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Purpose: Paediatric musculoskeletal injuries in association with increased participation in sports activities continue to increase. Arthroscopy is recognized as a safe and effective procedure in children. This study aims to identify trends in European paediatric sports centres over 20 years., Methods: A survey was performed across the European Paediatric Orthopaedic Society (EPOS) Sports Study Group focusing on 3 years (2000, 2009 and 2019). Centres were divided into two groups: Group 1 ( n  = 5, with data for 2000, 2009 and 2019) and Group 2 ( n  = 8, with data for 2009 and 2019). Data were analysed as the total annual number of cases and separately by anatomical region and patient demographics. A descriptive analysis was performed to characterize the trends., Results: Data from eight centres across Europe showed an increase in total annual arthroscopy cases (G1 from 53 to 202 and G2 from 393 to 615, p -value < 0.001) and as a percentage of paediatric orthopaedic surgeries (G1 from 1.6% to 5.2%; G2 from 5.1% to 6.8%) in seven out of eight centres. The knee remained the most commonly treated joint (G1 from 79.2% to 83.3%; G2 from 78.9% to 84.4%), despite the rise of others such as the elbow ( p -value = 0.020) and decline of the shoulder ( p -value = 0.014). Cases involving paediatric patients over 11 years increased while there was no gender distinction among paediatric patients., Conclusion: Paediatric arthroscopy procedures in Europe have increased in number over the past 3 decades. Technological advancements have allowed a surge in procedures and applications to new anatomical areas., Level of Evidence: IV - retrospective database review., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Background: Anterior cruciate ligament injury in the child and adolescent patient remains a controversial topic when considering management, especially regarding surgical choices. Treatment variations are seen not just when comparing different countries but also within nations. This arises partly as contemporary treatment is mostly inferred from the adult population who physiologically and in terms of outcomes differ significantly from children. There is an increasing body of evidence for this cohort of patients who have specific challenges and difficulties when determining the optimum treatment., Methods: Within this article, we will summarize the current evidence for surgical management of anterior cruciate ligament injury for the pediatric patient., Results and Conclusions: There remain many controversies and gaps inthe treatment of Paediatric Anterior cruciate ligament reconstruction and this high risk cohort continues to cause difficulty in identifying the best mode of surgical management., Level of Evidence: level IV., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Osteochondritis dissecans of the knee is a disease that typically affects skeletally immature patients. Clinically manifested with knee pain, limping, and joint disfunction, this condition has remained misunderstood and undervalued for a long period. Although being a rare condition, its awareness is of utmost clinical interest because of the possible severe consequences it can bring when misrecognized or inadequately treated. Its etiology remains unclear and is still debated. Many theories have been proposed, including inflammation, local ischemia, subchondral ossification abnormalities, genetic factors, and repetitive mechanical microtrauma, with a likely interplay of the same. This review article aims to deliver and discuss current and up-to-date concepts on epidemiology, etiology, and natural history of this pediatric condition. Level of evidence : level V., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Background: Patellofemoral instability is a frequent cause of referral in pediatric sports medicine. Isolated medial patellofemoral ligament reconstruction is widely used and provides satisfactory outcomes with a low failure rate. Given the success of this surgical technique, the literature on medial patellofemoral ligament reconstruction failures in the pediatric population is limited. Moreover, given the multifactorial nature of patellofemoral instability, the heterogeneity of the current literature, and the paucity of pediatric studies, medial patellofemoral ligament reconstruction failures are often difficult to analyze., Methods: The purpose of this study was to retrospectively review the associated risk factors, surgical management, and the clinical outcomes at 2-year follow-up of skeletally immature patients that presented to our clinic with a failed medial patellofemoral ligament reconstruction., Results: Of the 181 cases in 155 patients included in this study, treatment failed in 12 (7%). All 12 patients presented with at least one risk factor for patellofemoral instability, the most common being trochlear dysplasia and a high-grade J sign., Conclusions: We conclude that isolated medial patellofemoral ligament reconstruction for patellofemoral instability in children has a low failure rate. Clinicians must assess pre-operative risk factors before surgical treatment is considered. A high-grade J sign and high-grade trochlear dysplasia were associated with medial patellofemoral ligament reconstruction failure in this cohort. Tailoring treatment to patients' associated risk factors selection may improve outcomes., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: F.A. is a paid consultant for Zimmer Biomet. D.W.G. is a paid consultant for Arthrex and has royalties or licenses with Arthrex and Pega Medical., (© The Author(s) 2023.)

Osteochondritis dissecans of the knee is an idiopathic, focal, subchondral-bone abnormality that can cause instability or detachment of a bone fragment and overlying articular cartilage, with subsequent progression to osteoarthritis. The degree of lesion instability is best assessed by magnetic resonance imaging. Unstable lesions require operative management with fragment fixation. Level of evidence : V., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Purpose: The purpose of this study was to evaluate the current trends in the treatment of supracondylar humerus fractures as well as the preferred post-operative follow-up protocol among members of the European Paediatric Orthopaedic Society., Methods: The survey was composed by four main domains and 26 items: (1) surgeon information (3 items); (2) treatment (8 items); (3) post-operative treatment (3 items); and (4) factors influencing the outcome (12 items). All active members of European Paediatric Orthopaedic Society were invited by email to answer an electronic questionnaire., Results: The survey was submitted to 397 European Paediatric Orthopaedic Society active members; 184 members answered (46.3%) the questionnaire. Among respondents, 64.1% declared >10 years of experience and 55.4% declared to treat >20 supracondylar humerus fractures per year. Closed reduction, percutaneous pinning, and supine position were the preferred treatment option for Gartland type II and III supracondylar humerus fractures by 79.9%, 95.5%, and 84.8% of respondents, respectively. Supracondylar humerus fractures are treated within 24 h from trauma by 33.2% of respondents. Pins are removed 4 weeks from index procedure by 58.2% of respondents. Fracture type (72.3%), surgeon experience, and (71.2%) are of "crucial importance" for expected outcome of supracondylar humerus fractures treatment., Conclusion: Surgeon experience, type of fracture, treatment modality, and pins configuration were considered the main factors potentially influencing the outcome of supracondylar humerus fractures. European Paediatric Orthopaedic Society members agreed on the treatment modality of Gartland type II and III supracondylar humerus fractures, patient positioning, and timing of hardware removal. Other important issues such as timing of surgery, pins configuration, surgical approach, and post-operative protocol are still debated., Level of Evidence: level II., Competing Interests: Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)

Purpose: Calcaneonavicular coalition accounts for more than half of all tarsal coalitions. Resection of calcaneonavicular coalition by an open approach is the standard treatment. Treatment of calcaneonavicular coalition by an arthroscopic approach appears promising. The objective of our study was to compare the clinical outcomes of calcaneonavicular coalition resection by open approach versus arthroscopic approach., Methods: A retrospective cohort study was conducted to evaluate 127 patients who underwent a resection of calcaneonavicular coalition from 2009 to 2017. Patients were divided into two groups according to whether an arthroscopic approach or an open approach was used. Demographics, operative parameters, and clinical outcomes (foot and ankle ability measure score, subjective score, and global ankle estimation) were assessed., Results: Arthroscopic approach was used for 81 patients and open approach for 46 patients. Treatment with arthroscopic approach resulted in a shorter hospital stay (2.6 ± 0.6 days vs 3.0 ± 0.7; p  = 0.02) and a longer operative time (24.5 ± 8.1 min vs 20.5 ± 4.2; p  < 0.01) than with open approach. The foot and ankle ability measure sports subscale scored significantly higher in the arthroscopic approach group (90.9 vs 77.3; p  = 0.003). Revision rate was significantly higher in the arthroscopic approach group (12 (15%)) versus the open approach group (1 (2%)) ( p  = 0.024). Persistent symptoms ( n  = 12) were the main reason for revision., Conclusions: Arthroscopic treatment of calcaneonavicular coalition is associated with a higher revision rate than the open approach., Level of Evidence: Level III-retrospective comparative study., Competing Interests: Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)

Purpose: The use of isolated semitendinosus tendon for Anterior Cruciate Ligament Reconstruction bears several advantages and is popular worldwide. It assumes that the gracilis tendon is spared. The aim of the study was to measure the surface area of the gracilis tendon in children who had undergone arthroscopic reconstruction of the anterior cruciate ligament using a semitendinosus tendon graft. Our hypothesis was that the gracilis tendon may be unintentionally and iatrogenically sectioned due to the anatomical proximity and the small size of the patients., Methods: Fifty patients who had undergone a magnetic resonance imaging preoperatively and postoperatively at 1 year from the surgery and who had been operated between January 2017 and March 2019 were included in this prospective series. The surface area of the gracilis tendon was measured on fat-saturated T2-weighted axial views at the widest point of the medial epicondyle of the femur. Age, sex, body weight, and height were documented., Results: One hundred magnetic resonance imaging of 50 knees were reviewed, from 34 boys (68%) and 16 girls (32%). The mean age was 14.5 years (10-18). The gracilis was visualized in all cases at 1 year postoperatively. The average tendinous surface area of the gracilis before the surgical procedure was 7.13 mm 2 versus 8.73 mm 2 at 1 year, representing an increase of 1.6 mm 2 (p = 0.0003)., Conclusions: This study demonstrated that harvesting of the semitendinosus for the purpose of Anterior Cruciate Ligament Reconstruction was a safe technique that preserves the gracilis., Level of Evidence: III., Competing Interests: Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)

Purpose: The pediatric Simple Knee Value (pedi-SKV) is an outcome score in which paediatric patients are asked 'How would you rate your knee today as a percentage of normal (0% to 100% scale with 100% being normal)?'. The primary aim of this study was to validate the pedi-SKV by measuring its correlation with validated knee function scores used most often in paediatric orthopaedics., Methods: This prospective study was conducted at a teaching hospital to evaluate the pedi-SKV's validity. A total of 44 paediatric patients (ten to 15 years old), were enrolled prior to anterior cruciate ligament reconstruction as well as 17 healthy controls. A survey form consisting of the Lysholm, International Knee Documentation Committee Pediatric Form (Pedi-IKDC) and pedi-SKV was given to subjects twice (enrolment and six months postoperatively). The criterion validity of the pedi-SKV was determined by correlating it to existing knee functional scores. Responsiveness to change was evaluated by comparing the pedi-SKV scores before and after surgery (enrolment visit and six-month postoperative visit). Discriminative ability was evaluated by comparing the pedi-SKV distribution in patients versus controls., Results: There was a strong and significant correlation between the pedi-SKV and the Lysholm and Pedi-IKDC (p < 0.0001). The pedi-SKV had a good responsiveness to change (p < 0.0001 for the pedi-SKV before versus six months postoperatively). Like the other knee-specific functional sores (p < 0.0001), the pedi-SKV was able to distinguish between patients and controls (p < 0.0001)., Conclusion: The pedi-SKV is a valid outcome measure that is strongly correlated with the Lysholm and Pedi-IKDC. This is a novel simple score that can be used by physicians in their daily practice., Level of Evidence: II., (Copyright © 2021, The author(s).)

Purpose: The therapeutic algorithm of paediatric anterior cruciate ligament (ACL) tears remains controversial. The primary aim of the study was to describe variations in practice patterns among European Paediatric Orthopaedic Society (EPOS) and Pediatric Orthopaedic Society of North America (POSNA) members with respect to management of ACL tears in skeletally immature patients. The secondary objective was to determine the number, type and severity of growth disturbances associated with ACL reconstruction (ACLR)., Methods: An email invitation to complete a 52-question survey was sent to all members of POSNA and EPOS. Data were collected automatically. Descriptive statistics were applied., Results: In all, 305 (25.4%) surgeon members responded. Only 182 (60%) of the participants treated ACL injuries in skeletally immature patients and completed the survey. A total of 17% of EPOS and 70% of POSNA members recommended ACLR within three months for a prepubescent paediatric ACL tear. In total, 61% of POSNA and 83% of EPOS members recommended ACLR within three months for a pubescent paediatric ACL tear. Epiphyseal tunnels were the preferred technique in prepubescent children (43% at the tibia and 49% at the femur), while transphyseal tunnels were recommended preferentially in pubescent children (85% at the tibia and 63% at the femur). In all, 5.5% of participants reported growth disturbances after ACLR., Conclusion: Current practice patterns across the Atlantic remain varied and controversial. Consensus remains elusive; as such, research collaboration among societies will be important to develop an evidence-based treatment algorithm. The use of transphyseal tunnels has been reinforced. The number of cases of significant growth disturbance is minimal, yet worrisome., Level of Evidence: II., (Copyright © 2019, The author(s).)

Purpose: Bone reconstruction after malignant tumour of the lower limbs is a challenge. Our aim was to investigate the results of bone lengthening and transport using the Fitbone motorized lengthening nail., Methods: Eight patients were included. Two patients had had a tumour involving soft tissue only without bone resection. In six patients, the initial bone defect was 15.5 cm (8 to 24). The first step of reconstruction had consisted of temporary fixation and a cement spacer. The second step had consisted of bone grafting in five patients. One patient was managed with bone transport. Eventually, five patients had a limb-length discrepancy (LLD) managed with bone lengthening only. Two patients had a LLD and a nonunion managed with bone transport and lengthening. Mean age at bone lengthening was 15.2 years (11 to 19). Mean follow-up was 30.5 months (10 to 48)., Results: In all, 11 nails were implanted in eight patients (eight femurs, three tibias). Mean length gain per procedure was 54.5 mm (30 to 80). Mean healing index was 48.4 days per cm (22.6 to 85.7). The complication rate was 18%. In two cases we observed a loose locking screw, which was revised. In all cases the lengthening involved the short bone (femur or tibia). Mean Musculoskeletal Tumor Society (MSTS) score improved from 52.7 (16.6 to 73.3) to 79.9 (63.3 to 96.6)., Conclusions: Bone reconstruction using a motorized intramedullary nail stands as a safe and reliable alternative after malignant tumour. It allows biological reconstruction with satisfactory clinical and radiological outcome and low complication rate., Level of Evidence: III.

Purpose: To evaluate the feasibility of day surgery anterior cruciate ligament reconstruction (ACLR) in children. Our hypothesis was that proper patient selection, adequate information and a streamlined clinical pathway would allow for a safe and satisfactory procedure., Methods: A total of 20 patients, seven girls and 13 boys, who underwent outpatient ACLR at mean age of 14 years (8 to 16) were included in this single institution prospective case series. Surgery took place under simple general anesthesia while analgesia protocol combined local anesthesia, oral analgesics for the postoperative period and compressive cryotherapy. The main failure criterion was the inability to return home the day of surgery or the need for rehospitalization during the first week after discharge. Secondary evaluation parameters were the rate of postoperative complications, postoperative pain, quality of life (QOL) and patients' satisfaction outcome questionnaire (PSOQ) at postoperative day 1, 7 and 31., Results: Of the 20 patients included, only one failed the ambulatory mode. The mean PSOQ score was, respectively for children and parents, 91.4% and 90.7% at day 7 and 94.6% and 95.7% at one month. Postoperative QOL at day 7 was very satisfying for all patients. Two minor early complications were reported. Both of the late complications, which included one partial wound dehiscence and one persistent knee swelling, resolved spontaneously., Conclusion: This study indicates that, in a targeted and well-informed population, day surgery for children ACLR yields high level of patient and family satisfaction in a safely manner., Level of Evidence: IV, prospective case series.

Background: Management of moderately displaced slipped capital femoral epiphysis (SCFE) is debated, mostly because of the risks related to open reduction on one hand, and subsequent evolution toward femoroacetabular impingement (FAI) on the other., Method: All SCFE cases treated with in situ fixation (ISF) and a minimum of ten years of follow-up beyond skeletal maturity were analysed in a retrospective multicentre study. Coxometry parameters were measured. Long-term results of ISF were meanwhile analysed at our Institution., Results: A total of 222 patients were included. Patient reported outcome measurements were related to the severity of the initial slip. It suggested a 35.5° threshold for slip angle beyond which FAI was more frequent. Only slight remodelling at the head-neck junction is to be expected., Conclusion: Based on these findings, it seems reasonable to perform ISF only in SCFE with a slip angle below 35°.

Background: In situ pinning of slipped capital femoral epiphysis (SCFE) results in various degrees of deformity of the femoral head-neck junction. Repetitive trauma from cam-type femoroacetabular impingement (FAI) can lead to labral tears and injury to the articular cartilage causing loss of function. Arthroscopic osteoplasty is an alternative to open procedure and to Southwick/Imhäuser-type osteotomies in symptomatic selected cases., Surgical Technique: The amount of bone to be resected has to be carefully planned pre-operatively. Only gentle traction is applied on a well-padded perineal support. A spherical burr is used to gradually resect the prominence. Intra-operative fluoroscopy is very useful when checking adequate reshaping of the head-neck junction is obtained., Results: Arthroscopy often reveals acetabular cartilage lesions, labrum hyperhemia and fraying which rarely require repair. Arthroscopic osteoplasty provides satisfactory pain relief and, to a lesser extent, restores hip internal rotation., Conclusion: Arthroscopic osteoplasty is more technically and time-demanding in post SCFE than idiopathic FAI. It requires strong arthroscopic skills and experience in hip arthroscopy. It stands as a reasonable alternative to open procedure or flexion osteotomies in symptomatic FAI post mild to moderate SCFE. It provides pain relief and to a lesser extent restores internal rotation of the hip.

Purpose: Among posterior surgical techniques for treating adolescent idiopathic scoliosis (AIS), hybrid constructs with pedicle-screw fixation in the lumbar spine and other anchors in the thoracic spine have been reported to provide to be of more physiological value in postoperative thoracic kyphosis than all-screw constructs. The Universial Clamp (UC) equipped with a soft sublaminar band is a relatively new thoracic anchor that can be used in hybrid constructs. A dedicated reduction tool that applies traction to the sublaminar band permits gentle translation of the thoracic curve to the precontoured fusion rods, which have been previously anchored distally by pedicle screws and proximally by hooks in a claw configuration. The aim of this study was to evaluate radiographic results of AIS treatment using UC hybrid constructs., Methods: This was a prospective case series in which 29 consecutive patients with Lenke type 1, 2 or 3 AIS operated on by two surgeons in two centers were followed for 24 months. Necessity for anterior release was an exclusion criterion., Results: A total of 5.4 ± 1.4 UCs were used per patient. The major thoracic curve was reduced from 55 ± 7° to 14 ± 6° at 1 month and 17 ± 6° at 24 months (correction 70%) without complications. In the patients who had less than 20° of T5-T12 kyphosis preoperatively, thoracic kyphosis improved from 14 ± 4° to 20 ± 3° at 3 months and 24 ± 9° at 24 months. In the other patients, preoperative thoracic kyphosis (27° ± 6°) was unchanged by the operation., Conclusion: UC hybrid constructs appear to safely provide satisfying coronal correction while consistently improving thoracic kyphosis in patients who also have preoperative hypokyphosis. We hypothesize that diminution in thoracic kyphosis was consistently avoided due to the straightforward traction of the spine to the fusion rods into which the chosen kyphosis was contoured by the surgeon before applying the reduction tool to the sublaminar bands.

Purpose: Evaluation of a novel instrumentation device for adolescent idiopathic scoliosis., Methods: A new osteosynthesis implant (Universal Clamp) primarily consisting of a sublaminar band and titanium clamp was prospectively studied in 32 patients (average age, 15 years) with a major thoracic curve., Results: The Universal Clamp was used without anterior release to reduce and maintain correction of the thoracic curve, which improved from 55.1° preoperatively to 14.5° at 3 months without neurological complication or loss of kyphosis., Conclusions: This implant distributes stress over a larger area of the laminar cortex than sublaminar wires, patently reducing the risk of laminar fracture for equivalent reduction forces, and permits progressive reduction at several apical levels simultaneously.