Abstract: Background and purpose: For correction of leg-length discrepancy or angular deformity of the lower limb in skeletally immature patients temporary or permanent (hemi-)epiphysiodesis can be employed. These are reliable treatments with few complications. Recently, radiographic analysis of treatment-related alterations of the central knee anatomy gained interest among pediatric orthopedic surgeons. To date the comparison and adequate interpretation of potential changes of the central knee anatomy is limited due to the lack of defined standardized radiographic references. We aimed to establish new reference values of the central knee anatomy.Patients and methods: A retrospective analysis of calibrated longstanding anteroposterior radiographs of 254 skeletally immature patients with a chronological age ranging from 8 to 16 years was conducted. The following radiographic parameters were assessed: (1) femoral floor angle, (2) tibial roof angle, (3) width at femoral physis, and (4) femoral notch–intercondylar distance.Results: All observed radiographic parameters were normally distributed with a mean age of 12.4 years (standard deviation [SD] 2, 95% confidence interval [CI] 12.2–12.6). Mean femoral floor angle was 142° (SD 6, CI 141.8–142.9), mean tibial roof angle was 144° (SD 5, CI 143.7–144.1), mean width at femoral physis was 73 mm (SD 6, CI 72.8–73.9), and mean femoral notch–intercondylar distance was 8 mm (SD 1, CI 7.5–7.7). The estimated intraclass correlation coefficient values were excellent for all measurements.Conclusion: This study provides new radiographic reference values of the central knee anatomy for children between 8 and 16 years and we suggest considering values within the range of 2 SD as the physiological range.

Abstract: A 14-year-old pedestrian was hit by a car and encountered similar bilateral Gustilo IIIB open tibial fractures. The right tibial fracture involved a large borderline vital butterfly fragment without periosteal contact, which was retained and proceeded to sufficient healing within 12 weeks. The left tibial fracture was treated according to the principles for the treatment of severe open fractures in adults, involving resection of devitalized fragments and bone transport, and healed within 15 months. Conclusions: Teenagers do possess larger bone healing potential than adults. Therefore, a rapid bone union can be achieved even with apparently devitalized bone fragments if sufficient soft-tissue closure and stable fracture fixation is established early in the treatment of open limb fractures.

Abstract: Many patients with achondroplasia experience functional impairments because of rhizomelic upper extremities (proximal limb shortening). Bilateral humeral lengthening may overcome these functional limitations, but it is associated with several risks, such as radial nerve palsy and insufficient bone regeneration. Only a few studies have reported on patient satisfaction and functional outcome after humeral lengthening in patients with achondroplasia. Furthermore, the reported numbers of adverse events associated with lengthening procedures using external fixators vary widely. Questions/purposes (1) Does bilateral humeral lengthening with a monolateral external fixator in patients with achondroplasia reliably improve patient function and autonomy, and what proportion of patients achieved at least 8 cm of humeral lengthening? (2) What adverse events occur after bilateral humeral lengthening with monolateral external fixators? Methods Between 2011 and 2019, 44 patients underwent humeral lengthening at our institution. Humeral lengthening was performed in patients with severe shortening of the upper extremities and functional impairments. In humeri in which intramedullary devices were not applicable, lengthening was performed with monolateral external fixators in 40 patients. Eight patients were excluded because they underwent unilateral lengthening for etiologies other than achondroplasia, and another four patients did not fulfill the minimum study follow-up period of 2 years, leaving 28 patients with bilateral humeral lengthening to treat achondroplasia available for analysis in this retrospective study. The patients had a median (interquartile range) age of 8 years (8 to 10), and 50% (14 of 28) were girls. The median follow-up time was 6 years (4 to 8). The median humeral lengthening was 9 cm (9 to 10) with a median elongation of 73% (67% to 78%) from an initial median length of 12 cm (11 to 13). To determine whether this treatment reliably improved patient function and autonomy, surgeons retrospectively evaluated patient charts. An unvalidated retrospective patient-reported outcome measure questionnaire consisting of nine items (with answers of “yes” or “no” or a 5-point Likert scale) was administered to assess the patient’s functional improvement in activities of daily living, physical appearance, and overall satisfaction, such that 45 points was the highest possible score. The radiographic outcome was assessed on calibrated radiographs of the humerus. To ascertain the proportion of adverse events, study surgeons performed a chart review and telephone interviews. Major complications were defined as events that resulted in unplanned revision surgery, nerve injury (either temporary or permanent), refracture of the bone regenerate, or permanent functional sequelae. Minor complications were characterized as events that resolved without further surgical interventions. Results On our unvalidated assessment of patient function and independence, all patients reported improvement at their most recent follow-up compared with scores obtained before treatment (median [IQR] 24 [16 to 28] before surgery versus 44 [42 to 45] at latest follow-up, difference of medians 20 points, p 〈 0.001). A total of 89% (25 of 28) of patients achieved the desired 8 cm of lengthening in both arms. A total of 50% (14 of 28) of our patients experienced a major complication. Specifically, 39% (11 of 28) had an unplanned reoperation, 39% (11 of 28) had a radial nerve palsy, 18% (5 of 28) had a refracture of the regenerate, and 4% (1 of 28) concluded treatment with a severe limb length discrepancy. In addition, 82% (23 of 28) of our patients experienced minor complications that resolved without further surgery and did not involve radial nerve symptoms. Radial nerve palsy was observed immediately postoperatively in eight of 13 segments, and 1 to 7 days postoperatively in five of 13 segments. The treatment goal was not achieved because of radial nerve palsy in 5% (3 of 56) of lengthened segments, which occurred in 7% (2 of 28) of patients. Full functional recovery of the radial nerve was observed in all patients after a median (IQR) of 3 months (2 to 5). Refractures of bone regenerates were observed in 11% (6 of 56) of humeri in 18% (5 of 28) of patients. Of those refractures, 1 of 6 patients was treated nonsurgically with a hanging cast, while 5 of 6 patients underwent revision surgery with intramedullary rodding. Conclusion Most patients with achondroplasia who underwent humeral lengthening achieved the treatment goal without permanent sequelae; nonetheless, complications of treatment were common, and the road to recovery was long and often complicated, with many patients experiencing problems that were either painful (such as refracture) or bothersome (such as temporary radial nerve palsy). However, using a subjective scale, patients seemed improved after treatment; nevertheless, robust outcomes tools are not available for this condition, and so we must interpret that finding with caution. Considering our discoveries, bilateral humeral lengthening with a monolateral external fixator should only be considered in patients with severe functional impairments because of rhizomelic shortening of the upper extremities. If feasible, internal lengthening devices might be preferable, as these are generally associated with higher patient comfort and decreased complication rates compared with external fixators. Level of Evidence Level IV, therapeutic study.

Abstract: Primary aim: to compare complications of operative vs non-operative treatment of unstable distal radius fractures (DRF) fulfilling national clinical guidelines for operative treatment. Secondary aim: to compare the functional outcomes. Materials and methods A single-centre randomized controlled trial of unstable DRF. 50 patients: volar locking plate, 2 weeks casting + 3 weeks orthosis. 50 patients: 5 weeks casting. Primary outcome: complications assessed after 2 and 5 weeks and 6 and 12 months. Secondary outcomes: Quick-DASH, PRWHE, range of motion, grip strength, EQ-5D-3L. Results 148 patients were screened from November 2019 to March 2021. 48 patients did not want to participate or were unable to participate in the follow-up. 100 patients were randomized and 85 patients were available for full analysis due to there being 4 deaths, 6 withdrawals, 1 wrong inclusion, 1 emigration, 1 refracture, 1 patient with compartment syndrome, and 1 who was advised to undergo surgery after being randomized to non-operative treatment. Median age was 74 years (range 65–92), 81 women/19 men, 42 right/58 left side, 87 retired, 11 smokers, 86 ASA class 1 or 2. Complication rates did not statistical significantly vary between the operative and non-operative group: 20.9% (9/43) vs 16.6% (7/42), p  = 0.78 (Fisher’s exact test). Complications were driven by sensory disturbances. Four reoperations were performed: two in the non-operative group: carpal tunnel syndrome; two in the operative group: one carpal tunnel syndrome, one protruding screw causing extensor tendon irritation. Mean difference in Quick-DASH varied from 2.3 (95% CI − 3 to 8) pre-injury to 4.2 (− 4 to 12) at 12 months. Quick-DASH and PRWHE were neither statistically nor clinically-relevant different between groups. Conclusions Complication rates after operative and non-operative treatment of DRF were similar. Volar plating did not improve the functional outcome after 5 weeks, 6 months, and 12 months. These findings are in line with recent RCTs and mandate a revision of guidelines towards more conservative treatment. Take home messages: (1) consider non-operative treatment in elderly patients sustaining unstable DRFs; (2) choosing operative treatment in patients older than 65 years should not be the gold standard; (3) however, non-operative treatment still carries a risk for complications. Level of evidence II. Trial registration Clinicaltrials.gov NCT03716661, registered 23rd Oct 2018; Published protocol PMC6599306.