Biodegradable biomaterials in orthopedic surgery: A narrative review of the current evidence.

BACKGROUND: Biomaterials are routinely used in orthopedic surgery to fill bone defects, improve bone healing, and as degradable fixation material. A wide range of materials are currently in use, and the materials are chosen according to their bioactive properties. Osteoinductive materials stimulate bone healing by promoting osteogenesis. Osteoconductive materials facilitate bone growth on the surface of the material. Despite the many materials in use and an increasing number of published studies, randomized controlled trials on the subject are scarce. METHODS: This review aims to summarize the history of biodegradable biomaterials and also the published level I evidence currently available on orthopedic biomaterials. RESULTS: Most of the studies have been superiority trials with non-significant differences compared to conventional treatment options, confirming that several biomaterials are suitable treatment options for multiple indications including bone and/or tendon fixation, filling bone defects, and spinal fusion. Biomaterials help to avoid donor site complications associated with autogenous bone grafts and often eliminate the need for implant removal. However, the surgical technique may in some cases be more demanding than with conventional methods. Careful consideration of the pros and cons is therefore recommended in clinical practice. CONCLUSION: Biodegradable biomaterials complement the range of available treatment options in several fields of orthopedic surgery. However, some biomaterials performed worse than expected and were not recommended for clinical use, emphasizing the need for high-quality randomized trials. It is also noteworthy that several trials included only a limited number of patients, rendering the interpretation of the results of these underpowered studies challenging.

Maternal Smoking During Pregnancy and Offspring's Risk for Bone Fracture in Childhood and Adolescence.

Conditions during gestation, such as maternal smoking, may affect offspring's bone structure. This could increase the offspring's risk of bone fractures during childhood. In this study, we aimed to assess the association between prenatal exposure to maternal smoking and childhood bone fracture risk. We used a register-based birth cohort that included all children born in Finland between January 1987 and September 1990. After exclusions, the final study population consisted of 220,699 persons. Using a unique national identification number, we linked the cohort data to the fracture diagnosis in specialty care and covariate data using the Medical Birth Register (MBR), Statistics Finland and Care Register for Health Care (CRHC). The fractures were analyzed in three groups: all fractures, non-high-energy fractures, and high-energy fractures. The analyses were adjusted for sex, parity, child's year of birth, mother's age at childbirth, mother's and father's educational level, and mother's fracture status. We tested the association in three age groups: <1 year, 1-<5 years, and 5-<15 years using Cox and (recurrent fractures) Poisson regression. A total of 18,857 (8.5%) persons had at least one bone fracture diagnosis before the age of 15 years. In the age group 5-<15 years, maternal smoking during pregnancy was associated with higher fracture risk in all of the studied fracture groups: hazard ratio (HR) = 1.12 (95% confidence interval [CI] 1.06-1.17) in all fractures, 1.13 (95% CI 1.07-1.19) in non-high-energy, and 1.15 (95% CI 1.00-1.32) in high-energy fractures. There were no significant associations in other age groups in any of the fracture groups. No statistically significant association between maternal smoking during pregnancy and offspring's risk of recurrent fractures was found. In conclusion, 5- to 15-year-olds whose mothers have smoked during pregnancy have an increased risk of bone fractures treated in specialty care. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Girl predominance in trampoline-related forearm shaft fractures and their increasing incidence since 2000.

BACKGROUND: There are reports of increasing incidence of forearm shaft fractures in children. Their treatment has been preferably nonoperative but surgical fixation has gained popularity due to elastic stable intramedullary nailing. We aimed to study whether the incidence of pediatric both-bone forearm shaft fractures and their operative care have changed since year 2000. Trampoline injuries, in particular, and their treatment, re-displacement and short-term outcomes were the secondary outcomes of the study. METHODS: A population-based study in the geographic catchment area of Oulu University Hospital district in 20-years of time period (2000 - 2019) was performed. Altogether 481 diaphyseal both-bone forearm fractures in children (< 16 years) were included. Age- and sex-related incidence rates were determined, by using the official numbers of the population-in-risk by Statistics Finland. Trampoline jumping and other types of injury were reviewed, as well as particulars of treatment and outcomes. RESULTS: The incidence of diaphyseal both-bone forearm fractures increased from 9.4/100 000 in 2000-2001 to 41.7/100 000 in 2018-2019 (P < 0.001). Surgical treatment increased respectively (from 8.8/100 000 in 2000-2001 to 35.3/100 000 in 2018-2019, P < 0.0001). Trampoline injuries explained one in three (29%) of all fractures; they increased from 0% in 2000-2001 to 36.6% in 2018-2019 (P < 0.001). During the last four years of the study (2016-2019), most trampoline-related injuries occurred among girls (61.2%), compared to boys (38.8%) (P = 0.031). Trampoline-related injuries comprised 46.9% of all fractures in girls, compared to 26.0% among boys (Diff. 20.8%, 4.7% to 36.1%, P = 0.009). The mean age of the patients elevated from 6.4 years (2000-2001) to 8.6 years (2018-2019) (P = 0.015). Boys predominated (69.6%) in 2000-2009 but during the last ten years, there was no statistical difference in distribution between the genders (males 54.6%, P = 0.11). CONCLUSIONS: During the twenty-year's of study period, the incidence of pediatric diaphyseal forearm fractures increased fivefold. Trampolining was the most usual single reason for the fractures. More attention should be focused to increase the safety of trampoline jumping, in particular among the girls.

Clinical Follow-Up without Radiographs Is Sufficient after Most Nonoperatively Treated Distal Radius Fractures in Children.

Distal forearm fractures are common in children and are usually treated nonoperatively. No consensus has been reached on how to perform clinical and radiographic follow-up of these fractures. Our aim was to study whether radiographic and clinical follow-up is justified. We included 100 consecutive patients with non-operatively treated distal forearm fractures who were treated at Oulu University Hospital in 2010-2011. The natural history of the fractures during the nonoperative treatment was analyzed by measuring the potential worsening of the alignment during the follow-up period. The limits of acceptable fracture position were set according to the current literature using "strict" or "wide" criteria for alignment. We determined the rate of worsening fracture position (i.e., patients who reached the threshold of unacceptable alignment). In relation to splinting, we evaluated how many patients benefited from clinical follow-up. Most of the fractures (98%) preserved acceptable alignment during the entire follow-up period when wide criteria were used. The application of stricter criteria for alignment in radiographs showed loss of reduction in 19% of the fractures. Worsening of the alignment was recognized at a mean of 13 days (range 5-29) after the injury. One in three (32%) patients needed some intervention due to splint loosening or failure. Radiographic follow-up of nonoperatively treated distal forearm fractures remains questionable. Instead, clinical follow-up is important, as 32% of patients needed their splints fixed.

Abusive head trauma in small children - a single-centre experience in Finland.

Shaken baby syndrome (SBS) is a challenging condition from both a medical and legal perspective. The path of the patients differs significantly from those with noninflicted traumas. While treating these cases, it is essential that all history, information and treatment are comprehensively documented. This article describes the investigations and interventions necessary as soon as SBS is suspected. The Oulu University Hospital protocol for suspected child abuse is described. Authors also give an overview of the SBS path in Finland from the police and prosecution's point of view.

A randomized, controlled multicenter feasibility pilot trial on imaging confirmed uncomplicated acute appendicitis: Appendectomy vs. symptomatic treatment in pediatric patients (the APPSYPP) trial study protocol.

INTRODUCTION: Imaging-confirmed uncomplicated acute appendicitis can be effectively and safely treated with antibiotics in most adults and children. Symptomatic treatment may have similar efficacy and safety. METHODS AND ANALYSIS: The APPSYPP trial is a randomized national multicenter feasibility superiority pilot study comparing appendectomy with symptomatic treatment in children with imaging-confirmed uncomplicated acute appendicitis. INCLUSION CRITERIA: 1) age ≥ 7 and < 16 years, 2) imaging-confirmed uncomplicated acute appendicitis and 3) CRP ≤ 65 mg/l. Patients are randomized to receive emergency laparoscopic appendectomy or symptomatic treatment. To ensure patient safety, symptomatically treated patients are hospitalized for at least 24 h receiving standard practice intravenous fluids and analgesics according to standard clinical practice. Primary outcome is 30-day treatment success defined by the absence of any treatment failure criteria. In appendectomy, treatment failure is defined as normal appendiceal histopathology or any postintervention complication requiring general anesthesia. In symptomatic treatment, treatment failure is defined as 1) inability for hospital discharge without appendectomy within 48 h after randomization with a finding of histopathologically inflamed appendix, 2) appendectomy during the initial hospital stay due to clinical progression of appendicitis with complicated acute appendicitis both histopathologically and surgically, 3) appendectomy with a histopathological finding of acute appendicitis after hospital discharge, or 4) any complication of appendicitis requiring general anesthesia. Detailed predefined secondary outcomes will be analyzed. ETHICS AND DISSEMINATION: Study was approved by Ethics Committee of Helsinki University Hospital (ID:HUS/1993/2021), conducted in compliance with the declaration of Helsinki with results disseminated in peer-reviewed scientific journals. TRIAL REGISTRATION: ClinicalTrials.gov (NCT05289713).

Retrograde intramedullary nailing of the radius in children: A pilot magnetic resonance imaging study of soft-tissue findings.

Purpose: Unstable forearm shaft fractures in children are preferably treated surgically using elastic stable intramedullary nails. The radius is nailed retrograde from the distal metaphysis. There is a risk of surgery-related soft-tissue complications during the operation. Close evaluation of occult surgery-related soft-tissue lesions has not been possible previously, due to the titanium alloy hardware used in the process. The aim of the present study was to evaluate the potential findings in the surrounding soft tissues after intramedullary nailing of the radius, by using magnetic resonance imaging. Methods: The study population comprised 15 pediatric patients with forearm shaft fractures treated by polylactide-co-glycolide biodegradable intramedullary nails and postoperatively evaluated via magnetic resonance imaging. The main outcome was signal abnormality in any tendon at the entry point postoperatively. Secondarily, other changes in the soft tissues related to nailing were determined. Furthermore, the precise location of the entry point and the anatomic characteristics of the soft-tissue tunnel were described. Results: In total, 5 of 15 patients (33.3%) had transient signal pathology in a tendon postoperatively. Edema around the superficial radial nerve was detected in 13 of 15 patients (86.7%). The most common surgical approach was between the extensor pollicis brevis and the extensor carpi radialis longus tendons, which was applied in 10 of 15 patients (66.7%). Conclusions: One in three patients exhibited transient and occult surgery-related intraparenchymal signal pathology in a tendon, after forearm intramedullary nailing. Caution with surgical prepare of the soft-tissue cleavage is recommended. Level of evidence: IV.

Appearance or attitude: what matters to craniosynostosis patients? Association of self-esteem, depressive symptoms, and facial aesthetics in patients with sagittal and metopic synostosis.

PURPOSE: The aim of this study was to investigate the presence of depressive symptoms and self-esteem, and their association with facial asymmetry in adults who were operated on in early childhood due to metopic and sagittal craniosynostosis. METHODS: The study population consisted of 49 non-syndromic patients of whom 41 had premature fusion of the sagittal and 8 of metopic suture. There were 64 controls from the Finnish National Register. Self-esteem, depressive symptoms, and subjective satisfaction with one's appearance were evaluated by using the Rosenberg self-esteem questionnaire (RSE), the short form of Beck Depression Inventory (R-BDI), and a purpose-designed questionnaire on satisfaction with facial and overall appearance. Aesthetic evaluation was done from standard photographs using panels. The facial symmetry was calculated by using 3D photogrammetric methods. RESULTS: Patients did not have a lower self-esteem or experience significantly more moderate or severe depressive symptoms. However, 20% of the patients and 6% of the controls (p = 0.041) experienced mild depressive symptoms. There was no difference between self-assessed evaluation of appearance between the groups. Only weak correlation was found between facial asymmetry and RSE or R-BDI results (cc = 0.27-0.42, p < 0.05). The self-assessed evaluation of facial and overall appearance correlated strongly with the R-BDI results. CONCLUSION: Non-syndromic craniosynostosis patients are as satisfied with their appearance in adulthood as the control group and do not experience a lower self-esteem or more depressive symptoms. Facial asymmetry does not correlate with low self-esteem or clinically significant depressive symptoms in adulthood. Subjective evaluation of one's appearance correlated with depressive symptoms. Age and gender do not influence the former results. Overall, patients are satisfied with their appearance.

Increase in surgical fixation of pediatric midshaft clavicle fractures since 2008.

BACKGROUND: Clavicle fractures in children have traditionally been treated non-operatively. In adults, a great increase in operative treatment has been reported. We aimed to analyze the respective trend and potential explanatory factors in children. METHODS: This is a single-institution retrospective study in a subregion in Northern Finland. The ICD-code S42.0 was used to identify the cases in the hospital registry. Altogether, 214 children, aged < 16, with consecutive clavicle fractures were first enrolled in the area during 2008-2019. Hospital journals and radiographs were reviewed. After lateral and medial fractures and patients living outside the area were excluded, final study population was 172. The respective population at risk was extracted by Statistics Finland. Predictive factors and annual rates of operative treatment as adjusted for 100,000 children at risk were determined. RESULTS: The rate of the surgical treatment of clavicle fractures increased from zero in 2008 to 10.8 in 2019 per 100,000 age-adjusted children (ß = 0.864, 95% confidential intervals (CI) 0.4 to 1.4). There was a rise in the rate of surgery from 2.6% (2014-16) to 16.1% (2017-19) (diff. 13.5, 95% CI 1.7 to 23.3%). A displacement > 15 mm and a shortening of > 15 mm were associated with the increased risk of surgery but did not change during the study period. Age > 9 years increased the risk of surgery; the mean age increased from 5.5 years (2008-10) to 8.5 years (2017-19). There was a 3.6-fold increase in sports-related fractures (95% CI 7.4 to 26.4). The severity of the fractures did not change. CONCLUSIONS: There has been an increasing trend in the surgical fixation of pediatric middle shaft clavicle fractures since 2008. The available literature does not support the trend.

Calcaneal Bone Bruise After Surgery for Insertional Achilles Tendinopathy.

OBJECTIVE: Excision of the posterosuperior corner of the calcaneus (EPCC) is routinely undertaken in athletes after failure of conservative management of insertional Achilles tendinopathy. Some patients can experience sharp calcaneal pain during postoperative rehabilitation, a sign of a calcaneal bone bruise (CBB). DESIGN: Case series, level of evidence IV. SETTING: University teaching hospital. PATIENTS: This study reports 8 patients who developed postoperative CBB after having started impact training too early. INTERVENTION: Patients in whom a diagnosis of CBB had been formulated were followed to return-to-play and resolution of bone edema by MRI. MAIN OUTCOME MEASURES: Detection of CBB after EPCC. RESULTS: After routine EPCC for insertional Achilles tendinopathy, 8 patients presented with sharp pain for a mean 7.1 weeks (median 6 weeks, range 5-11 weeks) before clinical suspicion of CBB. At that stage, MRI showed clear evidence of a bone bruise, with a diagnosis of CBB formulated at an average of 10.8 postoperative weeks (range 6-16 weeks). Calcaneal bone bruise resolved with modified symptom-free loading. Patients returned to play at average on 5.6 months (range 2-9 months) after the diagnosis of postoperative CBB. CONCLUSIONS: We describe 8 athletes who developed painful CBB following routine EPCC for insertional Achilles tendinopathy after having increased their level of activities too soon after the index procedure. In these patients, the diagnosis of postoperative CBB can be formulated by MRI and more cautious rehabilitation implemented.

Craniofacial characteristics and cosmetic satisfaction of patients with sagittal and metopic synostosis: a case-control study using 3D photogrammetric imaging.

PURPOSE: The aim of this study was to investigate the craniofacial and aesthetic characteristics of adult metopic and sagittal craniosynostosis patients operated on in early childhood compared to controls. The goal was to find objective measurements that would correlate with the patient's subjective self-evaluation of their own cosmetic appearance. METHODS: The study population consisted of 49 patients from whom 41 had premature fusion of the sagittal and in 8 of metopic suture. There were 65 age and gender matching controls from The Finish National Register. The 3D photogrammetric models were created from all patients and controls. The images were analysed using Rapidform 2006. Facial landmarks were set by the standard Farkas points. Facial symmetry parameters were calculated by using the landmarks and the mirror shell of the face. Aesthetic evaluation was done from standard photographs using panels. Subjective satisfaction with one's own appearance was evaluated using questionnaires. RESULTS: Patients had the greatest asymmetry in the forehead area when compared to controls (symmetry percentage 59% versus 66%, p = 0.013). In the control group, the gap between the eyes was smaller than in the case group, resulting in an absolute 2 mm difference (p = 0.003). The area of the chin and the landmarks were more located on the left side in the patient group, resulting in up to a 1.1 mm difference between the groups (p = 0.003). Only a weak association was found between craniofacial symmetry and appearance evaluations. CONCLUSION: Patients operated on because of sagittal and metopic synostoses were found to have facial asymmetry at long follow-up. However, the differences were < 3 mm and not clinically important. The long-term aesthetical outcome of the surgery performed because of sagittal or metopic craniosynostosis based on the 3D image evaluation was good.

Long-Term Results of Pediatric Congenital Pulmonary Malformation: A Population-Based Matched Case-Control Study with a Mean 7-Year Follow-Up.

Symptomatic congenital pulmonary malformations (CPMs) are a group of anomalies involving the lungs. The long-term outcomes of these patients are not well known. The present research aimed to study the pulmonary function, respiratory morbidity, and health-related quality of life (QoL) of patients treated for CPMs. All children (<16 years of age) treated for CPMs in 2002−2012 (in Oulu University Hospital) were invited to the follow-up visit. Altogether, there were 22 patients, out of which 17 (77%) participated. The mean follow-up time was 6.6 (ranged from 3 to 16) years. Pulmonary function tests, diffusing capacity, respiratory morbidity, and QoL were determined as the primary outcomes. Potential residual malformations and lung anatomy were investigated using computer tomography (CT) imaging. The outcomes were compared to the age- and sex-matched healthy controls. The forced expiratory volume at 1 s (FEV1, Z-score) remained lower in operated patients compared to the healthy controls (−1.57 ± SD 1.35 vs. −0.39 ± SD −0.86, p-value 0.005). There were no differences in respiratory morbidity or QoL between the patients and the controls. The surgical approach (lobectomy vs. partial resection) did not affect lung function. A younger age (<1 year of age) at the time of the surgery seemed to result in a higher lung capacity, but the finding was not statistically significant. Patients with CPMs treated with surgery were satisfied with their wellbeing in the long-term. A lower lung function did not have an impact on their wellbeing. However, there was a slight decrease in lung function compared to the healthy controls, and a clinical follow-up of the patients was recommended.

Magnetic resonance imaging-guided biopsies in children.

BACKGROUND: Magnetic resonance imaging (MRI) is used far less as an imaging-guided method for percutaneous biopsies than computed tomography (CT) and ultrasound (US), despite its imaging benefits, particularly in children. PURPOSE: To evaluate the feasibility, accuracy and safety of MRI-guided biopsies in paediatric patient population. MATERIAL AND METHODS: The retrospective study included 57 consecutive paediatric patients (<18 years old). A percutaneous core needle biopsy (PCNB) or trephine biopsy was performed in 53 cases, and an additional fine-needle aspiration biopsy (FNAB) in 26 cases. In 4 cases, a stand-alone FNAB was taken. Biopsies were performed with 0.23 T open and 1.5 T closed MRI scanners. Statistical methods used for confidence intervals and p-values were Wilson score method and chi-square test. RESULTS: The overall diagnostic accuracy of histologic biopsy was 0.94, with sensitivity 0.82, specificity 1.00, positive predictive value (PPV) 1.00 and negative predictive value (NPV) 0.92. In histological bone biopsies, diagnostic accuracy was 0.96, with sensitivity 0.86, specificity 1.00, PPV 1.00 and NPV 0.94. The FNAB sample diagnosis was associated with the histological diagnosis in 79% of cases. There were no major primary complications and only a few late complications. After biopsy, 83% of the children were ambulatory in 6 h. Anti-inflammatory drugs and paracetamol provided satisfactory pain relief in 96% of the patients after biopsy. Most outpatients (71%) were discharged from hospital either on the same day or 1 day later. CONCLUSION: MRI is a technically feasible, accurate and safe guidance tool for performing percutaneous biopsies in children.

Casting versus flexible intramedullary nailing in displaced forearm shaft fractures in children aged 7-12 years: a study protocol for a randomised controlled trial.

INTRODUCTION: The forearm is the most common fracture location in children, with an increasing incidence. Displaced forearm shaft fractures have traditionally been treated with closed reduction and cast immobilisation. Diaphyseal fractures in children have poor remodelling capacity. Malunion can cause permanent cosmetic and functional disability. Internal fixation with flexible intramedullary nails has gained increasing popularity, without evidence of a better outcome compared with closed reduction and cast immobilisation. METHOD AND ANALYSIS: This is a multicentre, randomised superiority trial comparing closed reduction and cast immobilisation to flexible intramedullary nails in children aged 7-12 years with >10° of angulation and/or >10 mm of shortening in displaced both bone forearm shaft fractures (AO-paediatric classification: 22D/2.1-5.2). A total of 78 patients with minimum 2 years of expected growth left are randomised in 1:1 ratio to either treatment group. The study has a parallel non-randomised patient preference arm. Both treatments are performed under general anaesthesia. In the cast group a long arm cast is applied for 6 weeks. The flexible intramedullary nail group is immobilised in a collar and cuff sling for 4 weeks. Data are collected at baseline and at each follow-up until 1 year.Primary outcome is (1) PROMIS paediatric upper extremity and (2) forearm pronation-supination range of motion at 1-year follow-up. Secondary outcomes are Quick DASH, Paediatric Pain Questionnaire, Cosmetic Visual Analogue Scale, wrist and elbow range of motion as well as any complications and costs of treatment.We hypothesise that flexible intramedullary nailing results in a superior outcome. ETHICS AND DISSEMINATION: We have received ethical board approval (number: 78/1801/2020) and permissions to conduct the study from all five participating university hospitals. Informed consent is obtained from the parent(s). Results will be disseminated in peer-reviewed publications. TRIAL REGISTRATION NUMBER: NCT04664517.

Cast immobilisation in situ versus open reduction and internal fixation of displaced medial epicondyle fractures in children between 7 and 16 years old. A study protocol for a randomised controlled trial.

INTRODUCTION: Medial epicondyle fracture of the humerus is a common injury in childhood. There is uniform agreement that minimally displaced fractures (dislocation ≤2 mm) can be treated nonoperatively with immobilisation. Open fractures, fractures with joint incarceration or ulnar nerve dysfunction require surgery. There is no common consensus in treatment of closed medial epicondyle fractures with >2 mm dislocation without joint incarceration or ulnar nerve dysfunction. We hypothesise that there is no difference in treatment outcomes between nonoperative and operative treatment. METHODS AND ANALYSIS: This is a multicentre, controlled, prospective, randomised noninferiority study comparing operative treatment to non-operative treatment of >2 mm dislocated paediatric medial epicondyle fractures without joint incarceration or ulnar nerve dysfunction. A total of 120 patients will be randomised in 1:1 ratio to either operative or nonoperative treatment. The study will have a parallel nonrandomised patient preference arm. Operative treatment will be open reduction and internal fixation. Nonoperative treatment will be upper limb immobilisation in long arm cast for 4 weeks. Data will be collected at baseline and at each follow-up up to 2 years. Quick-DASH is used as primary outcome measure. Secondary outcomes are patient-reported pain, differences in range of motion, Pediatric Quality of Life Inventory, cosmetic visual analogue scale and Mayo Elbow Performance Score. ETHICS AND DISSEMINATION: Ethical approval has been obtained from Helsinki University Hospital (HUS) ethical board HUS/1443/2019. Each study centre has obtained their own permission for the study. A written authorisation from legal guardian will be acquired and the child will be informed about the trial. Results of the trial will be disseminated as published articles in peer-reviewed journals. TRIAL REGISTRATION: The trial has been registered at clinicaltrials.gov with registration number NCT04531085.

Posterior vault distraction technique: how I do it.

Posterior cranial vault distraction is an effective technique when a significant increase in the intracranial volume is required in patients with craniosynostoses. This technique has been proven to be safe and time saving and usually is associated with low perioperative morbidity as well as low intraoperative bleeding. Herein a technique is presented starting from the preoperative planning, describing the surgical steps of the operation and the postoperative distraction protocol used by the authors. The authors present important tips and tricks aiming to minimise complications and undesired events.

Physeal Fractures of Distal Tibia: A Systematic Review and Meta-analysis.

BACKGROUND: Fractures involving the distal tibia growth plate are common in children. Injury or treatment that damages the growth plate may result in progressive angular deformity or leg length discrepancy. There is no consensus on treatment and follow-up of these injuries. This study aims to describe which factors increase the risk of premature physeal closure (PPC). MATERIAL AND METHODS: A systematic review and meta-analysis were performed. Altogether 395 articles were reviewed, and ultimately 12 of them were found eligible, comprising 1997 patients. The most usual type of fracture was Salter-Harris (SH) II (n=855, 49%) followed by SH III (n=296, 17%) and SH I (n=261, 15%). The risk of PPC according to number of reduction attempts, method of treatment, and residual displacement was the primary outcome. RESULTS: The total rate of PPC was 13% (n=245). The PPC rate varied from 0.2% to 42% across the studies. Patients with SH IV fractures were most likely to develop PPC (20%), followed by those with SH II (12%) (P<0.05) and repeated (>2) reduction maneuvers were associated with a higher risk of PPC (pooled odds ratio, 8.5; 95% confidence interval, 6.3-12.17; P<0.05). Open reduction was associated with a lower risk of PPC when analyzing only displaced fractures (odds ratio, 0.63; 95% confidence interval, 0.38-0.91; P<0.05). INTERPRETATION: This meta-analysis implies that residual displacement after reduction is the most significant factor in predicting PPC. It seems that open reduction might reduce the PPC rate among patients with dislocated fractures. In addition, there is some evidence that a higher number of reduction attempts correlates positively with the risk of PPC.

Determining the development stage of the ossification centers around the elbow may aid in deciding whether to use ESIN or not in adolescents' forearm shaft fractures.

Background and purpose - Elastic stable intramedullary nailing (ESIN) is the preferred method of operative stabilization of unstable pediatric forearm shaft fractures. However, the decision whether to use ESIN or open reduction and internal fixation (ORIF) in older children or teenagers is not always straightforward. We hypothesized that the development stage of the elbow would aid in evaluating the eligibility of the patient for ESIN.Patients and methods - All eligible children, aged <16 years who were treated with ESIN in Oulu University Hospital, during 2010-2019 were included (N = 70). The development stages of 4 ossification centers were assessed according to the Sauvegrain and Diméglio scoring. The proportion of impaired union vs. union was analyzed according to bone maturity, by using the optimal cutoff-points determined with receiver operating characteristics (ROC).Results - Development stage ≥ 6 in the olecranon was associated with impaired union in 20% of patients, compared with none in stages 1-5 (95% CI of difference 8% to 24%). Trochlear ossification center ≥ 4 was associated with impaired union in 17% of patients (CI of difference 7% to 36%) and lateral condyle ≥ 6 in 13% of patients (CI of difference 3.4% to 30%). Proximal radial head ≥ 5.5 was associated with impaired union in 18% of patients (CI of difference 7% to 39%).Interpretation - Recognizing the rectangular or fused olecranon ossification center, referring to stage ≥ 6, was in particular associated with impaired fracture healing. This finding may aid clinicians to consider between ESIN and plating, when treating forearm shaft fracture of an older child or teenager.

Randomized Controlled Trial of the Clinical Recovery and Biodegradation of Polylactide-co-glycolide Implants Used in the Intramedullary Nailing of Children's Forearm Shaft Fractures with at Least Four Years of Follow-Up.

The preferred surgical fixation of forearm shaft fractures in children is Elastic Stable Intramedullary Nailing (ESIN). Due to known disadvantageous effects of metal implants, a new surgical method using biodegradable polylactide-co-glycolide (PLGA) intramedullary nails has been developed but its long-term outcomes are unclear. The aim of this study was to compare the long-term outcomes of Biodegradable Intramedullary Nailing (BIN) to ESIN and assess the biodegradation of the study implants via magnetic resonance imaging (MRI). The study population of the prospective, randomized trial consisted of paediatric patients whose forearm shaft fractures were treated with BIN (n = 19) or ESIN (n = 16). Forearm rotation at minimally four years' follow-up was the main outcome. There was no clinically significant difference in the recovery of the patients treated with the BIN as compared to those treated with the ESIN. More than half of the implants (57.7%, n = 15/26) were completely degraded, and the rest were degraded almost completely. The PLGA intramedullary nails used in the treatment of forearm shaft fractures in this study resulted in good function and anatomy. No unexpected disadvantages were found in the degradation of the implants. However, two implant failures had occurred in three months postoperatively.

Tears of biceps femoris, semimembranosus, and semitendinosus are not equal-a new individual muscle-tendon concept in athletes.

OBJECTIVES: Hamstring injuries are common and can now be accurately diagnosed. In addition, novel surgical indications have been introduced. However, evidence-based guidelines on the hamstring injuries in management of top-level athletes are missing. METHODS: The management methods and outcomes of treatment are classically based on relatively small case series. We discuss a novel concept based on the fact that each tendon of the hamstrings muscle should be managed in an individual fashion. Furthermore, suitable indications for hamstring surgery in athletes are introduced. RESULTS: The present study introduces modern treatment principles for hamstring injury management. Typical clinical and imagining findings as well as surgical treatment are presented based on a critical review of the available literature and personal experience. CONCLUSIONS: Hamstring injuries should not be considered to be all equal given the complexity of this anatomical region: The three separate tendons are different, and this impacts greatly on the decision-making process and outcomes in athletes.