Anterior cruciate ligament reconstruction in adolescents (Tanner stages 2 and 3).

PURPOSE: Management of anterior cruciate ligament injuries in skeletally immature patients (in Tanner stages 2 and 3) is controversial. Conventional reconstruction used in adults can cause iatrogenic growth disturbance due to physeal damage, and studies that report long-term results using a specific technique are scarce. The aim of this study is to evaluate in a large series the mid- and long-term results of a partial transphyseal technique and define the safe percentage of lesions of the femoral growth plate. METHODS: Between 1989 and 2012, 42 adolescents at risk of growth disturbances (growth prediction of lower limbs >5 cm-Tanner 2, 3) underwent reconstruction of the anterior cruciate ligament using the semitendinosus and gracilis tendons. Growth characteristics of all the patients were assessed preoperatively, and the percentage of damage that would be produced in the femoral physis by the drilling of a 6-mm-diameter tunnel was determined. The technique used achieved graft fixation at both insertion sites, drilling the femoral physis and avoiding the tibial physis. We distinguished two groups: (a) long-term follow-up (mean 13 years 7 months, min 10.9, max 16.2) and (b) medium follow-up (mean 6 years 3 months, min 3.7, max 9.9). All knees were evaluated subjectively by history and objectively by KT2000 testing, and X-rays of both knees were compared for osteoarthritis using the Kellgren-Lawrence classification. RESULTS: In group A (12 patients) one osteoarthritis grade 2, one instability, and ten good stability and function were observed. The mean KT2000 arthrometer values at 30 lb showed a difference of +2.4 mm (range 1-4 mm) between the operated and non-operated sides (p < 0.05). In group B (21 patients) no growth disturbance of the lower limbs, two failures (reinjury while participating in pivoting sports), and 19 good stability and function were observed. The mean KT2000 arthrometer values at 30 lb showed a difference of +1.9 mm (range 1-5 mm) between the operated and non-operated sides (p < 0.05). The average IKDC score of all the patients was 90 (min: 68, max: 97). None of the adolescents had consequences on growth after an eccentric damage passing tendons less than 7% on the frontal plane and of 1% on cross-sectional area of the femoral physis, and after an oblique tunnel passing 6-mm-diameter tendons of the tibial epiphyseal nucleus. CONCLUSIONS: This study defines the possibility to perform a partial transphyseal intra-articular ACL reconstruction in patients in Tanner stages 2 and 3 that avoids tibial physis, involves the distal femoral physis, and produces good results at mid- and long-term follow-up without causing growth disturbances. LEVEL OF EVIDENCE: IV.

Lyon bracing in adolescent females with thoracic idiopathic scoliosis: a prospective study based on SRS and SOSORT criteria.

BACKGROUND: The Lyon brace is commonly prescribed in many European countries to patients with thoracic curves and is based on the three-point pressure system. The purpose of this study was to evaluate the efficacy of Lyon bracing for the conservative treatment of adolescent females with idiopathic thoracic curves in a case series selected on the basis of the Scoliosis Research Society (SRS) Committee on Bracing and Nonoperative Management Standardization Criteria and followed the guidelines on management of idiopathic scoliosis with corrective braces, proposed by the International Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT). METHODS: Prospective study based on an ongoing database. From 1297 patients treated for idiopathic scoliosis between 1995 and 2014 fulfill the inclusion criteria 102 patients treated with Lyon brace. Of these, 69 patients had a definite outcome, 17 have abandoned treatment e 16 are still in treatment. The 104 patients were adolescent females with curvatures in the thoracic spine and a pre-treatment Risser score ranging from 0 to 2. All patients were prescribed with full-time Lyon bracing. The minimum duration of follow-up was 24 months after the end of weaning (mean: 41.64 ± 31.45 months). Anteroposterior radiographs were used to estimate the curve magnitude (CM) at 5 time points: beginning of treatment (t1), one year after the beginning of treatment (t2), intermediate time between t1 and t4 (t3), end of weaning (t4), 2-year minimum follow-up from t4 (t5). Three outcomes were distinguished: curve correction, curve stabilization and curve progression. RESULTS: The results from our study showed that of the 69 patients with a definite outcome the CM mean value was 31.51° ± 4.34 SD at t1 and 20° ± 7.6 SD at t5. Curve correction was accomplished in 85.5 % of patients, curve stabilization was obtained in 13 % of patients and curve progression was evident in only 1.5 %. None of the patients were recommended surgery post-bracing. Of 17 patients who abandoned the treatment, at the time of abandonment (14.4 age) have achieved curve correction in 13 cases (77 %), stabilization in 53 cases (18 %) and progression in 1 case (5 %). CONCLUSION: The Lyon brace, through its biomechanical action on vertebral modeling, is highly effective in correcting thoracic curves in particularly when the SOSORT guidelines were adopted in addition to the SRS criteria.

Radial neck fractures in children: results when open reduction is indicated.

BACKGROUND: Radial neck fractures in children are rare, representing 5% of all elbow pediatric fractures. Most are minimally displaced or nondisplaced. Severely displaced or angulated radial neck fractures often have poor outcomes, even after open reduction, and case series reported in literature are limited. The aim of the study is to analyze the outcomes of patients with a completely displaced and angulated fracture who underwent open reduction when closed reduction failed. METHODS: Between 2000 and 2009, 195 patients with radial neck fractures were treated in our institute. Twenty-four cases satisfied all the inclusion criteria and were evaluated clinically and radiologically at a mean follow-up of 7 years. At follow-up, the carrying angle in full elbow extension and the range of motion of the elbow and forearm were measured bilaterally. We recorded clinical results as good, fair, or poor according to the range of movement and the presence of pain. Radiographic evaluation documented the size of the radial head, the presence of avascular necrosis, premature physeal closure, and cubitus valgus. RESULTS: Statistical analysis showed that fair and poor results are directly correlated with loss of pronation-supination (P = 0.001), reduction of elbow flexion-extension (P = 0.001), increase of elbow valgus angle (P = 0.002), necrosis of the radial head (P = 0.001), premature physeal closure (P = 0.01), and associated lesions (olecranon fracture with or without dislocation of the elbow) (P = 0.002). DISCUSSION: In our cases, residual radial head deformity due to premature closure of the growth plate and avascular necrosis were correlated with a functional deficit. Associated elbow injury was coupled with a negative prognosis. In our series, about 25% of patients had fair and 20% had poor results. Outcomes were good in 55% and felt to represent a better outcome than if the fracture remained nonanatomically reduced with residual angulation and/or displacement of the radial head. This study reports the largest series of these fractures with a combination of significant angulation and displacement of the fracture requiring open reduction. We feel that open reduction is indicated when the head of the radius is completely displaced and without contact with the rim of the metaphysis.

Lateral Humeral Condyle Fracture in Childhood: Results of a New Surgical Technique.

Fractures of the lateral condyle of the humerus are one of the most common fractures in children, accounting for between 10% and 20% of fractures involving the elbow, with a peak incidence at 6 years of age. Treatment is often surgical for displaced fractures > 2 mm, according to Milch and Jakob classification. There is no consensus in the literature about the appropriate surgical management of these fractures. Objectives: The aim of this study is to describe, propose, and evaluate outcomes and complications of the surgical technique of reduction and osteosynthesis using trans-bone suture with resorbable threads. Methods: Patients with lateral condyle fractures treated with this surgical technique from 2015 to 2019 were included in this retrospective study, with a minimum follow-up of 24 months. For clinical and functional assessment of the elbow, Mayo Elbow Scores were recorded; we assessed the time of fracture healing, carrying angles, and Baumann angle of the affected limb compared to the healthy contralateral elbow for radiographic data. Complications have also been described. Results: We achieved satisfactory results; 36 patients with lateral condyle fractures were included in this study. Radiological healing was achieved in all cases. There was only one complication. No cases required additional surgical procedures. Almost all patients achieved a complete flexion of 110 degrees or more and complete extension. Conclusions: This surgical technique has good functional outcomes and fracture healing, a lower incidence of complications when compared to other surgical techniques, and no mechanical failure with good clinical and radiological results.

Paediatric Calcaneal Osteochondroma: A Case Report and a Literature Review.

BACKGROUND: Heel pain in children is a common condition. The aetiology can be ascribed to fractures, osteochondrosis, tendinitis, calcaneal-navicular or talo-calcaneal coalition, osteomyelitis, rheumatic diseases, anatomic variants, malignant tumours (osteosarcoma, Ewing's sarcoma), and benign lesions (bone cyst, aneurismal bone cyst, osteoid osteoma, or exostosis). In particular, this manuscript focuses on a case of calcaneal exostosis in the paediatric age, aiming to highlight its rarity. Osteochondromas are benign tumours of the surface of the bone and the overlying cartilage. They grow until skeletal maturity and can cause stiffness, pain, cosmetic alterations, tendinitis, and neuro-vascular compression. The calcaneus is an extremely rare site for these tumours. Only two case reports of paediatric exostosis of the calcaneus bone are available. METHODS: We describe a case of a girl of 16 years of age, affected by multiple cartilaginous exostosis, who presented with a painful mass on the inferior margin of the foot in the calcaneal region, which was diagnosed as an exostosis. The neoformation was excised, and the girl underwent clinical follow-up. RESULTS: The patient was promptly discharged in good condition, and on the 25th postoperative day, she was completely pain-free and allowed weight bearing. CONCLUSIONS: In the case of heel pain resistant to conservative treatment, the presence of an osteochondroma should be considered after excluding more common causes. If symptomatic, calcaneal osteochondromas could require surgical excision.

Long-term outcome after brace treatment of Scheuermann's kyphosis: an observational controlled cohort study.

BACKGROUND: In the literature, there are several papers on Scheuermann's kyphosis. It is a structural deformity of the spine that is characterized by anterior wedging of 5° or more of 3 adjacent thoracic vertebral bodies with kyphosis measuring greater than 45° between T5 and T12. Bracing treatment is able to obtain, during skeletal growth, remodeling of the deformed vertebrae. AIM: The aim of this study was to evaluate the effectiveness of conservative treatment in Scheuermann's kyphosis at a minimum follow-up of 10 years. DESIGN: This is an observational controlled cohort study nested in a prospective clinical on-going database in patients with Scheuermann kyphosis. SETTING: Inpatients and outpatients in Rome. METHODS: From a consecutive series of patients included in a prospective database, we selected 158 patients with thoracic Scheuermann's kyphosis who were treated using an anti-gravity brace: 93 males and 65 females. The mean age at the beginning of the treatment was 14 years. The time bracing prescribed was a max of 20 hours daily and a min of 16 hours daily. Weaning was started when a full recovery of vertebral geometry was seen on a lateral radiograph view or when growing was ended. Radiographical measurements were performed on radiographs from a lateral projection at baseline (t1), at the end of the treatment (t2) and at 10 years of minimum follow-up (t3). To avoid the great variance in the range of curve angles in thoracic kyphosis (TK) that rely on the radiological position, X-rays were performed observing the following position: standing with head straight, arms bent at 45° and hands lightly placed on a support. The anterior wedging angle (Alpha) of the apex vertebra and the degrees of the curve (Cobb methods) were analyzed using statistical analysis. RESULTS: The results from our study showed that in 158 patients with TK curves, the mean Cobb angle was 57.6±6.3 SD at baseline, 43.3±7.8 SD at the end of treatment and 44.49±7.4 SD at ten years of follow-up. The alpha angle was 14.43±2.535 SD at baseline and 8.571±3.589 SD at the end of treatment, and after ten years of follow-up, it was 8.654±3.57 SD. The mean duration of treatment was 28.42±12.07 months, and the mean follow-up was 128.3±11.07 months. The difference between baseline and end of treatment, tested with the one-way ANOVA comparisons test, was significant (P<0.0001) for both Cobb angle and alpha; instead, the difference between the end of treatment and follow-up was not significant (P=0.3277). CONCLUSIONS: The results confirm that conservative treatment in Scheuermann's kyphosis during skeletal growth is effective. Bracing treatment can remodel the deformed vertebrae. CLINICAL REHABILITATION IMPACT: At the 10-year follow-up after bracing, kyphosis curve correction was stable over time.

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.

Management of Open Pediatric Fractures: Proposal of a New Multidisciplinary Algorithm.

BACKGROUND: An algorithm for managing open fractures in children is still being debated; the present study suggests an evidence-based way to manage these patients in the emergency department. METHODS: The literature on "Open fractures in children" was carefully analyzed using keywords. The primary sources were The Cochrane Library, PubMed, and Researchgate. CONCLUSION: We proposed an evidence-based algorithm for managing open fractures in children to standardize clinical practice and improve the care of these patients.

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.

Patellar dislocation in skeletally immature patients: semitendinosous and gracilis augmentation for combined medial patellofemoral and medial patellotibial ligament reconstruction.

PURPOSE: Patellar instability is a frequent condition in children and adolescents. The problem can be associated with malalignment resulting from different anatomical abnormalities. Several surgical procedures have been suggested for recurrent patellar dislocation consequent to failed conservative treatment. METHODS: We present an original surgical procedure for reconstructing both the medial patellofemoral (MPFL) and medial patellotibial ligaments (MPTL) by semitendinosus (ST) tendon with gracilis (G) autograft augmentation in skeletally immature patients with recurrent patellar dislocation. RESULTS: This technique is effective and permits satisfactory patellar congruency documented by static and dynamic CT. CONCLUSIONS: The operation is associated with optimal functional results and is minimally invasive, causing no growth disturbance. LEVEL OF EVIDENCE: Expert opinion, Level V.

Galeazzi's modified technique for recurrent patella dislocation in skeletally immature patients.

BACKGROUND: A large number of surgical techniques have been proposed for the treatment of recurrent patellar dislocation in adolescents, one of the most famous being Galeazzi's semitendinosus tenodesis as modified by Baker. The aim of this study was to verify the mid-term results of this technique, the effectiveness of restoring the patellofemoral congruency, by both static and dynamic computed tomography (CT), and to determine whether the preoperative type of patellofemoral relationship affects the results. METHODS: The study included 14 patients (16 knees), with a mean age of 11.6 years, Tanner stage ≤3, with at least two to three episodes of patellar dislocation. The patients underwent surgery using Baker's modification of Galeazzi's technique. All 14 patients were evaluated preoperatively and at least 4 years afterward by static and dynamic CT. Clinical evaluation at follow-up was performed using the criteria described by Crosby and Insall. RESULTS: Clinical results at follow-up were excellent in 62.5% and good in 37.5%. As preoperative evaluation showed a high patella in 7 out of 16 knees, two groups were considered: A, high patella; B, not high patella. The data obtained with static CT show that the patella reached a satisfactory congruence in all knees. The data obtained with dynamic CT showed different results between group A and B. A preoperative high patella remains high with quadriceps contraction and again shows the change of tilt and subluxation. In group B, the data obtained with dynamic CT are comparable with those obtained with static CT. CONCLUSIONS: This technique produces good mid-term clinical results. However, the dynamic CT showed that in those patients with high patellas, semitendinosus tenodesis alone is not enough to stabilize the patella.

The conservative treatment of congenital scoliosis with hemivertebra: Report of three cases.

Introduction: Scoliosis is the most common type of congenital vertebral disease. This spinal disorder may be due to a failure of formation, segmentation, or a combination thereof. Complete failure of formation causes hemivertebra which can lead to unbalanced growth and deformation. Statistically, 25% of congenital curves do not evolve, 25% progress slightly, while the remaining 50% develop quickly and require treatment. Hemivertebrae can be divided into three types: non-segmented, semi-segmented, and fully-segmented. The fully-segmented types are most likely to progress. Hemivertebra in the thoracolumbar region shows higher rates of progression compared with those in the lumbar area. The treatment may be either conservative or surgical. In general, bracing is not recommended in short and rigid curves, although it may help process secondary curves. Objective: To assess the effectiveness of bracing in congenital scoliosis due to hemivertebra. Cases presentation: Searching in our database, we found three cases of patients with congenital scoliosis due to fully-segmented hemivertebra. The first of them was 6 years old at the time of diagnosis with a fully-segmented hemivertebra in L5, determining an L1-L5 (S1) lumbar curve. The second one was 10 years old at the time of diagnosis with a fully-segmented hemivertebra in L2 and a T11-L4 (L5 sacralized) thoracolumbar curve. The last one was 3 years old at the time of diagnosis with a fully-segmented hemivertebra in L3 (in six lumbar bodies), determining a thoracolumbar curve T12-L4. Results: We utilized a Milwaukee brace for the first patient, a Boston brace for the second patient, and a Progressive Action Short Brace (PASB) for the third patient. At the beginning of the treatment, the Cobb angles measured 23°, 53°, and 25°, respectively. During treatment, the Cobb angles measured 22°, 35°, and 15°, respectively. At the end of treatment, the Cobb angles measured 18°, 45°, and 12°, respectively. At long-term follow-up, the curves measured 20°, 45°, and 12° Cobb angles, respectively. Conclusions: Comparing our cases with those found in the literature we can confirm the ability of conservative treatment to change the natural history of congenital lumbar scoliosis due to failure of formation. From our experience, in all cases of CS with hemivertebra, before considering a surgical approach, conservative treatment should be implemented as early as possible without waiting for the progressive deformation of the adjacent normal vertebrae.

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.

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.

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.

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.

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.

Slipped capital femoral epiphysis: an ultrastructural study before and after osteosynthesis.

BACKGROUND AND PURPOSE: Several different theories have been proposed to explain the pathogenesis of slipped capital femoral epiphysis (SCFE). Using transmission electron microscopy (TEM), we carried out an ultrastructural study of core biopsy specimens of the physis at various stages of the disease. METHODS: Core biopsies were performed in 6 patients with different forms of SCFE during the first operation, and in 3 of them when removing the osteosynthesis material before physeal closure. The specimens were prepared for TEM examination. RESULTS: In 6 specimens obtained at first surgery, a marked distortion of the physeal architecture was observed. In 2 of the 3 specimens obtained at removal of the osteosynthesis material, the physis showed a more normal organization. INTERPRETATION: The improvement of the pathological alterations observed in the 2 cases after surgical intervention leads us to consider the possibility that when the growth plate is stabilized directly by pinning or indirectly by creating more optimal loading conditions with an intertrochanteric osteotomy, the morpho-functional characteristics of the physis can be restored and its growth process may resume.

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.