxial joint which becomes fixed in a rotated and subluxed position. The management of children with a delayed presentation of this condition is controversial. This is a retrospective study of a group of such children.

Pelvic obliquity is a common finding in adolescents with cerebral palsy, however, there is little agreement on its measurement or relationship with hip development at different gross motor function classification system (GMFCS) levels.

The purpose of this investigation was to study these issues in a large, population-based cohort of adolescents with cerebral palsy at transition into adult services.

The cohort were a subset of a three year birth cohort (n = 98, 65M: 33F, with a mean age of 18.8 years (14.8 to 23.63) at their last radiological review) with the common features of a migration percentage greater than 30% and a history of adductor release surgery.

Different radiological methods of measuring pelvic obliquity were investigated in 40 patients and the angle between the acetabular tear drops (ITDL) and the horizontal reference frame of the radiograph was found to be reliable, with good face validity. This was selected for further study in all 98 patients.

The median pelvic obliquity was 4° (interquartile range 2° to 8°). There was a strong correlation between hip morphology and the presence of pelvic obliquity (effect of ITDL on Sharpe’s angle in the higher hip; rho 7.20 (5% confidence interval 5.59 to 8.81, p < 0.001). This was particularly true in non-ambulant adolescents (GMFCS IV and V) with severe pelvic obliquity, but was also easily detectable and clinically relevant in ambulant adolescents with mild pelvic obliquity.

The identification of pelvic obliquity and its management deserves closer scrutiny in children and adolescents with cerebral palsy.

Cite this article: Bone Joint J 2015;97-B:1435–40.

The aim of this study was to determine whether an osteoplasty of the femoral neck performed at the same time as an intertrochanteric Imhäuser osteotomy led to an improved functional outcome or increased morbidity. A total of 20 hips in 19 patients (12 left, 8 right, 13 male, 6 female), who underwent an Imhäuser intertrochanteric osteotomy following a slipped capital femoral epiphysis were assessed over an eight-year period. A total of 13 hips in 13 patients had an osteoplasty of the femoral neck at the same time. The remaining six patients (seven hips) had intertrochanteric osteotomy alone. The mean age was 15.3 years (13 to 20) with a mean follow-up of 57.8 months (15 to 117); 19 of the slips were severe (Southwick grade III) and one was moderate (grade II), with a mean slip angle of 65.3° (50° to 80°); 17 of the slips were stable and three unstable at initial presentation. The mean Non-Arthritic Hip Scores (NAHS) in patients who underwent osteoplasty was 91.7 (76.3 to 100) and the mean NAHS in patients who did not undergo osteoplasty was 76.6 (41.3 to 100) (p = 0.056). Two patients required a subsequent arthroplasty and neither of these patients had an osteoplasty. No hips developed osteonecrosis or chondrolysis, and there was no increase in complications related to the osteoplasty. We recommend that for patients with a slipped upper femoral epiphysis undergoing an intertrochanteric osteotomy, the addition of an osteoplasty of the femoral neck should be considered.

Cite this article: Bone Joint J 2014;96-B:1119–23.

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.

The management of children’s fractures has evolved as a result of better health education, changes in lifestyle, improved implant technology and the changing expectations of society. This review focuses on the changes seen in paediatric fractures, including epidemiology, the increasing problems of obesity, the mechanisms of injury, non-accidental injuries and litigation. We also examine the changes in the management of fractures at three specific sites: the supracondylar humerus, femoral shaft and forearm. There has been an increasing trend towards surgical stabilisation of these fractures. The reasons for this are multifactorial, including societal expectations of a perfect result and reduced hospital stay. Reduced hospital stay is beneficial to the social, educational and psychological needs of the child and beneficial to society as a whole, due to reduced costs.

Cite this article: Bone Joint J 2015; 97-B:442–8.

The medial approach for the treatment of children with developmental dysplasia of the hip (DDH) in whom closed reduction has failed requires minimal access with negligible blood loss. In the United Kingdom, there is a preference for these children to be treated using an anterolateral approach after the appearance of the ossific nucleus. In this study we compared these two protocols, primarily for the risk of osteonecrosis.

Data were gathered prospectively for protocols involving the medial approach (26 hips in 22 children) and the anterolateral approach (22 hips in 21 children) in children aged <  24 months at the time of surgery. Osteonecrosis of the femoral head was assessed with validated scores. The acetabular index (AI) and centre–edge angle (CEA) were also measured.

The mean age of the children at the time of surgery was 11 months (3 to 24) for the medial approach group and 18 months (12 to 24) for the anterolateral group, and the combined mean follow-up was 70 months (26 to 228). Osteonecrosis of the femoral head was evident or asphericity predicted in three of 26 hips (12%) in the medial approach group and four of 22 (18%) in the anterolateral group (p = 0.52). The mean improvement in AI was 8.8° (4° to 12°) and 7.9° (6° to 10°), respectively, at two years post-operatively (p = 0.18). There was no significant difference in CEA values of affected hips between the two groups.

Children treated using an early medial approach did not have a higher risk of developing osteonecrosis at early to mid-term follow-up than those treated using a delayed anterolateral approach. The rates of acetabular remodelling were similar for both protocols.

Cite this article: Bone Joint J 2014;96-B:406–13.

We analysed retrospectively the risk factors leading to femoral overgrowth after flexible intramedullary nailing in 43 children (mean age 7.1 years (3.6 to 12.0)) with fractures of the shaft of the femur. We reviewed their demographic data, mechanism of injury, associated injuries, the type and location of the fractures, the nail–canal diameter (NCD) ratios and femoral overgrowth at a mean follow-up of 40.7 months (25.2 to 92.7). At that time, the children were divided into two groups, those with femoral overgrowth of < 1 cm (Group 1), and those with overgrowth of ≥ 1 cm (Group 2). The mean femoral overgrowth of all patients was 0.6 cm at final follow-up. Overgrowth of ≥ 1 cm was noted in 11 children (25.6%). The NCD ratio was significantly lower in Group 2 than in Group 1, with an odds ratio of 30.0 (p = 0.003).

We believe that a low NCD ratio is an indicator of an unstable configuration with flexible intramedullary nailing, and have identified an association between a low NCD ratio and femoral overgrowth resulting in leg-length discrepancy after flexible intramedullary nailing in paediatric femoral shaft fractures.

Cite this article: Bone Joint J 2013;95-B:254–8.

A small proportion of children with Gartland type III supracondylar humeral fracture (SCHF) experience troubling limited or delayed recovery after operative treatment. We hypothesised that the fracture level relative to the isthmus of the humerus would affect the outcome.

We retrospectively reviewed 230 children who underwent closed reduction and percutaneous pinning (CRPP) for their Gartland type III SCHFs between March 2003 and December 2012. There were 144 boys and 86 girls, with the mean age of six years (1.1 to 15.2). The clinico-radiological characteristics and surgical outcomes (recovery of the elbow range of movement, post-operative angulation, and the final Flynn grade) were recorded. Multivariate analysis was employed to identify prognostic factors that influenced outcome, including fracture level. Multivariate analysis revealed that a fracture below the humeral isthmus was significantly associated with poor prognosis in terms of the range of elbow movement (p < 0.001), angulation (p = 0.001) and Flynn grade (p = 0.003). Age over ten years was also a poor prognostic factor for recovery of the range of elbow movement (p = 0.027).

This is the first study demonstrating a subclassification system of Gartland III fractures with prognostic significance. This will guide surgeons in peri-operative planning and counselling as well as directing future research aimed at improving outcomes.

Cite this article: Bone Joint J 2015;97-B:134–40.

A total of 35 children with Erb’s palsy and shoulder abduction of < 90° underwent transfer of teres major. In 18 cases (group 1) a trapezius transfer was added (combined procedure). In 17 cases (group 2) teres major transfer was carried out in isolation (single procedure). The mean gain in abduction was 67.2° (60° to 80°) in group 1 and 37.6° (20° to 70°) in group 2, which reached statistical significance (p < 0.001).

Group 2 was further divided into those who had deltoid power of < M3 (group 2a) and those with deltoid power ≥ M3 (group 2b). The difference in improvement of abduction between groups 2a and group 2b was statistically significant (p < 0.001) but the difference between group 2b and group 1 was not (p = 0.07).

We recommend the following protocol of management: in children with abduction ≥ 90° a single procedure is indicated. In children with abduction < 90°: a combined procedure is indicated if deltoid power is < M3 and a single procedure is indicated if deltoid power is ≥ M3. If no satisfactory improvement is achieved, the trapezius can be transferred at a later stage.

We evaluated results at one year after surgical correction of internal rotation deformities in the shoulders of 270 patients with obstetric brachial plexus palsy. The mean age at surgery was 6.2 years (0.6 to 35). Two techniques were used: open subscapularis elongation and latissimus dorsi to infraspinatus transfer. In addition, open relocation was performed or attempted in all patients with subluxed or dislocated joints. A mixed effects model approach was used to evaluate the effects of surgery on internal and external rotation, abduction, flexion and Mallet score. Independent factors included operative status (pre- or post-operative), gender, age, the condition of the joint, and whether or not transfer was performed. The overall mean improvement in external rotation following surgery was 84.6° (95% confidence interval (CI) 80.2 to 89.1) and the mean Mallet score improved by 4.0 (95% CI 3.7 to 4.2). There was a mean decrease in internal rotation of between 27.6° and 34.4° in the relocated joint groups and 8.6° (95% CI 5.2 to 12.0) in the normal joint group. Abduction and flexion were unchanged following surgery. Adding a latissimus dorsi transfer did not result in greater improvement in the mean external rotation compared with elongation of the subscapularis alone.

Cite this article: Bone Joint J 2013;95-B:1432–8.

A total of 38 relapsed congenital clubfeet (16 stiff, 22 partially correctable) underwent revision of soft-tissue surgery, with or without a bony procedure, and transfer of the tendon of tibialis anterior at a mean age of 4.8 years (2.0 to 10.1). The tendon was transferred to the third cuneiform in five cases, to the base of the third metatarsal in ten and to the base of the fourth in 23. The patients were reviewed at a mean follow-up of 24.8 years (10.8 to 35.6). A total of 11 feet were regarded as failures (one a tendon failure, five with a subtalar fusion due to over-correction, and five with a triple arthrodesis due to under-correction or relapse).

In the remaining feet the clinical outcome was excellent or good in 20 and fair or poor in seven. The mean Laaveg-Ponseti score was 81.6 of 100 points (52 to 92). Stiffness was mild in four feet and moderate or severe in 23.

Comparison between the post-operative and follow-up radiographs showed statistically significant variations of the talo-first metatarsal angle towards abduction. Variations of the talocalcaneal angles and of the overlap ratio were not significant.

Extensive surgery for relapsed clubfoot has a high rate of poor long-term results. The addition of transfer of the tendon of tibialis anterior can restore balance and may provide some improvement of forefoot adduction. However, it has a considerable complication rate, including failure of transfer, over-correction, and weakening of dorsiflexion. The procedure should be reserved for those limited cases in which muscle imbalance is a causative or contributing factor.

Between June 2001 and November 2008 a modified Dunn osteotomy with a surgical hip dislocation was performed in 30 hips in 28 patients with slipped capital femoral epiphysis. Complications and clinical and radiological outcomes after a mean follow-up of 3.8 years (1.0 to 8.5) were documented. Subjective outcome was assessed using the Harris hip score and the Western Ontario and McMaster Universities osteoarthritis index questionnaire.

Anatomical or near-anatomical reduction was achieved in all cases. The epiphysis in one hip showed no perfusion intra-operatively and developed avascular necrosis. There was an excellent outcome in 28 hips. Failure of the implants with a need for revision surgery occurred in four hips.

Anatomical reduction can be achieved by this technique, with a low risk of avascular necrosis. Cautious follow-up is necessary in order to avoid implant failure.

We present the results of 90 consecutive children with displaced fractures of the forearm treated by elastic stable intramedullary nailing with a mean follow-up of 6.6 months (2.0 to 17.6). Eight (9%) had open fractures and 77 (86%) had sustained a fracture of both bones. The operations were performed by orthopaedic trainees in 78 patients (86%). All fractures healed at a mean of 2.9 months (1.1 to 8.7). There was one case of delayed union of an ulnar fracture. An excellent or good functional outcome was achieved in 76 patients (84%). There was no statistical difference detected when the grade of operating surgeon, age of the patient and the diaphyseal level of the fracture were correlated with the outcome. A limited open reduction was required in 40 fractures (44%).

Complications included seven cases of problematic wounds, two transient palsies of the superficial radial nerve and one case each of malunion and a post-operative compartment syndrome. At final follow-up, all children were pain-free and without limitation of sport and play activities.

Our findings indicate that the functional outcome following paediatric fractures of the forearm treated by elastic stable intramedullary nailing is good, without the need for anatomical restoration of the radial bow.

Extensive limb lengthening may be indicated in achondroplastic patients who wish to achieve a height within the normal range for their population. However, increasing the magnitude of lengthening is associated with further complications particularly adjacent joint stiffness and fractures. We studied the relationship between the magnitude of femoral lengthening and callus pattern, adjacent joint stiffness and fracture of the regenerate bone in 40 femoral lengthenings in 20 achondroplastic patients. They were divided into two groups; group A had lengthening of less than 50% and group B of more than 50% of their initial femoral length. The patterns of radiological callus formation were classified according to shape, type and features. The incidence of callus features, knee stiffness and regenerate bone fracture were analysed in the two groups. Group B was associated with an increased incidence of concave, lateral and central callus shapes, adjacent joint and stiffness and fracture. Statistically, the incidence of stiffness in adjacent joints and regenerate bone fracture was significantly associated with the magnitude of lengthening.

We suggest that careful radiological assessment of the patterns of callus formation is a useful method for the evaluation and monitoring of regenerate bone.

The outcome of 56 children (61 shoulders) treated surgically at the Rizzoli Institute between April 1975 and June 2010 for congenital elevation of the scapula is reported. There were 31 girls and 25 boys with a mean age at surgery of 6.4 years (2 to 15). The deformity involved the right shoulder in 20 cases, the left in 31 and was bilateral in five. The degree of the deformity was graded clinically and radiologically according to the classifications of Cavendish and Rigault, respectively. All patients underwent a modified Green procedure combined, in selected cases, with resection of the superomedial portion of the scapula and excision of any omovertebral connection. After a mean follow-up of 10.9 years (1 to 29.3), there was cosmetic improvement by at least one Cavendish grade in 54 shoulders (88.5%). The mean abduction of the shoulder improved from 92° (50° to 155°) to 112° (90° to 170°) and the mean flexion improved from 121° (80° to 160°) to 155° (120° to 175°). The unsatisfactory cosmetic result in seven shoulders was due to coexistent scoliosis in two cases and insufficient reduction of the scapular elevation in the other five. An incomplete upper brachial plexus palsy occurred post-operatively in three patients but resolved within seven months.

We suggest that a modified Green procedure combined with resection of the superomedial portion of the scapula provides good cosmetic and functional results in patients with Sprengel’s shoulder.

Between 2005 and 2010 ten consecutive children with high-energy open diaphyseal tibial fractures were treated by early reduction and application of a programmable circular external fixator. They were all male with a mean age of 11.5 years (5.2 to 15.4), and they were followed for a mean of 34.5 months (6 to 77). Full weight-bearing was allowed immediately post-operatively. The mean time from application to removal of the frame was 16 weeks (12 to 21). The mean deformity following removal of the frame was 0.15° (0° to 1.5°) of coronal angulation, 0.2° (0° to 2°) sagittal angulation, 1.1 mm (0 to 10) coronal translation, and 0.5 mm (0 to 2) sagittal translation. All patients achieved consolidated bony union and satisfactory wound healing. There were no cases of delayed or nonunion, compartment syndrome or neurovascular injury. Four patients had a mild superficial pin site infection; all settled with a single course of oral antibiotics. No patient had a deep infection or re-fracture following removal of the frame. The time to union was comparable with, or better than, other published methods of stabilisation for these injuries. The stable fixator configuration not only facilitates management of the accompanying soft-tissue injury but enables anatomical post-injury alignment, which is important in view of the limited remodelling potential of the tibia in children aged > ten years. Where appropriate expertise exists, we recommend this technique for the management of high-energy open tibial fractures in children.

We present our early experience of arthroscopic reduction of the dislocated hip in very young infants with developmental dysplasia of the hip (DDH).

Eight dislocated hips, which had failed attempts at closed reduction, were treated by arthroscopy of the hip in five children with a mean age of 5.8 months (4 to 7). A two-portal technique was used, with a medial sub-adductor portal for a 2.7 mm cannulated system with a 70° arthroscope and an anterolateral portal for the instruments. Following evaluation of the key intra-articular structures, the hypertrophic ligamentum teres and acetabular pulvinar were resected, and a limited release of the capsule was performed prior to reduction of the hip. All hips were reduced by a single arthroscopic procedure, the reduction being confirmed on MRI scan. None of the hips had an inverted labrum. The greatest obstacle to reduction was a constriction of the capsule. At a mean follow-up of 13.2 months (9 to 24), all eight hips remained stable. Three developed avascular necrosis. The mean acetabular index decreased from 35.5° (30° to 40°) pre-operatively to 23.3° (17° to 28°).

This study demonstrates that arthroscopic reduction is feasible using two standardised portals. Longer follow-up studies are necessary to evaluate the functional results.

We evaluated the morphological changes to the ulnar nerve of both elbows in the cubital tunnel by sonography in a total of 237 children, of whom 117 were aged between six and seven years, 66 between eight and nine years, and 54 between ten and 11 years. We first scanned longitudinally in the extended elbow and then transversely at the medial epicondyle with the elbow extended to 0°. We repeated the scans with the elbow flexed at 45°, 90°, and 120°. There were no significant differences in the area of the ulnar nerve, but the diameter increased as the elbow moved from extension to flexion in all groups. More importantly, the ulnar nerve was subluxated anteriorly on to the medial epicondyle by 1.5% to 1.9% in extended elbows, by 5.9% to 7.9% in those flexed to 45°, by 40.0% to 44% in those flexed to 90°, and by 57.4% to 58.1% in those flexed to 120°, depending on the age group. Sonography clearly and accurately showed the ulnar nerve and was useful for localising the nerve before placing a medial pin. Because the ulnar nerve may translate anteriorly onto the medial epicondyle when the elbow is flexed to 90° or more, it should never be overlooked during percutaneous medial pinning.

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.

Percutaneous epiphysiodesis using transphyseal screws (PETS) has been developed for the treatment of lower limb discrepancies with the aim of replacing traditional open procedures. The goal of this study was to evaluate its efficacy and safety at skeletal maturity. A total of 45 consecutive patients with a mean skeletal age of 12.7 years (8.5 to 15) were included and followed until maturity. The mean efficacy of the femoral epiphysiodesis was 35% (14% to 87%) at six months and 66% (21% to 100%) at maturity. The mean efficacy of the tibial epiphysiodesis was 46% (18% to 73%) at six months and 66% (25% to 100%) at maturity. In both groups of patients the under-correction was significantly reduced between six months post-operatively and skeletal maturity. The overall rate of revision was 18% (eight patients), and seven of these revisions (87.5%) involved the tibia. This series showed that use of the PETS technique in the femur was safe, but that its use in the tibia was associated with a significant rate of complications, including a valgus deformity in nine patients (20%), leading us to abandon it in the tibia. The arrest of growth was delayed and the final loss of growth at maturity was only 66% of that predicted pre-operatively. This should be taken into account in the pre-operative planning.

A delay in the diagnosis of paediatric acute and subacute haematogenous osteomyelitis can lead to potentially devastating morbidity. There are no definitive guidelines for diagnosis, and recommendations in the literature are generally based on expert opinions, case series and cohort studies.

All articles in the English literature on paediatric osteomyelitis were searched using MEDLINE, CINAHL, EMBASE, Google Scholar, the Cochrane Library and reference lists. A total of 1854 papers were identified, 132 of which were examined in detail. All aspects of osteomyelitis were investigated in order to formulate recommendations.

On admission 40% of children are afebrile. The tibia and femur are the most commonly affected long bones. Clinical examination, blood and radiological tests are only reliable for diagnosis in combination. Staphylococcus aureus is the most common organism detected, but isolation of Kingella kingae is increasing. Antibiotic treatment is usually sufficient to eradicate the infection, with a short course intravenously and early conversion to oral treatment. Surgery is indicated only in specific situations.

Most studies were retrospective and there is a need for large, multicentre, randomised, controlled trials to define protocols for diagnosis and treatment. Meanwhile, evidence-based algorithms are suggested for accurate and early diagnosis and effective treatment.

Compartment pressures have not previously been studied in healthy children. We compared the pressures in the four lower leg compartments of healthy children with those of healthy adults.

We included patients aged between two months and six years, and measured the pressures in 80 compartments of 20 healthy children using simple needle manometry. Measurements were repeated in a control group of 20 healthy adults.

The mean compartment pressure in the lower leg in children was significantly higher than in adults (p < 0.001). On average, pressures in the four compartments varied between 13.3 mmHg and 16.6 mmHg in the children and between 5.2 mmHg and 9.7 mmHg in the adults. The latter is in accordance with those recorded in the literature. The mean arterial pressure did not relate to age or to pressure in the compartment.

The findings of this study that the normal compartment pressure of the lower leg in healthy children is significantly higher than that in adults may be of considerable significance in clinical decision-making in children of this age.

We describe the long-term results in ten patients with obstetric brachial plexus palsy of anterior shoulder release combined with transfer of teres major and latissimus dorsi posteriorly and laterally to allow them to act as external rotators. Eight patients had a lesion of the superior trunk and two some involvement of the entire brachial plexus. The mean age at operation was six years, and the mean follow-up was 30 years.

Before operation, the patients were unable actively to rotate the arm externally beyond neutral, although this movement was passively normal. All showed decreased strength of the external rotator, but had normal strength of the internal rotator muscles. Radiologically, no severe bony changes were seen in the glenohumeral joint.

No clinically detectable improvement of active abduction was noted in any patient. The mean active external rotation after operation was 36.5°. This was maintained for a mean of ten years, and then deteriorated in eight patients. At the latest follow-up the mean active external rotation was 10.5°.

The early satisfactory results of the procedure were not maintained. In the long term there was loss of active external rotation, possibly because of gradual degeneration of the transferred muscles, contracture of the surrounding soft tissues and degenerative changes in the glenohumeral joint.

We describe our experience with the ‘four-in-one’ procedure for habitual dislocation of the patella in five children (six knees). All the patients presented with severe generalised ligamentous laxity and aplasia of the trochlear groove. All had a lateral release, proximal ‘tube’ realignment of the patella, semitendinosus tenodesis and transfer of the patellar tendon. The mean age at the time of the operation was 6.1 years (4.9 to 6.9), and the patients were followed up for a mean of 54.5 months (31 to 66). The clinical results were evaluated using the Kujala score.

There has been no recurrence of dislocation. All the patients have returned to full activities and the parents and children were satisfied with the clinical results. The mean Kujala score was 95.3 (88 to 98). Two patients had marginal skin necrosis which healed after debridement and secondary closure. These early results in this small group have shown that the ‘four-in-one’ procedure is effective in the treatment of obligatory dislocation of the patella in children with severe ligamentous laxity and trochlear aplasia.

This study evaluated the results of a physeal-sparing technique of intra-articular anterior cruciate ligament (ACL) reconstruction in skeletally immature patients, with particular reference to growth disturbance. Between 1992 and 2007, 57 children with a mean age of 12.2 years (6.8 to 14.5) underwent ACL reconstruction using the same technique. At a mean of 5.5 years (2 to 14) after surgery, 56 patients underwent clinical and radiological evaluation. At that time, 49 patients (87.5%) had reached bony maturity and 53 (95%) achieved A or B according to the IKDC 2000 classification. Four patients had stopped participation in sports because of knee symptoms, and three patients (5.4%) had a subsequent recurrent ACL injury. There was no clinical or radiological evidence of growth disturbance after a mean growth in stature of 20.0 cm (3 to 38).

This study demonstrates that ACL reconstruction sparing the physes in children is a safe technique protecting against meniscal tears and giving better results than reconstruction in adults, without causing significant growth disturbance.

We describe the early results of glenoplasty as part of the technique of operative reduction of posterior dislocation of the shoulder in 29 children with obstetric brachial plexus palsy. The mean age at operation was five years (1 to 18) and they were followed up for a mean of 34 months (12 to 67).

The mean Mallet score increased from 8 (5 to 13) to 12 (8 to 15) at final follow-up (p < 0.001). The mean passive forward flexion was increased by 18° (p = 0.017) and the mean passive abduction by 24° (p = 0.001). The mean passive lateral rotation also increased by 54° (p < 0.001), but passive medial rotation was reduced by a mean of only 7°. One patient required two further operations. Glenohumeral stability was achieved in all cases.

Flexible intramedullary nailing is gaining popularity as an effective method of treating long-bone fractures in children.

We retrospectively reviewed the records and radiographs of 56 unstable fractures of the tibia in 54 children treated between March 1997 and May 2005. All were followed up for at least two months after the removal of the nails.

Of the 56 tibial fractures, 13 were open. There were no nonunions. The mean time to clinical and radiological union was ten weeks. Complications included residual angulation of the tibia, leg-length discrepancy, deep infection and failures of fixation. All achieved an excellent functional outcome.

We conclude that flexible intramedullary fixation is an easy and effective method of management of both open and closed unstable fractures of the tibia in children.