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Khalifa A. Fix it or risk it? Revisiting contralateral hip prophylactic fixation in unilateral slipped capital femoral epiphysis: an updated review of the past decade's literature. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2025; 35:84. [PMID: 40025359 DOI: 10.1007/s00590-025-04191-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2024] [Accepted: 02/02/2025] [Indexed: 03/04/2025]
Abstract
Slipped capital femoral epiphysis (SCFE) is a common hip pathology occurring in pediatrics and adolescents, and its management is well documented in the literature regardless of its severity. In patients presenting with unilateral SCFE, the incidence of subsequent contralateral slip (SCS) is variable among studies, and the issue of contralateral hip prophylactic fixation (CHPF) becomes a concern. The fundamental rationale behind performing CHPF is to avoid the subsequent contralateral slip, which consequently lowers the risk of femoral head avascular necrosis and chondrolysis. However, prophylactic fixation carries the risk of altering proximal femoral growth, peri-implant fractures, and requiring secondary surgery for hardware removal. The current review was formulated based on the literature published in the last decade and aimed to evaluate the incidence of SCS and indications for CHPF. Apart from institutions' protocol or individual surgeons' preferences, various variables were suggested to justify CHPF, including patient-related variables such as the presence of endocrinopathy, those younger than 13 years old (10-13), and patients with mOBAS ≤ 20. Radiological parameters, posterior slip angle ≥ 14.5°, positive crossover sign, posterior epiphyseal tilt of ≥ 10°, alpha angle of ≥ 49°, and a Probability analysis of sequential SCFE (PASS score) of ≥ 3. However, there is still a controversy in the literature regarding CHPF performance and which parameter is highly dependable for predicting the SCS. The controversy extends to the effect and efficacy of various fixation hardware and whether keeping patients under observation is less effective than CHPF. Furthermore, well-designed randomized controlled trials are lacking, and their performance is warranted to establish clear indications for performing CHPF and to clarify its safety, possible consequences, and cost-effectiveness.
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Affiliation(s)
- Ahmed Khalifa
- Orthopedic Department, Qena Faculty of Medicine and University Hospital, South Valley University, Qena, Egypt.
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Klatt JB, Metz AK, Froerer DL, Featherall J, Cheminant JR, Rosenthal RM, Aoki SK. Association of Relative Skeletal Immaturity of the Triradiate Cartilage with Increased Proximal Femoral Deformity in Prophylactic Fixation for Slipped Capital Femoral Epiphysis: A Radiographic Study. J Am Acad Orthop Surg 2024; 32:401-409. [PMID: 38261798 DOI: 10.5435/jaaos-d-22-01204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 12/08/2023] [Indexed: 01/25/2024] Open
Abstract
INTRODUCTION The purpose of this study was to describe proximal femoral deformity after contralateral hip prophylactic fixation of slipped capital femoral epiphysis (SCFE) in patients and the association of relative skeletal immaturity with this deformity. METHODS A retrospective review of patients presenting with a SCFE was conducted from 2009 to 2015. Inclusion criteria were (1) radiographic evidence of a unilateral SCFE treated with in situ fixation, (2) contralateral prophylactic fixation of an unslipped hip, and (3) at least 3 years of follow-up. Measurements were made on radiographs and included greater trochanter height relative to the center of the femoral head, femoral head-neck offset, and femoral neck length. Skeletal maturity was evaluated by assessing the status of the proximal femoral physis and triradiate cartilage (TRC) of the hip, in addition to the length of time to closure of these physes. Values were compared from initial presentation to final follow-up. Statistical analysis included descriptive statistics and linear regression. RESULTS Twenty-seven patients were included. Bivariable linear regression demonstrated that an increased relative trochanteric overgrowth was associated with TRC width (β = 3.048, R = 0.585, P = 0.001) and an open TRC (β = -11.400, R = 0.227, P = 0.012). Time to proximal femoral physis closure (β = 1.963, R = 0.444, P = 0.020) and TRC closure (β = 1.983, R = 0.486, P = 0.010) were predictive of increased deformity. In addition, multivariable elimination linear regression demonstrated that TRC width (β = 3.048, R = 0.585, P = 0.001) was predictive of an increased relative trochanteric overgrowth. DISCUSSION Patients with an open TRC and increased TRC width are associated with increased relative trochanteric overgrowth when undergoing prophylactic fixation for a unilateral SCFE. Increased caution should be exercised when considering contralateral hip prophylactic fixation in skeletally immature patients presenting with a unilateral SCFE. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Joshua B Klatt
- From the Department of Orthopaedic Surgery, University of Utah (Klatt, Metz, Froerer, Featherall, Cheminant, Rosenthal, and Aoki), and the School of Medicine, University of Utah, Salt Lake City, UT (Froerer)
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Winger BJ, Dobbe AM, Cheng TL, Little DG, Gibbons PJ. Who Benefits From Allowing the Physis to Grow in Slipped Capital Femoral Epiphysis? J Pediatr Orthop 2023; 43:e427-e432. [PMID: 36977364 DOI: 10.1097/bpo.0000000000002407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
BACKGROUND The globally acknowledged treatment for mild to moderate slipped capital femoral epiphysis (SCFE) is single screw in situ fixation, also used for prophylactic contralateral fixation. The Free-Gliding Screw (FG; Pega Medical) is a 2-part free-extending screw system designed to allow the growth of the proximal femur. We aimed to analyze the relationship between skeletal maturity and potential growth of the proximal physis and remodeling of the femoral neck using this implant. MATERIALS AND METHODS Females below 12 years and males below 14 years undergoing in situ fixation for stable SCFE or prophylactic fixation were treated using the implant. Three elements of the modified Oxford Bone (mOB 3 ) score were used to measure maturity (triradiate cartilage, head of the femur, and greater trochanter). Radiographs were analyzed immediately postoperatively and at a minimum of 2 years for a change in screw length, posterior-sloping angle, articulotrochanteric distance, α angle, and head-neck offset. RESULTS The study group comprised 30 (F:M=12:18) of 39 hips treated with SCFE and 22 (F:M=13:9) of 29 hips managed prophylactically using the free-Gliding screw. In the therapeutic group, chronologic age was a less valuable predictor of future screw lengthening than mOB 3 . An mOB 3 of ≤13 predicted future growth of >6 mm but did not reach statistical significance ( P =0.07). Patients with open triradiates showed a mean screw lengthening of 6.6 mm compared with those with closed triradiates (4.0 mm), but this did not reach significance ( P =0.12). In those with mOB 3 ≤13, the α angle reduced significantly ( P <0.01) and the head-neck offset increased significantly, suggesting remodeling. There was no change in these parameters when mOB 3 ≥14. In the prophylactic group, change in screw length was significant with mOB 3 of ≤13 (mean=8.0 mm, P <0.05), as was the presence of an open triradiate cartilage (mean=7.7 mm, P <0.05). In both cohorts, posterior-sloping angle and articulotrochanteric distance did not change, indicating no slip progression in either treatment or prophylactic groups and minimal effect on the proximal physeal growth relative to the greater trochanter. CONCLUSIONS Growing screw constructs can halt slip progression while allowing proximal femoral growth in young patients with SCFE. Ongoing growth is better when the implant is used for prophylactic fixation. The results in treated SCFE need to be expanded to demonstrate a clinically meaningful cut-off for significant growth, but SCFE patients with an open triradiate remodel significantly more than those where it is closed. LEVEL OF EVIDENCE Level III-retrospective comparative study.
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Affiliation(s)
| | | | - Tegan L Cheng
- The Children's Hospital at Westmead, Sydney, NSW
- The University of Sydney, Sydney, New South Wales, Australia
| | - David G Little
- The Children's Hospital at Westmead, Sydney, NSW
- The University of Sydney, Sydney, New South Wales, Australia
| | - Paul J Gibbons
- The Children's Hospital at Westmead, Sydney, NSW
- The University of Sydney, Sydney, New South Wales, Australia
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Via GG, Brueggeman DA, Lyons JG, Edukugho DO, Froehle AW, Martinek MA, Albert MC. Screw Thread Configuration Has No Effect on Outcomes of In Situ Fixation for Stable Slipped Capital Femoral Epiphysis. J Pediatr Orthop 2022; 42:e767-e771. [PMID: 35671226 DOI: 10.1097/bpo.0000000000002192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND No consensus exists regarding the optimal surgical management of slipped capital femoral epiphysis (SCFE). Treatment goals include avoiding slip progression and sequelae such as avascular necrosis (AVN). Factors associated with surgical implants merit further research. This study investigates the effect of screw thread configuration and the number of screws on surgical outcomes. METHODS A total of 152 patients undergoing cannulated, stainless steel, in situ screw fixation of SCFE between January 2005 and April 2018 were included. Procedure laterality, screw number and thread configuration (partially threaded/fully threaded), bilateral diagnosis, Loder classification, final follow-up, patient demographics, and endocrinopathy history were analyzed. Primary outcomes were return to the operating room (ROR), AVN, hardware failure/removal, and femoroacetabular impingement (FAI). RESULTS Most patients received a single (86.2%), partially threaded (81.6%) screw; most were unilateral (67.8%) and stable (79.6%). Mean follow-up was 2.0±2.7 years, with a 15.8% rate of ROR, 5.3% exhibiting AVN, 6.6% exhibiting FAI, and 9.2% experiencing hardware failure/removal. Number of screws was the sole predictor of ROR [odds ratio (OR)=3.35, 95% confidence interval (CI): 1.18-9.49]. Unstable SCFE increased the odds of AVN (OR=38.44; 95% CI: 4.35-339.50) as did older age (OR=1.43, 95% CI: 1.01-2.03). Female sex increased risk for FAI (OR=4.87, 95% CI: 1.20-19.70), and bilateral SCFE elevated risk for hardware failure/removal versus unilateral SCFE (OR=4.41, 95% CI: 1.39-14.00). Screw thread configuration had no significant effect on any outcome (for each, P ≥0.159). CONCLUSIONS Rates of ROR, AVN, FAI, and hardware failure/removal did not differ between patients treated with partially threaded or fully threaded screws. The use of 2 screws was associated with an increased likelihood of ROR. These findings suggest that screw thread configuration has no impact on complication rates, whereas screw number may be an important consideration in SCFE fixation. LEVEL OF EVIDENCE Level III-retrospective cohort study.
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Affiliation(s)
- Garrhett G Via
- Department of Orthopaedic Surgery, Wright State University
| | | | - Joseph G Lyons
- Department of Orthopaedic Surgery, Wright State University
| | | | | | - Melissa A Martinek
- Department of Orthopaedic Surgery, Dayton Children's Hospital, Dayton, OH
| | - Michael C Albert
- Department of Orthopaedic Surgery, Dayton Children's Hospital, Dayton, OH
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Vink SJC, van Stralen RA, Moerman S, van Bergen CJA. Prophylactic fixation of the unaffected contralateral side in children with slipped capital femoral epiphysis seems favorable: A systematic review. World J Orthop 2022; 13:515-527. [PMID: 35633749 PMCID: PMC9124999 DOI: 10.5312/wjo.v13.i5.515] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 03/21/2022] [Accepted: 04/25/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Slipped capital femoral epiphysis (SCFE) occurs in adolescents and has an incidence of around 10 per 100000 children. Children presenting with a unilateral SCFE are 2335 times more likely to develop a contralateral SCFE than the general population. Prognostic factors that have been suggested to increase the risk of contralateral slip include a younger patient, an underlying endocrine disorder, growth hormone use and a higher radiographic posterior sloping angle. However, there is still much debate on the advantages and disadvantages of prophylactic fixation of the unaffected side in an otherwise healthy patient. AIM To investigate the risk rate of contralateral SCFE and assess the (dis)advantages of prophylactic fixation of the contralateral hip. METHODS A systematic literature search was performed in the Embase, Medline, Web of Science Core Collection and Cochrane databases. Search terms included 'slipped capital femoral epiphysis,' 'fixation,' 'contralateral,' and derivatives. The eligibility of the acquired articles was independently assessed by the authors and additional relevant articles were included through cross-referencing. Publications were considered eligible for inclusion if they presented data about otherwise healthy children with primarily unilateral SCFE and the outcomes of prophylactically pinning their unaffected side, or about the rates of contralateral slips and complications thereof. The study quality of the included articles was assessed independently by the authors by means of the methodological index for non-randomized studies criteria. RESULTS Of 293 identified unique publications, we included 26 studies with a total of 12897 patients. 1762 patients (14%) developed a subsequent symptomatic contralateral slip. In addition, 38% of patients developed a subsequent slip on the contralateral side without experiencing clinical symptoms. The most outspoken advantage of prophylactic fixation of the contralateral hip in the literature is prevention of an (asymptomatic) slip, thus reducing the increased risk of avascular necrosis (AVN), cam morphology and osteoarthritis. Disadvantages include an increased risk of infection, AVN, peri-implant fractures, loss of fixation as well as migration of hardware and morphologic changes as a consequence of growth guidance. These risks, however, appeared to only occur incidentally and were usually mild compared to the risks involved with an actual SCFE. CONCLUSION The advantages of prophylactic pinning of the unaffected side in otherwise healthy patients with unilateral SCFE seem to outweigh the disadvantages. The final decision for treatment remains to be patient-tailored.
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Affiliation(s)
- Steven J C Vink
- Department of Orthopedic Surgery, Erasmus Medical Center, Rotterdam 3015GD, Netherlands
| | - Renée A van Stralen
- Department of Orthopedic Surgery, Erasmus Medical Center, Rotterdam 3015GD, Netherlands
| | - Sophie Moerman
- Department of Orthopedic Surgery, University Medical Center Groningen, Groningen 9713GZ, Netherlands
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Hansen CH, Bomar JD, Badrinath R, Upasani VV. Telescoping screw fixation compared to traditional in situ screw fixation for slipped capital femoral epiphysis: clinical, radiographic and patient-reported outcomes. J Pediatr Orthop B 2022; 31:224-231. [PMID: 34050119 DOI: 10.1097/bpb.0000000000000869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study compares clinical, radiographic and patient-reported outcomes among telescoping and traditional screws for the treatment of slipped capital femoral epiphysis (SCFE). We hypothesized that telescoping screws would prevent slip progression and result in preserved femoral neck growth and improved patient-reported outcomes. Traditional screws were compared to telescoping screws in a 2:1 matched cohort based on age at initial surgery, length of radiographic follow-up and whether or not the hip was pinned prophylactically or as a treatment for SCFE. Neck length and telescoping screw length were measured. The patient-reported outcomes were obtained at routine clinic visits. Total 42 hips were included with a mean follow-up of 24.5 ± 3.3 months. No patients developed avascular necrosis, chondrolysis or needed revision surgical procedures. Telescoping screws increased in length for the entire cohort by a mean of 6.0 ± 4.3 mm. Neck length change was not different in SCFE hips when treated with traditional screws vs. telescoping screws (P = 0.527). However, there was a difference in neck length change between the two groups when comparing prophylactically treated hips (P = 0.001). There were no significant differences in patient-reported outcomes among hips treated with telescoping screws compared to traditional screws. Traditional and telescoping screws are both effective for the treatment of SCFE. Telescoping screws have an advantage when prophylactically treating hips that are at risk of slipping as they don't lead to the coxa breva that is seen with traditional screws. However, both treatment methods had similar patient-reported outcomes.
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Affiliation(s)
- Cody H Hansen
- Department of Orthopedics, University of California, San Diego Medical Center, San Diego, California
| | - James D Bomar
- Department of Orthopedics, Rady Children's Hospital, San Diego, California, USA
| | - Raghav Badrinath
- Department of Orthopedics, University of California, San Diego Medical Center, San Diego, California
| | - Vidyadhar V Upasani
- Department of Orthopedics, University of California, San Diego Medical Center, San Diego, California
- Department of Orthopedics, Rady Children's Hospital, San Diego, California, USA
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Montgomery BK, Gamble JG, Kha ST, Hecht GG, Vorhies JS, Lucas JF. Indications for and Risks Associated With Implant Removal After Pediatric Trauma. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202204000-00016. [PMID: 35427259 PMCID: PMC10566936 DOI: 10.5435/jaaosglobal-d-22-00050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 02/14/2022] [Indexed: 06/14/2023]
Abstract
A wide range of implants are used in the treatment of pediatric fractures, including wires, plates, screws, flexible rods, rigid rods, and external fixation devices. Pediatric bones differ from adult bones both mechanically and biologically, including the potential for remodeling. Implants used in pediatric trauma patients present a unique set of circumstances regarding indications, risks, timing of implant removal, weight-bearing restrictions, and long-term sequelae. Indications for implant removal include wire/pin fixation, when substantial growth remains, and infection. When considering implant removal, the risks and benefits must be assessed. The primary risk of implant removal is refracture. The timing of implant removal varies widely from several weeks to a year or more with the option of retention depending on the fracture, type of implant, and skeletal maturity of the patient.
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Affiliation(s)
- Blake K. Montgomery
- From the Department of Orthopaedic Surgery, Santa Clara Valley Medical Center, San Jose, CA (Dr. Lucas and Dr. Hecht); Stanford Orthopaedics, San Jose, CA (Dr. Lucas and Dr. Hecht); and the Department of Orthopaedic Surgery, Stanford University, Redwood City, CA (Dr. Montgomery, Dr. Gamble, Dr. Kha, and Dr. Vorhies)
| | - James G. Gamble
- From the Department of Orthopaedic Surgery, Santa Clara Valley Medical Center, San Jose, CA (Dr. Lucas and Dr. Hecht); Stanford Orthopaedics, San Jose, CA (Dr. Lucas and Dr. Hecht); and the Department of Orthopaedic Surgery, Stanford University, Redwood City, CA (Dr. Montgomery, Dr. Gamble, Dr. Kha, and Dr. Vorhies)
| | - Stephanie T. Kha
- From the Department of Orthopaedic Surgery, Santa Clara Valley Medical Center, San Jose, CA (Dr. Lucas and Dr. Hecht); Stanford Orthopaedics, San Jose, CA (Dr. Lucas and Dr. Hecht); and the Department of Orthopaedic Surgery, Stanford University, Redwood City, CA (Dr. Montgomery, Dr. Gamble, Dr. Kha, and Dr. Vorhies)
| | - Garin G. Hecht
- From the Department of Orthopaedic Surgery, Santa Clara Valley Medical Center, San Jose, CA (Dr. Lucas and Dr. Hecht); Stanford Orthopaedics, San Jose, CA (Dr. Lucas and Dr. Hecht); and the Department of Orthopaedic Surgery, Stanford University, Redwood City, CA (Dr. Montgomery, Dr. Gamble, Dr. Kha, and Dr. Vorhies)
| | - John S. Vorhies
- From the Department of Orthopaedic Surgery, Santa Clara Valley Medical Center, San Jose, CA (Dr. Lucas and Dr. Hecht); Stanford Orthopaedics, San Jose, CA (Dr. Lucas and Dr. Hecht); and the Department of Orthopaedic Surgery, Stanford University, Redwood City, CA (Dr. Montgomery, Dr. Gamble, Dr. Kha, and Dr. Vorhies)
| | - Justin F. Lucas
- From the Department of Orthopaedic Surgery, Santa Clara Valley Medical Center, San Jose, CA (Dr. Lucas and Dr. Hecht); Stanford Orthopaedics, San Jose, CA (Dr. Lucas and Dr. Hecht); and the Department of Orthopaedic Surgery, Stanford University, Redwood City, CA (Dr. Montgomery, Dr. Gamble, Dr. Kha, and Dr. Vorhies)
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Advantages of Telescopic Screw in Slipped Capital Femoral Epiphysis Treatment: A Retrospective Study and Review of the Literature. CHILDREN 2022; 9:children9040469. [PMID: 35455513 PMCID: PMC9026982 DOI: 10.3390/children9040469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/06/2022] [Accepted: 03/23/2022] [Indexed: 11/16/2022]
Abstract
Background: Slipped capital femoral epiphysis is due to proximal femur physis failure in adolescent patients. Early iatrogenic closure of proximal growth cartilage in children with significant residual growth potential causes complications such as coxa breva, coxa vara, and lower limb length inequalities. The Free-Gliding SCFE Screw System is a self-extending cannulated screw used in Slipped Capital Femoral Epiphysis (SCFE) fixation and femoral neck fractures. Materials and Method: We conducted a retrospective study on 16 patients. All patients under 11 years old were treated by telescopic cannulated screws fixation. The youngest patient was 7 years old. Results: Out of the 22 operated hips, 2 screws have failed, thus resulting in a lack of telescoping of the screw. We discovered an average lengthening of approximately 10 mm at 24 months postoperative check-up in 20 hips in which lengthening took place. According to the Notzli method, none of the patients had an alpha angle value greater than 48 degrees. Conclusion: Fixation with telescopic screw for SCFE in patients less than 11 years old, with mild to moderate slippage, allows the continuous growth and remodeling of the proximal femur, thus avoiding deformities such as coxa breva, coxa vara, FAI, AVN, limb length discrepancies and also allows good range of motion.
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Andras LM, Abousamra O. What's New in Pediatric Orthopaedics. J Bone Joint Surg Am 2021; 103:287-294. [PMID: 33369978 DOI: 10.2106/jbjs.20.01953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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