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Abstract: Orthopaedic device-related infection is one of the most devastating complications in orthopaedic and trauma surgery. With increasing life expectancies as well as the lifelong risk of bacterial seeding on an implant, the prevention and treatment of device-related infection remains an important area for research and development. To facilitate information exchange and enhance collaboration among various stakeholders in the orthopaedic community, the U.S. Food and Drug Administration (FDA) Center for Devices and Radiological Health (CDRH) organized an inaugural workshop on orthopaedic device-related infections, exploring the regulatory challenges that are faced when proceeding from the bench level to marketing and clinical implementation of new infection-control devices and products. This article summarizes the perspectives of scientists, clinicians, and industry partners on the current regulatory approval process for orthopaedic anti-infective technologies as well as the proposed strategies to overcome these regulatory challenges., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G506)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Some surgical strategies can maintain or restore thoracic kyphosis (TK); however, next-generation surgical schemes for adolescent idiopathic scoliosis (AIS) should consider anatomical corrections. A four-dimensional correction could be actively achieved by curving the rod. Thus, anatomically designed rods have been developed as notch-free, pre-bent rods for easier anatomical reconstruction. This study aimed to compare the initial curve corrections obtained using notch-free rods and manually bent, notched rods for the anatomical reconstruction of thoracic AIS. Two consecutive series of 60 patients who underwent anatomical posterior correction for main thoracic AIS curves were prospectively followed up. After multilevel facetectomy, except for the lowest instrumented segment, either notch-free or notched rods were used. Patient demographic data, radiographic measurements, and sagittal rod angles were analyzed within 1 week after surgery. Patients with notch-free rods had significantly higher postoperative TK than patients with notched rods (P < .001), but both groups achieved three-dimensional spinal corrections and significantly increased postoperative rates of patients with T6-T8 TK apex (P = .006 for notch-free rods and P = .008 for notched rods). The rod deformation angle at the concave side was significantly lower in the notch-free rods than in the notched rods (P < .001). The notch-free, pre-bent rod can maintain its curvature, leading to better correction or maintenance of TK after anatomical spinal correction surgery than the conventional notched rod. These results suggest the potential benefits of anatomically designed notch-free, pre-bent rods over conventional, manually bent rods.

Aims: The principle strategies of fracture-related infection (FRI) treatment are debridement, antimicrobial therapy, and implant retention (DAIR) or debridement, antimicrobial therapy, and implant removal/exchange. Increasing the period between fracture fixation and FRI revision surgery is believed to be associated with higher failure rates after DAIR. However, a clear time-related cut-off has never been scientifically defined. This systematic review analyzed the influence of the interval between fracture fixation and FRI revision surgery on success rates after DAIR., Methods: A systematic literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, in PubMed (including MEDLINE), Embase, and Web of Science Core Collection, investigating the outcome after DAIR procedures of long bone FRIs in clinical studies published until January 2020., Results: Six studies, comprising 276 patients, met the inclusion criteria. Data from this review showed that with a short duration of infection (up to three weeks) and under strict preconditions, retention of the implant is associated with high success rates of 86% to 100%. In delayed infections with a fracture fixation-FRI revision surgery interval of three to ten weeks, absence of recurrent infection was reported in 82% to 89%. Data on late FRIs, with a fracture fixation-FRI revision surgery interval of more than ten weeks, are scarce and a success rate of 67% was reported., Conclusion: Acute/early FRI, with a short duration of infection, can successfully be treated with DAIR up to ten weeks after osteosynthesis. The limited available data suggest that chronic/late onset FRI treated with DAIR may be associated with a higher rate of recurrence. Successful outcome is dependent on managing all aspects of the infection. Thus, time from fracture fixation is not the only factor that should be considered in treatment planning of FRI. Due to the heterogeneity of the available data, these conclusions have to be interpreted with caution. Cite this article: Bone Joint J 2021;103-B(2):213-221.

Antibiotic resistance represents a threat to human health. It has been suggested that by 2050, antibiotic-resistant infections could cause ten million deaths each year. In orthopaedics, many patients undergoing surgery suffer from complications resulting from implant-associated infection. In these circumstances secondary surgery is usually required and chronic and/or relapsing disease may ensue. The development of effective treatments for antibiotic-resistant infections is needed. Recent evidence shows that bacteriophage (phages; viruses that infect bacteria) therapy may represent a viable and successful solution. In this review, a brief description of bone and joint infection and the nature of bacteriophages is presented, as well as a summary of our current knowledge on the use of bacteriophages in the treatment of bacterial infections. We present contemporary published in vitro and in vivo data as well as data from clinical trials, as they relate to bone and joint infections. We discuss the potential use of bacteriophage therapy in orthopaedic infections. This area of research is beginning to reveal successful results, but mostly in nonorthopaedic fields. We believe that bacteriophage therapy has potential therapeutic value for implant-associated infections in orthopaedics. Cite this article: Bone Joint J 2021;103-B(2):234-244.

Background: Open fractures constitute an important mortality and morbidity cause among all musculoskeletal system injuries and bring along many social and economic problems. The cost occurring due to both long treatment duration and the delay in returning to work made these conditions more complicated. The present study aims to evaluate of the complications which may occur in cases with an application of internal fixation following external fixator in upper and lower extremity open fractures retrospectively., Methods: Forty-nine patients, who applied to the emergency service between 2007 and 2013, participated in this study. Thirty-two of these patients consisted of the patients to whom external fixator was first placed, and then internal fixation was performed by us, while 17 patients were treated in another center with the external fixator, and then their treatments were performed by us. All patients' injury mechanism, duration of follow-up with an external fixator, whether debridement was performed after external fixator, the period between external fixation and internal fixation, pin site infection, duration of the union, delayed union, nonunion, whether bone graft was used during internal fixation, internal fixation type, reoperation, development of osteomyelitis and follow-up parameters were recorded., Results: Results were evaluated separately for radius, humerus, tibia and femur fractures. Of the 49 patients, 39 were male, and 10 were female. Mean follow-up time for tibia 28.6 months, for femur 34, for humerus 26.9, for Radius 27 months. Of the 49 patients who participated in this study, 15 applied with upper extremity (11 humeri, 4 Radius) injury and 34 applied with lower extremity (25 tibias, 9 femora) injury. Of the 49 patients, 32 had pin tract infection, 11 had nonunion, 11 had delayed union, two had osteomyelitis., Conclusion: Open fractures are always hard to treat. After external fixation to the internal fixation process have some complications, phsycians should be aware of all these problems and plan according to the situation.

The management of idiopathic scoliosis in the skeletally immature patient can be challenging. Posterior spinal fusion and instrumentation is indicated for severe scoliosis deformities. However, the skeletally immature patient undergoing posterior fusion and instrumentation is at risk for developing crankshaft deformities. Moreover, bracing treatment remains an option for patients who are skeletally immature, and although it was found to be effective, it does not completely preclude deformity progression. Recently, fusionless treatment options, such as anterior vertebral body growth modulation, have been developed to treat these patients while avoiding the complications of posterior rigid fusion. Good results have been shown in recent literature with proper indications and planning in the skeletally immature patient.

Study Design: Analysis of explanted MAGnetic Expansion Control (MAGEC) growing rods., Objective: The aim of this study was to quantify the rate of locking pin breakage in explanted MAGEC rods and compare with the manufacturer's data., Summary of Background Data: On June 25, 2019, NuVasive released an Urgent Field Safety Notice stating that MAGEC rods manufactured before March 26, 2015 had a higher than expected locking pin breakage rate of 5%. For rods made on or after that date, no pin breakages had occurred., Methods: From our independent explant database of 139 explanted MAGEC rods supplied from 10 UK spinal centers (Belfast, Bristol, Birmingham, Edinburgh, Exeter, Leeds, Newcastle, Nottingham, Oxford, and Sheffield) and one Danish center (Aarhus), we divided the rods into those manufactured before March 26, 2015, and those manufactured on or after that date. MAGEC rods were cut open to fully assess internal components including locking pins. From each of the two cohorts, 10 locking pins were selected at random and their diameters were measured using a micrometer., Results: One hundred and five explanted MAGEC rods were made before March 26, 2015 and could be disassembled to allow the locking pin to be examined. Fifty-nine percent (62/105) of these locking pins had fractured. For the MAGEC rods manufactured on or after March 26, 2015, 21% (6/29) were found to have fractured locking pins. Locking pins in MAGEC rods made on or after March 26, 2015 were of a stronger material and a larger diameter., Conclusion: Fifty-nine percent of the locking pins in MAGEC rods manufactured before March 26, 2015 had fractured, far greater than the 5% stated in the Urgent Field Safety Notice. Locking pin fracture still occurred in MAGEC rods manufactured on or after that date, in 21% of cases. This contrasted with the 0% reported by the manufacturer., Level of Evidence: 4.

The medial malleolus, once believed to be the primary stabilizer of the ankle, has been the topic of conflicting clinical and biomechanical data for many decades. Despite the relevant surgical anatomy being understood for almost 40 years, the optimal treatment of medial malleolar fractures remains unclear, whether the injury occurs in isolation or as part of an unstable bi- or trimalleolar fracture configuration. Traditional teaching recommends open reduction and fixation of medial malleolar fractures that are part of an unstable injury. However, there is recent evidence to suggest that nonoperative management of well-reduced fractures may result in equivalent outcomes, but without the morbidity associated with surgery. This review gives an update on the relevant anatomy and classification systems for medial malleolar fractures and an overview of the current literature regarding their management, including surgical approaches and the choice of implants. Cite this article: Bone Joint J 2019;101-B:512-521.

The intact one-piece sternum is indispensible to the thorax for its normal physiological biomechanics. To overcome tri-planar forces acting on the sternum following midsagittal osteochondrotomy, it must be reconstructed using an optimal technique to withstand distraction loads of normal respiration and violent cough. It should be fixed rigidly to reconstitute the anterior coronal column of the axial skeleton to maintain erect posture and prevent kyphosis. Sterile or infective non-union of the sternum compromises the physical endurance of patients and has an immense psychological effect. From an engineering perspective, there is no substantially proven gold standard technique to fix a divided sternum. Stainless steel wire applied in various configurations to a variety of shapes and sizes has become an acceptable standard of care due to its long-standing history and cost-effectiveness. Recently there has been a proliferation of innovative techniques to deal with primary and failed union of the sternum in an effort to prevent mechanical failure and serious deep surgical wound infection progressing to mediastinitis. Among the newer implant designs, the ones currently in use are shaped like clamps and clasps to compress the sternal halves together as well as alphabet-shaped mini-plating systems. In this section of the review series, mechanisms, pros and cons of currently available implants to reconstruct the bisected sternum, and external support systems considered necessary in high-risk clients are discussed.

Aims: The aim of this study was to compare the outcomes of surgery using growing rods in patients with severe versus moderate early-onset scoliosis (EOS)., Patients and Methods: A review of a multicentre EOS database identified 107 children with severe EOS (major curve ≥ 90°) treated with growing rods before the age of ten years with a minimum follow-up of two years and three or more lengthening procedures. From the same database, 107 matched controls with moderate EOS were identified., Results: The mean preoperative major curve was 101° (90 to 139) in the severe group and 67° (33° to 88°) in the moderate group (p < 0.001), which was corrected at final follow-up to 57° (10° to 96°) in the severe group and 40° (3° to 85°) in the moderate group (p < 0.001). T1-S1 height increased by a mean of 54 mm (-8 to 131) in the severe group and 27 mm (-4 to 131) in the moderate group at the initial surgery (p < 0.001), and by 50 mm (-17 to 200) and 54 mm (-11 to 212), respectively, during distraction (p = 0.84). The mean number of complications per patient was 2.6 (0 to 14) in the severe group and 1.9 (0 to 10) in the moderate group (p = 0.040). Five patients (4.7%) in the severe group and three (2.8%) in the moderate group developed a neurological deficit postoperatively (p = 0.47)., Conclusion: Severe EOS can be treated effectively using growing rods, but the risk of complications is high. Cite this article: Bone Joint J 2018;100-B:772-9.

Aims: The aim of this study was to describe the technique of distraction osteogenesis followed by arthrodesis using internal fixation to manage complex conditions of the ankle, and to present the results of this technique., Patients and Methods: Between 2008 and 2014, distraction osteogenesis followed by arthrodesis using internal fixation was performed in 12 patients with complex conditions of the ankle due to trauma or infection. There were eight men and four women: their mean age was 35 years (23 to 51) at the time of surgery. Bone healing and functional recovery were evaluated according to the criteria described by Paley. Function was assessed using the ankle-hindfoot scale of the American Orthopedic Foot and Ankle Society (AOFAS)., Results: A solid fusion of the ankle and eradication of infection was achieved in all patients. A mean lengthening of 6.1 cm (2.5 to 14) was achieved at a mean follow-up of 25.2 months (14 to 37). The mean external fixation index (EFI) was 42 days/cm (33.3 to 58). The function was judged to be excellent in six patients and good in six patients. Bone results were graded as excellent in ten patients and good in two patients. The mean AOFAS score was 37.3 (5 to 77) preoperatively and 75.3 (61 to 82) at the final follow-up. Minor complications, which were treated conservatively, included pain, pin-tract infection, loosening of wires, and midfoot stiffness. Major complications, which were treated surgically included grade V pin-tract infection with inflammation and osteolysis, poor consolidation of the regenerate bone, and soft-tissue invagination. The reoperations required to treat the major complications included the exchange of pins and wires, bone grafting and invagination split surgery., Conclusion: The technique of distraction osteogenesis followed by arthrodesis using internal fixation is an effective form of treatment for the management of complex conditions of the ankle. It offers a high rate of union, an opportunity to remove the frame early, and a reduced EFI without infection or wound dehiscence. Cite this article: Bone Joint J 2018;100-B:755-60.

Introduction: The operative treatment of unstable pelvic injuries in paediatrics is not frequently indicated. The detailed modes of pelvic ring failure, surgical techniques, fixation choices, and peri-operative difficulties are not well reported., Methods: From September 2010 to March 2016, 62 paediatric patients were admitted to an academic level I trauma center with the diagnosis of pelvic ring injury. Of them, 29 (17 males and 12 females) had operative fixation of unstable pelvic injuries. Their average age was 11.7 ± 4.4 years., Results: There were six Tile's B injuries and 23 type C injuries. The commonest modes of pelvic ring failure were pubic rami fractures anteriorly and ligamentous sacroiliac joint injuries posteriorly. The iliac apophysis was avulsed in nine patients. Supra-acetabular external fixators were frequently used for anterior fixation while iliosacral IS screws and lateral compression LC screws were commonly used posteriorly. Difficulties were encountered with open reduction and repair of avulsed iliac apophyses in two patients. The IS screws pierced the soft iliac wing in three patients. In two patients with open triradiate cartilage, the purchase of retrograde LC screws was weak due the small sized crescent fragment., Conclusion: The iliac apophysis needs to be repaired following reduction of the displaced hemipelvis. Anterior supra-acetabular external fixation is a good choice in paediatrics even with pubic symphysis diatasis as the pathology is commonly a pubic apophysis avulsion. IS screws might be inserted through plates to prevent piercing the soft iliac wing. Retrograde LC screws should be avoided in young children.

Purpose: The purpose of this study was to examine time to union of extra-articular distal tibia nonunions based on fracture type and fixation methods: intramedullary nail (IMN), plate osteosynthesis (PO), and external fixation (EF)., Methods: This retrospective chart review included all patients who presented at a Level I trauma center with AO/OTA 43A & distal third 42A-C fracture nonunions between 2008 and 2014. Fixation methods were recorded and patient course was followed until nonunion had healed clinically., Results: Thirty-three distal tibia nonunions were included, and 29 reached eventual union (88%). Five AO/OTA fracture types were present. Mean times to union from nonunion diagnosis between original fracture types were compared (p = 0.203). Comminuted fracture types had longer times to union from nonunion diagnosis compared to simple fracture types (78 vs. 46 weeks, p = 0.051) and more revision fixations (1.5 vs. 0.5, p = 0.037). Mean time to union from nonunion diagnosis was shorter when no revision fixation was done compared to revisions (15 vs. 42 weeks, p = 0.102). Times to union from nonunion diagnosis without revision fixation were: IMN (12 weeks), PO (27 weeks), and EF (13 weeks) (p = 0.202). Times to union from definitive revision fixation were: IMN (17 weeks), PO (21 weeks), and EF (66 weeks) (p = 0.009), with EF taking significantly longer than both other methods. 21 patients (64%) underwent revision fixation. Revision fail rates were: IMN (0/6, 0%), PO (2/8, 25%), and EF (15/21, 71%). Time to union was longer in revisions that changed fixation method compared to revisions that used the same method (51 vs. 18 weeks, p = 0.030). Deep infections were also associated with longer union times (81 vs. 47 weeks, p = 0.040)., Conclusions: In this nonunion population, comminuted fracture types needed more time and revisions to reach union. Time to union was only clinically shorter when revision fixation was not performed, but IMN and PO were both successful fixation options with significantly shorter times to union than EF. Mean time to union increased even more when revision of fixation method was performed vs. exchange revision, as did nonunions with deep infections.

Purpose: Varus or valgus deformity of the distal femur may progress into knee osteoarthritis. To delay or prevent this, various types of corrective osteotomy techniques have been used to shift the mechanical axis from the diseased compartment to the healthy one. We introduced a new, minimally invasive osteotomy of the distal femur with the assistance of temporary external fixation., Methods: We retrospectively studied 25 legs that underwent open-wedge osteotomy of the distal femur, involving insertion of a Schanz pin at the medial femoral condyle and another pin at the distal diaphysis of the femur. At the meta-diaphyseal junction, osteotomy was performed. After achieving angular correction, two pins were locked for temporary external fixation and a locking plate was fixed at the lateral side of the femur submuscularly. Radiological and functional outcomes were evaluated, including mechanical lateral distal femoral angle (m-LDFA), mechanical axis deviation, tibiofemoral angle, osseous union, and knee joint motion., Results: The minimum follow-up was 12 months (mean, 39 months; range, 12-88 months). Bone healing occurred in all legs, with an average of 16.6 weeks. The m-LDFA was corrected from 77.7° (18 valgus) and 104.6° (7 varus) to 88.1° after surgery, with an average correction of 12.9°. At the final follow-up, the mechanical axis deviation averaged 7.6 mm and the tibia-femoral angle averaged 5.6°. Most of legs (88%) achieved acceptable m-LDFA (87° ± 3°)., Conclusions: A new, minimally invasive osteotomy of the distal femur offers excellent bone healing with few complications, attributable to preserved blood supply., (Copyright © 2016 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

We present a case of a 25-year-old male patient suffering from severe prolonged pain after uneventful pectus excavatum repair that could be treated successfully by paravertebral nerve radiofrequency thermoablation. The patient was scheduled for a minimally invasive Nuss pectus excavatum repair. Surgical correction was performed under general anesthesia in combination with a thoracic peridural catheter. The immediate postoperative course was uneventful; however, the patient developed severe prolonged bilateral chest wall pain across segments T8 and T9. After failure of conservative treatment options, a specialized interventional anesthesiologist performed paravertebral nerve radiofrequency thermoablation of segment T9 bilaterally, after which the patient was pain free until scheduled removal of the pectus bar 3 years after placement.

Objectives: Pediatric forearm torus fracture, a frequent reason for emergency department visits, can be immobilized by both rigid cast and nonrigid methods. However, controversy still exists regarding the optimal treatment of the disease. The aim of this study was to compare, in a systematic review, clinical efficacy of rigid cast with nonrigid methods for immobilization of the pediatric forearm torus fractures., Methods: Literature search was performed of PubMed and Cochrane Library by 2 independent reviewers to identify randomized controlled trials comparing rigid cast with nonrigid methods for pediatric forearm torus fractures from inception to December 31, 2013, without limitation of publication language. Trial quality was assessed using the modified Jadad scale., Results: Eight randomized controlled trials with a total of 781 participants met all inclusion criteria. The nonrigid methods for immobilization included soft cast, splint, bandage, and slab. Results showed that nonrigid immobilizations had better clinical efficacy than rigid cast regarding functional recovery, treatment cost, and complication rate (relative risk, 3.02; 95% confidence interval, 1.70-5.37; P = 0.0002). Compared with rigid cast, more patients would like to choose the nonrigid methods of immobilization for future use. However, discrepant results sill surrounds the pain levels of the patients., Conclusions: The current study suggests that the nonrigid immobilization methods have more advantages than rigid cast for immobilization of pediatric forearm torus fracture. The former strategies are also safe enough for clinical therapy.

Exothermic reaction of plaster is a very important characteristic to understand, especially when it comes to complications which can occur during local temperature change during molding plaster of Paris. And these complications directly influence the speed and quality of treatment. In this paper we measured temperatures of plaster bandage tiles 10×10 cm, from three different manufacturers in Croatian hospitals: Safix plus (Hartmann, Germany), Cellona (Lohmann &Rauscher, Austria) and Gipsan ( Ivo Lola Ribar, Croatia). We made three different plaster tiles 10×10 cm, from 10, 15 and 30 layers of plaster bandages. We immersed plaster tiles in two different water temperatures, one group in water 22 °C, and another in 34 °C. Although all plaster bandages have similar chemical characteristics, we have measured some differences. All three kinds of plaster bandages used in Croatia have low exothermic reaction when plaster molding is done in standard conditions, average local temperature is low and there is no danger of local burns. We immersed a plaster tile with 15 layers in water on 34° C, and highest average temperature was measured at Gipsan (46.2 °C), then Cellona (41.3 °C) and Safix plus (38.9 °C). On the same water immersion temperature, on plaster tile with 30 layers average temperatures were Gipsan (48.4°C), Cellona (45.4 °C), and lowest in Safix plus (41.3 °C). Plaster tiles form all manufacturers, when used 15-30 layers thick, and water immersion temperature is 34°C, develop average temperature over 40°C, in duration from 8-12 minutes. Between three different plaster bandages analyzed, Gipsan (Ivo Lola Ribar, Croatia) developed highest temperature, and some plaster tiles were measured over 50 °C.

Orthognathic surgery procedures mark the endpoint of lengthy orthodontic-surgical preparations and herald the completion of treatment for patients and their families. The main types of procedure are full maxillary Le Fort I osteotomies, mandibular osteotomies and chin surgery. To ensure a successful outcome, all require a favorable environment and extreme technical skill. But, like all surgical operations, they are also subject to peri- and post-operative complications resulting from treatment hazards or errors. Whatever the cause, surgical complications can entail failures in the management of the malformation. By seeking to understand and analyzing these complications, we can already help to prevent and reduce the contingent risks of failure., (© EDP Sciences, SFODF, 2016.)

Prosthetic joint infections (PJI) in orthopedic related devices (ORD) are major issues following replacement of joints. It results in serious morbidity and mortality and is expensive to treat and manage. The pathogenesis of these infections is related to the presence of biofilm on the metallic and plastic surfaces of the devices. This biofilm results in poor penetration of antibiotics resulting in persistence and difficulty in eradication of the infection despite appropriate antibiotics. This paper summarizes the present data of biofilm as it relates to PJI/ORD.

Introduction: The objective of this study was to evaluate the changes of skeletal and dental structures in mild to moderate skeletal Class III children following the use of a new magnetic orthopedic appliance (MOA-III)., Methods: A total of 36 patients (14 boys and 22 girls, mean age 9 years and 5 months) who presented with a mild to moderate skeletal Class III jaw discrepancy were treated with MOA-III. Another group of 20 untreated patients (9 boys and 11 girls, mean age 9 years and 2 months) with the same level of deformity served as the control group. The average treatment time was 6.6 months. Radiographs were taken at the same time intervals for both groups. A paired t test was used to determine the significant differences before and after treatment, and a two-sample t test was used to analyze the differences between the treatment and control groups., Results: The anterior crossbite in all subjects was corrected after MOA-III therapy. The maxillomandibular relationship showed favorable changes (ANB, Wits, overjet increased significantly, P < 0.001). The maxilla was anteriorly positioned (SNA, ptm-A, ptm-S increased significantly, P < 0.001) with clockwise rotation (PP-FH increased, P < 0.001). The mandible showed a slight downward and backward rotation (SNB decreased, P < 0.05, MP-SN, Y-axis increased, P < 0.05). The length of the mandibular body showed no significant changes (Go-Pg, P > 0.05). Significant upper incisor proclination and lower incisor retroclination were observed (UI-NA increased, P < 0.001, LI-NB, FMIA decreased, P < 0.001). The upper lip moved forward, and the lower lip moved backward (UL-EP increased, P < 0.001, LL-EP decreased, P < 0.05). In the control group, most of the parameters showed normal growth, except for some unfavorable mandibular skeletal and soft tissue changes (Go-Pg, Go-Co, MP-SN, N'-SN-Pg' increased, P < 0.001). Significant positive changes were induced with the MOA-III appliance compared to the untreated group., Conclusions: The MOA-III was effective for the early treatment of a mild to moderate Class III malocclusion in children.

Orthopaedic infections that occur after trauma are common. Clinical examination, laboratory markers, imaging modalities, and culture and molecular technologies are used to aid the diagnosis of infection. Culture methods comprise the backbone of diagnostic systems used in hospital laboratory settings; however, several studies have questioned the ability of these techniques to adequately identify infections, particularly in cases where orthopaedic implants were used or when the presence of biofilm bacteria is suspected. Advances in imaging and molecular diagnostics can provide orthopaedic surgeons with an improved means of diagnosing and treating infections., (Copyright 2015 by the American Academy of Orthopaedic Surgeons.)

Study Design: Retrospective cohort., Objective: The primary goal is to compare the clinical results of 2 types of constructs commonly used at the cervicothoracic junction: small rods (3.2-mm/3.5-mm rods) or transitional constructs. The secondary goal is to perform a case-control study of risk factors for pseudarthrosis at the cervicothoracic junction., Summary of Background Data: Various constructs have been used to stabilize across the cervicothoracic junction; however, no study to date has objectively compared their outcome. Our hypothesis was that both constructs would have similar fusion and complication rates., Methods: A retrospective review of a prospectively collected database revealed 135 patients with the aforementioned constructs and having followed up with imaging at 6 months, 12 months, and 24 months. Univariate analysis comparing the 2 different construct groups was performed. Multivariate analysis for risk factors of pseudarthrosis was also performed., Results: There were a total of 10 patients with pseudarthrosis at 2-year follow-up. There was no difference in pseudarthrosis rate between the small rods (7%) and transitional constructs (8.6%) (P = 0.99). The overall construct lengths were similar (5.8 levels in small rods, 6.7 levels in transitional construct). Blood loss was higher in transitional constructs (574 ± 69 mL) than in small rods (236 ± 53 mL) (P < 0.001). Transitional constructs also had longer operating times (249 min) than small rods (207 min) (P < 0.03). Overall complication rate was higher in the transitional constructs (P < 0.03). Tobacco use, corpectomy, lack of an anterior construct, and construct length were all risk factors for cervicothoracic junction pseudarthrosis in the multivariate analysis., Conclusion: Overall pseudarthrosis rates were similar between small rods and transitional constructs. There was higher complications rate, blood loss, and operating time associated with transitional constructs. Pseudarthrosis risk factors at the cervicothoracic junction include tobacco use, corpectomy, lack of an anterior construct, and longer constructs., Level of Evidence: 3.

Study Design: This is a cadaveric biomechanical study evaluating the biomechanical properties of a novel spinopelvic fixation technique with percutaneous lumbo-sacro-iliac (LSI) screws in an unstable total sacrectomy model., Objective: To compare standard posterior dual rod spinopelvic fixation alone with dual rod fixation supplemented with LSI screw fixation., Summary of Background Data: Primary or metastatic tumors of the sacrum requiring a total sacrectomy can result in spinopelvic instability if inadequate fixation is achieved. Many fixation techniques have been proposed to address this instability. However, to date, an optimal fixation technique has not been established., Materials and Methods: Ten fresh-frozen cadaveric spinopelvic specimens were randomized according to bone mineral density (BMD) to either posterior rod fixation (control group) or posterior rod fixation with supplemental LSI screws (LSI group). After fixation, a total sacrectomy of each specimen was performed. Specimens where then potted and axially loaded in a caudal direction. Stiffness, yield load, energy absorbed at yield load, ultimate load, and energy absorbed at ultimate load were computed. A Student t test was used for statistical analysis with significance set at P<0.05., Results: The average age and BMD were not significantly different between the control and LSI groups (age: P=0.255; BMD: P=0.810). After normalizing for BMD, there were no significant differences detected for any of the biomechanical parameters measured between the 2 fixation techniques: stiffness (P=0.857), yield load (P=0.219), energy at yield load (P=0.293), ultimate load (P=0.407), and energy at ultimate load (P=0.773). However, both fixation techniques were able to withstand physiological loads., Conclusions: Our study did not demonstrate any biomechanical advantage for supplemental LSI screw fixation in our axial loading model. However, given the theoretical advantage of this percutaneous technique, further studies are warranted that take into account forward bending and sagittal stability.

Timing of third molar removal in relation to bilateral sagittal split osteotomy (BSSO) is controversial, especially with regard to post-operative complications. We investigated the influence of mandibular third molar presence on complications after BSSO with sagittal splitters and separators, by a retrospective record review of 251 patients (502 surgical sites). Mandibular third molars were present during surgery at 169 sites and removed at least 6 months preoperatively in 333 sites. Bad splits occurred at 3.0 % (5/169) and 1.5% (5/333) of the respective sites. Presence of mandibular third molars significantly increased the risk of bad splits (OR 1.08, CI 1.02-1.13, p < 0.01). The mean incidences of permanent neurosensory disturbances, post-operative infection, and symptomatic removal of the osteosynthesis material were 5.4% (OR, 0.89; 95% CI, 0.79-1.00; p = 0.06), 8.2% (OR, 1.09; 95% CI, 0.99-1.20; p = 0.63), and 3.4% (OR, 0.97; 95% CI, .92-1.03; p = 0.35) per site, respectively, without a significant influence of mandibular third molar status. In conclusion, the presence of mandibular third molars during surgery increases the possibility of bad split but does not affect the risk of other complications. Therefore, third molars can be removed concomitantly with BSSO using sagittal splitters and separators., (Copyright © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: To evaluate the clinical results of using end plate rings in preventing subsidence of titanium cage in anterior cervical corpectomy and fusion (ACCF) surgery., Methods: The clinical data of 71 patients with cervical spondylotic myelopathy underwent ACCF in single segment from February 2008 to February 2011 were retrospectively analyzed. There were 38 males and 33 females, aged from 39 to 74 years old with a mean of 53.8 years. Thirty-three were used end plate rings and thirty-eight were not used (end plate rings group and no end plate ring group, respectively). The Japanese Orthopaedic Association (JOA) score, Odom's scale, imaging data were used to evaluate the clinical effects. Imaging data including Cobb angle of fusion segment, intervertebral height of anterior border (Da) and posterior border (Dp), the mean intervertebral height (Dm)., Results: All patients were followed up from 13 to 34 months with an average of 19.5 months. Between two groups, there was no significant difference in Cobb angle of fusion segment and the mean intervertebral height (Dm) before surgery and one week after surgery. Whereas, one year after surgery, the Cobb angle of end plate ring group was (9.4 ± 3.8) degrees, and contral group was (7.5 ± 3.9) degrees, which was significantly lower than that of end plate ring group. Meanwhile, the Dm of end plate ring group was (57.3 ± 2.2) mm, and no end ring group was (55.2 ± 2.6) mm which was significantly lower than that of end plate ring group. The subsidence in end plate ring group was 57.6%, and was 78.9% in no end plate ring group. There was no significant difference in JOA score before and after surgery between two groups. At 1 year after operation, 90.9% (30/33) got excellent or good results in end plate ring group, 89.5% (33/38) got excellent or good results in contral group., Conclusion: The use of end plate rings could not completely prevent the subsidence of titanium cage, however, which can decrease the occurrence rate of the subsidence and lessen its degree.

Surgical site infections are a major complication of instrumented orthopaedic surgery, affecting 0.5 to 2% of patients following arthroplasty, and up to 30% of patients after fixation of open fractures. Acute infections may result from exogenous inoculation during or in the weeks following surgery (early infections), or from hematogenous seeding from a remote origin at any time after implantation (late infections). These infections are generally due to virulent organisms, such as Staphylococcus aureus, and must be treated rapidly. Delayed infections, arising between 3 and 24 months after surgery, are caused by low-virulence organisms such as coagulase-negative staphylococci. Diagnosis of delayed infections may be difficult because clinical presentation is often subtle and limited to chronic pain, and relies on imaging studies and culture of synovial fluid aspirates. Strong collaboration between surgeon, microbiologist and infectious disease specialist is essential for management of implant-associated infections, which almost always necessitates surgical intervention and prolonged antimicrobial therapy. The choice of the type of surgical intervention (debridement, or removal with or without exchange of the implant) depends on the duration of infection signs, on the pathogen species and antibiotic susceptibility, and on the patient general and local condition. Antibiotics are chosen according to pathogen susceptibility and to pharmacokinetic parameters such as bioavailability and penetration into the bone tissue. Patients treated in accordance with current guidelines are cured of their infection in 60 to 80% of cases.

Slipped upper femoral epiphysis is a disabling condition with an annual incidence of 2-13 per 100,000. In situ surgical fixation is the preferred initial treatment for both stable and unstable slipped capital femoral epiphysis (SCFE) cases. The main aim is to avoid further slippage and complications such as osteonecrosis and chondrolysis. The choice of medical implants in managing this condition has changed along the years from large nail-like devices to cannulated screws. The biomechanical properties of different fixation techniques have been studied. All implants have been associated with complications that can occur intraoperatively as well as in the early and late postoperative periods. This report examines a number of different implants used and identifies complications and ways on how to avoid such complications. It also looks at the complications directly related to medical implants in the management of SCFE. We looked at published literature in peer-reviewed journals describing the use of the different medical implants and the documented complications. We also examined literature that suggests ways on how to avoid and manage these complications. A review of the current literature is presented in this text.

A 16-year-old male who had undergone 6 months before an anterior cruciate ligament (ACL) reconstruction with an autologous hamstring graft fixed with a suspensory fixation device (XoButton device; ConMed Linvatec, Largo, FL), complained of a slightly painful mass in the distal posterolateral aspect of the thigh. The knee was otherwise stable. A 79 × 60 × 17 mm multilobulated tumor surrounding the implant device was observed in magnetic resonance images. The revision arthroscopy showed an intact ACL graft. The tumor was excised through a longitudinal posterolateral approach. It had a myxoid appearance. The undamaged implant was also removed. Two months after surgery, the patient was already asymptomatic. Although most fixation device problems occur in the perioperative period due to an inadequate technique which may lead to graft instability, this case reminds clinicians of the possibility of later developing clinically relevant complications with suspensory fixation devices., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Harrington rods have been successfully implanted in thousands of patients for the correction of scoliotic deformity since the 1950s. An exceedingly rare complication of Harrington rod placement is loosening with resultant migration. The authors present a 50-year-old woman who had a single Harrington rod placed when she was 15 years old. Thirty-five years later, she presented with acute sensory changes in her lower extremities. Imaging revealed rod failure and migration of the hardware distally, resulting in penetration of the wall of the rectum. Due to the unique anatomical position of the migrated hardware, sigmoidoscopy was used to directly visualize and remove the rod. The patient ultimately made a full recovery. Rod migration is an exceedingly rare complication that has been described only a few times since the introduction of Harrington rods over 60 years ago. The case herein is particularly unique given the extensive period of time that passed before migration (35 years) and the use of sigmoidoscopy for hardware removal., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objectives: Minimally invasive repair of pectus excavatum, the so-called Nuss procedure, has become a popular technique in recent years. The internal mammary arteries (IMAs) lie on the posterolateral surface of the sternum, and the Nuss bar is likely to obstruct the blood flow in these arteries. This obstruction could become important in the later stages of the lives of these young people if they were to require coronary artery bypass grafting. The goal of this study is to investigate the extent of obstruction of the IMAs caused by Nuss bars., Methods: Data were collected prospectively on all patients who underwent the Nuss procedure between October 2011 and May 2012. Patients with a history of pectus excavatum repair by open surgery and those who were younger than 16 years of age were excluded. Computed tomography-angiography (CTA) was performed for the detection of IMA blood flow preoperatively and on the 10th postoperative day. Blood flow in the IMAs was evaluated blindly by two radiologists and classified as blood flow unaffected (group I) or affected (group II) by comparing the assessment of preoperative and postoperative CTAs. The patients in group II were also categorized as having blood flow obstructed bilaterally, blood flow obstructed unilaterally and others (diminished unilaterally/diminished on one side or obstructed on the other side)., Results: Thirty-four patients (31 male and three female; mean age 20.7 ± 4.2 years) underwent surgery. Blood flow was affected in 15 patients (44%), with bilateral obstruction in five, unilateral obstruction in seven, and unilateral diminished flow in two patients. In one patient, blood flow was diminished on one side and obstructed on the other. There was no significant difference between unaffected group I patients and affected group II patients in terms of sex, age, type of deformity, Haller index and the number of bars placed., Conclusions: Nuss bars cause pressure on the IMAs, but a risk factor for this effect could not be identified. This is a relatively common clinical consequence of minimally invasive repair of pectus excavatum, and the long-term effects will be apparent following bar removal.

Cephalomedullary devices (CMN) have become an increasingly popular for treatment of intertrochanteric hip fractures compared to sliding hip screw and side plate (SHS) devices. Failed fixation is often treated with conversion total hip arthroplasty (THA). We performed a multi-institutional study in which 60 patients with SHS devices and 31 patients with CMN devices were converted to THA. Harris Hip Score improved from 41.6 preoperatively to 83.6 at final follow-up in the SHS group and from 41.6 to 78.6 in the CMN group, with no significant difference between the groups (P=0.23). However, the complication rate in converted CMN patients was significantly higher at 41.9% compared with 11.7% (P=0.001) in converted SHS patients. Prior fixation with CMN may be associated with significantly higher complication rates during conversion., (© 2013.)

Syndesmotic diastasis can occur as an isolated injury or with concomitant fractures. A review of 37 patients with 64 TightRopes® for syndesmotic repair was performed, with a mean follow-up of 23.6 ± 4.3 months, from 2007 to 2011. The patients' mean age was 40.67 (range 14 to 87) years. The mean initial measurements were as follows: tibiofibular clear space (TFCS) = 4.1 ± 1.1 mm, tibiofibular overlap (TFO) = 7.2 ± 2.7 mm, and medial clear space (MCS) = 2.9 ± 0.5 mm. The mean final measurements were as follows: TFCS = 4.2 ± 1.3 mm, TFO = 7.4 2.8 mm, and MCS = 3.0 0.5 mm. The calculated measurable difference from the initial to final TFCS, TFO, and MCS was significantly less than the maximum threshold for allowable widening of the syndesmosis: TFCS, p < .001; TFO, p < .002; and MCS, p < .001. Complications occurred in 10 patients; 7 (19%) experienced knot irritation and 3 (8%) developed an infection. The mean interval to weightbearing was 33.2 ± 12.7 days. The mean postoperative American Orthopaedic Foot and Ankle Society score was 97 (range 90 to 100). Of 64 suture endobuttons, 4 (6.25%) required removal. The fracture types were as follows: 3 (8%) isolated syndesmotic injuries, 9 (24%) trimalleolar fractures, 10 (27%) bimalleolar fractures, 7 (18%) Weber B fractures, 3 (8%) Weber C fractures, 1 (3%) Salter Harris type 3 fracture, and 4 (11%) Maisonneuve fractures. TightRope® fixation was advantageous because it rarely required removal, allowed for physiologic motion of the syndesmosis, and resulted in an early return to weightbearing. In addition, we have concluded that the TightRope® provides long-term stability of the ankle mortise, which was confirmed by the radiographic criteria and excellent American Orthopaedic Foot and Ankle Society scores., (Copyright © 2013 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

The surgical correction of hammer digits offers a variety of surgical treatments ranging from arthroplasty to arthrodesis, with many options for fixation. In the present study, we compared 2 buried implants for arthrodesis of lesser digit deformities: a Smart Toe® implant and a buried Kirschner wire. Both implants were placed in a prepared interphalangeal joint, did not violate other digital or metatarsal joints, and were not exposed percutaneously. A retrospective comparative study was performed of 117 digits with either a Smart Toe® implant or a buried Kirschner wire, performed from January 1, 2007 to December 31, 2010. Of the 117 digits, 31 were excluded because of a lack of 90-day radiographic follow-up. The average follow-up was 94 to 1130 days. The average patient age was 61.47 (range 43 to 84) years. Of the 86 included digits, 48 were left digits and 38 were right. Of the digits corrected, 54 were second digits, 24 were third digits and 8 were fourth digits. Fifty-eight Smart Toe® implants were found (15 with 19-mm straight; 2 with 19-mm angulated; 34 with 16-mm straight; and 7 with 16-mm angulated). Twenty-eight buried Kirschner wires were evaluated. No statistically significant difference was found between the Smart Toe® implants and the buried Kirschner wires, including the rate of malunion, nonunion, fracture of internal fixation, and the need for revision surgery. Of the 86 implants, 87.9% of the Smart Toe® implants and 85.7% of the buried Kirschner wires were in good position (0° to 10° of transverse angulation on radiographs). Osseous union was achieved in 68.9% of Smart Toe® implants and 82.1% of buried Kirschner wires. Fracture of internal fixation occurred in 12 of the Smart Toe® implants (20.7%) and 2 of the buried Kirschner wires (7.1%). Most of the fractured internal fixation and malunions or nonunions were asymptomatic, leading to revision surgery in only 8.6% of the Smart Toe® implants and 10.7% of the buried Kirschner wires. Both the Smart Toe® implant and the buried Kirschner wire offer a viable choice for internal fixation of an arthrodesis of the digit compared with other studies using other techniques., (Copyright © 2013 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Two patients underwent arthroscopic anatomic double-bundle anterior cruciate ligament (ACL) reconstruction using the EndoButton for femoral fixation. The femoral tunnels were created by the inside-out technique through a far anteromedial portal. The patients postoperatively developed moderate lateral knee pain without instability. At the second-look arthroscopic evaluation, the two EndoButtons were removed. Both patients were completely asymptomatic several months after implant removal, implying that the EndoButtons caused the mechanical irritation in the iliotibial band. This is the first report describing removal of EndoButtons because of pain caused by friction with the iliotibial band. In anatomic ACL reconstruction, if the femoral tunnel exit is positioned near the lateral femoral epicondyle, care should be taken to prevent iliotibial band friction syndrome that could result because of the EndoButton., (Copyright © 2013 Elsevier B.V. All rights reserved.)

Aim: Night-time postural equipment (NTPE) can prevent hip subluxation in children with severe motor disorders (SMDs). However, it is unclear how it affects ventilatory function. The aims of the study were to determine how NTPE use affects ventilatory function and to compare night-to-night variability of ventilatory function in children with SMDs and typically developing healthy children., Method: Fifteen NTPE users (six males, nine females), aged 1 to 19 years (mean age 8y 7mo) alternated sleep condition between NTPE and sleeping unsupported for 14 nights. In all but two participants, gross motor function was classified as Gross Motor Function Classification System (GMFCS) level V; in the other two it was level IV. Oxyhaemoglobin saturation (SpO2 ) was monitored each night and transcutaneous CO2 (PtcCO2 ) for one night in each sleep condition. In 17 healthy children of similar age, home SpO2 only was monitored for seven nights., Results: In 13 of 15 NTPE users and 12 of the 17 typically developing children, SpO2 monitoring was satisfactorily completed. Of the children with SMDs, two had mean SpO2 levels below the treatment threshold for supplemental oxygen, which was uniquely associated with use of NTPE in only one participant, and three had nocturnal hypoventilation, which was uniquely associated with NTPE use in only one case. Night-to-night SpO2 variability was higher in children with SMDs than in typically developing children., Interpretation: NTPE may impair or enhance ventilatory function in a minority of children. Owing to night-to-night variability in SpO2 , at least three nights of monitoring are recommended to determine optimal positioning for effective ventilation before and after NTPE introduction., (© 2013 Mac Keith Press.)

The incidence rate of spinal infections has been rising in last decades, and despite the advances in medicine, they still represent a therapeutic challenge, especially when related to spinal implants. The majority of spinal infections in developed world are caused by pyogenic bacteria, with Staphylococcus aureus as a leading cause among gram-positive cocci and Escherichia coli among gram-negative bacteria, whereas coagulase-negative staphylococci are frequently involved in implant-associated spinal infections. Implant-associated spinal infections are caused by bacteria capable of biofilm production on the implant surface rendering them resistant to majority of antimicrobial drugs. Spinal infections in patients without implants can be treated conservatively with pathogen-directed antimicrobial therapy, whereas in implant-associated spinal infections combined surgical and antibiotic therapy is necessary. Empiric antimicrobial treatment of spinal infections without microbiological diagnosis should be discouraged in the era of drug resistant pathogens.

The optimal choice for the treatment of end-stage primary glenohumeral osteoarthritis remains controversial, with alternatives including total shoulder replacement (TSR) and humeral head replacement (HHR). The objective of this review is to analyze the effect of TSR compared with HHR on rates of pain relief, range of motion, patient satisfaction and revision surgery in patients with primary glenohumeral osteoarthritis. Compared with HHR, TSR provided significantly greater pain relief, gain in forward elevation, and gain in external rotation and patient satisfaction. Furthermore, TSR required significantly less revision surgery glenoid component loosening than patients undergoing HHR (progression of osteoarthritis changes with subchondral sclerosis, joint space narrowing and glenoid subsidence). A convex-back pegged glenoid component with a modern instrumented cement pressurization technique achieves risk of loosening. For 10 years, a high interest regarding new designs of un-cemented metal back glenoid components has developed with promising results, because they allow glenoid bone graft in case of glenoid erosion or dysplasia and a one-stage glenoid bone reconstruction in case of revision surgery.

Background: Although TSA has been shown to significantly yield better outcomes than hemiarthroplasty, glenoid prosthesis loosening remains the most common complication. Inadequate primary fixation enables the glenoid component to move. In primary glenohumeral osteoarthritis (GHOA), glenoid involvement and proper morphology vary considerably. Postero-inferior glenoid hypoplasia could be associated with some degree of osteoarthritis. According to Walch, 24 % of glenoids in GHOA are type B2 or C (excessive posterior retroversion), which increases the challenge for the glenoid component fixation., Materials and Methods: A total of 30 cases of TSR with glenoid type B2 (20 cases) and type C (10 cases) were reviewed. Mean follow-up was 11.2 months. A metal-backed (MB) glenoid component was implanted, with a posterior bone graft reconstruction. Pre- and post-operative clinical evaluation was done using the Constant-Murley score and the SST from Matsen., Results: There is no glenoid loosening, no joint narrowing and no radiolucent line. There was no bone graft osteolysis. With 4 patients revised (4 conversions from TSR to RSR for 3 instabilities and 1 secondary rotator cuff tear), on the overall 30 patients cohort, Constant score pain increased from 1.6 to 13.4, forward flexion from 92° to 146° and Constant score from 27 (36 %) to 70 (95 %). The statistical difference between pre- and post-operative values is greatly significant., Conclusion: Although MB prostheses have been noted to have a higher rate of loosening than full-cemented PE, this is not our experience, even in case of glenoid type B2 or C, where the technical challenge is demanding and most of the time a posterior bone graft is necessary.

Introduction: Pectus Excavatum (PEx) is the most frequent congenital chest wall deformity; surgical correction has a complication rate of 10%-50%. The purpose of this study was to evaluate outcomes in a recent cohort of pediatric patients from a single institution and investigate factors associated with complications., Methods: A review of all patients with PEx treated with a Nuss procedure from 2003 to 2011 was performed. Complications included hemo/pneumothorax, infection, bar migration, and operative injury. Chi-square, Student's t-test, and logistic regression were performed., Results: The study included 127 Nuss patients with a the median age of 15.2 years (5.4-18.7) and a mean Haller index of 4.2 (+1.6). The total complication rate was 26% and bar migration rate was 18%. The use of a stabilizer was associated with fewer overall complications (17% vs 41%,p=0.006), decreased reoperation (16% vs 41%,p=0.003), decreased readmission (15% vs 39%,p=0.004), and decreased bar migration rate (9% vs 36%,p=0.001) compared to patients without a stabilizer. On multivariate analysis, the use of a stabilizer (OR 0.18,p=0.011,95% CI 0.049-0.68) and the use of a pericostal suture (OR 0.19,p=0.03,95% CI 0.41-0.85) were associated with decreased rates of bar migration., Conclusion: The use of a lateral stabilizer and pericostal sutures decreased complication and reoperation rates for the Nuss procedure., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Study Design: A retrospective registry review., Objectives: To determine the incidence of cervical spine (CS) injuries and collar complications in severely injured paediatric trauma patients., Setting: Regional Trauma Centre, Children's Hospital., Methods: A retrospective review of 365 paediatric severe trauma patients (0-17 years), defined as an Injury Severity Score (ISS)≥12, admitted to the paediatric intensive care unit (PICU)., Results: Clinically significant CS injuries occurred in 5% (n=18/365) of trauma patients, in 9% (n=13/149) of traumatic brain injury (TBI) patients and in 11% (n=6/56) of in-hospital trauma deaths. CS injuries were suspected before imaging in 33% (n=6/18) of patients based on either motor/sensory impairment or shock. CS injuries were deemed unstable in 61% (n=11/18) of patients. Patients with CS injuries had higher ISS, and longer PICU and hospital stays (P<0.05). CS collar complications occurred in 10% of patients, mainly identified by day 6 and consisting of either erythema or ulcers. Patients with CS collar complications were older and more likely to have TBI, lower Glasgow Coma Scale (GCS) scores, longer PICU and hospital stays, and increased days to CS clearance (P<0.05). Three CS X-rays, together with flexion/extension views, were used most frequently for CS clearance., Conclusion: CS injuries were prevalent in severely injured paediatric trauma patients, particularly in those with TBI and in nonsurvivors. CS collar complications were associated with a lower GCS and longer CS clearance times. Attention to CS collar management protocols and earlier CS clearance with computed tomography/magnetic resonance imaging in obtunded patients might reduce CS collar complications.