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Paediatric orthopaedic and trauma surgery has undergone profound changes in recent years, and in some ways has come closer to its adult counterpart in terms of increasing hyperspecialization. Indeed, pediatric orthopaedic and trauma surgery has developed areas of hyperspecialization such as upper extremity/hand, spine, hip/lower extremity, foot/ankle, trauma, neuromuscular/genetic disorders, infections and tumours, as reflected in the number and quality of scientific publications and the emergence of subspecialty journals.

From the beginning, the stated goal was to collect papers of high scientific quality, representative of the diverse academic and medical realities, covering clinical aspects and innovations in paediatric orthopaedic and trauma surgery. The various original articles were carefully analysed by two to four reviewers and two guest editors, one managing the review process and one acting as senior peer reviewer. This process ensured a careful, competent and transparent selection of the articles that the reader will find in this issue. The acceptance rate was less than 25%, with more than 130 papers submitted to the journal. The accepted papers came from four continents and authors from 35 different countries (Table 1).

Table 1 Geographic region of lead author and main topic of accepted papers
Full size table

Hip and lower extremity

Four articles reported on different aspects of the management of developmental dysplasia of the hip (DDH) [2,3,4,5]. Ömeroğlu et al. pointed out the importance of the Delphi approach to identify the practical opinions of experts from different geographical origins that are useful for clinicians managing children with DDH, although such an approach may not be applicable in all settings [3]. Kang et al. reported that total hip arthroplasty in patients with DDH younger than 20 years resulted in excellent survival rates, especially when ceramic-on-ceramic bearings were used [2]. Feng et al. proposed MR-enhanced high-resolution 3D water-selective cartilage as a new imaging modality to study the vascular supply of the paediatric hip [4]. Zhang et al. evaluated the efficacy of arthroscopic debridement and reduction for the treatment of developmental hip dislocation after failure of initial closed reduction and found the technique to be a safe and feasible surgical option [5].

Agarwal et al. evaluated various factors that influence the rate of correction in temporary hemiepiphysiodesis around the knee joint. They found that correction was influenced by valgus, femoral location, and younger patient age [1]. In another paper, the same group evaluated the impact of nonvascularized fibular harvesting on donor limbs with more than ten years of follow-up. They reported that the procedure is safe when the longitudinal integrity of the fibula is restored, but when it is not regenerated, the donor limb may be prone to the development of ankle valgus [6]. Elbarbary et al. presented the technique of correcting multiplanar deformities around the knee in pediatric patients without limb length discrepancy using a monolateral external fixator and reported that it could achieve multiplanar correction when used properly. [7]. The paper by Johari and Anjum evaluated patients with congenital posteromedial bowing of the tibia who were treated with an external fixator and followed up at skeletal maturity. They reported that the result of lengthening was satisfactory, but the procedure was associated with difficulties such as ankle stiffness, tibial valgus, pin tract infections, and fractures of the regenerated bone [8].

Traumatology and cruciate ligaments reconstruction

Several articles included in the special issue deal with trauma and reconstruction of the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) of the knee in skeletally immature patients [9,10,11,12,13,14,15,16,17]. Sanpera et al. evaluated functional and cosmetic outcomes in children with residual rotational deformity after supracondylar elbow fractures. They reported that there was a weak correlation between varus and rotational malalignment and that patients with a moderate degree of residual malrotation could be expected to have a good outcome [9]. Guzikiewicz et al. and Lu et al. reported good functional and radiographic results in patients with isolated radial neck and T-condylar fractures treated with closed reduction and percutaneous fixation, respectively [10, 11], confirming that even complex fractures can be successfully treated with less invasive techniques that take advantage of the plasticity of the tissues in young individuals. A similar point was made by Hu et al., who reported that mini-approach fasciotomy combined with vacuum-assisted drainage was an effective and safe method of treating acute forearm and lower extremity compartment syndrome secondary to fractures [12]. Zhi et al. compared the outcomes of conservative and surgical treatment of paediatric phalangeal neck fractures and completed their research with a meta-analysis. They found that despite comparable radiographic outcomes, conservatively treated patients had lower complication rates and better functional outcomes than surgically treated patients [13]. Acciaro et al. reported that Ishiguro’s technique had better results than conservative orthotic treatment in paediatric patients with mallet finger; no epiphyseal damage or nail deformity was reported, and a high percentage of excellent and good results were achieved [14]. In another article, Wang et al. develop a new classification system for proximal femur fractures based on anterior–posterior and lateral radiographs, rather than just anterior–posterior as in the Delbet-Colonna classification. Although the results were inconclusive, Wang et al. used a robust methodology and outlined the need for a more comprehensive classification and visualisation of such injuries [15].

Among the papers focusing on ligament reconstruction, Ursei et al. reported persistent gait abnormalities in asymptomatic children who had ACL reconstruction two years earlier and suggested that such findings may guide specific neuromuscular rehabilitation to improve clinical outcomes and reduce re-rupture rates [16]. Liu et al. reported that arthroscopic physeal-sparing PCL reconstruction is indicated in adolescents with open physis, as they demonstrated significant improvement in knee function without growth arrest and angular deformity of the affected limb in short-term follow-up [17].

Foot and ankle

Foot and ankle surgery also attracted several submissions [18,19,20,21]. Among the accepted papers focusing on surgical outcomes, Aroojis et al. demonstrated complete Achilles tendon regeneration with percutaneous tenotomy in older children with delayed-onset idiopathic clubfoot treated according to the Ponseti principles [18], while Fadle et al. reported that joint-preserving bony osteotomies (lateral column lengthening, medial displacement calcaneal osteotomy, and double calcaneal osteotomy) combined with selective soft tissue procedures provide acceptable functional and radiologic outcomes in young patients with spastic flatfoot deformity [19]. However, Bouchard et al. highlighted the need for cultural validity of patient-reported outcome measures by comparing patient-reported outcomes of the Oxford Ankle and Foot Questionnaire in children with clubfoot from two different geographical and cultural settings. They observed a difference in scores between the two sites, suggesting that there may be differences in how these populations perceive personal health outcomes [20]. However, Bouchard et al. pointed out that standardized outcome measures may not fully reflect how populations perceive personal health outcomes. Specifically, they compared patient-reported outcomes of the Oxford Ankle and Foot Questionnaire in children with clubfoot from two different geographic and cultural settings that provided different scores for similar items [20]. In another paper, Chhabra et al. demonstrated a high rate of incidental findings of peroneal tendon pathology on magnetic resonance imaging in paediatric patients despite a negative clinical examination [21].

Spine

Several papers concern the paediatric spine, mostly focusing on deformities in patients younger than ten years of age [22,23,24,25]. Raitio et al. evaluated occult blood loss and bleeding characteristics in children with congenital scoliosis undergoing spinal osteotomies and reported that occult blood loss accounted for 40% of total bleeding, suggesting that younger age is a risk factor for bleeding and that occult blood loss should be considered in the perioperative management of these patients [22]. Johari et al. reported on a large series of Indian children with congenital scoliosis and kyphosis and evaluated the rate of occult spinal dysraphism. They found that the incidence of occult spinal dysraphism in their Indian population was higher than in series from other regions of the world, and that diastematomyelia, followed by tethered cord were the most common abnormalities [23]. In another paper, Oggiano et al. evaluated the correlation between plain radiographs and ultrasound during lengthening in patients treated with growing rods for early-onset scoliosis. They found that ultrasound overestimated thoracic spine lengthening compared to plain radiographs and suggested that this information should be considered when measuring lengthening in this patient population [24]. In another paper on magnetic growth lengthening, Mainard et al. addressed the question of whether or not to remove the magnetic rods. In their retrospective comparative multicentre study, they showed that the rods can be left in place at the end of the lengthening program without necessarily performing a definitive arthrodesis, although this is not in accordance with the manufacturer's recommendations [25].

Infection, tumours and rare disorders

Ng et al. aimed to determine the rates and predictors of reoperation and readmission in children with septic arthritis treated at a facility without routine clinical practice guidelines. They found that the rates of readmission and reoperation were similar to those reported in the literature, despite the lack of a standardized care pathway or discharge protocol. However, they noted a high rate of unplanned ED visits after discharge [26].

Scheider and Farr retrospectively evaluated various surgical treatment modalities for simple bone cysts of the humerus and found that the incidence of treatment failure was significantly higher in the curettage, allograft, adjuvants group than in the osteosynthesis alone group. In addition, they reported that no failures were observed in the osteosynthesis alone group, which had the best results [27].

In another paper, Patwardhan et al. reported the outcome of patients with idiopathic condrolysis of the hip, a condition of unknown etiology that leads to progressive hip joint destruction. They reported that minimally invasive treatment with intra-articular steroid injection, manipulation, and traction immobilization improved patient function and reduced the need for further surgical intervention [28].

Upper extremity

Balloufaud et al. evaluated the correlation between shoulder abnormalities on magnetic resonance imaging and shoulder deficits in children with neonatal brachial plexus palsy. They suggested that subscapularis impairments play a major role in the functional limitations of these patients and suggested that they undergo muscular examination in addition to the routine assessment of bone parameters on magnetic resonance imaging [29].

Neuromuscular and genetic disorders

Neuromuscular and genetic disorders are a broad and complex area of pediatric orthopaedics. Osteogenesis imperfecta requires treatment of bone deformities, although the rate of complications is not negligible. Li et al. demonstrated that although the risk factors for developing a complication are mainly age at surgery, type of surgery, and severity of bone deformity, a lower incidence of implant-related complications was observed in patients treated with telescopic rods compared with those treated with plates and screws, Kirschner wires, and elastic nails [30].

Yamada and Fucs described the clinical and radiographic results in cerebral palsy patients with painful hip deformity treated with the Castle salvage procedure. The procedure was associated with few major complications, little or no pain, and improved lower limb mobility, facilitating wheelchair positioning; in addition, the majority of families and caregivers reported an improvement in ease of patient care, resulting in improved quality of life scores [31].

Given the variety of articles published (Table 1), the special issue is intended to be of interest not only to paediatric orthopaedists, but also to adult orthopaedic surgeons interested in the latest news and trends in children’s orthopaedic and trauma surgery, a rapidly evolving field. All of these efforts now await the judgment of the discerning reader, which we trust will be positive.

The guest editors would like to thank International Orthopaedics and its Board of Editors for entrusting them with this challenging and rewarding task, and all the authors whose research contributed to this Special Issue, without whom none of this would be possible.

Federico Canavese, Patricia Maria de Moraes Barros Fucs, Ashok N. Johari.