Who Benefits From Allowing the Physis to Grow in Slipped Capital Femoral Epiphysis?

BACKGROUND: The globally acknowledged treatment for mild to moderate slipped capital femoral epiphysis (SCFE) is single screw in situ fixation, also used for prophylactic contralateral fixation. The Free-Gliding Screw (FG; Pega Medical) is a 2-part free-extending screw system designed to allow the growth of the proximal femur. We aimed to analyze the relationship between skeletal maturity and potential growth of the proximal physis and remodeling of the femoral neck using this implant. MATERIALS AND METHODS: Females below 12 years and males below 14 years undergoing in situ fixation for stable SCFE or prophylactic fixation were treated using the implant. Three elements of the modified Oxford Bone (mOB 3 ) score were used to measure maturity (triradiate cartilage, head of the femur, and greater trochanter). Radiographs were analyzed immediately postoperatively and at a minimum of 2 years for a change in screw length, posterior-sloping angle, articulotrochanteric distance, α angle, and head-neck offset. RESULTS: The study group comprised 30 (F:M=12:18) of 39 hips treated with SCFE and 22 (F:M=13:9) of 29 hips managed prophylactically using the free-Gliding screw. In the therapeutic group, chronologic age was a less valuable predictor of future screw lengthening than mOB 3 . An mOB 3 of ≤13 predicted future growth of >6 mm but did not reach statistical significance ( P =0.07). Patients with open triradiates showed a mean screw lengthening of 6.6 mm compared with those with closed triradiates (4.0 mm), but this did not reach significance ( P =0.12). In those with mOB 3 ≤13, the α angle reduced significantly ( P <0.01) and the head-neck offset increased significantly, suggesting remodeling. There was no change in these parameters when mOB 3 ≥14. In the prophylactic group, change in screw length was significant with mOB 3 of ≤13 (mean=8.0 mm, P <0.05), as was the presence of an open triradiate cartilage (mean=7.7 mm, P <0.05). In both cohorts, posterior-sloping angle and articulotrochanteric distance did not change, indicating no slip progression in either treatment or prophylactic groups and minimal effect on the proximal physeal growth relative to the greater trochanter. CONCLUSIONS: Growing screw constructs can halt slip progression while allowing proximal femoral growth in young patients with SCFE. Ongoing growth is better when the implant is used for prophylactic fixation. The results in treated SCFE need to be expanded to demonstrate a clinically meaningful cut-off for significant growth, but SCFE patients with an open triradiate remodel significantly more than those where it is closed. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Long-Arm Splinting Versus Above-Elbow Casting for Type 1 Supracondylar Fractures of the Humerus in Children: a Randomized Controlled Trial.

Type 1 supracondylar humerus (SCH) fractures tend to heal well when immobilized by above-elbow casting or long-arm splinting. There is no consensus as to whether one treatment method is more effective than the other for this injury. The purpose of this study was to compare the radiographic and functional outcomes of long-arm splinting and above-elbow casting as the definitive treatment for children with type 1 SCH fractures. The study was set up as a randomized controlled non-inferiority trial. Patients between three and 12 years old presenting with a type 1 SCH fracture were randomized into splint or cast groups, or an observational arm. Baumann's angle, functional assessment scores, and Flynn's criteria score were measured at initial injury and at six months post-injury. In total, 34 patients were enrolled in the study with 13 in the randomized arm and 21 in the observational arm. Due to lack of follow-up data at 6 months post-injury, five splint patients and 10 cast patients were included in the final cohort for data analysis. The average change in Baumann's angle at 6-month follow-up was 3° or less for each treatment arm. The splint group obtained excellent Flynn's criteria scores while the cast group reported good and excellent scores. Complications reported in the splint group included device breakdown, a conversion to above-arm cast, and significant itchiness. Preliminary findings suggest functional and radiological outcomes with splinting are non-inferior to casting; however, a larger sample size is required to more accurately compare the two modalities. This study was registered with the U.S. National Institutes of Health (ClinicalTrials.gov, #NCT01912365).

Functional Outcomes of Isolated Infrasyndesmotic Fibula Fractures.

BACKGROUND: Ankle fractures are among the most common injuries encountered by orthopedic surgeons, with an incidence ranging from 71 to 187 per 100 000 people. Few studies have reliably investigated injuries involving isolated fractures of the distal fibula below the level of the ankle syndesmosis. Therefore, this study details on the patient-reported outcomes of nonoperatively managed isolated infrasyndesmotic fibula (ISF) fractures with a minimum 3-year follow-up. METHODS: A retrospective population-based cohort study was undertaken across all emergency departments serving a major urban population. Among 159 consecutive patients meeting inclusion criteria, 108 agreed to participate. Clinical information, functional outcomes, and radiographic measurements were collected from electronic medical records and 3 validated outcome measures: the American Academy of Orthopaedic Surgeons (AAOS) Foot & Ankle Scale (FAS), the AAOS Shoe-Comfort Scale (SCS), and a general questionnaire. RESULTS: An incidence of 22 ISF fractures per 100 000 people/year was found with FAS (91.2 ± 12.9) and SCS scores (76.8 ± 27.7), similar to reported population norms. Approximately 40% of patients (n = 43) reported continuing symptoms including pain (81.8%), stiffness (68.1%), and/or instability (39.0%). Less than 13% (n = 14) reported "severe" disabilities, and no patients required operative intervention within the follow-up period. Less-favorable outcomes were reported among work-related injuries, female patients, and "avulsion-type" fractures less than 10 mm in height (P < .01). No relationships were identified between age, degree of articular-incongruity, fracture-displacement, and self-reported outcomes. CONCLUSIONS: The majority of patients with nonoperatively managed ISF fractures reported good-to-excellent early functional outcomes. Less-favorable outcomes were reported among work-related injuries, female patients, and "avulsion-type" fractures. LEVEL OF EVIDENCE: Level III, comparative series.

Common paediatric conditions of the lower limb.

Growing children are susceptible to a number of disorders to their lower extremities of varying degrees of severity. The diagnosis and management of these conditions can be challenging. With musculoskeletal symptoms being one of the leading reasons for visits to general practitioners, a working knowledge of the basics of these disorders can help in the appropriate diagnosis, treatment, counselling, and specialist referral. This review covers common disorders affecting the hip, the knee and the foot. The aim is to assist general practitioners in recognising developmental norms and differentiating physiological from pathological conditions and to identify when a specialist referral is necessary.

Three-dimensional geometric analysis of the talus for designing talar prosthetics.

Proper understanding of the complex geometric shape of the talus bone is important for the design of generic talar body prosthetics and restoration of the proper ankle joint function after surgery. To date, all talus implants have been patient-specific with the limitation that complex computer modeling is required to produce a mirrored image from the unaffected opposite side followed by machining a patient-specific prosthesis. To develop an "off-the-shelf" non-custom talar prosthesis, it is important to perform a thorough investigation of the geometric shape of the talus bone. This article addresses the applicability of a scaling approach for investigating the geometric shape and similarity of talus bones. This study used computed tomography scan images of the ankle joints of 27 different subjects to perform the analysis. Results of the deviation analyses showed that the deviation in the articulating surfaces of the talus bones was not excessive in terms of talus size. These results suggest that a proposed range of five implant sizes is possible. Finally, it is concluded that the talus bones of the ankle joints are geometrically similar, and a proposed range of five implant sizes will fit a wide range of subjects. This information may help to develop generic talus implants that might be applicable to patients with a severe talus injury.