Risk Factor Analysis for Growth Arrest in Paediatric Physeal Fractures-A Prospective Study.

Background: Fractures through the physis account for 18-30% of all paediatric fractures, leading to growth arrest in up to 5.5% of cases. We have limited knowledge to predict which physeal fractures result in growth arrest and subsequent deformity or limb length discrepancy. The purpose of this study is to identify factors associated with physeal growth arrest to improve patient outcomes. Methods: This prospective cohort study was designed to develop a clinical prediction model for growth arrest after physeal injury. Patients ≤ 18 years old presenting within four weeks of injury were enrolled if they had open physes and sustained a physeal fracture of the humerus, radius, ulna, femur, tibia or fibula. Patients with prior history of same-site fracture or a condition known to alter bone growth or healing were excluded. Demographic data, potential prognostic indicators, and radiographic data were collected at baseline, during healing, and at one- and two-years post-injury. Results: A total of 332 patients had at least six months of follow-up or a diagnosis of growth arrest within six months of injury. In a comparison analysis, patients who developed growth arrest were more likely to be older (12.8 years vs. 9.4 years) and injured on the right side (53.0% vs. 45.7%). Initial displacement and angulation rates were higher in the growth arrest group (59.0% vs. 47.8% and 47.0% vs. 38.8%, respectively), but the amount of angulation was similar (27.0° vs. 28.4°). Rates of growth arrest were highest in distal femoral fractures (86%). Conclusions: The incidence of growth arrest in this patient population appears higher than the past literature reports at 30.1%. However, there may be variances in diagnostic criteria for growth arrest, and the true incidence may be lower. A number of patients were approaching skeletal maturity, and any growth arrest is likely to have less clinical significance in these cases. Further prospective long-term follow-up is required to determine risk factors, incidence, and true clinical impact of growth arrest when it does occur.

Traumatic cubitus valgus consequent of distal humeral fracture: Two case studies from the Holocene Later Stone Age in southern Africa.

OBJECTIVES: Distal fractures of the humerus and their complications have rarely been described or analysed in the palaeopathological literature. The objective of this study was to evaluate two cases of distal humeral fracture with associated cubitus valgus observed in two individuals from the context of the Later Stone Age (LSA) in southern Africa. MATERIALS: Skeletal remains of two individuals. A middle-aged female radiocarbon dated to c.160 BP and a middle-aged male radiocarbon dated to c.2 300 BP. METHODS: Remains were macroscopically and radiographically assessed for injury. RESULTS: Both cases presented with healed antemortem injury to the right elbow attributed to possible falls. Distal humeral fracture resulted in non-union of the lateral epicondyle with extensive morphological changes to the elbow joint including an increased carrying angle. Morphological and osteoarthritic changes suggest a survival period of several years post-injury. SIGNIFICANCE: Cubitus valgus following traumatic injury has rarely been reported amongst historic or prehistoric populations. The described injuries would have had physical and functional consequences, raising questions relating to probable care received during the healing process. The elbow injuries would have resulted in restricted motion and instability of the elbow joint, with a high likelihood of ulnar neuropathy. LIMITATIONS: The contextual information for these individuals is limited and do not permit broader population level study. SUGGESTIONS FOR FURTHER RESEARCH: Formal biomechanical analysis including cross-sectional geometry analysis will provide further information regarding complications and strengthen the diagnosis of ulnar neuropathy. Further research is necessary on the prevalence and complications of humeral fracture.

Three-dimensional computed tomographic angular measurements of the canine tibia using a bone-centered coordinate system.

Introduction: Canine tibial alignment is determined by two-dimensional angular measurements, and tibial torsion is challenging. Aim of the study was the development and evaluation of a CT technique to measure canine tibial varus and torsion angles independent from positioning and truly three-dimensional. Materials and methods: A bone-centered 3D cartesian coordinate system was introduced into the CT-scans of canine tibiae and aligned with the anatomical planes of the bone based on osseous reference points. Tibial torsion, and varus (or valgus) angles were calculated based on geometric definition of projection planes with VoXim® medical imaging software using 3D coordinates of the reference points. To test accuracy of the tibial torsion angle measurements, CT scans of a tibial torsion model were performed in 12 different hinge rotation setups ranging from the normal anatomical situation up to +/ 90° and compared to goniometer measurements. Independency of tibial positioning on the CT scanner table was evaluated in 20 normal canine tibiae that were scanned in a position parallel to the z-axis and two additional off-angle double oblique positions having 15° and 45° deviation in direction of the x- and y-axes. Angular measurements in oblique positions were compared with the normal parallel position by subtraction. Precision was tested using clinical CT scans of 34 canine patients with a clinical diagnosis of patellar luxation. Results: Accuracy testing in the tibial torsional deformity model revealed a difference of 0.2° demonstrated by Passing-Bablok analysis and Bland-Altman-Plots. Testing for independency from tibial positioning resulted in mean differences less than 1.3°. Precision testing in clinical patients resulted in coefficients of variation for repeated measurements of 2.35% (intraobserver agreement) and 0.60% (interobserver agreement) for the tibial torsion angle, and 2.70% (intraobserver agreement) and 0.97% (interobserver agreement) for the tibial varus (or valgus) angle. Discussion: The technique is lacking determination of bone deformities in the sagittal plane, and demonstration of accuracy in severe complex bone deformities in multiple planes.In conclusion, we developed a method to measure canine tibial torsional and varus or valgus deformities, that calculates in 3D space, and we demonstrated its accuracy in a torsional deformity model, and its precision in CT data of clinical patients.

The efficacy of hemiepiphysiodesis for idiopathic knee coronal angular deformity by reconstruction plate and screw: A pilot study.

Background: Angular deformities of the lower extremities are among the most common findings in pediatric orthopedics. Alteration of the mechanical axis in the lower extremity affects the cosmetic appearance and may lead to gait disturbances, knee discomfort, patellar maltracking with or without pain, and early joint osteoarthritis. In the current study, we aimed to investigate the efficacy of 3-hole 3.5 mm reconstruction plates in tension-band temporary hemiepiphysiodesis for correcting idiopathic knee coronal angular deformities. Methods: The surgical procedure was performed using an extraperiosteal tension band plate (a 3-hole reconstruction plate) and two 3.5 mm cortical screws to treat idiopathic knee coronal angular deformity in children. The location of the hemiepiphysiodesis was determined based on the type of angular deformity present. Postoperative follow-ups were conducted through x-rays to measure the medial proximal tibial angle and lateral distal femoral angle of the limbs. Statistical analysis was then performed to evaluate the efficacy of the surgical treatment based on the rate of alignment change exhibited. Results: The study included 14 patients (25 limbs) with genu valgum deformity who underwent temporary hemiepiphysiodesis on both the distal femur and proximal tibia, with 16 proximal tibias and 15 distal femurs being corrected. The correction rate for genu valgum was found to be 0.59° per month for both proximal tibial and distal femoral hemiepiphysiodesis. Six patients (12 limbs) were also identified with genu varum deformity, and the correction rates for proximal tibial lateral hemiepiphysiodesis and distal femoral lateral hemiepiphysiodesis were 0.85° and 0.15° per month, respectively. During a mean follow-up duration of 11 ± 5.7 months, only one case of physeal plate closure was observed, and there were no other significant complications. Conclusion: Temporary hemiepiphysiodesis with a 3-hole R-plate and two cortical screws takes advantage of physiological physeal growth to successfully treat idiopathic angular deformities with low complication rates.

Antegrade Intramedullary Femoral Lengthening and Distal Temporary Hemiepiphysiodesis for Combined Correction of Leg Length Discrepancy and Coronal Angular Deformity in Skeletally Immature Patients.

Leg length discrepancies (LLD) are frequently associated with coronal malalignment. Temporary hemiepiphysiodesis (HED) is a well-established procedure for the correction of limb malalignment in skeletally immature patients. For treatment of LLD > 2 cm, lengthening with intramedullary devices gains increasing popularity. However, no studies have investigated the combined application of HED and intramedullary lengthening in skeletally immature patients. This retrospective single-center study evaluated the clinical and radiological outcomes of femoral lengthening with an antegrade intramedullary lengthening nail combined with temporary HED performed in 25 patients (14 females) between 2014 and 2019. Temporary HED through the implantation of flexible staples of the distal femur and/or proximal tibia was either performed prior (n = 11), simultaneously (n = 10) or subsequently (n = 4) to femoral lengthening. The mean follow-up period was 3.7 years (±1.4). The median initial LLD was 39.0 mm (35.0-45.0). Twenty-one patients (84%) presented valgus and four (16%) showed varus malalignment. Leg length equalization was achieved in 13 of the skeletally mature patients (62%). The median LLD of the eight patients with residual LLD > 10 mm at skeletal maturity was 15.5 mm (12.8-21.8). Limb realignment was observed in nine of seventeen skeletally mature patients (53%) in the valgus group, and in one of four patients (25%) in the varus group. Combining antegrade femoral lengthening and temporary HED is a viable option to correct LLD and coronal limb malalignment in skeletally immature patients; however, achieving limb length equalization and realignment may be difficult in cases of severe LLD and angular deformity, in particular.

Simultaneous anterior cruciate ligament reconstruction and implant-mediated guided growth to correct genu valgum in skeletally immature patients.

OBJECTIVES: Adolescents with anterior cruciate ligament (ACL) tears can present with concomitant lower extremity coronal plane angular deformity (CPAD) that both predispose to injury as well as may increase the risk of graft rupture following ACL reconstruction (ACLR). The goal of this study was to examine the safety and efficacy of concomitant ACLR with implant-mediated guided growth (IMGG) compared to isolated IMGG procedures in paediatric and adolescent patients. METHODS: Operative records of all paediatric and adolescent patients (age ≤ 18 years) that underwent simultaneous ACLR and IMGG by one of two paediatric orthopaedic surgeons between 2015 and 2021 were retrospectively reviewed. A comparison cohort of isolated IMGG patients was identified and matched based on bone age within one year, sex, laterality, and fixation type (i.e. transphyseal screw vs. tension band plate and screw construct). Pre- and post-operative mechanical axis deviation (MAD), angular axis deviation (AAD), lateral distal femoral angle (LDFA), and medial proximal tibial angle (MPTA) were recorded. RESULTS: A total of 9 participants who underwent concomitant ACLR and IMGG (ACLR â€‹+ â€‹IMGG) were identified, with 7 of these participants meeting the final inclusion criteria. The participants had a median age of 12.7 (IQR â€‹= â€‹12.1 - 14.2) years and median bone age of 13.0 (IQR â€‹= â€‹12.0 - 14.0) years. Of the 7 participants that underwent ACLR and IMGG, 3 underwent a modified MacIntosh procedure with ITB autograft, 2 received quadriceps tendon autograft, and 1 underwent hamstring autograft reconstruction. There were no significant differences in the amount of correction obtained between ACLR â€‹+ â€‹IMGG and matched IMGG subjects with respect to any measurement variable (MAD difference: p â€‹= â€‹0.47, AAD difference: p â€‹= â€‹0.58, LDFA difference: p â€‹= â€‹0.27, MPTA difference: p â€‹= â€‹0.20). There were also no significant differences in alignment variables per unit time between cohorts (MAD/month: p â€‹= â€‹0.62, AAD/month â€‹= â€‹0.80, LDFA/month â€‹= â€‹0.27, MPTA/month â€‹= â€‹0.20). CONCLUSION: The results of the current study indicate that concomitant ACLR and lower extremity CPAD correction is a safe approach to treat CPAD concomitantly with ACLR in young patients who present with an acute ACL tear. Furthermore, one can expect reliable correction of CPAD after combined ACLR and IMGG, no different than the correction obtained in the setting of IMGG alone. LEVEL OF EVIDENCE: III.

The effectiveness of physeal bar resection with or without Hemi-Epiphysiodesis to treat partial growth arrest.

PURPOSE: To evaluate the outcomes of distal femoral, proximal tibial, and distal tibial physeal bar resection combined with or without the Hemi-Epiphysiodesis procedure and provide a better understanding of the application of physeal bar resection combined with Hemi-Epiphysiodesis procedure in the treatment of physeal bar growth arrest. METHODS: We retrospectively reviewed the patients who suffered physeal bar and underwent physeal bar resection with or without the Hemi-Epiphysiodesis technique during 2010-2020. All were followed up for at least 2 years or to maturity. A modified mapping method was used to determine the area of a physeal bar by CT data. The aLDFA, aMPTA, aLDTA, MAD, and LLD were measured to assess the deformity of the lower limb. RESULTS: In total, 19 patients were included in this study. The average age was 8.9 years (range 4.4 to 13.3 years old). During the follow-up, 4 (21.1%) patients had an angular change < 5°; 12 (63.2%) patients had angular deformity improvement > 5° averaging 10.0° (range 5.3° to 23.2°), and 3 (15.8%) patients had improvement of the angular deformity averaging 16.8° (range 7.4° to 27.1°). Eleven patients (57.9%) had significant MAD improvement. After surgery, we found that 7 (36.8%) patients had an LLD change of < 5 mm and were considered unchanged. Only 2 (15%) patients had an LLD improvement > 5 mm averaging 1.0 cm (range 0.7 to 1.3 cm), and 7 (36.8%) patients had increasing of LLD > 5 mm averaging 1.3 cm (range 0.5 to 2.5 cm). There were no postoperative fractures, infections, or intraoperative complications such as neurovascular injury. CONCLUSION: Physeal bar resection combined with Hemi-epiphysiodesis is helpful for partial epiphysis growth arrest. Without statistically verifying, we still believe that patients with limited growth ability could benefit more from physeal bar resection combined with Hemi-epiphysiodesis.

Guided Growth Technique for Epiphysiodesis and Hemiepiphysiodesis: Safety and Performance Evaluation.

BACKGROUND: Guided-growth modulation is a first-line treatment widely adopted to correct lower-limb angular deformities and limb-length discrepancies (LLD) in the paediatric population. METHODS: We conducted a retrospective study to evaluate the safety and performance of a new construct (8-Plate Plus or Guided-Growth Plate System Plus, Orthofix S.r.l) used to correct angular deformities and LLD in non-skeletally mature children. The primary endpoint was safety (from plate implantation to removal). The secondary endpoint was performance; patients treated for LLD achieved complete correction if a pre- and post-surgery difference of <0 was observed; angular deformities performance was measured in terms of IMD, ICD, mMPTA, and mLDFA. RESULTS: We performed 69 procedures in 41 patients. A total of 10 patients had an LLD, and 31 had an angular deformity. We observed nine minor complications in the hemiepiphysiodesis group. One patient experienced rebound. All 10 LLD patient treatments were successful. A total of 30/31 patients with an angular deformity had a successful treatment; the remaining patient had a partial correction. CONCLUSIONS: Guided-growth by temporary epiphysiodesis or hemiepiphysiodesis was safe and effective for angular deformities and limb-length discrepancies. Further prospective and/or randomized controlled trial studies assessing more significant cohorts of patients and a comparison group could add evidence to our findings.

Introduction of a bone-centered three-dimensional coordinate system enables computed tomographic canine femoral angle measurements independent of positioning.

Introduction: Measurement of torsional deformities and varus alignment in the canine femur is clinically and surgically important but difficult. Computed tomography (CT) generates true three-dimensional (3D) information and is used to overcome the limitations of radiography. The 3D CT images can be rotated freely, but the final view for angle measurements remains a subjective variable decision, especially in severe and complex angular and torsional deformities. The aim of this study was the development of a technique to measure femoral angles in a truly three-dimensional way, independent of femoral positioning. Methods: To be able to set reference points in any image and at arbitrary positions of the CT series, the 3D coordinates of the reference points were used for mathematical calculation of the angle measurements using the 3D medical imaging Software VoXim®. Anatomical reference points were described in multiplanar reconstructions and volume rendering CT. A 3D bone-centered coordinate system was introduced and aligned with the anatomical planes of the femur. For torsion angle measurements, the transverse projection plane was mathematically defined by orthogonality to the longitudinal diaphyseal axis. For varus angle measurements, the dorsal plane was defined by a femoral retrocondylar axis. Independence positioning was tested by comparison of angle measurement results in repeated scans of 13 femur bones in different parallel and two double oblique (15/45°) positions in the gantry. Femoralvarus (or valgus), neck version (torsion), and inclination angles were measured, each in two variations. Results: Resulting mean differences ranged between -0.9° and 1.3° for all six determined types of angles and in a difference of <1° for 17 out of 18 comparisons by subtraction of the mean angles between different positions, with one outlier of 1.3°. Intra- and inter-observer agreements determined by repeated measurements resulted in coefficients of variation for repeated measurements between 0.2 and 13.5%. Discussion: The introduction of a bone-centered 3D coordinate system and mathematical definition of projection planes enabled 3D CT measurements of canine femoral varus and neck version and inclination angles. Agreement between angular measurements results of bones scanned in different positions on the CT table demonstrated that the technique is independent of femoral positioning.

Angular deformities after percutaneous epiphysiodesis for leg length discrepancy.

Purpose: The purpose of this study was to systematically analyze the presence of secondary angular deformities after percutaneous epiphysiodesis based on long-standing radiographs, and to see if the occurrence and magnitude of angular deformities after percutaneous epiphysiodesis correlated with the amount of remaining growth at the time of surgery. Methods: From a local Health Register consisting of patients investigated using the Moseley Straight-Line Graph, we identified 269 patients who had undergone percutaneous epiphysiodesis from 2002 until 2020. Radiographic analysis included the measurement of mechanical axis and joint orientation angles on long-standing anterior-posterior radiographs. Remaining growth was analyzed based on the Menelaus method. Results: One hundred and forty epiphysiodeses (71 femurs and 69 tibiae) in 88 patients (39 girls and 49 boys) could be included in the study. Mean age at surgery was 13.2 (10-16.8) years, and mean skeletal age at surgery was 13.0 (9.8-15.7) years. A change of the MA (Mechanical axis) ≥10 mm was found in eight patients (9%). Secondary frontal plane deformities after percutaneous epiphysiodesis correlated significantly with the remaining growth at the time of surgery (p = 0.003). Conclusion: We found a high rate of secondary angular deformities after percutaneous epiphysiodesis, and the magnitude of the deformities correlated with the amount of remaining growth at the time of surgery. A modification of the original surgical method for percutaneous epiphysiodesis to also include ablation of central parts of the growth plate might be considered. Patients should be enrolled in a systematic follow-up scheme which allows for the early detection of possible angular deformities. Level of evidence: level III study.

Tibial Lengthening along Submuscular Plate with Simultaneous Acute Tibial Deformity Correction by High-Energy Osteotomy: A Comparative Study.

Submuscular plating and osteotomy using power saw have shown the benefits in certain situations of limb lengthening. However, no previous studies combining both procedures have been conducted for acute tibial deformity correction and limb lengthening. Nineteen cases were enrolled in this study. Ten patients received tibial lengthening with acute knee angular deformity correction using high-energy osteotomy (Group 1), and nine patients received tibial lengthening only with osteotomy using multiple drills and osteotome (Group 2). Radiographic parameters retrieved before and after the operation included leg-length discrepancy, tibial length, length gained, mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), and mechanical axis deviation (MAD). There were significant differences between groups in terms of external fixator index (EFI) (p = 0.013) and healing index (HI) (p = 0.014), but no significance in the length gained (p = 0.356). The latest postoperative mLDFA (p = 0.315), MPTA (p = 0.497), and MAD (p = 0.211) of Group 1 were not distinguishable from Group 2. The functional outcomes were excellent, and there were no permanent complications. Despite showing a longer healing time, this alternative lengthening procedure which combines fixator-assisted plate lengthening in the tibia with simultaneous surgical intervention of acute tibial deformity correction using an oscillating saw is appropriate for patients with leg-length discrepancy and angular deformity of the tibia.

Alargamiento óseo con clavos magnéticos. Experiencia en pacientes menores de 18 años / Bone lengthening with magnetic nails. Experience in patients younger than 18

Antecedentes y objetivo: El alargamiento óseo con clavos endomedulares magnéticos (CEM) se plantea como alternativa ventajosa a otros alargamientos, al eliminar los inconvenientes de la fijación externa. El objetivo de este trabajo es analizar los resultados y valorar las complicaciones en una serie de pacientes menores de 18 años. Material y métodos: Entre 2014 y 2019 se han realizado 31 alargamientos con CEM tipo Precice2® (23 fémures, 8 tibias), en 28 pacientes menores de 18 años (15 varones y 13 mujeres). Este estudio retrospectivo observacional incluye pacientes con seguimiento de más de 18 meses. La edad media ha sido de 14,4 años (8-18). Los aspectos más relevantes analizados han sido: acortamiento/deformidad previos, alargamiento/corrección conseguidos y tiempo hasta carga completa. Además, se han revisado las complicaciones y reintervenciones. Resultados: El alargamiento conseguido ha sido de 5,5cm de media (3-8). En 28 alargamientos (90,3%) se ha conseguido o superado el objetivo planificado. El índice de curación (IC) medio fue de 1,1 meses/cm. Más de la mitad de los alargamientos (55%) han presentado alguna complicación. Aunque estas solo han dejado secuelas permanentes en 2 pacientes (7,1%), 9 de ellos han precisado reintervención (13 operaciones). No ha habido infecciones. Conclusiones: La elongación ósea con CEM en pacientes menores de 18 años ha conseguido su objetivo en más de un 90% de casos de manera eficaz, precisa y segura. En esta serie, los CEM han eliminado la necesidad de fijadores externos y han tutorizado eficazmente el segmento operado. La alta incidencia de complicaciones sigue siendo preocupante.(AU)

Background and goal: Bone elongation with magnetic endomedullary nails (MEN) has been proposed as an advantageous alternative to other techniques, by eliminating the drawbacks of external fixation. The aim of this work is to analyze the results and assess the complications in a series of patients under the age of 18. Material and methods: From 2014 to 2019, 31 elongations (23 femurs, 8 tibias) using MEN (Precice2™) have been performed in 28 patients younger than 18 (15 males and 13 females). In this observational retrospective study, only patients with follow-up longer than 18 months have been included. The average age has been 14.4 years (8–18). The most relevant aspects analyzed have been: previous shortening/deformity, elongation/correction achieved and time to full weight bearing. Complications and re-interventions have also been assessed. Results: The elongation achieved has been 5.5cm on average (3–8). In 28 elongations (90.3%) the planned goal of lengthening was achieved. The mean healing index was 1.1months/cm. More than half of elongations (55%) presented complications. Although they produced permanent sequelae in only two patients (7.1%), a total of 9 patients required re-intervention (13 operations). No infections were detected. Conclusions: Bone lengthening with MEN in individuals younger than 18 has achieved its goal in more than 90% of patients in an effective, accurate and safe manner. The use of MEN in this series has eliminated the need for external fixators and has successfully tutorized the operated segment. The high number of complications detected in this study remains a concern.(AU)

[Translated article] Bone lengthening with magnetic nails. Experience in patients younger than 18 / Alargamiento óseo con clavos magnéticos. Experiencia en pacientes menores de 18 años

Antecedentes y objetivo: El alargamiento óseo con clavos endomedulares magnéticos (CEM) se plantea como alternativa ventajosa a otros alargamientos, al eliminar los inconvenientes de la fijación externa. El objetivo de este trabajo es analizar los resultados y valorar las complicaciones en una serie de pacientes menores de 18 años. Material y métodos: Entre 2014 y 2019 se han realizado 31 alargamientos con CEM tipo Precice2® (23 fémures, 8 tibias), en 28 pacientes menores de 18 años (15 varones y 13 mujeres). Este estudio retrospectivo observacional incluye pacientes con seguimiento de más de 18 meses. La edad media ha sido de 14,4 años (8-18). Los aspectos más relevantes analizados han sido: acortamiento/deformidad previos, alargamiento/corrección conseguidos y tiempo hasta carga completa. Además, se han revisado las complicaciones y reintervenciones. Resultados: El alargamiento conseguido ha sido de 5,5cm de media (3-8). En 28 alargamientos (90,3%) se ha conseguido o superado el objetivo planificado. El índice de curación (IC) medio fue de 1,1 meses/cm. Más de la mitad de los alargamientos (55%) han presentado alguna complicación. Aunque estas solo han dejado secuelas permanentes en 2 pacientes (7,1%), 9 de ellos han precisado reintervención (13 operaciones). No ha habido infecciones. Conclusiones: La elongación ósea con CEM en pacientes menores de 18 años ha conseguido su objetivo en más de un 90% de casos de manera eficaz, precisa y segura. En esta serie, los CEM han eliminado la necesidad de fijadores externos y han tutorizado eficazmente el segmento operado. La alta incidencia de complicaciones sigue siendo preocupante.(AU)

Background and goal: Bone elongation with magnetic endomedullary nails (MEN) has been proposed as an advantageous alternative to other techniques, by eliminating the drawbacks of external fixation. The aim of this work is to analyze the results and assess the complications in a series of patients under the age of 18. Material and methods: From 2014 to 2019, 31 elongations (23 femurs, 8 tibias) using MEN (Precice2™) have been performed in 28 patients younger than 18 (15 males and 13 females). In this observational retrospective study, only patients with follow-up longer than 18 months have been included. The average age has been 14.4 years (8–18). The most relevant aspects analyzed have been: previous shortening/deformity, elongation/correction achieved and time to full weight bearing. Complications and re-interventions have also been assessed. Results: The elongation achieved has been 5.5cm on average (3–8). In 28 elongations (90.3%) the planned goal of lengthening was achieved. The mean healing index was 1.1months/cm. More than half of elongations (55%) presented complications. Although they produced permanent sequelae in only two patients (7.1%), a total of 9 patients required re-intervention (13 operations). No infections were detected. Conclusions: Bone lengthening with MEN in individuals younger than 18 has achieved its goal in more than 90% of patients in an effective, accurate and safe manner. The use of MEN in this series has eliminated the need for external fixators and has successfully tutorized the operated segment. The high number of complications detected in this study remains a concern.(AU)

[Translated article] Bone lengthening with magnetic nails. Experience in patients younger than 18.

BACKGROUND AND GOAL: Bone elongation with magnetic endomedullary nails (MEN) has been proposed as an advantageous alternative to other techniques, by eliminating the drawbacks of external fixation. The aim of this work is to analyse the results and assess the complications in a series of patients under the age of 18. MATERIAL AND METHODS: From 2014 to 2019, 31 elongations (23 femurs, 8 tibias) using MEN (Precice2®) have been performed in 28 patients younger than 18 (15 males and 13 females). In this observational retrospective study, only patients with follow-up longer than 18 months have been included. The average age has been 14.4 years (8-18). The most relevant aspects analysed have been: previous shortening/deformity, elongation/correction achieved and time to full weight bearing. Complications and re-interventions have also been assessed. RESULTS: The elongation achieved has been 5.5cm on average (3-8). In 28 elongations (90.3%) the planned goal of lengthening was achieved. The mean healing index (HI) was 1.1months/cm. More than half of elongations (55%) presented complications. Although they produced permanent sequelae in only two patients (7.1%), a total of 9 patients required re-intervention (13 operations). No infections were detected. CONCLUSIONS: Bone lengthening with MEN in individuals younger than 18 has achieved its goal in more than 90% of patients in an effective, accurate and safe manner. The use of MEN in this series has eliminated the need for external fixators and has successfully tutorized the operated segment. The high number of complications detected in this study remains a concern.

The Comparison of Lower Extremity Length and Angle between Computed Radiography-Based Teleoroentgenogram and EOS® Imaging System.

Background and objectives: The differences between computed radiography-based teleoroentgenograms (CR-based teleoroentgenograms) and an EOS® imaging system were evaluated by measuring lower extremity lengths and alignments. Materials and methods: The leg length [L], femur length [F], tibia length [T], and hip−knee−ankle (HKA) angle were measured in 101 patients with lower extremity disease by a CR-based teleoroentgenogram with computed radiography and an EOS®. The additive length of the femoral and tibial segments (F + T) was determined by adding the two length values. Then, the differences among all five parameters between the two techniques were analyzed. The magnification (mm) was calculated by subtracting the length measurements on the EOS® from those in the scanogram. Furthermore, the magnification percentage (%) was calculated by dividing the magnification with the measurements on the EOS®. Results: The magnification errors (mean ± standard deviation), when comparing both right and left sides, were 7.80 ± 1.41%, 7.3 ± 6.01%, 5.16 ± 1.25%, and 6.45 ± 0.94% for L, F, T, and F + T, respectively. For limb length, the CR-based teleoroentgenogram had an average magnification of 6.8% (range, 5.2 to 7.8%) compared to the EOS® imaging. The two groups displayed a statistical difference (p < 0.01), except for the HKA angle. Conclusions: The CR-based teleoroentgenogram had a magnification of about 6.8% compared to the EOS® imaging system in evaluating lower extremity length. Therefore, more attention must be given to CR-based teleoroentgenograms to correct angular deformities.

Rebound phenomenon and its risk factors after hemiepiphysiodesis using tension band plate in children with coronal angular deformity.

BACKGROUND: This study was performed to evaluate the rebound phenomenon after the correction of coronal angular deformity by hemiepiphysiodesis using tension band plate in children and to identify its risk factors. METHODS: We reviewed 50 children (mean age, 11.0 ± 2.5 years) with 94 physes who had undergone hemiepiphysiodesis using tension band plate due to coronal angular deformity of the lower limb. Patients' demographic data including sex, age at initial surgery and plate removal, affected bone (distal femur or proximal tibia), affected side, and body mass index were collected. The mechanical lateral distal femoral angle (mLDFA) and the mechanical medial proximal tibial angle (mMPTA) were measured from the teleradiogram, Physes were divided into rebound and non-rebound group, and rebound group was defined as the physes which had ≥ 5° of mLDFA or mMPTA returning to its original deformity. Generalized estimating equation based multivariable analysis was used to identify the risk factors for the rebound phenomenon after the deformity correction. RESULTS: A total of 41 physes classified into rebound group and 53 physes into non-rebound group. There were significant differences in the age at initial surgery (p = 0.004), the age at implant removal (p = 0.002), the amount of correction (p = 0.001), and the rate of correction (p < 0.001) between two groups. The rate of correction was significantly associated with the rebound phenomenon (p = 0.044). The risk of rebound phenomenon was 1.2-fold higher as the rate of correction increased by 1° per year. The cutoff values of the correction rate between the two groups were 6.9°/year (p < 0.001). CONCLUSIONS: This study showed that the rebound group had younger age and faster correction rate than those in the non-rebound group. In addition, the correction rate for deformity was a significant risk factor for the rebound phenomenon after hemiepiphysiodesis using the tension band plate. Close monitoring after implant removal is required for children who have a rapid correction rate over 7°/year.

Osteofibrous dysplasia of the tibia : the importance of deformity in surveillance.

AIMS: 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. METHODS: A retrospective review at three paediatric tertiary centres identified 101 cases of tibial OFD in 99 patients. The clinical records, radiological images, and histology were analyzed. RESULTS: Mean age at presentation was 13.5 years (SD 12.4), and mean follow-up was 5.65 years (SD 5.51). At latest review, 62 lesions (61.4%) were in skeletally mature patients. The most common site of the tibial lesion was the anterior (76 lesions, 75.2%) cortex (63 lesions, 62.4%) of the middle third (52 lesions, 51.5%). Pain, swelling, and fracture were common presentations. Overall, 41 lesions (40.6%) presented with radiological deformity (> 10°): apex anterior in 97.6%. A total of 41 lesions (40.6%) were treated conservatively. Anterior bowing < 10° at presentation was found to be related to successful conservative management of OFD (p = 0.013, multivariable logistic regression). Intralesional excision was performed in 43 lesions (42.6%) and a wide excision of the lesion in 19 (18.8%). A high complication rate and surgical burden was found in those that underwent a wide excision regardless of technique employed. There was progression/recurrence in nine lesions (8.9%) but statistical analysis found no predictive factors. No OFD lesion transformed to adamantinoma. CONCLUSION: This study confirms OFD to be a benign bone condition with low rates of local progression and without malignant transformation. It is important to distinguish OFD from adamantinoma by a histological diagnosis. Focus should be on angular deformity, monitored with full-length tibial radiographs. Surgery is indicated in symptomatic patients and predicted by the severity of the initial angular deformity. Surgery should focus more on the deformity rather than the lesion. Cite this article: Bone Joint J 2022;104-B(2):302-308.

Safe corridors for external skeletal fixator pin placement in feline long bones.

OBJECTIVES: External skeletal fixation is an established technique in cats for biological fixation of long bone fractures, stabilisation of the joints, and treatment of shearing injuries and angular deformities. As appropriate and accurate pin insertion is imperative for a successful outcome, knowledge of topographic anatomy and areas that are safe (safe corridors) for pin placement is integral to successful surgery. At present, however, safe corridors have not been determined fully in feline orthopaedics, with surgeons having to rely on knowledge based on canine orthopaedics. This study was performed to determine safe corridors for pin placement in feline long bones. METHODS: The limbs of six feline cadavers were frozen. Only limbs with no history of orthopaedic conditions were used. Transverse sections through the limbs were examined, and anatomical structures were determined in relation to the bone. These structures were compared with those of the contralateral limbs, which were dissected for topographic assessment. Safe corridors were defined as topographic areas where no vital structures, muscles or joints were present. RESULTS: Examination of the humerus revealed safe corridors at its proximal craniolateral aspect and on the medial and lateral humeral condyles. Safe corridors of the antebrachium were identified on the lateral aspect of the olecranon, the distal two-thirds of the medial antebrachium and the distal third of the lateral antebrachium. Safe corridors in the femur consisted of a small area lateral to and just below the major trochanter, and on the medial and lateral femoral condyles. Evaluation of the tibia revealed safe corridors on the medial aspect of the entire tibia, the cranial aspect of the proximal tibia on the tibial crest and the area just proximal to the lateral malleolus. CONCLUSIONS AND RELEVANCE: Safe corridors for pin placement during external skeletal fixation in feline limbs differed from those in canine limbs. Knowledge of canine anatomy may be inapplicable to pin placement in feline limbs undergoing external skeletal fixation.

Assessment of Skeletal Maturity and Postoperative Growth Disturbance After Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: A Systematic Review.

BACKGROUND: Growth disturbance is an uncommon but potentially serious complication after anterior cruciate ligament (ACL) reconstruction in skeletally immature patients. PURPOSE: To describe how the pediatric ACL literature has assessed preoperative skeletal maturity and the amount of growth remaining and to comprehensively review the incidence, reporting, and monitoring of postoperative growth disturbance. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: This review included studies reporting original research of clinical outcomes of skeletally immature patients after ACL reconstruction. Patient characteristics, surgical techniques, preoperative assessments of skeletal maturity or growth remaining, and postoperative assessments of growth disturbances were extracted. RESULTS: A total of 100 studies met inclusion criteria. All studies reported chronological age, and 28 studies (28%) assessed skeletal age. A total of 44 studies (44%) used Tanner staging, and 12 studies (12%) obtained standing hip-to-ankle radiographs preoperatively. In total, 42 patients (2.1%) demonstrated a leg length discrepancy (LLD) >10 mm postoperatively, including 9 patients (0.5%) with LLD >20 mm; furthermore, 11 patients (0.6%) with LLD underwent growth modulation. Shortening was the most common deformity overall, but overgrowth was reported more frequently in patients who had undergone all-epiphyseal techniques. Most LLDs involved the femur (83%). A total of 26 patients (1.3%) demonstrated a postoperative angular deformity ≥5°, and 9 of these patients underwent growth modulation. The most common deformities were femoral valgus (41%), tibial recurvatum (33%), and tibial varus (22%). Although standing hip-to-ankle radiographs were the most common radiographic assessment of growth disturbance, most studies inadequately reported the clinical and radiographic methods of assessment for growth disturbance. Additionally, only 35% of studies explicitly followed patients to skeletal maturity. CONCLUSION: This systematic review described significant variability in the reporting and monitoring of growth-related complications after ACL reconstruction in skeletally immature patients. The incidence of LLD and angular deformity appeared to be low, but the quality of research was not comprehensive enough for accurate assessment. REGISTRATION: CRD42019136059 (PROSPERO).

Bone lengthening with magnetic nails. Experience in patients younger than 18. / Alargamiento óseo con clavos magnéticos. Experiencia en pacientes menores de 18 años.

BACKGROUND AND GOAL: Bone elongation with magnetic endomedullary nails (MEN) has been proposed as an advantageous alternative to other techniques, by eliminating the drawbacks of external fixation. The aim of this work is to analyze the results and assess the complications in a series of patients under the age of 18. MATERIAL AND METHODS: From 2014 to 2019, 31 elongations (23 femurs, 8 tibias) using MEN (Precice2™) have been performed in 28 patients younger than 18 (15 males and 13 females). In this observational retrospective study, only patients with follow-up longer than 18 months have been included. The average age has been 14.4 years (8-18). The most relevant aspects analyzed have been: previous shortening/deformity, elongation/correction achieved and time to full weight bearing. Complications and re-interventions have also been assessed. RESULTS: The elongation achieved has been 5.5cm on average (3-8). In 28 elongations (90.3%) the planned goal of lengthening was achieved. The mean healing index was 1.1months/cm. More than half of elongations (55%) presented complications. Although they produced permanent sequelae in only two patients (7.1%), a total of 9 patients required re-intervention (13 operations). No infections were detected. CONCLUSIONS: Bone lengthening with MEN in individuals younger than 18 has achieved its goal in more than 90% of patients in an effective, accurate and safe manner. The use of MEN in this series has eliminated the need for external fixators and has successfully tutorized the operated segment. The high number of complications detected in this study remains a concern.