Implants removal in children: results of a survey among Italian orthopaedic surgeons.

In the treatment of paediatric limb disorders, the use of metal implants has been increasing over the last decades. Recent studies have addressed the decision of orthopaedic surgeons regarding the removal of implants after the treatment of fracture, and there is a growing consensus within the scientific community supporting the choice of not removing implants in children. This survey aimed to investigate the rationale behind the Italian orthopaedic community's decision regarding metal implant removal in paediatric patients. An electronic questionnaire was sent to all members of the Italian Paediatric Orthopaedic and Traumatology Society, Italian Orthopaedic and Traumatology Society, Italian Club of Osteosynthesis, and South Italy Society of Orthopaedic and Traumatology. The survey comprised 34 questions about hardware removal after the treatment of long bone fractures, epiphyseal growth plate injuries, slipped capital femoral epiphysis (SCFE), and flat foot. Of the 3500 orthopaedic surgeons who received the questionnaire, 5.5% responded. The leading indications for implant removal were the patient's intolerance, pain, ROM limitations, and hardware breakage. Removal of elastic nails for long bone fractures, cannulated screws for growth plate injuries, and SCFE and screws for arthroereisis for flat foot correction were analysed in detail. The consensus among Italian Orthopaedic Surgeons is to remove elastic nails and cannulated screws in cases of pain, intolerance, or breakage and to reduce further risks during patient growth. An increasing number of physicians, however, are endorsing and advocating the growing trend in the literature of not routinely removing the hardware.

Vertebral Rotation in Functional Scoliosis Caused by Limb-Length Inequality: Correlation between Rotation, Limb Length Inequality, and Obliquity of the Sacral Shelf.

BACKGROUND: Scoliosis is a structured rotatory deformity of the spine defined as >10° Cobb. Functional scoliosis (FS) is a curve < 10° Cobb, which is non-rotational and correctable. FS is often secondary to leg length inequality (LLI). To observe vertebral rotation (VR) in functional scoliosis due to LLI, one must demonstrate a correlation between LLI, sacral shelf inclination (SSI), and VR and discover a predictive value of LLI capable of inducing rotation. METHODS: We studied 89 patients with dorso-lumbar or lumbar curves < 15° Cobb and radiographs of the spine and pelvis. We measured LLI, SSI, and VR. The patients were divided into VR and without rotation (WVR) groups. Statistical analysis was performed. RESULTS: The mean LLI value was 6.5 ± 4.59 mm, and the mean SSI was 2.8 ± 2.53 mm. The mean value of LLI was 5.2 ± 4.87 mm in the WVR group and 7.4 ± 4.18 mm in the VR group. The mean SSI value for WVR was 1.4 ± 2.00 and that for VR was 3.9 ± 2.39. For each mm of LLI, it was possible to predict 0.12° of rotation. LLI ±5 mm increased the probability of rotation (R2.08 p < 0.0016), while this was ±2 mm for SSI (R2 0.22 p < 0.01). Each mm of LLI corresponded to 0.3 mm of SSI (R2 0.29, p < 0.01). CONCLUSIONS: FS secondary to LLI can cause VR, and 5 mm of LLI can cause SSI and rotation.

Anterolateral congenital tibial bowing: case report.

Background: The treatment of congenital curvatures (bowing) of the tibia still represents a challenging problem for all pediatric orthopedic surgeons because of its unpredictable course, especially if pseudoarthrosis occurs after a pathologic fracture of the tibia. Case presentation: We describe the case of a child affected by an isolated curvature of his left leg. The congenital malformation was discovered at birth and no other pathological clinical finding was present. The first x-ray showed the presence of a congenital curvature of the tibia of the antero-lateral type. He was born in another country (Romania) and when he first came to our clinical observation at the Orthopedic and Traumatology Department, Pediatric Hospital "Bambino Gesu'", Rome, the child was 14 months of age and had already started walking. Only a leg discrepancy of about 2 cm was present with consequent pelvis obliquity. At the beginning, we prescribed external lower limb orthoses and a simple shoe rise to prevent a tibial pathologic fracture and reduce pelvic obliquity. At periodical clinical follow-up visits and despite the external lower limb orthoses prescribed, a progressive worsening of the severe congenital tibial curvature was observed together with signs and symptoms, such as pain and limping, that suggested an objective "pre-fracture stage" of the tibial curvature; we decided to perform surgery. At the time of surgery, the child was three and a half years old. Surgery consisted of a double osteotomy, both of the fibula and of the tibia. Subtraction of the distal meta-diaphyseal portion of the fibula and tibial osteotomy in Correspondence: of the major anterolateral curvature. The tibial osteotomy was then stabilized by an internal Rush rod inserted proximally to the tibia under the cartilage growth plate and made it end inside the distal tibial epiphysis, crossing the distal tibial cartilage growth plate, preserving the ankle joint. Results: The patient had an immediately excellent outcome. The tibial osteotomy site healed perfectly. At periodical orthopedic follow-up visits, the child was found to be always better. No clinical significative evidence of growth disturbances, due to the Rush rod that crossed the distal tibial cartilage growth plate, were noted. X-rays showed that the Rush rod progressively migrated with tibial growth together with the tibial bone growth, always getting further away from the distal tibial cartilage growth plate. Moreover, even the leg-length discrepancy and the pelvic obliquity improved. After an eight-year follow up, the patient, now a young boy of 11 and a half years, has an excellent outcome. Conclusions: Our case report undoubtedly provides further important information for the treatment of these rare congenital disorders. In particular, it highlights the management of the "pre-fracture stage" in a severe congenital tibial antero-lateral curvature in a very young child and describes the surgical technique performed.

Is Surface Topography Useful in the Diagnosis of Scoliosis? Validation of the Biometrical Holistic of Human Body (BHOHB).

BACKGROUND: The concern around repeated exposure to X-rays has been motivating doctors involved in scoliosis to seek alternative solutions. Surface topography (ST) analysis is a modern system that has been shown to have good results. The purpose of the study is to validate the new BHOHB hardware for the investigation of scoliosis in adolescents by comparing it to X-ray examinations and to assess the reliability of intraoperator and interoperator tests. METHODS: Ninety-five patients were enrolled in our study. All the patients were analyzed via the BHOHB method 2 times by 2 independent physicians (t0) and for a second time 2 or 3 months later (t1). The Pearson correlation coefficient was used to evaluate the relationship between the measurements obtained by BHOHB and the gold standard. The intraclass correlation coefficient (ICC) was used to assess intra- and interoperator reliability. Statistical analysis was performed with the GraphPad Prism 8 software. RESULTS: The correlations between the first and second operators in the measurements and between the BHOHB method and X-ray showed a very good to excellent r for both. A very good correlation was also confirmed for prominence measured by operators and by the BHOHB machine. Intra- and interoperator reliability was found to be very positive for both the first and the second physicians. CONCLUSIONS: We can state that ST can be useful for diagnosing and treating scoliosis. The recommendation is to use it primarily to evaluate the evolution of the curve, as in this mode, you can reduce the patient's exposure to X-rays. The results indicate that BHOHB measures are comparable to radiographs and not influenced by the operator.

Evaluation of Gartland Classification, Baumann Angle and Anterior Humeral Line in Paediatrics Supracondylar Fractures: An Inter and Intra-Observer Reliability Study.

Supracondylar fractures of the humerus are frequent paediatric injuries. The aims of this study were to evaluate the applicability and reproducibility of the Gartland and Wilkins classification, the Baumann angle (BA) and the Anterior Humeral Line (AHL). This retrospective monocentric observational study was conducted on 217 patients. Four observers assessed the pre-operative radiographs by applying the Gartland and Wilkins classification and the post-operative X-rays by measuring the BA and AHL. The kappa coefficient (K) and the Cohen's kappa were used for the reliability of the Gartland classification; the Intraclass Correlation Coefficient (ICC) for that of the BA. The AHL was evaluated in a double manner by using first the K and the Cohen's kappa and then the ICC. A total of 186 patients were eligible. Inter-observer reliability for the Gartland classification was K = 0.73-0.61 for type III, 0.65-0.61 for type Ia and 0.43-0.26 for type IIb. The Baumann angle mean value in the first data collection was 73.5 ± 6.85 (inter-observer ICC 0.74) and 72.9 ± 6.83 (inter-observer ICC 0.77) for the second data collection; AHL: inter-observer ICC 0.87 for the first evaluation and 0.80 for the second one. Gartland's classification modified by Wilkins has a high degree of reliability. BA and AHL appear reproducible and reliable.

Bone wax in the treatment of partial epiphysiodesis of distal femoral growth plate: Case report at 10-year follow-up.

The growth plate is the weakest structure in the skeleton of a child and a frequent site of injury or fracture; physeal injuries represent 15%-30% of all fractures in children. Of all growth plate fractures, the incidence of growth arrest and disorders is around 15%. Here, we discuss a female patient who, at the age of 5 years, was treated for a polytrauma that involved a complex lesion of the growth plates of the knee. Four days after trauma, she underwent closed reduction surgery and internal fixation with cannulated screws for femoral and tibial fractures of the growth plate. A 20° valgus deviation of the left knee was found at 3-month postoperative clinical check-up likely as a result of a growth disorder of the femur. She was diagnosed with valgus knee secondary to epiphysiodesis of the lateral portion of the femoral physis and she was readmitted to the hospital. In the operating theater, an open femoral de-epiphysiodesis was performed with a burr; the drilled hole was then filled with bone wax. At 20-month post-trauma follow-up, the left knee was still valgus about 20° relative to the other side. During follow-up, a slow but progressive improvement in the axis of the lower limbs was noted. Clinical and radiographic control 10 years after the trauma showed a complete recovery of the axis of the lower limbs. In the initial stages, the presence of bone wax in the area of de-epiphysiodesis allowed for stabilization of the deformity on the 20° of preoperative valgus. The interpretation of the growth cartilage activity occurred in an asymmetrical way such as to realign the femoral load axis, it can be based on the different mechanical stimulus on the two knee areas due to the preexisting deformity. There is no unanimous evidence in the literature in terms of management of growth disorders resulting from this type of injury. Bone wax resulted in effectively filling the hole of de-epiphysiodesis in the distal femoral growth plate and allowed us to obtain the response of the growth plate and to improve the recovery time in young children.

Clinical report and predictors of sequelae of 319 cases of pediatric bacterial osteomyelitis.

Pediatric osteomyelitis is an insidious disease that can lead to permanent sequelae, the management of which still relies on lengthy intravenous antibiotic therapy. The purpose of this study is to report and describe the clinical course and outcome of pediatric bacterial osteomyelitis in our experience. We reported the clinical, diagnostic, and treatment characteristics of all cases of osteomyelitis in children younger than 18 years of age who were hospitalized between January 2010 and December 2021 at the Bambino Gesù Children's Hospital in Rome, Italy, we compared patients with and without complications at follow-up, to identify any predictive factor for sequelae. The study sample included 319 cases of pediatric bacterial osteomyelitis. The median age was 7.77 years. Males (60.8%) were more affected than females. The most affected bones were the femur, tibia, and spine. Etiology was identified in 40.1% of cases, with S.aureus as the most common causative agent. Sequelae were reported in 43 cases (13.5%). The main predictors of sequelae were sepsis on admission and hypergammaglobulinemia. Our results show that a severe presentation with sepsis and hypergammaglobulinemia on admission may be associated with a higher frequency of late sequelae. Early recognition and aggressive treatment of this subgroup of patients may lead to a reduction in complications.

Characterization of Extracellular Vesicles in Osteoporotic Patients Compared to Osteopenic and Healthy Controls.

Extracellular vesicles (EVs) are mediators of a range of pathological conditions. However, their role in bone loss disease has not been well understood. In this study we characterized plasma EVs of 54 osteoporotic (OP) postmenopausal women compared to 48 osteopenic (OPN) and 44 healthy controls (CN), and we investigated their effects on osteoclasts and osteoblasts. We found no differences between the three groups in terms of anthropometric measurements and biochemical evaluation of serum calcium, phosphate, creatinine, PTH, 25-hydroxy vitamin D and bone biomarkers, except for an increase of CTX level in OP group. FACS analysis revealed that OP patients presented a significantly increased number of EVs and RANKL+ EVs compared with both CN and OPN subjects. Total EVs are negatively associated with the lumbar spine T-score and femoral neck T-score. Only in the OPN patients we observed a positive association between the total number of EVs and RANKL+ EVs with the serum RANKL. In vitro studies revealed that OP EVs supported osteoclastogenesis of healthy donor peripheral blood mononuclear cells at the same level observed following RANKL and M-CSF treatment, reduced the ability of mesenchymal stem cells to differentiate into osteoblasts, while inducing an increase of OSTERIX and RANKL expression in mature osteoblasts. The analysis of miRNome revealed that miR-1246 and miR-1224-5p were the most upregulated and downregulated in OP EVs; the modulated EV-miRNAs in OP and OPN compared to CN are related to osteoclast differentiation, interleukin-13 production and regulation of canonical WNT pathway. A proteomic comparison between OPN and CN EVs evidenced a decrease in fibrinogen, vitronectin, and clusterin and an increase in coagulation factors and apolipoprotein, which was also upregulated in OP EVs. Interestingly, an increase in RANKL+ EVs and exosomal miR-1246 was also observed in samples from patients affected by Gorham-Stout disease, suggesting that EVs could be good candidate as bone loss disease biomarkers. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Translation and Cross-Cultural Adaptation of the Pediatric Outcomes Data Collection Instrument into the Italian Language.

(1) Background: The Pediatric Outcomes Data Collection Instrument (PODCI) is an English-language questionnaire specifically designed to assess health-related quality of life in children and adolescents with musculoskeletal disorders. This scoring system has been translated into several languages. Given the lack of an Italian version of the PODCI, this study aimed to translate, cross-culturally adapt, and assess the psychometric properties of the PODCI score in the Italian pediatric population. (2) Methods: The PODCI questionnaire was culturally adapted to Italian patients in accordance with the literature guidelines. The study included 59 participants from a single orthopedic institution who underwent orthopedic surgery for various skeletal conditions. The questionnaire was administered to participants at multiple time-points (T0, T1, T2). Internal consistency was evaluated using Cronbach's alpha. Reproducibility was assessed using the intraclass correlation coefficient (ICC) between T0 and T1 assessment. Criterion validity was assessed using Spearman's correlation coefficients between PODCI and the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS). Responsiveness was evaluated by the difference between T0 and T2 using the effect size (ES) and the standardized response mean (SRM) calculation. (3) Results: Cronbach's alpha was acceptable in both the self- and parent-reported versions with values of 0.78 (0.68-0.90) and 0.84 (0.60-0.92), respectively. The ICC fluctuated between 0.31 and 0.89 for self-reported and 0.49 to 0.87 for pediatrics. The Spearman's r showed a moderate correlation between HSS Pedi-FABS and the "Sport & Physical Functioning" and "Global Functioning" domains. ES and SRM varied from small to moderate across all the domains. (4) Conclusions: This study demonstrates that the Italian version of the PODCI, translated following the international standardized guidelines, is reliable, valid, and responsive in pediatric patients who underwent orthopedic surgery.

Trend of hoverboard related injuries at a pediatric emergency department.

INTRODUCTION: Understanding how the use of hoverboards (HBs) can affect a child's safety is crucial. We describe the characteristics of HB related injuries and provide key messages about child prevention when using these leisure devices. METHODS: This was a retrospective study at an emergency department (ED) of a level-III-trauma center from 2016 to 2019. We tested the differences in children presenting for injury associated with HBs between 2016-2017 and 2018-2019 to better describe the temporal trend of the phenomenon. RESULTS: The rate of Injury associated with HBs / Total injury per 1,000 increased from 0.84 in 2016 to 7.7 in 2017, and then there was a gradual decline. The likelihood of injury was more common in younger children, increasing by 17% with decreasing age in 2018-2019 compared with 2016-2017 (OR: 0.83; 95%CI: 0.71-0.97; p = 0.021). The occurrence of injury in the April-June period was over twice as common in 2018-2019 (OR: 2.05; 95%CI: 1.0-2.05; p = 0.05). Patients were over 4 times more likely to have injured the lower extremity during the 2018-2019 period rather than other body regions (OR: 4.58; 95%CI: 1.23-4.58; p = 0.02). The odds of the indoor injury were more than twice as high in 2018-2019 (OR: 2.04; 95%CI: 1.077-2.04; p = 0.03). CONCLUSION: Despite a decrease in the frequency of HB related injuries after 2017, during the 2018-2019 period, the younger the children, the more they were exposed to injury risk, in addition to a greater occurrence of indoor injuries from HBs compared with 2016-2017. The enhancement of preventive measures is necessary to ensure child safety when using HBs.

Initial In-Brace Correction: Can the Evaluation of Cobb Angle Be the Only Parameter Predictive of the Outcome of Brace Treatment in Patients with Adolescent Idiopathic Scoliosis?

Background: Patients with a better initial in-brace correction could show a higher probability of a successful outcome. However, no one has investigated whether parameters can affect the outcomes. The aim of this retrospective study was to evaluate if the initial correction rate (ICR) could be predictive of the bracing outcome and to determine the role of some mechanical and biological parameters in ICR. Methods: The study population comprised 449 patients who met the inclusion criteria. Curve correction > 10° Cobb defines brace treatment success. Success and failure groups were compared in terms of the Risser sign, initial Cobb angle, initial Perdriolle value and ICR. Results: ICR significantly correlates with initial Perdriolle. The success group had a significantly lower value of Pedriolle and initial Cobb angles, Risser sign and ICR than the failure group. The ICR and lower Risser were significantly associated with the brace treatment outcome. This seems particularly suitable for positivity prediction (Predicting value VP+: 87%). Conclusions: This study confirms that immediate in-brace correction can foretell the brace treatment outcome. Patients with a low Risser sign and a high rate of in-brace correction showed a bracing success of 87%. A correlation between rotation and in-brace correction confirms that rotation is among the parameters that influence the deformed spine reaction to corrective actions the most.

Management of slipped capital femoral epiphysis: What hardware we can use in osteosynthesis in situ?

Epiphysiolysis (or Slipped Capital Femoral Epiphysis, SCFE) is a hip disorder involving children during prepubescence age. Traditionally, it is defined as a postero-medial slippage of the femoral epiphysis on the metaphysis, but, considering that femoral epiphysis is almost "stored" in the acetabulum, it could be better defined as laterally and anterior slippage of femoral metaphysis under the epiphysis.

Italian consensus on the therapeutic management of uncomplicated acute hematogenous osteomyelitis in children.

BACKGROUND: Acute hematogenous osteomyelitis (AHOM) is an insidious infection of the bone that more frequently affects young males. The etiology, mainly bacterial, is often related to the patient's age, but it is frequently missed, owing to the low sensitivity of microbiological cultures. Thus, the evaluation of inflammatory biomarkers and imaging usually guide the diagnosis and follow-up of the infection. The antibiotic treatment of uncomplicated AHOM, on the other hand, heavily relies upon the clinician experience, given the current lack of national guidelines for the management of this infection. METHODS: A systematic review of the studies on the empirical treatment of uncomplicated AHOM in children published in English or Italian between January 1, 2009, and March 31, 2020, indexed on Pubmed or Embase search engines, was carried out. All guidelines and studies reporting on non-bacterial or complicated or post-traumatic osteomyelitis affecting newborns or children older than 18 years or with comorbidities were excluded from the review. All other works were included in this study. RESULTS: Out of 4576 articles, 53 were included in the study. Data on different topics was gathered and outlined: bone penetration of antibiotics; choice of intravenous antibiotic therapy according to the isolated or suspected pathogen; choice of oral antibiotic therapy; length of treatment and switch to oral therapy; surgical treatment. CONCLUSIONS: The therapeutic management of osteomyelitis is still object of controversy. This study reports the first Italian consensus on the management of uncomplicated AHOM in children of pediatric osteomyelitis, based on expert opinions and a vast literature review.

Superficial peroneal nerve entrapment in ankle sprain in childhood and adolescence.

Traumatic injuries of the ankle are the most common injuries in sports. Up to 40% of patients who have undergone inversion ankle sprain report residual symptoms. The primary purpose of the study is to evaluate the incidence of SPN entrapment as consequence of acute severe inversion ankle sprain in children and adolescents; the secondary is to report the diagnostic pathway and the results after surgical treatment. From 2000 to 2015 were reviewed to summarize patients under the age of 15 years treated for a first episode of severe inversion ankle sprain. Cases with persistent symptoms (more than 3 months) indicative for SPN neuropathy were then identified. Instrumental investigations were recovered and a pre-operative assessment of pain (VAS) was recorded. Patients were evaluated at minimum of 1-year post-operative follow-up. 981 acute ankle sprains have been evaluated. 122 were considered severe according to van Dijk criteria. 5 patients were considered affected by neuropathy of the SPN. All patients underwent surgery consisting in neurolysis and capsular retention and ligament reconstruction. At 25 months of follow-up AOFAS moved from 57.6 to 98.6. The study highlights a previously unreported condition of perineural fibrosis of the superficial peroneal nerve at the level of the ankle following first acute severe inversion ankle sprain in children.

Resilience Against COVID-19: How Italy Faced the Pandemic in Pediatric Orthopedics and Traumatology.

BACKGROUND: We aimed to investigate the variation of medical and surgical activities in pediatric orthopedics in Italy, during the year of the COVID-19 pandemic, in comparison with data from the previous two years. The differences among the first wave, phase 2 and second wave were also analyzed. METHODS: We conducted a retrospective multicenter study regarding the clinical and surgical activities in pediatric orthopedics during the pandemic and pre-pandemic period. The hospital databases of seven tertiary referral centers for pediatric orthopedics and traumatology were queried for events regarding pediatric orthopedic patients from 1 March 2018 to 28 February 2021. Surgical procedures were classified according to the "SITOP Priority Panel". An additional classification in "high-priority" and "low-priority" surgery was also applied. RESULTS: Overall, in 2020, we observed a significant drop in surgical volumes compared to the previous two years. The decrease was different across the different classes of priority, with "high-priority" surgery being less influenced. The decrease in emergency department visits was almost three-fold greater than the decrease in trauma surgery. During the second wave, a lower decline in surgical interventions and a noticeable resumption of "low-priority" surgery and outpatient visits were observed. CONCLUSION: Our study represents the first nationwide survey quantifying the impact of the COVID-19 pandemic on pediatric orthopedics and traumatology during the first and second wave.

Neonatal osteomyelitis: an Italian multicentre report of 22 cases and comparison with the inherent literature.

OBJECTIVE: The primary objective of this study is to report and compare our data with the most relevant literature of the past decade about neonatal osteomyelitis. STUDY DESIGN: We retrospectively review the data of 22 subjects aged 35 days or less who were admitted to three different sites in Italy with a radiological diagnosis of osteomyelitis. The inherent literature was searched and reviewed: five studies were considered for comparison with our data. RESULTS: All the neonates, except three (two pre-term and one post-term), were born at term. The male to female ratio was 1.75 (14 males and 8 females). The mean age at presentation was 19.5 days. The most common presenting signs of the infection were local swelling and reduced mobility of the affected segment. The most common sites of infection were the femur, humerus, and tibia. The mean duration of intravenous antibiotic therapy was 29.5 days. In most neonates the diagnosis was prompt and the antibiotic treatment immediate. A low rate of sequelae was reported. All infants survived through follow up. The data from the inherent literature showed a wide variability, probably owing to the setting and the historical period of the different studies. CONCLUSION: Neonatal osteomyelitis is an alarming yet poorly understood disease. Nonetheless, our report suggests that a quick diagnosis and treatment can be easily achieved, with good outcome on the remarkably plastic structure of neonatal bones.

Long-term results after brace treatment with Progressive Action Short Brace in adolescent idiopathic scoliosis.

BACKGROUND: In the literature, there are few papers on long-term results after brace treatment and there is no consensus on whether scoliotic curves stop progressing at skeletal maturity. To date the factors that could influence curve behaviour following bracing have not been fully determined. AIM: The aim of this study was to evaluate the results and the loss of the scoliotic curve correction in a cohort of patients treated with Progressive Action Short Brace (PASB) brace during adolescence and to compare patient outcomes of under and over 30 Cobb degrees 10 years after brace removal. DESIGN: This is an observational controlled cohort study nested in a prospective clinical on-going database including 1536 patients with idiopathic scoliosis. SETTING: Inpatients and outpatients in Rome. POPULATION: The study enrolled 163 patients with idiopathic adolescent scoliosis who had been treated with the PASB brace at a 10 years minimum long-term follow-up examination. METHODS: One hundred sixty-three (female) patients with adolescent idiopathic scoliosis (AIS) treated with the Progressive Action Short Brace (PASB) at a mean age of 13.4 years (range 10-34) had accepted to undergo long-term follow-up examination. All patients had clinical and radiological examinations, but only 62 replied to some simple questions (including work status, pregnancy and pain) the population was divided into two groups based on Cobb degrees (< 30° and ≥ 30°). Statistical analysis was applied to test the efficacy of our hypothesis. RESULTS: The patients underwent a long-term follow-up after brace removal at a mean age of 13.46 years (±3.4). The prebrace mean curve was 28.98° (±7.918); after treatment, the mean was 13.88° and increased to a minimum of 15.35° in the 10 years following brace removal. However, there was no significant difference between the mean Cobb angle at the end of weaning and the mean Cobb angle at long-term follow-up. The curve angle at baseline of patients who were treated with a brace was reduced by 15° during the treatment, but at follow-up the curve size was found to have lost 2°. The over 30° group showed a prebrace scoliotic mean curve of 37.26°; at the end of weaning, the mean curve angle was 22.98° which increased to a mean of 25.07° at follow-up. The <30° group showed a prebrace scoliotic mean curve of 24.40° which, at the end of weaning, had reduced to a mean of 8.69°, increasing to 9.98° at follow-up. There was no significant difference in the mean progression of curve magnitude between the ˂ 30° and ≥ 30° groups at the long-term follow-up. Work status was 62% full-time and 11% part-time. 24% had given birth. Three percent presented back pain related to instability of the spine. No patients underwent surgery after maturity but one patient had indication to surgical treatment. CONCLUSIONS: The PASB brace is effective for the treatment of lumbar and thoracolumbar scoliosis and is characterized by positive long-term outcomes, including in patients demonstrating moderate curves. In both groups, at 10-years minimum follow-up after bracing, scoliotic curves did not deteriorate beyond their original curve size after bracing in both groups at the 10-years minimum follow-ups. CLINICAL REHABILITATION IMPACT: At 10 years follow-up after bracing, scoliotic curves had not deteriorated beyond their original curve size.

Recommendations from the Italian Society of Pediatric Orthopaedics and Traumatology for the management of pediatric orthopaedic patients during the COVID19 pandemic and post-pandemic period in Italy.

The rapid spread of the COVID-19 outbreak in Italy has dramatically impacted the National Healthcare System, causing the sudden congestion of hospitals, especially in Northern Italy, thus imposing drastic restriction of almost all routine medical care. This exceptional adaptation of the Italian National Healthcare System has also been felt by non-frontline settings such as Pediatric Orthopaedic Units, where the limitation or temporary suspension of most routine care activities met with a need to maintain continuity of care and avoid secondary issues due to the delay or suspension of the routine clinical practice. The Italian Society of Pediatric Orthopaedics and Traumatology formulated general and specific recommendations to face the COVID-19 outbreak, aiming to provide essential care for children needing orthopaedic treatments during the pandemic and early post-peak period, ensure safety of children, caregivers and healthcare providers and limit the spread of contagion.

Bifocal Avulsion of the Patellar Tendon From the Distal Patella and Tibial Tuberosity in a Skeletally Immature Patient: A Case Report.

CASE: A 13-year-old boy suffered a sports injury of the right knee. The clinical examination showed swelling, inability to bear weight, and pain involving the inferior apex of the patella and the anterior tibial tuberosity. Imaging studies showed an avulsion fracture, sleeve-like, from the patella apex and avulsion of the tibial tuberosity. The patient underwent open reduction and internal fixation. At the 24-month follow-up, no pain, limitation, or complication was reported. CONCLUSIONS: Bifocal patellar tendon avulsion in a skeletally immature patient is an extremely rare injury, and to our knowledge, only one case is reported.

Oblique pelvic osteotomy in the treatment of bladder exstrophy in neonates.

Bladder exstrophy is a congenital and rare malformation of the lower abdominal wall with exposure of the bladder mucosa to the external environment, and it is related to pelvis abnormalities. Eighteen patients with bladder exstrophy were treated with bilateral oblique pelvic osteotomy in conjunction with urologic reconstruction after they were stabilized by cast. No failure of midline closure was observed (wound dehiscence or recurrence of bladder exstrophy). Follow-up showed no leg length discrepancy or problems in walking. Bilateral oblique pelvic osteotomy is a safe procedure to treat bladder exstrophy, and it results in good orthopedic and urological function.