Changes in gait patterns after anterior cruciate ligament reconstruction in children.

PURPOSE: Anterior cruciate ligament reconstruction (ACLR) in children is indicated to reduce recurrent knee instability and further damage to the joint. Postoperative modified gait pattern was reported in the adult population after ACLR. The aim of this study was to analyse gait abnormalities, and especially knee and ankle adaptations during gait in children after ACLR. METHODS: A prospective study was performed between 2018 and 2022 on 50 children, aged nine to 15 years with unilateral ACL deficiency. Changes in gait pattern were evaluated by gait analysis before surgery and at the latest follow-up of 24 months. Kinematic data of ACL-deficient limb were compared to contralateral limb and to those of a matched control group of healthy children. RESULTS: Compared to control group, knee flexion was decreased for both ACL-deficient and contralateral knee before surgery. Decreased knee flexion during gait cycle persisted at latest follow-up. Ankle kinematics showed decreased dorsal flexion for both ACL-deficient and contralateral limb before surgery. At latest follow-up, ankle kinematics were modified for ACL-reconstructed limbs only at initial contact and showed no significant difference for contralateral limb compared to the control group. CONCLUSION: In children with ACL injury, abnormal gait patterns persist two years after ligament reconstruction, in spite of extensive rehabilitation and no clinical complaints. These findings might guide neuromuscular training to improve clinical outcomes and reduce the rerupture rate.

Influence of a posteromedial meniscocapsular injury on the knee anterior laxity. A cadaveric study.

PURPOSE: The number of anterior cruciate ligament (ACL) injuries has considerably increased in the recent years, especially in young adults and adolescents. Associated meniscal tears increase anterior and rotary laxity. Posterior peripheral meniscocapsular tear of medial meniscus is also called ramp lesion. Prevalence of 9% to 17% in adults and up to 23% in pediatric population has been reported. The aim of this study was to determine anterior laxity of cadaveric ACL-deficient knees with several size of ramp lesions. METHODS: Fresh cadaveric knees were explored. Major osteoarthritis and/or ACL and meniscal tears on arthroscopy were exclusion criteria. Mean age at death was 86 years old. Dynamic laximetry with GNRB® device was made in several conditions: Knee prior to any procedure, after arthroscopic exploration, after ACL section, and then after increasing sizes of ramp lesions up to 30 mm. Anteroposterior laxity was measured with 2 loading forces successively (134N and 200N). RESULTS: After ACL section only, tibiofemoral joint anterior laxity was significantly increased. Mean increase was 156% regardless of the loading force. No statistical laxity difference was found between knees with ACL section only and knees with ACL and meniscal section for any size of ramp lesions. Increasing size of ramp lesion was not correlated with increasing of laxity. CONCLUSION: We could not find a threshold size of ramp lesion which increases knee anterior laxity. We were not able to determine a threshold recommending a ramp lesion repair.

Analysis of Growth After Transphyseal Anterior Cruciate Ligament Reconstruction in Children.

BACKGROUND: Pediatric transphyseal anterior cruciate ligament reconstruction (ACLR) bears several advantages and is widely used. The main concern is the risk of growth disturbance. Our purpose was to investigate the incidence and risk factors of growth disturbance in skeletally immature patients who underwent transphyseal ACLR. We hypothesized that this procedure would generate neither clinically relevant limb length discrepancy (LLD) nor axis deviation. METHODS: This prospective, consecutive, single-center series included skeletally immature patients who underwent primary transphyseal ACLR using semitendinosus tendon autograft, with a 2-year follow-up bone length standing radiograph of both lower limbs from pelvis to ankle in anterior posterior view. Lower limb length, mechanical axis deviation (MAD), lateral distal femoral angle (LDFA), and medial proximal tibial angle (MPTA) were measured. The definition of postoperative growth disturbance was defined as ≥10 mm for LLD or ≥3 degrees for axis deviation in comparison to the contralateral lower limb. Predictive variables included age at surgery, gender, side, and diameter of bone tunnels. Student or Mann-Whitney test was used for numerical variables, and Chi-square test or Fisher exact test was used for categorical variables. P values <0.05 were considered statistically significant. RESULTS: Fifty consecutively treated patients were included. Forty-seven patients (31 boys, 16 girls) with a mean age of 13.2 years (range, 9 to 16) at the time of surgery were available for analysis. Six patients had an LLD of at least 10 mm. Twenty-five patients had a difference in MPTA of a least 3 degrees (range, 5 to 8). Sixteen patients had a difference in LDFA of a least 3 degrees (range, 4 to 9). No patients presented with a clinical deformity or related symptoms. Regarding coronal alignment, there was no statistical difference in mechanical axis deviation, LDFA, or MPTA. Gender, side, age, and bone tunnel diameter did not influence growth disturbance. CONCLUSIONS: Transphyseal pediatric ACLR generated a high rate of growth disturbances (leg length discrepancy and axis deviation) although none clinically relevant. Mild proximal tibial axis deviation in patients operated on near skeletal maturity should be further investigated. LEVEL OF EVIDENCE: Level III. STUDY DESIGN: Case-control study.

Does a combined screw and dowel construct improve tibial fixation during anterior cruciate ligament reconstruction?

PURPOSE: The aims of the present study were to compare the biomechanical properties of tibial fixation in hamstring-graft ACL reconstruction using interference screw and a novel combination interference screw and dowel construct. MATERIAL AND METHODS: We compared the fixation of 30 (2- and 4-stranded gracilis and semitendinosis tendons) in 15 fresh-frozen porcine tibiae with a biocomposite resorbable interference screw (Group 1) and a screw and dowel construct (Group 2). Each graft was subjected to load-to-failure testing (50 mm/min) to determine maximum load, displacement at failure and pullout strength. RESULTS: There were no significant differences between the biomechanical properties of the constructs. Multivariate analysis demonstrated that combination constructs (ß = 140.20, p = 0.043), screw diameter (ß = 185, p = 0.006) and 4-strand grafts (ß = 51, p = 0.050) were associated with a significant increase in load at failure. Larger screw diameter was associated with increased construct stiffness (ß = 20.15, p = 0.020). CONCLUSION: The screw and dowel construct led to significantly increased fixation properties compared to interference screws alone in a porcine model. Increased screw diameter and utilization of 4-strand ACL grafts also led to improvement in load-to-failure of the construct. However, this is an in vitro study and additional investigations are needed to determine whether the results are reproducible in vivo. LEVEL OF EVIDENCE: Level V; Biomechanical study.

Simple Knee Value: a simple evaluation correlated to existing knee PROMs.

PURPOSE: The Simple Knee Value (SKV) is an outcome score in which patients are asked to grade their knee function as a percentage of that of a normal knee. The primary aim of this study was to validate the SKV by measuring its correlation with existing knee-related PROMs. METHODS: This was a prospective study conducted at a teaching hospital to assess the SKV's validity. The study enrolled 47 young patients (16-54 years old), 49 older patients (≥ 55 years) and 30 healthy controls. A paper questionnaire consisting of the Lysholm, IKDC, KOOS, WOMAC and SKV was given to subjects three times (enrolment, 1-month preoperative visit and 6 months postoperative visit). The criterion validity of the SKV was determined by correlating it to existing knee PROMs using the Spearman correlation coefficient (S). SKV test-retest reliability was assessed by the intraclass correlation coefficient (ICC) between two time points (initial consultation at enrolment and preoperative visit, reflecting the same clinical condition). Responsiveness to change was determined by comparing the SKV scores before and after surgery (enrolment consultation and 6 months postoperative). Discriminative ability was determined by comparing the SKV distribution in patients and controls. RESULTS: There was a strong and significant correlation between the SKV and the gold standard Lysholm, IKDC, KOOS and WOMAC in the younger patients and the older patients (p < 0.0001). The reliability between the SKV at the initial consultation and before surgery was excellent (ICC 0.862, 95% CI 0.765; 0.921) in the younger patients, and moderate (ICC 0.506, 95% CI 0.265; 0.688) in the older patients. The SKV was responsive to change in both patient groups (p < 0.0001 for the SKV before versus 6 months after surgery). Like the other knee-specific PROMs (p < 0.0001), the SKV was able to distinguish between patients and controls (p < 0.0001). CONCLUSIONS: The SKV is valid as it is significantly correlated to existing knee PROMs. It is also reliable, responsive to change and discriminating. Its simplicity gives it many advantages and it can be used by physicians in their daily practice. LEVEL OF EVIDENCE: Level II.

Evolution of Hip Dysplasia in Pediatric Patients With Prader-Willi Syndrome Treated With Growth Hormone Early in Development.

BACKGROUND: Prader-Willi syndrome (PWS) is a rare genetic disorder characterized by obesity, hypotonia, feeding difficulties, obesity, musculoskeletal manifestations including scoliosis, and hip dysplasia (HD). The aim of this study was to characterize the clinical and radiographic evolution of HD in the pediatric PWS population. METHODS: The authors performed a retrospective cohort study of 72 patients (147 anteroposterior pelvic radiographs) between January 2004 and December 2016. Center-edge angle (CEA) of Wiberg, acetabular index (AI), and neck-shaft angle (NSA) were measures in all hips. The relationship between radiographic and demographic parameters of age, sex, and body mass index z-score (BMIzs) were assessed. RESULTS: A total of 274 radiographic measurements were performed and analyzed in 72 patients. The mean CEA, AI, and NSA were 21.8±7.1 degrees (range, 5 to 35 degrees), 16.7±7 degrees (range, 5 to 45 degrees), and 142±8.5 degrees (range, 128 to 165 degrees), respectively. HD was diagnosed in 79 (29%) hip radiographs and varied significantly between the age groups (P<0.01). A statistically significant association was identified between age and CEA [ß coef, 0.80; 95% confidence interval (CI), 0.6-1; P<0.01], AI (ß coef, -0.90; 95% CI, -1.1 to -0.7; P<0.01), and NSA (ß coef, -1.11; 95% CI, -1.4 to -0.9; P<0.01) angles. Sex and BMIzs were not identified as independent predictors of radiographic hip angles (P>0.1). CONCLUSIONS: The present study demonstrated favorable evolution of hip radiographic parameters in the PWS population treated with growth hormone early in development. This finding should prompt orthopedists to consider observation alone in the management algorithm for HD in patients with PWS. LEVELS OF EVIDENCE: Level III-a retrospective comparative study.

Delayed reconstruction and high BMI z score increase the risk of meniscal tear in paediatric and adolescent anterior cruciate ligament injury.

PURPOSE: The purpose of this study was to identify epidemiologic risk factors for secondary meniscal tears in paediatric and adolescent patients who sustain an anterior cruciate ligament (ACL) tear. The hypothesis was that delayed reconstruction and elevated BMI z score, increase the risk for secondary meniscal tears. METHODS: A prospective, descriptive and analytical study of consecutively accrued children and adolescents with an ACL tear was performed. One hundred and sixty subjects (114 males and 46 females) were identified between 2006 and 2015 at one institution. The age range was between 7 and 19 years. Fifteen parameters were recorded and analysed: age at initial trauma, initial trauma circumstance, sex, BMI z score, affected side, type of sport, Tegner score, athletic level, time to MRI, time to first referral, time to surgery, age at surgery, attempted non-operative treatment, operative report and associated meniscal tear. These meniscal lesions could be diagnosed by an MRI and / or during surgery. RESULTS: Out of the 160 cases, 143 were treated surgically and 17 cases non-operatively. Median corrected BMI z score was 0.5 (range - 1.8 to 4.7). 41.9% had one or more meniscal lesions. 55 patients were initially treated non-operatively, of which 39 patients were secondarily operated. There was a positive relationship between meniscal lesion and: BMI z score (p = 0.0364), attempted non-operative treatment (p = 0.001) and time to surgery (p = 0.002). The median time to ACL reconstruction was 229 days for patients with secondary meniscal lesions. CONCLUSIONS: Patients with ACL tears treated non-operatively developed secondary meniscal lesions requiring delayed surgical management. There was a positive correlation between BMI z score and secondary meniscal lesions. Thus, early ACL reconstruction is advocated in young athletes. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

Correction of hypokyphosis in thoracic adolescent idiopathic scoliosis using sublaminar bands: a 3D multicenter study.

INTRODUCTION: The comparison of implants and correction methods remain controversial in AIS. Excellent frontal and axial correction rates have been reported with all-screw constructs, but at the expense of sagittal alignment, which has a tendency to flatten postoperatively. Posteromedial translation using hybrid constructs seems to preserve and improve thoracic kyphosis (TK), but no series exist to date with a significant number of hypokyphotic patients. In addition, the measures of TK in 2D are often wrong in severe AIS due to axial rotation. The goals of this study were therefore to analyze the 3D radiological outcomes of a group of hypokyphotic AIS patients operated with sublaminar bands. METHODS: 35 consecutive AIS hypokyphotic patients (T4T12 <15°) operated in three centers were included, with a minimum 2-year follow-up. The surgical technique was similar in all centers, associating lumbar pedicle screws and thoracic sublaminar bands. Posteromedial translation was the main correction technique, and no patient underwent prior anterior release. 3D spinal reconstructions were performed preoperatively, postoperatively and at the latest follow-up by an independent observer using SterEOS (EOS imaging, Paris, France), and 2D and 3D measurements were compared. In addition, a new 3D parameter [sagittal shift of the apical vertebra (SSAV)], reflecting the translation of the apical vertebra of the main curve in the patient sagittal plane, was described and reported. RESULTS: The age of the cohort was 16 years and the number of sublaminar bands used for correction averaged 6 (±1.5). T1T12 and T4T12 sagittal Cobb angles appeared to be overestimated on 2D postoperatively (3°, p = 0.002 and 4°, p < 0.001, respectively). Hence, only 3D measurements were kept for the quantitative analysis of the postoperative correction. T4T12 TK significantly increased after surgery (average 8° ± 7°, p < 0.001), but 11 patients (31.4%) remained hypokyphotic. Seven out of the eight patients (87.5%) who presented a thoracic lordosis (i.e., T4T12 <0°) preoperatively were corrected after surgery (mean gain 16° ± 4°). A posterior shift (positive SSAV) of the apical vertebra was reported in 24 patients (68.6%). In this subgroup, the mean SSAV was +2 cm (±1). Good correlation was found between the SSAV and the postoperative change in 3D T4T12 kyphosis (r = 0.62). CONCLUSION: Measures in 2D tend to overestimate sagittal alignment and are not sufficient to evaluate postoperative correction. SSAV is a new 3D parameter reflecting the TK change that needs to be further investigated and used in the future. This series confirms that sublaminar bands should be considered in hypokyphotic patients, since thoracic sagittal alignment was restored in 68.6% of the cases.

Arthroscopic Treatment of Pediatric Fractures.

Management of pediatric articular fractures has evolved over the years with a growing interest in arthroscopic handling. Several factors account for this recent appeal among which are progress in technology with increased availability of diagnostic methods, rise in athletic activities responsible for these fractures, and pediatric orthopaedic surgeons getting familiar with arthroscopic techniques. In our institution, 9 of 100 arthroscopic procedures are performed as a consequence of an articular fracture. In total, 80% of the fractures concern the knee (56% of tibial eminence fracture, 24% osteochondral fracture). Most of the remaining 20% are located at the ankle joint. Given the thorough articular exploration that arthroscopy provides, any associated cartilaginous or meniscal lesions is identified and addressed in the same procedure as the fracture fixation. Being a less invasive surgery with low complication rate, arthroscopic management of pediatric articular fractures provides very satisfactory results with earlier recovery. Of note, it is technically demanding and requires constant training. The operative time should be monitored and alternative options considered for each surgery. In this regard, arthroscopy has to be viewed as a means not an end.

Magnetically controlled growing rod in early onset scoliosis: a 30-case multicenter study.

PURPOSE: Preliminary results of magnetically controlled growing rods (MCGR) are encouraging. However, only short case series of MCGR for the treatment of early onset scoliosis (EOS) have been reported. Our aim was to evaluate its effectiveness and complications. METHODS: We report a 30-case retrospective, consecutive, multicenter series of MCGR. Effectiveness was judged upon: deformity correction and difficulties to achieve desired distraction. Secondary endpoints included complications and revision surgeries. RESULTS: Median age at surgery was 9.1 years (5-13). Mean follow-up was 18.4 months (12-33.9). Mean Cobb angle was 66° preoperatively and 44° at latest follow-up. MCGR has avoided an average of 2.03 scheduled surgical procedures per patient compared to traditional growing rod (GR). The intended total length gain was 40.1 mm per patient (5-140) and the total measured length gain was 21.9 mm (45.5% discrepancy). There were 24 complications: 7 proximal pull-outs of the hooks, 3 rod breakages, 6 failures of the lengthening of which 4 complete blockages and 2 complete blockages followed by backtracking, 1 proximal junctional kyphosis, 1 wound dehiscence, 1 superficial infection, 1 deep infection requiring implant removal, 1 pulmonary embolism, 1 pulmonary insufficiency, 1 secondary lumbar scoliosis, and 1 painful outpatient distraction. Eight patients had a gradual loss of effectiveness of distractions. There were 13 revision surgeries in 9 patients. CONCLUSIONS: MCGR provides satisfactory deformity correction and avoids repeated surgical procedures for lengthening. However, it has substantial complication rate. Although less frequent than in GR, the law of diminishing returns also applies to MCGR.

Relationship between tibial spine size and the occurrence of osteochondritis dissecans: an argument in favour of the impingement theory.

PURPOSE: Pathophysiology of osteochondritis dissecans (OCD) of the medial femoral condyle remains uncertain. Specifically, the relationship between the size of the anterior tibial spine (ATS) and the presence of OCD has not been explored. The purpose of this study was to evaluate the relationship between ATS size and the occurrence of OCD. METHODS: Seventy-nine children between 8 and 17 years of age were included in two groups: OCD (n = 37) and control (n = 42). The groups were matched in terms of age, gender, BMI and weight. Two independent observers performed an MRI analysis of the size of the tibial spine and intercondylar notch relative to the size of the respective epiphyses. For this study, the "S ratio" was calculated by dividing the height of the tibial spine by the height of the tibial epiphysis. The "N ratio" was calculated by dividing the height of the notch by the height of the femoral epiphysis. These two ratios for both groups were compared using Student's t test. RESULTS: The mean value of the S ratio in the OCD group was 0.39 ± 0.06; the mean value of the S ratio in the control group was 0.32 ± 0.03 (P = 0.004). The mean value of the N ratio in the OCD group was 0.70 ± 0.08; the mean value of the N ratio in the control group was 0.70 ± 0.07 (n.s.). CONCLUSION: This study's findings confirm our hypothesis that patients with OCD have a more prominent tibial spine than in patients without OCD. LEVEL OF EVIDENCE: IV.

Gartland types IIB and III supracondylar fractures of the humerus in children: is Blount's method effective and safe?

BACKGROUND: Blount's method is controversial for the treatment of Gartland types IIB and III supracondylar fracture of the humerus (SCFH) in children. The purpose of this study was to evaluate the clinical and radiologic outcomes and the failure and complication rates. METHODS: All types IIB and III SCFH treated with Blount's method from 2003-2013 were included in this retrospective single-center study. Clinical assessment was performed according to Flynn criteria. Baumann angle, anteversion angle, anterior humeral line, and humeroulnar angle were measured for radiographic assessment. RESULTS: Among 447 children with types IIB and III SCHF, 339 were treated according to Blount's method. There were 173 boys (51%), and the mean age was 6.3 years (1-14 years); 71% were type III. Mean time to surgery was 5.7 hours. According to Flynn criteria, results were satisfactory in 91% of cases. No compartment syndrome was encountered. There were 16 (4.7%) secondary displacements requiring surgical revision. Five (1.9%) children developed a cubitus varus deformity. At latest follow-up, the mean Baumann angle was 74.7° (95% confidence interval, 74.1-75.3), the mean anteversion angle was 39.9° (95% confidence interval, 39.5-40.3), the anterior humeral line was normal in 87.6% of cases, and the mean humeroulnar angle was 8.7°. CONCLUSION: Blount's method is appropriate to manage types IIB and III SCFH, provided anatomic and stable reduction is obtained.

Cartilaginous tibial eminence fractures in children: which recommendations for management of this new entity?

PURPOSE: Cartilaginous tibial eminence fracture (CTEF) is a new pattern of ACL rupture in children under the age of nine. MRI signs have been recently reported, but no series gave information about outcomes. It was hypothesized that primary treatment gave better results than delayed management due to frequent misdiagnosis. METHOD: This retrospective study focused on 15 patients, managed acutely (n = 7) or delayed (n = 8). The patients' median age at the time of initial injury was 6.5 years (range 5-9). Lysholm, IKDC 2000 subjective scores, and the measurement of the residual laxity by a side-to-side difference with a KT-1000 junior arthrometer were used at the time of revision. RESULTS: After a mean follow-up of 9.8 years (range 1-18.5), the mean Lysholm and IKDC subjective scores were, respectively, 97.7 ± 2.6 and 97 ± 3.4. The median residual laxity was 2 mm (range 0-4). Non-operative treatment lead to 2 failures: intermeniscal ligament entrapment and combined avulsion fracture at the femoral site. Suture fixation of the avulsed fragment allows regularly good results when performed acutely or even 4 years after the injury. The hypothesis that primary treatment gives better result than delayed treatment tends to be wrong as 2 failures were reported in each group. An ACL reconstruction was performed in 3 out of the 4 treatment failures. Progressive resorption of the avulsed fragment was noticed in 3 of the 4 failures suggesting an associated ACL resorption. CONCLUSION: CTEF has a good prognosis even after misdiagnosis and treatment at the time of non-union; this could be due to low-energy mechanism of injury and low rate of associated lesion. Orthopaedic treatment for acute minimally displaced fractures is only indicated under strict MRI control, and suture fixation is the recommended strategy in other situations. Conservative management of non-union could expose to ACL involution and cannot be recommended. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Triple osteotomy of the pelvis for Legg-Calve-Perthes disease: a mean fifteen year follow-up.

PURPOSE: This study presents the results of a prospective consecutive cohort of patients with Legg-Calvé-Perthes disease (LCPD) operated with triple osteotomy of the pelvis (TOP) between 1989 and 2005. We attempted to determine whether the results of TOP remain stable with time and consequently lower the risk of subsequent osteoarthritis. The primary study aims were to determine the maintenance of head coverage and joint congruity, and functional outcomes of this surgery. METHODS: Forty-five patients with a mean follow-up of 15.2 years (range eight to 24) were included. RESULTS: At latest follow-up, two patients were lost to follow-up, and two required a surgical reoperation. Cumulative maintenance of head coverage and joint congruity rate for all TOP was 84.6 % (95 % CI: 82.3-90.6 %) at 15 years. Factors significantly associated with poor long-term results were the age at diagnosis and Greene index. CONCLUSION: TOP in LCPD provides satisfactory and reproducible long-term clinical results.

Low-dose biplanar radiography can be used in children and adolescents to accurately assess femoral and tibial torsion and greatly reduce irradiation.

PURPOSE: To evaluate in children the agreement between femoral and tibial torsion measurements obtained with low-dose biplanar radiography (LDBR) and CT, and to study dose reduction ratio between these two techniques both in vitro and in vivo. MATERIALS AND METHODS: Thirty children with lower limb torsion abnormalities were included in a prospective study. Biplanar radiographs and CTs were performed for measurements of lower limb torsion on each patient. Values were compared using Bland-Altman plots. Interreader and intrareader agreements were evaluated by intraclass correlation coefficients. Comparative dosimetric study was performed using an ionization chamber in a tissue-equivalent phantom, and with thermoluminescent dosimeters in 5 patients. RESULTS: Average differences between CT and LDBR measurements were -0.1° ±1.1 for femoral torsion and -0.7° ±1.4 for tibial torsion. Interreader agreement for LDBR measurements was very good for both femoral torsion (FT) (0.81) and tibial torsion (TT) (0.87). Intrareader agreement was excellent for FT (0.97) and TT (0.89). The ratio between CT scan dose and LDBR dose was 22 in vitro (absorbed dose) and 32 in vivo (skin dose). CONCLUSION: Lower limb torsion measurements obtained with LDBR are comparable to CT measurements in children and adolescents, with a considerably reduced radiation dose. KEY POINTS: • LDBR and CT lower-limb torsion measurements are comparable in children and adolescents. • LDBR considerably reduced radiation dose necessary for lower-limb torsion measurements. • LDBR can be used for evaluation of lower limb-torsion in orthopaediatric patients.

Use of the Universal Clamp in adolescent idiopathic scoliosis.

UNLABELLED: The Universal Clamp (UC) equipped with a soft sublaminar band is a relatively new thoracic anchor that can be used in hybrid constructs. A dedicated reduction tool that applies traction to the sublaminar band permits gentle translation of the thoracic curve to the pre-contoured fusion rods, which have been previously anchored distally by pedicle screws and proximally by hooks in a claw configuration. METHODS: A literature review concerning the use of UC in adolescent idiopathic Scoliosis was performed. RESULTS: The results confirm the efficacy with the UC hybrid constructs, the good correction (71-66%) of the main thoracic curve and low loss of correction at 2-year follow-up (3-4%). The thoracic curve correction achieved and maintained in the AIS patients appears to be substantially higher than that reported for all hook and hook hybrid techniques. Regardless of the deformity correcting method employed with all-screw constructs, the Cobb angle correction achieved is equivalent to that achieved with UC hybrid devices. Among the present AIS patients who had normal values of thoracic kyphosis pre-operatively, there was almost no change in average thoracic kyphosis at the latest follow-up. However, among the patients with low pre-operative values of T5-T12 kyphosis, the average T5-T12 kyphosis improved. CONCLUSION: Hybrid construct with UC is safe, with reduced operative time and blood loss. While achieving deformity correction in the coronal and axial planes equivalent to the best-reported results of all screw or previous hybrid constructs, the UC hybrid technique appears to provide superior correction in the sagittal plane. The excellent outcome is maintained at the 2-year follow-up.

Ewing sarcoma of the acetabulum in children: a "growth plate-based" surgical strategy.

BACKGROUND: Surgical strategy for Ewing sarcoma (ES) of the pelvis relies on Enneking classification. In adults, in case the acetabulum is involved, excision of the entire acetabulum is needed and often leads to loss of function. In children, the surgeon may adopt a strategy, such as in metaphyseal tumors of long bones where an unaffected growth plate allows a transepiphyseal resection, therefore sparing the joint. METHODS: We present a "triradiate cartilage strategy" for the excision of ES of the pubic component of the acetabulum, which allows a wide resection while preserving most of the socket. The approach is ilioinguinal. Osteotomies of the iliopubic and ischio pubicrami are performed, followed by hip arthrotomy and anterior dislocation. Transacetabular resection is achieved using osteotomes, under image intensifier guidance, with no further reconstruction. Cases are presented for 2 boys aged 6.5 and 9.5 years, treated with chemotherapy and transacetabular resection. RESULTS: Resections were all rated R0. Patient #1 remained asymptomatic, including during sport activities, and had normal hip range of motion at 12-year follow-up. Radiograph demonstrated mild protrusio acetabuli. Patient #2 had no complain at 3-year follow-up with normal hip range of motion, although he presented with an equinus gait. Radiographs demonstrated a well-covered femoral head without medial shift. CONCLUSIONS: A "growth plate-based" surgical strategy can be adapted to malignant pelvic tumors in skeletally immature children. This technique leaves intact the ilio ischiatic component of the triradiate cartilage, which, according to Ponseti, contributes the most to the growth of the acetabulum. Joint sparing improves the functional result and decreases the risk of complication. LEVEL OF EVIDENCE: IV.

Corrosion of a Fassier-Duval Telescopic Nail Causing Pain and Osteolysis: A Case Report.

CASE: A 15-year-old girl known with osteogenesis imperfecta presented with left femoral pain. She had been treated with multiple Fassier-Duval intramedullary nails, which were still in situ. Radiographic imaging demonstrated focal osteolysis and periosteal reaction at the telescopic junction of the rod in the distal femur. She underwent implant removal. Intraoperative sampling demonstrating acute sterile inflammation and presence of brownish colored particles consistent with metal debris and osteolysis. Explant analysis confirmed corrosion of the stainless-steel telescopic nail as the underlying cause. CONCLUSION: Osteolysis and periosteal reaction because of corrosion should be considered in conjunction with other more common causes of pain, such as fracture or infection, in patients treated with telescopic intramedullary nails.

Tibial spine fractures: State of the art.

Tibial spine fractures (TSFs) are avulsion fractures at the site where the anterior cruciate ligament inserts onto the tibial eminence. TSFs typically affect children and adolescents aged 8-14 years. The incidence of these fractures has been reported to be approximately 3 per 100,000 per year, but the rising involvement of paediatric patients in sporting activities is increasing the number of these injuries. TSFs are historically classified on plain radiographs according to the Meyers and Mckeever classification system, which was introduced in 1959, but the renewed interest in these fractures and the increasing use of magnetic resonance imaging led to the recent development of a new classification system. A reliable grading protocol for these lesions is paramount to guide orthopedic surgeons in determining the correct treatment for young patients and athletes. TSFs can be addressed conservatively in the case of nondisplaced or reduced fractures or surgically in the case of displaced fractures. Different surgical approaches and, specifically, arthroscopic techniques have been described in recent years to ensure stable fixation while limiting the risk of complications. The most common complications associated with TSF are arthrofibrosis, residual laxity, fracture nonunion or malunion, and tibial physis growth arrest. We speculate that advances in diagnostic imaging and classifications, combined with greater knowledge of treatment options, outcomes, and surgical techniques, will likely reduce the occurrence of these complications in paediatric and adolescent patients and athletes, allowing them a timely return to sports and everyday activities.