Bioresorbable implants vs. Kirschner-wires in the treatment of severely displaced distal paediatric radius and forearm fractures - a retrospective multicentre study.

BACKGROUND: Distal radius fractures are very common in paediatric patients. Severely displaced fractures may require surgical intervention. The gold standard surgical method is percutaneous K-wire osteosynthesis followed by immobilisation. Metal implants can be removed with a second intervention; however, these extra procedures can cause further complications. Several studies confirm the benefits of bioabsorbable implants for paediatric patients. The aim of this retrospective study was to compare the complication rates of displaced distal metaphyseal radius (AO 23r-M/3.1) and forearm (AO 23-M/3.1) fractures in children operated on with K-wires versus a novel technique with bioresorbable implants. METHODS: We retrospectively reviewed 94 patients in three paediatric trauma centres who underwent operations due to severely displaced distal forearm or metaphyseal radial fractures between January 2019 and January 2020. The mean age was 8.23 (ranging from 5-12). 30 patients (bioresorbable group, BR-group) were treated with biodegradable PLGA implants (Bioretec®, ActivaPin®), 40 patients with one or two stainless steel Kirschner-wires (K-wires, Sanatmetal®) which were buried under the skin (KW I-group) and 24 children with K-wires left outside the skin. (KWII. Group). We examined the number of minor and major complications as well as the need for repeated interventions. Follow-up was at least one and half year. RESULTS: There was no significant difference between the complication rates at the two KW groups (p = 0.241; Cramer's V = 0.211), while the complication rate of the BR group was significantly lower. (p = 0.049; Cramer's V = 0.293 and p = 0.002; Cramer's V = 0.418 respectively). No later than half a year after the injury, no difference was observed between the functional outcomes of the patients in each group. One and a half years after the injury, no signs of growth disturbance were found in any of the children. No second surgical intervention was required in the BR group. CONCLUSIONS: Surgeries with bioresorbable intramedullary implants may have fewer complications than K- wire osteosynthesis in the treatment of severely displaced distal forearm fractures. The benefits are most pronounced in the first six weeks after surgery, reducing the number of outpatient visits and increasing the child's sense of comfort. As no second intervention is required, this can lead to significant cost savings. After half a year, there is no difference in the outcomes between the different surgical treatment strategies.

[Ultrasonographic diagnosis of distal pediatric forearm fractures]. / Gyermekkori csuklótáji törések diagnosztikája ultrahanggal.

INTRODUCTION AND AIM: The aim of our prospective study was to evaluate the effectivity of sonographic diagnosis of pediatric wrist fractures and analyzing the results of two pediatric musculoskeletal centers. METHOD: Between 2011 January and 2015 December 467 children aged 0-15 with closed wrist injuries and open growth plates were sonographically and radiologically evaluated by an orthopaedic surgeon or a resident in trainee. Sonography was performed immediately after physical examination with linear probes of 7-14 Mhz frequency. Results were compared to conventional two plane wrist x-rays. RESULTS: We found 97 sensitivity and 96 specificity of the sonographic evaluation. Fractures with dislocations and more serious clinical consequences were never missed. CONCLUSION: Musculoskeletal ultrasound is a very effective tool in daily routine for diagnosing or excluding pediatric wrist fractures. Orv Hetil. 2017; 158(24): 944-948.

Management of Juvenile Osteochondral Fractures Utilising Absorbable PLGA Implants.

The incidence of articular injury, particularly osteochondral fractures (OCFs), has seen a cinnotable increase in recent years. Regardless of their location, fragments can be overlooked by plain radiographs, which might lead to osteoarthritis in the long run. Diagnostic imaging has a pivotal role in the assessment and classification of the fracture severity, as well as the presence of any associated dislocations. These fractures require surgical intervention for the restoration of joint function and the reduction of long-term complications. This paper aims to present the surgical correction and post-operative treatment of osteochondral fractures with absorbable implants in four children. The following affected areas are discussed: lateral condyle of the femur, patella and radial head. Utilising absorbable implants for the management of OCFs provides numerous advantages, including the elimination of the need for re-anaesthesia and reoperation, reduction of complications and facilitation of early rehabilitation. This approach also minimises the period of hospitalisation and proves effective in pediatric OCF treatment.

[Orthopaedic relevance of baby carrying]. / A babahordozás ortopédiai és traumatológiai vonatkozásai.

Recently, various ways of carrying a baby have become popular again. Different methods and options of infant carrying are largely influenced by current fashion trends. The term of baby carrying refers to carrying the infant close to the caregiver's body with special devices, which aid attachment parenting. The authors often face the question in the pediatric orthopedic clinic: what kind of carrying method to recommend to the parents. In this article the authors briefly present the different means of carrying devices and they review the literature regarding orthopedic consequences of baby carrying. For the healthy development of a child, position and correct support of the hips and the spine are essential, whereas the carrier's spinal protection is also an important aspect. After reviewing the literature, the authors conclude that baby carrying with an adequate device has advantages from orthopaedic point of view.

Pediatric medial humeral epicondyle fracture in children: Are biodegradable pins with tension band absorbable sutures efficient?

Medial humeral epicondyle fractures account for 10% to 20% of elbow injuries in children. We hypothesized that in the fixation of medial humeral epicondyle fractures, safety and efficiency of bioabsorbable poly(l-lactide-co-glycolic acid) implant are comparable to traditional metallic and other novel approaches. A retrospective cohort study was performed between 2016 and 2019, analyzing 24 children who had medial humeral epicondyle fractures. Every fracture was stabilized with biodegradable poly(l-lactide-co-glycolic acid) implants (Bioretec® ActivaPin®) and tension band polydioxanone sutures. Indications for surgery included closed fractures with >1 cm dislocation and incarcerated fractures. Postoperatively, the degree of anatomic reduction and the presence or absence of nonunion or fragmentation were confirmed with X-rays. In this clinical study, we evaluated the operation time, age, and gender distribution. The mean age at the time of injury was 12.3 (8-16 years). In the fourth week, every patient's X-ray showed callus formation, and the range of motion of the elbow after 6 months of the operation was almost complete in all children. Transient ulnar nerve palsy was developed in 1 patient, which was spontaneously resolved in the fourth postoperative month. No other complications were observed during the average follow-up period of 34 months (16-60 months). Bioabsorbable pins with absorbable sutures are a good alternative treatment of medial epicondyle humeral fracture. No permanent complications were noted while using this technique. We suggest this method because it does not require a secondary (metal removal) operation.

Making Hardware Removal Unnecessary by Using Resorbable Implants for Osteosynthesis in Children.

INTRODUCTION: Following osteosynthesis, children generally require a second surgery to remove the hardware. This becomes unnecessary, by using resorbable implants. Limiting the number of required surgeries and their associated risks, this technique provides critical aspects of minimally invasive surgery. This review focuses on resorbable implants for osteosynthesis for the treatment of fractures in children and discusses their clinical features. METHOD: We provide an overview of the two most common technologies used in resorbable osteosynthesis materials: polymer- and magnesium-based alloys. Clinical examples of osteosynthesis are presented using polymer-based ActivaTM products and magnesium-based Magnezix® products. RESULTS: Polymer-based implants demonstrate surgical safety and efficacy. Due to their elasticity, initial placement of polymer-based products may demonstrate technical challenges. However, stability is maintained over the course of healing. While maintaining good biocompatibility, the rate of polymer-resorption may be controlled by varying the composition of polyesters and copolymers. Similarly, magnesium-based implants demonstrate good mechanical stability and resorption rates, while these characteristics may be controlled by varying alloy components. One of the significant shortcomings of magnesium is that metabolism results in the production of hydrogen gas. Both technologies provide equally good results clinically and radiographically, when compared to non-resorbable implants. CONCLUSION: Resorbable osteosynthesis materials demonstrate similar therapeutic results as conventional materials for osteosynthesis. Resorbable implants may have the potential to improve patient outcomes, by sparing children a second surgery for hardware removal.

Pilot Study and Preliminary Results of Biodegradable Intramedullary Nailing of Forearm Fractures in Children.

(1) Background: Diaphyseal forearm fractures are a common injury in children and adolescents. When operative treatment is needed, elastic stable intramedullary nailing (ESIN) is the most common surgical procedure. Although there is no clear evidence, hardware removal after fracture healing is performed in many patients. Often, the primary minimal invasive incision needs to be widened during implant removal. In order to decrease the burden of care of pediatric fractures, significant efforts were made to develop biodegradable implants, which make hardware removal unnecessary. Our study will conduct an observational trial on the clinical use of the Activa IM-Nail™ in forearm fractures in children between 3 and 13 years of age. The objective of this trial is to evaluate the risks and benefits of the Activa IM-Nail™. Among other objectives, the rate of refracture will be determined. (2) Methods: An international Europe-based, multicenter, prospective, single-arm, open-label study will be performed to ascertain the rate of refracture and to determine the subjective benefits of Activa IM-Nail™ for patients, parents and other caregivers. The study will include clinical follow-up including early post-operative complication, radiographs until bony healing and an additional follow-up after 1 year. At this stage, preliminary results and early complications on 76 patients are analyzed in this study and presented. (3) Results: As of April 2022, 76 patients were enrolled as per study protocol. There were 31 girls (40.8%) and 45 boys (59.2%). The mean age at the time of inclusion was 8.9 years (±2.4 years). The mean operation time was 58.9 ± 22.9 min (range, 15-119 min). The mean follow-up time was 8.9 ± 5.1 months (range, 0.2-18.6). Up to now, one refracture has occurred in one child falling from a height of about one meter 7 months after index surgery (1/76; 1.3%). (4) Conclusion: The research project assesses the safety and effectiveness of Activa IM-Nails™ as part of the surgical treatment of dislocated forearm fractures in children in the context of a PMCF study. The use of Activa IM-Nails™ with regard to various objectives, including postoperative complications and refracture rate, seems to be equal to the standard titan ESIN procedure compared to the literature. Preliminary results are encouraging and are made available.

Two- plane point of care ultrasonography helps in the differential diagnosis of pulled elbow.

INTRODUCTION: Pulled elbow (PE) is one of the most common injury in children under the age of five years. Diagnosis of PE is usually based on the typical anamnesis and clinical symptoms. A simple reduction maneuver without the need of any imaging modality can eliminate the problem. Certain fractures however can mimic the physical findings of PE and in this cases reduction should not be attempted. The aim of our prospective diagnostic study was to evaluate the accuracy of a sonographic testing method in the differential diagnosis of PE. METHODS: 205 children aged 0-5 with clinical suspicion for PE were enrolled in our study. Inclusion criteria were the typical clinical sign of PE: painful, motionless, extended or slightly flexed and pronated arm following a traumatic event under the age of five. We excluded older children and patients with pronounced elbow swelling and initially flexed and supinated upper arm position. A two plane point of care sonographic examination was carried out at each patient immediately after history taking and primary physical survey. Presence of the elevated dorsal sonographic fat pad sign(FPS) and the synovial fringe enlargement (SFE) were examined from dorsal and ventral longitudinal planes. Children with FPS positivity and/or unsuccessful reduction were x-rayed. Suspected occult fractures with persistent complains were also x-rayed on the 3rd week. Sonographic pictures and x-rays were analyzed and compared to clinical findings. RESULTS: The diagnosis of PE was confirmed in 196 cases. (95.6%). 9 children had type I. supracondylar humerus fractures. (4.39%) Out of these 2 proved to be occult fractures.(0.97%). SFE positivity was detected only in the PE group (156 cases, 76%) fractures have not shown this sign. Elevated FPS was negative in all but one PE cases, while all fractures showed FPS positivity without exception. Evaluating the two parameters together both sensitivity, specificity, negative and positive predictive value were 100%. CONCLUSIONS: The two plane sonographic point of care method is an effective tool for confirming the diagnosis of PE and excluding the presence of fractures. It is an easy, standard and objective procedure which can be used as a fast diagnostic test before reduction attempts.

Standardized sonographic examination of pediatric elbow injuries is an effective screening method and improves diagnostic efficiency.

INTRODUCTION: Positive role of ultrasound in the diagnosis of pediatric elbow injuries were confirmed by many papers but no comprehensive, standardized method has been developed for daily clinical practice. The aim of our prospective diagnostic study was to prove the efficacy of a five point sonographic point of care method for detecting different pediatric elbow fractures or dislocations. METHODS: Between 2016 January and 2017 March 365 children (age 1-14) with suspected closed elbow injury were enrolled in our study. Sonographic point of care examination was carried out by a properly trained resident and two orthopedic surgeons immediately after physical survey. We used a standardized five point sonographic examination. Two plane x-rays were made following sonography according to protocol. Utility of sonographic pictures were analyzed by a radiologist. Cases with images which have not met with standard requirements were excluded. In those cases when primary x-rays were negative and/or any of the ultrasound planes showed positive findings, radiography was repeated after 4 weeks of injury. If we detected callus formation the fracture was considered occult. Cases with images which have not met with standard requirements were excluded. Ultrasonic pictures, evaluation sheets and x-ray results were compared. RESULTS: Out of the 365 cases we identified 165 with positive findings (45, 2%) by primary x-rays. Distribution of the different injuries were the following: Radial condylar fractures, (n = 29) supracondylar humeral fractures (n = 84 proximal radial fractures, (n = 19) proximal ulnar fractures, (n = 7) fractures with joint dislocations (n = 3) joint dislocations without fractures, n = 2 medial epicondyle fractures (n = 14) fracture combinations (n = 7) We did not find injuries in this series that we could not categorize into these groups. Evaluating the abnormal sonographic dorsal fat pad sign (FPS) as a sole parameter for fracture detection we found sensitivity: 0, 97, specificity: 0,97, positive predictive value: 0,97, negative predictive value: 0,97 Evaluating the effectivity of the four cortical planes we calculated sensitivity 0, 85 specificity 0.96 positive predictive value: 0. 95 negative predictive value 0.87. The overall values of the five planes were the following: specificity0.97 sensitivity 1, positive predictive value 0.97 negative predictive value: 1 Interrater agreements on the cortical plane abnormality were considered good at two examiners and very good at one examiner. (Kappa = 0.79, 0, 81, 0, 79) Agreements on differentiation of elevated, normal fat pad) or lipohaemarthrosis in sonographic pictures were very good in all cases. (Kappa = 0,83, 0,86,0,82) While identification of any displacement or dislocation was possible in 96%, of all cases(n = 59)the exact determination of the type of the injury was possible in only 70,3% (n = 116) CONCLUSIONS: Using the five point ultrasonic examination provides enough information for excluding or confirming the presence of any pediatric elbow fractures or dislocations. The method is quick, simple and can help in the immediate differentiation of the severity of injuries. Sonographic lipohaemarthrosis seems to be more sensitive than elevated fat pad sign for the detection of potential occult fractures. Positive cases should be cleared by x-rays because the exact nature of the fractures are not identifiable only by ultrasound.

Distance of the fracture from the radiocarpal surface in childhood: does it determine surgical technique? A retrospective clinical study: A STROBE compliant observational study.

Unstable distal metaphyseal and dia-metaphyseal fractures of the radius may have treated with a variety of operative techniques, Kirschner wires (K-wires), dorsally inserted titanium elastic stable intramedullary nailing (DESIN), and short titanium elastic stable intramedullary nailing (SESIN) in children.The aim of this study was to evaluate the differences in clinical and radiographic outcomes between these methods.Between January 2009 and December 2017 196 children were treated for forearm fractures in the distal third of the distal radius. Gender of the patients, different types of surgical techniques, number of postoperative X-rays, date of metal removal and degree of axis deviation after the metal removal were studied. Distance of the fracture line from the radiocarpal surface, the width of the distal epiphysis of the radius, and the cumulative width of the distal epiphysis of the ulna and radius were analyzed.Out of the 196 children, stabilization of the fracture was achieved by K-wire in 139, by DESIN in 44, and by SESIN in 13 patients. The average time of metal removal was significantly shorter (3.8 months), following stabilization with K-wire. In children treated with K-wire, axial deviation of <5° was seen in 118 patients, 5° to 10° deviation in 15 patients, while deviation was above 10° in 6 children. In the DESIN group, <5° axial deviation was found in 37 patients and 5° to 10° in seven patients. In all 13 children treated with SESIN, axial deviation was measured to be <5°. The fracture distance from the radiocarpal surface was on average 23.7 and 45.6 mm in the children treated with K-wire and DESIN, respectively.Fracture distance from the radiocarpal surface might determine the type of surgical technique required. If the distance of the fracture line is less than the width of the distal radius, osteosynthesis with a K-wire is recommended, while if the distance of the fracture is more than the cumulative width of the radius and the ulna, then DESIN may provide better results. The use of SESIN may be indicated when the area of the growth plate is injured.

Intraoperative sonography may reduce the risk of extensor pollicis longus tendon injury during dorsal entry elastic intramedullary nailing of the radius in children.

Extensor pollicis longus tendon (EPL) injury is a potential complication of dorsal entry radial elastic nailing technique in children. The aim of this study was to investigate if intraoperative ultrasonographic guidance can reduce the risk of (EPL) injury.Correlation between sonographic and operative findings were examined first in 6 adult cadavers. Position of Lister's tubercle, EPL, and extraosseal end of the elastic nail were detected by ultrasound imaging during a minimally invasive dorsal entry nailing. Radial slope of Lister's eminence was determined as a safe and easily identifiable entry point for opening the medullary canal. Extraosseal ends of the nails were bended in a slight radial direction and cut immediately beneath the skin in a maximally palmar-flexed wrist position. Cadaveric dissections followed our procedures all correlated with ultrasonographic findings, we have not seen tendon damage, obstruction or friction by the implant's end.After cadaveric experiments, we began using intraoperative sonography for monitoring elastic nail insertion in pediatric radial fractures.Between January 2015 and November 2016, 77 pediatric closed diaphyseal radial fractures were operated by dorsal approach ESIN under intraoperative sonographic checking.Procedures were executed by 2 orthopedic surgeons experienced in ESIN technique with basic musculoskeletal ultrasonographic qualifications.Sonographic identification of EPL and Lister's tubercle in the transverse view was possible in all cases. Determination of the position of the nail end to EPL was also possible in all cases. Mean distance of the transverse view center of the EPL and nail was 0.49 cm (range 0.3-0.62 cm, SD = 0.66). Based on the sonographic transverse view, the operator decided repositioning the nails by 2 patients.We have not found EPL injury postoperatively. All patients were followed for at least 12 months after operations. Nails were removed in all children without further complications.Intraoperative sonography helps determining optimal insertion point and the risk of EPL injury may be reduced during dorsal entry approach.Although the procedure is relatively easy, authors take note that surgical and sonoanatomic knowledge, basic sonographic skills and experience in the ESIN technique are equally necessary for its successful application. A greater number of cases is necessary to confirm our initial promising experiences.

Short, double elastic nailing of severely displaced distal pediatric radial fractures: A new method for stable fixation.

RATIONALE: Short double elastic nailing is a minimal invasive, modified ESIN (elastic stable intramedullary nailing) technique for severely displaced distal radial fracture in children. The aim of this technical report is to introduce our new method and evaluate the final results of the procedure. PATIENT CONCERNS: We reviewed retrospectively 24 patients who underwent short double elastic nailing due to distal radial fractures between November 2012 and December 2015. Indications for surgery included closed, severely displaced, unstable metaphyseal or diametaphyseal fractures of the radius. INTERVENTION: The fractures were stabilized by 2 prebent short elastic titanium nails inserted from the distal side of the fracture. In cases of associated ulnar fracture, a classic anterograd ESIN nailing was also performed. Patients were mobilized immediately in a removable short splint which was removed after 1 to 2 weeks. There has been no additional splinting or casting. OUTCOMES: There were 17 males and 7 females with an average age of 9.8 years (range, 4-16 years). The right hand was involved in 16 cases and the left hand in 8 cases. The average follow-up was 17.8 months (range, 7-28 months). Of the 24 patients, 3 presented irritation of the skin, which resolved after removal of the radial nail. All the patients regained full range of motion without any complications. LESSONS: Our technique is an effective, safe, and easily learnable procedure for unstable fractures of the distal third of the radius. It achieves good functional and radiological results, and allows early mobilization without the need of casting. Avoiding the physeal plates, we reduce the risk of iatrogenic postoperative deformity. Further prospective and biomechanical investigations are necessary to verify our experience.