Outcomes and complications of surgical treatment modalities for simple bone cysts of the humerus in children and adolescents.

PURPOSE: The aim of this study was to evaluate and compare different surgical treatment modalities for simple bone cysts (SBC) of the humerus regarding their effectiveness and recurrence rate. METHODS: In this retrospective study, patients who received surgical treatment for previously untreated primary SBCs of the humerus were analyzed. Demographic data, cyst-specific as well as treatment-specific parameters, complications, treatment failures, and recurrence rates were collected and correlated with different treatment modalities. Observed procedures were categorized as open procedure (n=20) or osteosynthesis alone (n=3). For the open procedure group, four subgroups could be defined. RESULTS: Twenty-three patients were included. The mean age at diagnosis was 11.6 ± 2.5 years, and the mean postoperative follow-up was 3.9 ± 2.6 years (range 1.0-10.3). After surgical intervention, a total of five (21.7%) patients showed at least one recurrence. Fracture occurred in three (13.0%) cases. The incidence of treatment failure was significantly higher in the curettage, allograft, adjuvants group, with five (83.3%) of six cases showing recurrence, than in the other subgroups (≤ 25.0%) including the osteosynthesis alone group (p=.024). For the open procedure group, the failure-free survival rates were 80.0% after two years and 50.4% after five years. For the three cases treated by osteosynthesis alone, no failures were observed. CONCLUSION: Open procedures showed similar failure rates except for the subgroup using curettage, allograft, and adjuvants which showed significantly higher treatment failure. Promising results were observed in the group which received solely osteosynthesis without cyst excision or filling, as no treatment failure was observed here.

Do's and Don'ts in Primary Aneurysmal Bone Cysts of the Proximal Femur in Children and Adolescents: Retrospective Multicenter EPOS Study of 79 Patients.

BACKGROUND: Aneurysmal bone cysts (ABC) are rare benign cystic bone tumors, generally diagnosed in children and adolescents. Proximal femoral ABCs may require specific treatment strategies because of an increased pathologic fracture risk. As few reports are published on ABCs, specifically for this localization, consensus regarding optimal treatment is lacking. We present a large retrospective study on the treatment of pediatric proximal femoral ABCs. METHODS: All eligible pediatric patients with proximal femoral ABC were included, from 11 tertiary referral centers for musculo-skeletal oncology (2000-2021). Patient demographics, diagnostics, treatments, and complications were evaluated. Index procedures were categorized as percutaneous/open procedures and osteosynthesis alone. Primary outcomes were: time until full weight-bearing and failure-free survival. Failure was defined as open procedure after primary surgery, >3 percutaneous procedures, recurrence, and/or fracture. Risk factors for failure were evaluated. RESULTS: Seventy-nine patients with ABC were included [mean age, 10.2 (±SD4.0) y, n=56 male]. The median follow-up was 5.1 years (interquartile ranges=2.5 to 8.8).Index procedure was percutaneous procedure (n=22), open procedure (n=35), or osteosynthesis alone (n=22). The median time until full weight-bearing was 13 weeks [95% confidence interval (CI)=7.9-18.1] for open procedures, 9 weeks (95% CI=1.4-16.6) for percutaneous, and 6 weeks (95% CI=4.3-7.7) for osteosynthesis alone ( P =0.1). Failure rates were 41%, 43%, and 36%, respectively. Overall, 2 and 5-year failure-free survival was 69.6% (95% CI=59.2-80.0) and 54.5% (95% CI=41.6-67.4), respectively. Risk factors associated with failure were age younger than 10 years [hazard ratios (HR)=2.9, 95% CI=1.4-5.8], cyst volume >55 cm 3 (HR=1.7, 95% CI=0.8-2.5), and fracture at diagnosis (HR=1.4, 95% CI=0.7-3.3). CONCLUSIONS: As both open and percutaneous procedures along with osteosynthesis alone seem viable treatment options in this weight-bearing location, optimal treatment for proximal femoral ABCs remains unclear. The aim of the treatment was to achieve local cyst control while minimizing complications and ensuring that children can continue their normal activities as soon as possible. A personalized balance should be maintained between undertreatment, with potentially higher risks of pathologic fractures, prolonged periods of partial weight-bearing, or recurrences, versus overtreatment with large surgical procedures, and associated risks. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Age-related Outcomes and Complications of Osteodistraction in the Pediatric Upper Extremity: A Large Retrospective Single-center Study of 61 Cases.

BACKGROUND: The study purpose was to assess: (1) the complication rate of osteodistraction in the pediatric upper extremity, its severity and relation to patient-specific and treatment-specific parameters, and (2) dedicated patient-reported outcome scores after these procedures. METHODS: This retrospective study analyzed a chart of patients undergoing osteodistraction of the upper limb between 2003 and 2020. Demographics, distraction-specific parameters, healing index, and any complications graded according to the Sink grading scale (grades 1 to 5) were extracted. An additional phone interview was performed to assess patient satisfaction and functionality of the elongated limb using the Quick-DASH (Disabilities of Arm, Shoulder, and Hand) score. RESULTS: This study included 61 cases from 48 individual patients. The mean age at the start of distraction was 11.5±3.6 years. The ulna was the most frequently lengthened bone, with 21 (34.4%) cases. Ninety-four complications were observed, with an average complication rate of 77.0%. Based on the Sink grading scale (1 to 5), grade 3 complications were most common (n=29; 47.5%) followed by grade 1 (n=14; 23.0%), 2 (n=14; 23.0%), and 4 (n=4; 6.6%). A significantly lower and thus better bone healing index was observed for the age category less than 10 years compared with the 14 to 18 years group (P=0.006). The average satisfaction was 4.2±1.0 points of 5. The mean Quick-DASH score was 14.1±12.5, indicating very good clinical outcomes. CONCLUSIONS: Despite the occurrence of numerous complications, high patient satisfaction and good daily life functionality of the treated limb was observed. An age of more than 14 years at the beginning of therapy had a negative prognostic effect on bone healing during distraction. Thus, osteodistraction in the upper extremity may preferably be performed less than 10 years of age because of enhanced bone regeneration. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Early Distal Radius Remodeling after Radius Dome Osteotomy in Madelung's Deformity.

Background Distal radius realignment procedures such as the dome osteotomy have been shown to reliably correct the geometry of this three-dimensional deformity. However, it has not been clarified whether the correction is durable over time. We thus reviewed a prospective Madelung's database and evaluated all patients who received a radius dome osteotomy to see whether there was any loss of correction over time. Patients and Methods A total of 16 patients with 19 operated wrists were included. Mean age at surgery was 14 years; the most recent radiograph that was considered for analysis was obtained at a mean of 20 months after the index surgery. Three established radiographic deformity parameters (ulnar tilt, lunate subsidence, palmar carpal displacement) were repetitively measured by an independent observer over the course of the postoperative follow-up and compared using the analysis of variance statistics. Results A mild but nonsignificant worsening of deformity parameters was observed in six patients (32%). Overall, ulnar tilt improved from 50 to 40 degrees after surgery and was 43 degrees at latest follow-up. The values for lunate subsidence were -5.5, 0, and -1.6 mm, respectively. Palmar carpal displacement did not recur after correction (21, 17, and 16 mm, respectively). Conclusions Frontal plane parameters remodeled to a certain degree, although not in a statistically significant manner, soon after corrective osteotomies in Madelung's deformity. Although mild surgical overcorrection may be warranted in younger patients, it remains unclear if a concomitant distal radial epiphysiodesis would generally be beneficial. Level of Evidence Level IV.

As simple as it sounds? The treatment of simple bone cysts in the proximal femur in children and adolescents: Retrospective multicenter EPOS study of 74 patients.

Purpose: Simple bone cysts are among the most prevalent benign cystic tumor-like lesions in children. Proximal femoral simple bone cysts may require specific treatment because of increased fracture risk. With limited literature available on this specific localization, consensus regarding optimal treatment is lacking. We present a large international multicenter retrospective cohort study on proximal femoral simple bone cysts. Methods: All consecutive pediatric patients with proximal femoral simple bone cyst from 10 tertiary referral centers for musculoskeletal oncology were included (2000-2021). Demographics, primary treatment, complications, and re-operations were evaluated. Primary outcomes were time until full weight-bearing and failure-free survival. Results: Overall, 74 simple bone cyst patients were included (median age 9 years (range = 2-16), 56 (76%) male). Median follow-up was 2.9 years (range = 0.5-21). Index procedure was watchful waiting (n = 6), percutaneous procedure (n = 12), open procedure (n = 50), or osteosynthesis alone (n = 6). Median time until full weight-bearing was 8 weeks (95% confidence interval = 0.1-15.9) for watchful waiting, 9.5 (95% confidence interval = 3.7-15.3) for percutaneous procedure, 11 (95% confidence interval = -0.7 to 13.7) for open procedure, and 6.5 (95% confidence interval = 5.9-16.1) for osteosynthesis alone (p = 0.58). Failure rates were 33%, 58%, 29%, and 0%, respectively (p = 0.069). Overall failure-free survival at 1, 2, and 5 years was 77.8% (95% confidence interval = 68.2-87.4), 69.5% (95% confidence interval = 58.5-80.5), and 62.0% (95% confidence interval = 47.9-76.1), respectively. Conclusion: A preferred treatment for proximal femoral simple bone cysts remains unclear, with comparable failure rates and times until full weight-bearing. Watchful waiting may be successful in certain cases. If not feasible, osteosynthesis alone can be considered. Treatment goals should be cyst control, minimizing complications and swift return to normal activities. Therefore, an individualized balance should be made between undertreatment, with potentially higher complication risks versus overtreatment, resulting in possible larger interventions and accompanying complications. Level of evidence: Level IV, retrospective multicentre study.

Course of Treatment and Short-Term Outcome of Surgically Treated Paediatric Upper Limb Fractures during the COVID-19 Pandemic-Experiences of a Level 1 Trauma Centre in Central Europe.

The COVID-19 pandemic and the resulting restrictions led to a reduced number of surgeries. This study examines its impact on the course of treatment and clinical outcome of surgically treated paediatric upper limb fractures during that specific period. This retrospective cohort study evaluated all children aged 0-18 years presenting with an upper limb fracture treated surgically at the level 1 trauma centre of the University Clinic of Orthopaedics and Trauma Surgery of Vienna within lockdown from 16 March to 29 May 2020 (definition applied through corresponding legislation) compared to the same period from 2015 to 2019. A total number of 127 children (m:63; f:44) were included. The lockdown did not lead to a significant increase in complications during and after initial surgery. Time until removal of implant was not significantly prolonged (p = 0.068; p = 0.46). The clinical outcome did not significantly differ compared to previous years. The experience of a level 1 trauma centre showed that despite reduced surgical capacity during the COVID-19 pandemic, no negative differences concerning course of treatment and clinical outcome of surgically treated paediatric upper limb fractures were present. These findings are still of importance since the COVID-19 pandemic continues and several countries in Central Europe are currently under their fourth lockdown.

Temporary epiphysiodesis in adolescent patients with ulnocarpal impaction syndrome: a preliminary case series of seven wrists.

Adolescents with ulnar positive variance can develop ulnocarpal symptoms due to ulnocarpal impaction syndrome. Common treatment methods are conservative therapy, distal ulna epiphysiodesis or eventually ulnar shortening osteotomy. The aim of this preliminary case series was to investigate a recently described, new therapeutic approach using a reversible, temporary epiphysiodesis technique, following the principles of guided growth. Seven cases with the diagnosis of a painful ulnar positive variance, which underwent a temporary epiphysiodesis, were retrospectively evaluated. These cases consisted of four individual patients who received an intraoperatively customized plate fixation to slow down growth. The following parameters were collected: diagnosis, age at surgery, age at explantation, growth plate status at explantation, ulnar variance before and after surgery, complications and any clinical and radiological abnormalities. The radiological measurements of ulnar variance were performed according to the Gelbermann method. The seven investigated cases (average age at surgery 12.4 years; average age at explantation 14.7 years), in which a temporary epiphysiodesis was performed, showed an average ulnar variance of +3.9 mm (range: from +1.9 mm to +6.1 mm) before the start of therapy. After explantation, an average ulnar variance of +0.1 mm (range: from -3.2 mm to +5.0 mm) was observed, which corresponds to an average reduction/improvement of -3.8 mm (range: from -0.5 mm to -9.3 mm). The ulnocarpal wrist complaints were significantly reduced after the intervention. One case needed a secondary ulnar shortening osteotomy. The described method of a temporary, reversible epiphysiodesis is an elegant, less invasive technique to correct the ulnar positive variance without irreversibly closing the growth plate. In case of therapy failure, a secondary ulna shortening osteotomy is still possible.

Maintaining Medical Resources to Treat Paediatric Injuries during COVID-19 Lockdown Is Essential-An Epidemiological Analysis of a Level 1 Trauma Centre in Central Europe.

BACKGROUND: This study examined the effect of the COVID-19 pandemic and the resulting decrease in the incidence of various categories of injuries, with the main focus on fractures and mild traumatic brain injuries in a paediatric population. METHODS: This retrospective cohort study evaluated all children from 0 to 18 years of age presenting with an injury at the level 1 trauma centre of the University Clinic of Orthopaedics and Trauma Surgery in Vienna during the lockdown from 16 March to 29 May 2020 compared to records over the same timeframe from 2015 to 2019. RESULTS: In total, 14,707 patients with injuries were included. The lockdown did not lead to a significant decrease in fractures but, instead, yielded a highly significant increase in mild traumatic brain injuries when compared to all injuries that occurred (p = 0.082 and p = 0.0001) as well as acute injuries (excluding contusions, distortions and miscellaneous non-acute injuries) (p = 0.309 and p = 0.034). CONCLUSIONS: The percentage of paediatric fractures did not decrease at the level 1 trauma centre, and a highly significant proportional increase in paediatric patients with mild traumatic brain injuries was observed during the COVID-19 lockdown. Therefore, medical resources should be maintained to treat paediatric trauma patients and provide neurological monitoring during pandemic lockdowns.

Complications of hardware removal in pediatric upper limb surgery: A retrospective single-center study of 317 patients.

Previous studies indicated that hardware removal may lead to increased morbidity and therefore, at least in adults, remains questionable for certain indications. However, risks such as corrosion or local reactions may be less likely in younger patients with current, improved hardware materials. We sought to retrospectively determine complication rates of hardware removal in pediatric upper limb surgery, and establish potential risk factors for increased morbidity.All children and adolescents who underwent inpatient hardware removal under anesthesia after previous upper limb surgery between 2002 and 2016 were retrospectively evaluated. The following details were extracted at the latest follow-up: demographics, implant location, hardware material, duration of surgery, duration of hardware in situ, and any complications graded according to Goslings et al (grade 0-5) and Sink et al (grade 1-5), respectively. Correlations were calculated to establish potential relationships between specific outcome parameters (e.g., location, duration of surgery etc.) and complication grades.A total of 2089 children were evaluated of whom 317 patients with 449 interventions (mean age 9.4 years) fulfilled the inclusion criteria for this study. Overall, 203 K-wires (46%), 97 plates (22%), 102 external fixators (23%), 32 intramedullary nails (7%), 6 screws (1%), 4 cerclages (1%) and 1 pin (0.2%) were removed; most common locations were the forearm (34%) and humerus (24%). The mean duration of surgery was 40 minutes (± 50.9), mean time in situ was 194 days (± 319.6). Complication rates were low overall, with most being grade 0 (n = 372; 83%) or 1 (n = 60; 13%) according to Goslings et al and grade 1 (n = 386; 86%) and 2 (n = 42; 9%) according to Sink et al. No severe complications were observed. The following predictors were related to the severity of the complications in linear regression analysis: more distal localizations, external fixators, longer duration of surgery and female sex.Hardware removal under anesthesia in the pediatric upper extremity has produced a low complication rate with no severe complications and can thus be considered to be safe. Increased morbidity occurred in more distal localizations, external fixators, longer surgeries and females.Level of Evidence: Therapeutic, Level IV.