Limb Length Discrepancy After Intraosseous Line Malpositioning: A Case Report.

CASE: We will present the case of a 6-year-old girl who presented with a 3-cm limb length discrepancy after intraosseous line placement at age 14 months without other known history of trauma or infection to account for the growth arrest. Imaging revealed a left proximal tibial physeal bar amenable to surgical resection with autologous lipotransfer. At 10 months postoperatively, physical examination and imaging demonstrated a stable 3-cm leg length discrepancy with an interval increase in the length of the left tibia in proportion to the growth of the right side with an increase in valgus alignment that will continue to be monitored and addressed as indicated. CONCLUSION: Pediatric intraosseous line placement presents unique challenges and can ultimately lead to physeal injury and growth arrest in the case of malpositioning.

Percutaneous transphyseal screw induces varus proximal femoral growth modulation in a growing pig model-A three-dimensional analysis.

Bone and joint angular deformities are common pediatric orthopedic problems that are often corrected surgically. Previous studies successfully demonstrated proximal femoral growth modulation in animal models, however outcome measurements were limited by two-dimensional analysis. In this study, six Yorkshire cross male piglets were treated with unilateral percutaneous transphyseal screw placement across the medial aspect of the proximal femoral physis and analyzed using three-dimensional (3D) techniques. Three primary outcome measures were considered-physis angle, version, and femoral length. Compared to paired controls, all treated femurs displayed varus correction and shortening after an average treatment period of 10 weeks. The amount of varus change was 11.6 ± 2.8° (mean ± SD) (p = 0.0002, 95% confidence interval [CI] [8.659, 14.589]) and shortening was 4.3 ± 1.6 mm (p = 0.0011, 95% CI [2.672, 5.942]). Four animals demonstrated retroversion and two demonstrated anteversion compared to controls (4.1 ± 5.4° retroversion, p = 0.1169, 95% CI [-1.483, 9.765]). The amount of varus correction was strongly correlated with the orientation of the screw relative to the medial/lateral axis of the physis (r = -0.887, p = 0.0183, 95% CI [-0.988, -0.271]). The amount and direction of version was strongly correlated with how eccentrically anterior or posterior the screw was placed relative to the center of the physis (r = -0.850, p = 0.0322, 95% CI [-0.983, -0.123]) as well as the angle of the screw relative to the posterior condylar axis of the femur (r = -0.980, p = 0.0006, 95% CI [-0.998, -0.822]). This study is the first to use 3D analysis to quantify proximal femur growth modulation and identify associations between the growth modulation outcomes and screw placement parameters.

Physeal Bar Formation After Pediatric Medial Malleolus Fractures.

Pediatric medial malleolus fractures are commonly Salter-Harris (SH) type III or IV fractures of the distal tibia and are associated with a risk of physeal bar formation and subsequent growth disturbance. The purpose of this study was to determine the incidence of physeal bar formation following pediatric medial malleolus fracture and evaluate for patient and fracture characteristics predictive of physeal bar formation. Seventy-eight consecutive pediatric patients during a 6-year period who had either an isolated medial malleolar or a bimalleolar ankle fracture were retrospectively reviewed. Forty-one of 78 patients had greater than 3 months of radiographic follow-up and comprised the study population. Medical records were reviewed for demographic information, mechanism of injury, treatment, and need for further surgery. Radiographs were reviewed to assess for initial fracture displacement, adequacy of fracture reduction, SH type, percentage of the physeal disruption from the fracture, and physeal bar formation. Twenty-two of 41 patients (53.7%) developed a physeal bar. The mean time to diagnosis of physeal bar was 4.9 months (range, 1.6-11.8 months). Twenty-seven percent (6 of 22) of bars were diagnosed at greater than 6 months from injury. Adequacy of reduction was predictive of physeal bar formation, although all patients were reduced to within 2 mm. The mean residual displacement of patients with a bar was 1.2 mm compared with 0.8 mm for those without a bar (P=.03). Because the bar formation rate is greater than 50% on radiographs, routine radiographic assessment of all pediatric medial malleolar fractures should continue for at least 12 months after injury. [Orthopedics. 2024;47(1):e33-e37.].

Physeal Migration During Knee-guided Growth With Tension Band Plates: Influence of Implant Position.

OBJECTIVE: Physeal migration during guided growth with tension band plates (TBPs) has been poorly described. The positioning factors associated with this phenomenon and its clinical implications are unknown. Our aim is to determine the influence of implant position on the risk of physeal migration during knee-guided growth with TBP. METHODS: Retrospective study of 491 patients who underwent temporary hemi or epiphysiodesis with TBP around the knee between 2007 and 2019. We identified 29 patients who presented physeal migration during follow-up. Demographic and clinical data were collected, and the following measures were obtained from the immediate postoperative radiographs: epiphyseal screw base-physis distance/epiphyseal screw tip-physis distance, interscrew angle, epiphyseal screw-physis angle(ES-PHa)/metaphyseal screw-physis angle, plate-physis angle, epiphyseal screw-plate angle/metaphyseal screw-plate angle, and epiphyseal screw-physis length ratio. Using follow-up radiographs, the type of physeal migration of the epiphyseal screw (touch, occupy, or traverse) and the status of the physis after implant removal (unaltered, physeal bar, and skeletal maturity) were also recorded. A descriptive analysis of the cases and a case-control comparison of imaging studies were performed. RESULTS: The median patient age at intervention was 12.2 years (interquartile range: 11.3 to 14.1), and 76% were males. A statistically significant difference between cases and controls was obtained for epiphyseal screw base-physis distance (3.7 vs 6.3; P = 0.029), epiphyseal screw tip-physis distance (3.6 vs 7.85; P = 0.002), ES-PHa (-0.1 vs 7.45; P = 0.007), and plate-physis angle (85.45 vs 88.60; P = 0.012). In a categorical analysis, a significant difference was found for the ES-PHa categories ( P = 0.002) and for the ES-PHa/metaphyseal screw-physis angle categorical pair ( P = 0.018). In 16, 17, and 12 cases the physis was touched, occupied, or traversed, respectively, although we found no physeal alterations after plate removal. CONCLUSIONS: In our study, physeal migration of TBP is not an uncommon phenomenon, although no physeal abnormalities were detected. Convergent placement of the epiphyseal screw with the base or tip close to the physis should be avoided as this position is associated with a higher risk of physeal migration. LEVEL OF EVIDENCE: Level III-case-control study.

Use of a Cannulated, Percutaneous Expandable Reamer for Physeal Sparing Excision of a Femoral Head Chondroblastoma.

The treatment of chondroblastoma in the epiphysis of the femoral head in skeletally immature individuals is challenging and often requires surgical hip dislocation. We present a unique method of percutaneous use of an expandable reamer (X-REAM, Wright Medical) to treat a chondroblastoma of the femoral head in a 9-year-old boy without requiring surgical hip dislocation. The described technique provides access to the tumor in the proximal femoral epiphysis and local tumor control. However, the approach involves placing a cannula through the epiphyseal plate, resulting in partial premature epiphyseal closure. At 5 years after surgery, the patient has an asymptomatic leg-length discrepancy and radiographic evidence of premature physeal closure, but no restrictions on activity or evidence of local recurrence. A percutaneous expandable reamer can be used to treat chondroblastoma of the femoral head while avoiding surgical hip dislocation.

A More Conservative Approach in the Surgical Management of Pediatric Physeal Ankle Fractures Should be Preferred: Mid to Long-term Functional Outcomes of Three Different Surgical Techniques for Salter-Harris Type II and Triplane Distal Tibial Fractures.

BACKGROUND: Pediatric physeal ankle fractures carry a high risk of complications. This study aimed to (1) investigate the effect of anatomic reduction of the physis on mid to long-term functional outcomes in Salter-Harris type II and triplane distal tibial physeal fractures (DTPFs) and (2) compare the outcomes of 3 different surgical techniques applied in these fractures. METHODS: The database of a single level-I trauma center was retrospectively reviewed for DTPFs between 2012 and 2022. A total of 39 eligible patients with operative Salter-Harris type II and triplane fractures between 2012 and 2022 were included. Surgical treatment methods were closed reduction-percutaneous fixation (CR-PF), open reduction-screw fixation, or open reduction-plate fixation. Patients were further divided into subgroups for fractures reduced anatomically (<1 mm) or nonanatomically (1 to 3 mm). The primary outcome measures were the American Orthopaedic Foot and Ankle Society Score, ankle range of motion, presence of premature physeal closure and angular deformities, and Takakura ankle osteoarthritis grade. RESULTS: A total of 39 patients were included, with an average age of 12.9 ± 2.2 years. The mean follow-up time was 68.9±38.0 months. The CR-PF group had higher postoperative fracture displacement ( P = 0.011). American Orthopaedic Foot and Ankle Society scores were excellent in all groups, statistically similar between surgical techniques, and similar between anatomic and nonanatomic reduction groups. The CR-PF group ( P =0.030) and nonanatomic reduction ( P = 0.030) provided a significantly lower ankle osteoarthritis rate. All 4 patients with premature physeal closure were observed in patients treated with open techniques. CONCLUSIONS: CR-PF for the treatment of DTPFs should be preferred in suitable cases as it is less invasive and provides satisfactory mid to long-term functional outcomes without increasing complications compared with anatomic reduction and open techniques. LEVEL OF EVIDENCE: Level III.

Delayed open surgery for distal radius epiphyseal plate fracture in children.

OBJECTIVES: This study assessed the feasibility of open surgery and determined outcome predictors for late management of epiphyseal plate fracture of the distal radius in children. METHODS: This retrospective study included 25 patients (22 male, 3 female) who underwent open surgery for late management of epiphyseal plate fracture of the distal radius. Wrist function was evaluated on Cooney score. Potential predictors comprised age, gender, fracture type, days after injury (DAI), degree of violence (DOV), and dorsal angulation before surgery (DABS). RESULTS: Overall, wrist function after surgery was classified as excellent for 16 patients (64%), good for 6 (24%), and fair for 3 (12%). The rate of excellent wrist function was 86.7% (13/15) in children older than 10 years but only 40% (4/10) for those aged under 10 years (p = 0.0280). Cooney score correlated positively with age, but there was no correlation with gender, fracture type, DAI, DOV or DABS. CONCLUSION: Open reduction surgery for late management of distal radius epiphyseal fracture yielded good results in patients aged over 10 years. LEVEL OF EVIDENCE: III.

Epidemiology of Physeal Fractures and Clinically Significant Growth Disturbances Affecting the Distal Tibia, Proximal Tibia, and Distal Femur: A Retrospective Cohort Study.

INTRODUCTION: Childhood fractures involving the physis potentially result in premature physeal closure that can lead to growth disturbances. Growth disturbances are challenging to treat with associated complications. Current literature focusing on physeal injuries to lower extremity long bones and risk factors for growth disturbance development is limited. The purpose of this study was to provide a review of growth disturbances among proximal tibial, distal tibial, and distal femoral physeal fractures. METHODS: Data were retrospectively collected from patients undergoing fracture treatment at a level I pediatric trauma center between 2008 and 2018. The study was limited to patients 0.5 to 18.9 years with a tibial or distal femoral physeal fracture, injury radiograph, and appropriate follow-up for determination of fracture healing. The cumulative incidence of clinically significant growth disturbance (CSGD) (a growth disturbance requiring subsequent physeal bar resection, osteotomy, and/or epiphysiodesis) was estimated, and descriptive statistics were used to summarize demographics and clinical characteristics among patients with and without CSGD. RESULTS: A total of 1,585 patients met the inclusion criteria. The incidence of CSGD was 5.0% (95% confidence interval, 3.8% to 6.6%). All cases of growth disturbance occurred within 2 years of initial injury. The risk of CSGD peaked at 10.2 years for males and 9.1 years for females. Complex fractures that required surgical treatment, distal femoral and proximal tibial fractures, age, and initial treatment at an outside hospital were significantly associated with an increased risk of a CSGD. DISCUSSION: All CSGDs occurred within 2 years of injury, indicating that these injuries should be followed for a period of at least 2 years. Patients with distal femoral or proximal tibial physeal fractures that undergo surgical treatment are at highest risk for developing a CSGD. LEVEL OF EVIDENCE: Level III Retrospective Cohort Study.

Child Fractures: Are We Getting More Surgical? / Fraturas na criança: Estamos ficando mais cirúrgicos?

Abstract Historically, surgeries on the immature skeleton were reserved for open or articular fractures. In recent years, the improvement in the quality and safety of anesthesia, new imaging equipment, implants designed especially for pediatric fractures, associated with the possibility of shorter hospitalization time and rapid return to social life has demonstrated a new tendency to evaluate and treat fractures in children. The purpose of this update article is to answer the following questions: (1) Are we really turning more surgical in addressing fractures in children? (2) If this is true, is this surgical conduct based on scientific evidence? In fact, in recent decades, the medical literature demonstrates articles that support better evolution of fractures in children with surgical treatment. In the upper limbs, this is very evident in the systematization of the reduction and percutaneous fixation of supracondylar fractures of the humerus and fractures of the forearm bones. In the lower limbs, the same occurs with diaphyseal fractures of the femur and tibia. However, there are gaps in the literature. The available published studies show low scientific evidence. Thus, it can be inferred that, even though the surgical approach is more present, the treatment of pediatric fractures should always be individualized and conducted according to the knowledge and experience of the professional physician, taking into account the presence of technological resources available for the care of the small patient. All possibilities, non-surgical and/or surgical, should be included, always instituting actions based on science and in agreement with the family's wishes.

Resumo Historicamente, as cirurgias no esqueleto imaturo eram reservadas às fraturas expostas ou articulares. Nos últimos anos, a melhora na qualidade e segurança das anestesias, novos equipamentos de imagem, implantes desenhados especialmente para fraturas pediátricas, associados à possibilidade de menor tempo de hospitalização e rápido retorno ao convívio social vêm demonstrando uma nova tendência de avaliar e tratar fraturas na criança. O objetivo deste artigo de atualização é responder às seguintes questões: (1) estamos realmente ficando mais cirúrgicos na abordagem das fraturas em crianças? (2) Caso isto seja verdadeiro, esta conduta cirúrgica está baseada em evidências científicas? De fato, nas últimas décadas, a literatura médica demonstra artigos que suportam melhor evolução das fraturas na criança com o tratamento cirúrgico. Nos membros superiores, isto fica muito evidente na sistematização da redução e fixação percutânea das fraturas supracondilianas do úmero e das fraturas de ossos do antebraço. Nos membros inferiores, o mesmo ocorre com fraturas diafisárias do fêmur e tíbia. No entanto, há lacunas na literatura. Os estudos publicados são geralmente com baixa evidência científica. Assim, pode-se deduzir que, mesmo sendo a abordagem cirúrgica mais presente, o tratamento de fraturas pediátricas deve ser sempre individualizado e conduzido de acordo com o conhecimento e experiência do médico profissional, levando em conta a presença de recursos tecnológicos disponíveis para o atendimento do pequeno paciente. Deve-se incluir todas as possibilidades, não cirúrgicas e/ou cirúrgicas, sempre instituindo ações baseadas na ciência e em concordância com os anseios da família.

Temporary hemiepiphysiodesis using eight-plates for angular deformities of the lower extremities in children with X-linked hypophosphataemic rickets.

PURPOSES: Temporary hemiepiphysiodesis (TH) using eight-plates is one of the most frequently performed surgeries for correcting angular deformities of the lower extremities in adolescents. Rarely have studies examined children with X-linked hypophosphataemic rickets (X-LHPR) treated with TH using eight-plates. This study was conducted to investigate the efficacy, the endpoint, and the complications of TH using eight-plates to correct angular deformities of the lower extremities in skeletally immature children. METHODS: We reviewed a total of 26 children (86 physes, 52 knees) with X-LHPR (mean age of 6.2 years, range from 2 to 13 years) who underwent TH using eight-plate to correct angular deformities of the lower extremities. Radiographs and clinical records of these patients were evaluated for demographic data and related clinical factors. RESULTS: The average correction of the mechanical lateral distal femoral angle (mLDFA) was 11.7 ± 8.7° (range from 1.0 to 29.7°), and the average correction of the mechanical medial proximal tibial angle (mMPTA) was 8.4 ± 5.0° (range from 0.3 to 16.7°). The mean deformity correction time was 22.7 months (range from 7 to 60 months), and the mean follow-up after eight-plate removal was 43.9 months (range from 24 to 101 months). Overall, 76.9% (20/26 patients) of the angular deformities of the knee were completely corrected and 15.4% (4/26) of the patients received osteotomy surgery. The femoral correction velocity (0.9° per month) was significantly higher than the proximal tibial (0.6° per month) (p = 0.02). The correction velocity of the mLDFA and mMPTA with the TH procedure was faster than that in the absence of intervention (0.9° vs. 0.2°, 0.7° vs. 0.4° per month, p < 0.05). The correction velocity of the mLDFA (1.2° vs. 0.5° per month, [Formula: see text]) and mMPTA (0.7° vs. 0.5° per month, p = 0.04) of patients whose age ≤ five years old was faster than that of patients whose age > five years old. A total of 69.2% (18/26) patients experienced one TH procedure using eight-plates only. Two patients had screw loosening (2/26, 7.7%). One patient (1/26, 3.8%) had a rebound phenomenon after the removal of eight-plate and had the TH procedure again. There was no breakage, infection, physis preclosure, or limited range of movement found in the follow-up. CONCLUSION: TH using eight-plates is a safe and effective procedure with a relatively low incidence of complication and rebound, and it could be used as part of a streamlined treatment for younger X-LHPR patients with resistant or progressive lower limb deformity despite optimal medical treatment. Early intervention can achieve better results.

The effectiveness of physeal bar resection with or without Hemi-Epiphysiodesis to treat partial growth arrest.

PURPOSE: To evaluate the outcomes of distal femoral, proximal tibial, and distal tibial physeal bar resection combined with or without the Hemi-Epiphysiodesis procedure and provide a better understanding of the application of physeal bar resection combined with Hemi-Epiphysiodesis procedure in the treatment of physeal bar growth arrest. METHODS: We retrospectively reviewed the patients who suffered physeal bar and underwent physeal bar resection with or without the Hemi-Epiphysiodesis technique during 2010-2020. All were followed up for at least 2 years or to maturity. A modified mapping method was used to determine the area of a physeal bar by CT data. The aLDFA, aMPTA, aLDTA, MAD, and LLD were measured to assess the deformity of the lower limb. RESULTS: In total, 19 patients were included in this study. The average age was 8.9 years (range 4.4 to 13.3 years old). During the follow-up, 4 (21.1%) patients had an angular change < 5°; 12 (63.2%) patients had angular deformity improvement > 5° averaging 10.0° (range 5.3° to 23.2°), and 3 (15.8%) patients had improvement of the angular deformity averaging 16.8° (range 7.4° to 27.1°). Eleven patients (57.9%) had significant MAD improvement. After surgery, we found that 7 (36.8%) patients had an LLD change of < 5 mm and were considered unchanged. Only 2 (15%) patients had an LLD improvement > 5 mm averaging 1.0 cm (range 0.7 to 1.3 cm), and 7 (36.8%) patients had increasing of LLD > 5 mm averaging 1.3 cm (range 0.5 to 2.5 cm). There were no postoperative fractures, infections, or intraoperative complications such as neurovascular injury. CONCLUSION: Physeal bar resection combined with Hemi-epiphysiodesis is helpful for partial epiphysis growth arrest. Without statistically verifying, we still believe that patients with limited growth ability could benefit more from physeal bar resection combined with Hemi-epiphysiodesis.

Predisposing factors for migration of epiphyseal screws into physis in tension band plating.

The migration of epiphyseal screws into growing physis in tension band plating is a known complication. We investigated the screw migration into physis in 10 patients (18 plates) to study the various technical details, which may have contributed to this complication. The methodology involved retrospective review of radiological records. Among these 10 affected patients, in four patients, there were eight additional tension band plates, which had remained uncomplicated ('controls') at the time when implant failure was detected. We statistically compared the length of epiphyseal screw, proximity of screw start point to the physis, screw trajectory angle, interscrew angle and correction rate between the migrated and other uncomplicated plates. Majority patients were postrachitic ( n = 7). The mean time from primary procedure to detection of radiological complication was 15.1 months. The mean epiphyseal screw length proportion in migrated and uncomplicated plates matched. The starting point of epiphyseal screw was relatively closer to physis in migrated plates. The trajectory of epiphyseal screw with respect to physis was more divergent in the migrated plates ( P = 0.02). All implants were inserted in a divergent manner with mean interscrew angle being 22.3° for migrated and 13.8° for the uncomplicated plates ( P = 0.02). The correction rate of the implant reduced as it failed. Osteopenic bone and pathological physis predispose to migrated plates. Technically, a wider trajectory of epiphyseal screw and too divergent screws should be avoided. A migrated implant becomes less effective in its function.

Double vascularized fibula growth plate transfer for the reconstruction of long segmental tibia in pediatric patients: Report of three cases.

Osteosarcoma is a common bone tumor for pediatric patients that has a complex treatment including chemotherapy and radical surgical resection. There are few functional leg reconstruction possibilities described in the literature for pediatric patients due to limited growth potential. The aim of this report is to show long-term results using double vascularized growth plate flaps for the long segmental tibial reconstruction in growing children with satisfactory functionality and preserved limb growth without the use of permanent foreign materials. Three patients with sarcoma in the proximal part of the tibial bone were treated with complex therapy that included preoperative chemotherapy, radical resection of proximal metaepiphysis with tibial growth plate and half of the diaphysis and transplantation of double fibula growth plate flaps-the pedicled ipsilateral and the contralateral as a microvascular flap. The first patient, a male, 13 year with periosteal sarcoma, underwent 17 cm tibial resection with transplantation of the ipsilateral fibula 20 cm and contralateral fibula 20.1 cm, and continued follow-up for 6 years. The second patient, a male, 6 years of age with osteosarcoma, had 14 cm tibial resection with 16 cm ipsilateral and 16.1 cm contralateral fibular transplantation, continued follow-up for 5 years. The third patient, a female, 12 years of age with osteosarcoma, underwent 14 cm tibial resection with 15.4 cm ipsilateral and 15.9 cm contralateral fibular transplantation, and current follow-up of 1 year. Double fibular growth plate transfer is limb-sparing method for a proximal tibial reconstruction with natural growth potential for the pediatric patients.

An Anatomic Study of the Proximal Tibial Epiphysis With Relevance to Percutaneous Epiphysiodesis Using Transphyseal Screws (PETS).

BACKGROUND: Percutaneous epiphysiodesis using transphyseal screws (PETS) is a common procedure to correct lower extremity limb-length discrepancies in the pediatric population. A potential complication of this procedure is development of tibial valgus deformity, which may occur secondary to decreased screw purchase in the thinner medial proximal tibial epiphysis. The thickness of the proximal tibial epiphysis has not yet been well quantified, which was the aim of this study. METHODS: Three-dimensional surface scans of 32 cadaveric proximal tibial epiphyses in specimens aged 3 to 17 years old were obtained and computer modeling software was utilized to measure the thickness of the proximal tibial epiphysis at 20 standardized potential screw insertion points according to a generated 5×4 map. RESULTS: When normalized to the total width of the proximal tibial epiphysis, the lateral side is thicker compared with the medial side. The positions with the greatest thickness are located at the midline in the sagittal plane and 33% of the total physeal width away from the medial and lateral edges in the coronal plane (0.265 and 0.261 normalized thickness, respectively). The proximal tibial epiphysis is particularly thin 25% from the medial edge (normalized thickness range: 0.196 to 0.221). Multiple regression analysis revealed a significant relationship between increasing age and female sex with thinner normalized medial and lateral heights. CONCLUSIONS: During PETS, areas for greater screw purchase are located centrally in the sagittal plane and 33% of the total width away from the medial and lateral edges of the proximal tibial epiphysis in the coronal plane. Caution should be taken when inserting screws in the medial 25% of the proximal tibial epiphysis as it is thinner relative to the lateral edge, particularly in females. CLINICAL RELEVANCE: This study provides quantitative, anatomic data on the thickness of the proximal tibial epiphysis, which can direct screw placement during PETS for correcting limb-length discrepancies. These data may help lessen the risk of developing tibial valgus deformity although future clinical studies are necessary to fully evaluate this possibility.

The Influence of Retrograde Femoral Nail Removal With and Without Interpositional Fat Grafting on Distal Femoral Physeal Behavior: A Sheep Study.

BACKGROUND: Previous investigations have demonstrated that up to 7% of the distal femoral physis can be violated using a rigid, retrograde nail without growth inhibition or arrest. The purpose of this investigation was to evaluate the behavior of the distal femoral physis after retrograde femoral nail removal in a sheep model, with and without placement of an interpositional fat graft. METHODS: Retrograde femoral nails were placed in 8 skeletally immature sheep. Implants were removed at 8 weeks, with the residual defects left open (n=4) or filled with autologous fat graft (n=4). Differences in femoral length between surgical versus contralateral control femurs were measured after an additional 3 (n=4) or 5 months (n=4) before sacrifice, and the physis was evaluated histologically. RESULTS: When compared with control limbs, femoral length was significantly shorter in limbs sacrificed at 3 months (mean: 3.9±1.3 mm; range: 2.7 to 5.7 mm) compared with limbs at 5 months (mean: 1.0±0.4 mm; range: 0.4 to 1.2 mm) ( P =0.005). No significant difference in mean shortening was appreciated in limbs without (2.4±1.6 mm) versus with fat grafting (2.5±2.3 mm) ( P =0.94). Histologic analysis revealed no osteoid formation across the physis in sheep sacrificed at 3 months, whereas there was evidence of early osteoid formation across the physis in sheep at 5 months. All specimens demonstrated evidence of an active physes. CONCLUSIONS: Femurs undergoing retrograde implant placement were significantly shorter when compared with control limbs in sheep sacrificed at 3 months, whereas differences were nominal in sheep sacrificed at 5 months after retrograde implant removal, suggesting growth inhibition with nail removal improved with time. Fat grafting across the distal femoral physis did not result in a significant difference in femoral lengths. Histologic evidence at 5 months revealed early development of a bone bridge, emphasizing the importance of follow-up to skeletal maturity in patients treated with retrograde nailing across an open physis. LEVEL OF EVIDENCE: Level IV.

Anterior Cruciate Ligament Rupture in Skeletally Immature Patients.

In the past 20 years, sports injuries in pediatric and adolescent athletes have increased dramatically, with anterior cruciate ligament (ACL) injuries accounting for more than 25% of all knee injuries at this age. Diagnosis is based on detailed clinical history, physical examination, and imaging assessment, where magnetic resonance imaging plays a central role. The growing immature skeleton presents specific characteristics, which require unique methods for surgical reconstruction, ideally avoiding the physes or minimizing the risk of damaging them. Specific rehabilitation protocols are needed, and these patients face a higher risk of recurrent and contralateral ACL injury. Nonsurgical treatment or delayed reconstruction has been associated with persistent instability, activity modifications, worst functional outcomes, and increased risk of irreparable injuries to menisci and articular cartilage. Consequently, surgical stabilization is the preferred treatment for most patients, despite the eventual risk of angular deformities or limb-length discrepancies due to iatrogenic physeal injury. A variety of surgical techniques have been described, depending on the skeletal maturity and growth remaining. Targeted prevention programs play a key role in reducing the risk of ACL injury, are easy to implement, and require no additional equipment. High-quality evidence supports its use in all pediatric athletes.

Limb Reconstruction After Premature Growth Arrest Secondary to Bone Infections.

During recent years, the detection of osteoarticular infections has increased, thanks to improvement and wide availability of diagnostic tools. Despite that, surgeons and patients still have to deal with long-term sequelae, including osteoarthritis, chronic osteomyelitis, and premature physeal arrest. Subsequent joint reconstruction is the most difficult challenge when the hip or knee has been affected. Most surgical procedures described to manage these devastating consequences are only palliative, with the goal focused on improving stability and pain control, but seldom ending with a highly functional joint. Premature physeal arrest has an unpredictable course after an osteoarticular infection. The prognosis depends on the age of the child, the type of injury (partial or total bony bar), the proportion of the physeal surface affected, and the bone compromised. Peripheral injuries lead to angular limb deformities, whereas central bars lead to limb-length discrepancies. Surgical treatment should be oriented to preserve physeal function and allow normal growth to resume. In those cases where preserving physeal function is not possible, the orthopaedic surgeon must deal with the sequelae of limb-length discrepancies and/or bone deformities.

Factors Affecting Slip Progression After In Situ Screw Fixation of Stable Slipped Capital Femoral Epiphysis.

BACKGROUND: Slip progression after in situ fixation of slipped capital femoral epiphysis (SCFE) has been reported as occurring in up to 20% of patients. We review SCFE treated with in situ single screw fixation performed at 2 hospitals over a 15-year period to determine the factors associated with slip progression. METHODS: This case-control study reviews SCFE treated with in situ single cannulated screw fixation with minimum follow up of 1 year and full closure of the affected physis. Slip progression (failure) was defined as worsening of the Southwick slip angle of 10 or more degrees or revision surgery for symptomatic slip progression. Univariate and multivariate analyses were performed comparing success and failure groups for patient characteristics, screw type and position, and radiographic measurements. RESULTS: Ninety three patients with 108 slips met all criteria, with 15 hips (14%) classified as having slip progression (failure). All failures had 3 threads or fewer across the physis. Five hips had 2 threads across the physis, and 4 of the 5 were classified as failures. Lower modified Oxford bone scores were found in the failure group, though the difference was small (0.9, P=0.013). Failure was also associated with partially threaded screws (P=0.001). Failed hips were associated with lower initial Southwick angles (32.8 degrees) than successful hips (40.4 degrees) (P=0.047). In the stepwise model for multivariate regression, 4 factors were identified as significant, with lower initial number of threads (P<0.0001), mild initial Southwick category (P=0.0050), male sex (P=0.0061), and partially threaded screw type (P=0.0116) predicting failure. CONCLUSION: This study is the largest to date evaluating risk factors for slip progression after SCFE fixation, and the first to consider revision surgery for symptomatic slip progression. For stable SCFE, we demonstrate that 4 threads across the physis with a fully threaded screw of 6.5 mm diameter or greater was sufficient to avoid slip progression. We provide a risk stratification for progression of slip showing that in some cases 3 threads across the physis may be sufficient. LEVEL OF EVIDENCE: Level III-case-control study.

Intercalary reconstruction of the distal femur with or without physeal preservation: results and impact on limb growth.

PURPOSE: Allograft reconstruction with or without vascularized fibula can be a valuable solution to treat childhood intercalary tumours of the distal femur. We aimed to assess the oncological status, complication rate and survival of distal femur intercalary reconstruction after trans-metaphyseal (TMR) and trans-epiphyseal resection (TER). We also evaluated the impact of distal temporary graft fixation on skeletal growth after TMR. METHODS: We retrospectively reviewed 23 skeletally immature patients affected by distal femur osteosarcoma (18) and Ewing sarcoma (5). Mean patients age was 10.3 years. In 11 cases, TMR was performed with physis preservation and temporary distal graft fixation. In 9 patients, TER was performed with growth plate sacrifice. The last 3 cases were treated with TMR and sliding plate fixation. RESULTS: Mean follow-up was 8.4 years. No deaths occurred, but 3 patients presented lung metastasis and 2 cases presented local recurrence in soft tissues. 10 implant-related complications occurred, all surgically treated. At skeletal maturity, mean femoral dysmetria was 2.3 cm after TMR and temporary epiphysiodesis, and 3.1 cm after TER. In TMR group, a strong trend towards physeal recovery was observed after epiphyseal screws removal (p = 0.061), but valgus deformity in distal femur was more frequent (p = 0.049). MSTS score was good or excellent in all patients, with no statistically significant difference between TMR and TER. CONCLUSIONS: Intercalary graft reconstruction after TMR and TER allows good local disease control and excellent functional results with long-term follow-up. Temporary distal fixation might reduce the final limb discrepancy after TMR, but valgus deformity could develop. LEVEL OF EVIDENCE: Level IV.

Double Vascularized Fibula Proximal Growth Plate Transplantation: Novel Technique for the Radial Longitudinal Deficiency (RLD) Grade IV Reconstruction.

Radial absence or severe hypoplasia in radial longitudinal deficiency (RLD) is most commonly treated through stabilization of the carpus on the ulna (centralization or radialization) with or without preliminary distraction. Alternative methods include bone transfer to replace the absent or deficient radius using the proximal fibula, vascularized or nonvascularized, and more recently the transfer of a vascularized second metatarsophalangeal joint. There is paucity of articles suggesting vascularized fibula growth plate transfer for RLD grade III where proximal part of radius can be found and none about double fibular growth plate transplantation. We developed new technique a bilateral growth plate transplantation for the pediatric patient with unilateral RLD stage IV (Bayne and Klug). Totally 2 patients were operated using new technique. No vascular problems occurred and no peroneal nerve damage were observed at the follow-ups. Annual growth was determined on x-rays at the 1 and 2-year follow-ups measuring 0.75 to 0.9 cm with open growth plates. The x-rays also show no changes that can harm the long-term growth potential in the forearm, demonstrating this technique's capacity to achieve better results for forearm length and functionality in comparison to the Vilkki procedure or radialization operation and there is no need to sacrifice second toe. Thumb reconstruction can be done at age 3 or 4 years using pollicization or toe-to hand transplantation techniques. The patients and parents are satisfied with functional and esthetic outcomes. We believe the double fibular growth plate transplantation is a promising method to use to reconstruct unilateral RLD grade IV.