Original Clinical Article

Use of resorbable magnesium screws in children:

systematic review of the literature and short-term
follow-up from our series
Marco Baldini1 Conclusion: Evidence on resorbable Mg implants is low but
Valentino Coppa1 promising in adults and nearly absent in children. Our se-
ries included apophyseal avulsion, epiphyseal fractures, os-
Danya Falcioni2
teochondritis dissecans, displaced osteochondral fragment
Elisa Senigagliesi1 and tendon-to-bone fixation. Mg screws guaranteed stable
Mario Marinelli1 fixation, without implant failure, with good clinical and radi-
Antonio Pompilio Gigante1,2 ological results and no adverse events.

Level of evidence: IV – Single cohort retrospective analysis

Abstract with systematic review
Purpose: Biodegradable implants are of major interest in Cite this article: Baldini M, Coppa V, Falcioni D, Senigagliesi
orthopaedics, especially in the skeletally immature popula- E, Marinelli M, Gigante AP. Use of resorbable magnesium
tion. Magnesium (Mg) implants are promising for selected screws in children: systematic review of the literature and
surgical procedure in adults, but evidence is lacking. Thus, short-term follow-up from our series. J Child ­Orthop 2021;15.
the aim of this study is to analyze the safety and efficacy of DOI: 10.1302/1863-2548.15.210004
resorbable Mg screw in different orthopaedic procedures in
skeletally immature patients. In addition, we present a sys- Keywords: Magnesium; resorbable implant; paediatrics
tematic review of the current literature on the clinical use of
Mg implants.

Methods: From 2018 until the writing of this manuscript, con- Introduction
secutive orthopaedic surgical procedures involving the use of Osteosynthesis technique and orthopaedic implants have
Mg screws performed at our centre in patients < 15 years of developed over the last decades with an increase of surgi-
age were retrospectively reviewed. In addition, a systematic cal indications in treating orthopaedic and traumatologi-
review of the literature was performed in the main databas- cal conditions. The need for the removal of orthopaedic
es. We included clinical studies conducted on humans, using implants is controversial in the literature. In adults, it is
Mg-alloy implants for orthopaedic procedures. usually indicated only in cases of intolerance or related
Results: A total of 14 patients were included in this retro- complications. On the other hand, in skeletally imma-
spective analysis. Mean age at surgery was 10.8 years (sd ture patients, routine removal of orthopaedic implants is
2.4), mean follow-up was 13.8 months (sd 7.5). Healing was usually recommended for several reasons, in particular to
achieved in all the procedures, with no implant-related ad- avoid interference with growth. For this reason, a progres-
verse reaction. No patients required any second surgical pro- sive interest has been shown on biodegradable materials,
cedure. The systematic review evidenced 20 clinical studies, which do not require further surgery for their removal.1
19 of which conducted on an adult and one including paedi- Biodegradable implants may be subdivided into three
atric patients. groups. The first group is represented by polymers, such
as poly-L-lactic acid or poly-lactic-co-glycolic acid. Poor
mechanical properties and lack of osteoconductivity2 limit
1
Clinical Orthopedics, Department of Clinical and Molecular their use. The second category includes ceramics such as
Science, School of Medicine, Università Politecnica delle Marche,
hydroxyapathite, which have shown high biocompatibil-
Ancona, Italy
2
Clinic of Adult and Paediatric Orthopedic, Azienda Ospedal- ity and osteoconductivity. However, ceramics have slow
iero-Universitaria, Ospedali Riuniti di Ancona, Ancona, Italy degradation rates and poor load-bearing capacity.3 Biode-
gradable metals have the greatest tensile and load-bear-
Correspondence should be sent to: Dr. Marco Baldini Clinical
ing properties than the other groups. Among them,
Orthopedics, Department of Clinical and Molecular Science, School
of Medicine, Università Politecnica delle Marche, Via Tronto, 10/A, magnesium (Mg) is one of the most interesting due to its
60126 - Ancona, Italy biocompatibility, osteoconductivity and mechanical prop-
E-mail: baldini.m93@gmail.com erties.4,5
 RESORBABLE MAGNESIUM SCREWS IN CHILDREN

Preclinical studies have shown that Mg alloys are well uation and radiological exams, months of FU and eventual
tolerated both by osteoblasts and growth plate chondro- complications were recorded.
cytes6 whilst biomechanical testing showed higher pull- Potential implant-related adverse reactions were con-
out forces of Mg screw as compared with polymeric ones.7 sidered: abnormal discomfort at the site of the implant and
Moreover, the elastic modulus and density of Mg are presence of inflammatory signs at the site of the implant.
much more similar to that of cortical bone, as compared Implant failure was considered as loss of integrity of the
with titanium and stainless steel.8 This would reduce the implant associated with: malunion, nonunion or delayed
so-called stress shielding around the implant.9 The princi- union of fractures, failure of the epiphysiodesis or failure
pal limitations of Mg implants have been shown to be the of the tenodesis.
inability to control their degradation rate and the release
of important amount of gas during corrosion.10 Moreover, Review
fast degradation rate has been associated with implant The review process was conducted according to the
failure and early loss of stability. In order to prevent these Preferred Reporting Items for Systematic Reviews and
problems, Mg alloys have been introduced in clinical prac- Meta-Analyses guidelines18. The Medline-PubMed,
tice and a large number of alloying solutions are currently Embase, Web of Science and Cochrane Systematic Review
under investigation. databases were searched for studies published in English
In addition, Mg++ has been shown to have an osteo- up to 31 November 2020. The primary search keywords
genic effect by activating the Wnt pathway causing bone were: “magnesium orthopedics”, “magnesium screw”,
marrow stromal cells (BMSCs) to differentiate towards the “magnesium pin”, “magnesium implant orthopedics”.
osteoblast lineage.11 Lastly, Mg implants have been shown Papers were screened by title and abstract to identify
to produce less imaging artifacts during radiograph, CT relevant articles. Their reference lists were checked man-
and MRI than other materials (e.g. titanium (Ti) screws).12 ually for additional articles. All the results were analyzed
Mg implants have shown to be interesting for some independently by two revisors. Exclusion criteria were
orthopaedic surgical procedure in adults, such as hallux considered: in vitro or in vivo preclinical study conducted
valgus osteotomy fixation,13,14 anterior cruciate ligament on animals, clinical procedures not concerning the ortho-
(ACL) reconstruction,15 stabilization of bone grafting in paedic field (such as odontology, maxillo-facial surgery).
osteonecrosis of the femoral head treatment16 and fixation Inclusion criteria were: clinical studies conducted on
of intraarticular fractures.17 Nevertheless, one of the most humans using Mg or Mg-alloy implants for orthopaedic
interesting settings for resorbable Mg alloys is paediatric procedures. The selection process is described in detail in
surgery. Figure 1.
The aim of this study is to analyze the safety and efficacy
of the clinical applications of resorbable Mg screws in dif-
ferent orthopaedic and traumatology procedures in skele- Results
tally immature patients, retrospectively analyzing a series Retrospective analysis
of cases from our centre. We then conducted a systematic
A total of 14 patients were included in the retrospective
review of the literature to assess the actual evidence of the
analysis. The male/female ratio was 1:1 and mean age at
use of Mg implants in orthopaedic procedures focusing
on the age of the patients, diagnosis, surgical approach,
outcome and implant-related adverse reaction.

Materials and methods

Case series
After approval of the study by the local ethics commit-
tee, the database of Salesi Children’s Hospital was mined
for the records of all surgical procedure performed from
01 January 2018 to 30 June 2020. The patients’ parents/
guardians provided their informed consent to the use of
the children’s medical charts. Inclusion criteria were: age
at surgery < 15 years, orthopaedic or traumatological
pathologies with surgical indication treated by Mg screw Fig. 1 Selection protocol: abstract selection chart according to
implant and follow-up (FU) three or more months. Diag- our inclusion criteria. Abstract inclusion and exclusion criteria are
nosis, age at surgery, sex, surgical procedure, clinical eval- highlighted in the box.

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RESORBABLE MAGNESIUM SCREWS IN CHILDREN

surgery was 10.8 years (sd 2.4). Surgery was performed the 3.2-mm Herbert type screw of appropriate length was
for different conditions: ten for epiphyseal fractures or inserted with mild compression (Fig. 3)
apophyseal avulsion, two for epiphysiodesis, one for The patient was discharged with a knee brace in
osteochondritis dissecans (OCD) and one for tendon-to- fixed-extension position and non-weight-bearing prescrip-
bone fixation. A total of seven procedures involved the tion for four weeks. After the first month, he started with
lower limb, while seven involved the upper limb. Mean partial weight-bearing and physiotherapy. By the eighth
clinical FU was 13.8 months (sd 7.5; 6 to 26). All the pro- week after the procedure the patient was full weight-bear-
cedures were performed using the same implant: 3.2-mm ing, with complete active and passive range of movement
Herbert type, cannulated screw (MAGNEZIX; Syntellix AG, (ROM). Radiological imaging taken three months postop-
Hannover, Germany) of appropriate length using manu- eratively are shown in Figure 4.
facturer’s instructions and proper surgical kit. At 18 months after surgery the patient was subjectively
Clinical and radiological healing was achieved in all the well, with a Visual Analogue Score (VAS)19 of 0 during
procedures. No clinical evidence of either local or systemic activities of daily living and fitness training at the gym.
implant-related adverse reaction was registered. Diagno- Active and passive ROM were complete, symmetric and
sis, age at surgery, sex, surgical procedure, clinical and pain-free, with a modified knee Hospital for Special Sur-
radiological FU and eventual complications are recorded gery (HSS) score of 95 (Fig. 5).20
in Table 1.
Systematic review
Case description of a patellar fracture dislocation and technical
After duplicate removal, a total of 655 abstracts were
notes
found. Of these, 635 abstracts were excluded because
A 13-year-old male was diagnosed with a fracture, a lat- they were either in vitro studies, animal model-based
eral dislocation of the left patella, which occurred playing studies, odontology or maxillofacial surgery procedures.
amateur basketball. A radiograph was carried out before We found 20 clinical orthopaedic studies conducted on
reduction of the patella and after the reduction a second humans, including five case reports, five retrospective
radiograph and a preoperative CT scan were performed. case series, five retrospective case-control studies and two
The osteochondral fragment measured approximately 2.5 randomized control trials (RCTs). In 19 out of the 20 stud-
cm × 1.5 cm × 3.5 cm (Fig. 2). ies, the patients were older than 20 years old. Only one
The surgical procedure was performed by an arthroto- study was conducted among a potential skeletally imma-
mic open reduction and internal fixation with three ture population.21
MgYREZr cannulated screws (MAGNEZIX; Syntellix AG) For all comparative studies (RCTs, case-control studies)
and a medial patello-femoral ligament reconstruction. treatment with Mg implants proved not to be inferior in
After patellar exposure the fracture was anatomically terms of standard of care, and in one case yielded superior
reduced and temporarily fixed with three guide wires. results.16 In all single cohort studies the authors reported
Using the manufacturer’s drill-bit, a hole was made and good results without noteworthy complications. Only one

Table 1 Diagnosis, age at surgery, sex, surgical procedure, clinical and radiological follow-up and eventual complication of the patients undergoing
surgical procedure with magnesium resorbable screws between January 2018 and June 2020

Diagnosis Age (years) Sex Treatment Follow-up, mths Complications

Tibial spine avulsion fracture 12 F ARIF (two cannulated screws)* 26 None

II toe F1 macrodactyly 9 F Epiphysiodesis F1 (one cannulated screw)* 26 None
Clubfoot relapse 10 M Partial tibialis anterior transposition with 24 None
one interference screw*
Fracture-dislocation of patella 13 M ORIF (three cannulated screws)* 18 None
Medial epicondyle avulsion 10 F ORIF (two cannulated screws)* 16 None
Medial epicondyle avulsion 11 M ORIF (two cannulated screws)* 14 Detachment of the screw head
Tibial distal epiphysis fracture 12 M CRIF (one all-epiphyseal cannulated screw* 16 None
+ one trans-physeal Kirschner-wire)
Flat foot and hallux valgus 8 F CNF + hallux proximal physis 12 None
emiepiphysiodesis (one cannulated screw)*
Osteochondritis dissecans of the knee 13 F Anterograde drilling + fixation (one 12 None
cannulated screw)*
Medial epicondyle avulsion 14 M ORIF (two cannulated screws)* 6 None
Tibial distal epiphysis fracture (Tillaux) 13 F ORIF (two transphyseal cannulated screws)* 6 None
Medial epicondyle avulsion 5 M ORIF (two cannulated screws)* 6 None
Medial epicondyle avulsion 11 F ORIF (one cannulated screw)* 6 None
Medial epicondyle avulsion 10 M ORIF (one cannulated screw)* 6 None

*resorbable MAGNEZIX screw (Syntellix AG; Hannover, Germany)

ARIF, arthroscopic reduction internal fixation; ORIF, open reduction internal fixation; CRIF, closed reduction internal fixation; CNF: calcanear notch filler

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 RESORBABLE MAGNESIUM SCREWS IN CHILDREN

Fig. 2 a) and b) Sagittal and axial radiograph showing fracture and lateral dislocation of the patella; c) and d) sagittal and axial CT slices
after reduction of the patella, showing residual subluxation and a free osteochondral fragment along the trochlear groove.

case report revealed implant failure after Scapho-Trape- ble OCD lesions or displaced osteochondral fragments; 3)
zo-Trapezoideal arthrodesis, leading to revision surgery22 fixation with Mg-based pins (MAGNEZIX); and 4) a min-
(Table 2). 13,14,16,17 21-34 imum FU of six months. Complete radiographic healing
Jungesblut et al,21 prospectively analyzed a cohort of was achieved in 12 patients, while in the others the pro-
19 patients (mean age 13.7 years (sd 1.9; 11 to 17); ten cess was still ongoing. One patient needed revision sur-
female, nine male) after open or arthroscopic fixation of gery due to implant failure with intraarticular migration of
unstable OCD lesions or displaced osteochondral frag- a pin 11 weeks after index surgery.
ments with resorbable Mg pins. The aim of that study
was to analyze the safety, efficacy and limitations of Mg
pin-based fixation of unstable OCD lesions and displaced Discussion
osteochondral fragments, analyzing clinical and radiolog-
The aim of the present preliminary study was to evalu-
ical outcomes at a minimum of six months FU. Inclusion
ate the safety and efficacy of the use of Mg-alloy based
criteria were: 1) age < 18 years; 2) MRI-confirmed unsta-
implants in orthopaedic procedures in skeletally immature

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Fig.3 a) Free osteochondral fragment after removal from the trochlear groove; b) and c) fixation of the osteochondral fragments with
guide wires and magnesium (Mg) cannulated screw according to the manufacturer instruction; d) intraoperative image intensifier
confirms the position of the interfragmentary compressive Herbert type Mg screws.

patients. In addition, we conducted a systematic review of In the context of body fluids, Mg alloys degrade with
the current literature. different corrosion reactions including microgalvanic
The first application of Mg in surgery started 187835 and pitting corrosion. This is achieved with production
when it was used as a wire for a vessel anastomosis and of hydroxides, oxides and H2 gas species.36 Gas produc-
later for orthopaedics and general surgery. Since the firsts tion has not been associated with clinically relevant con-
applications and in more recent times, orthopaedic clini- sequences and has been directly related to the rate of
cal use of those implants raised two main problems: the corrosion: faster corrosion produces a greater amount of
inability to control their degradation rate and the release released gas. Gas analysis, performed by McBride,37 40
of an important amount of gas during corrosion.10 days after pure Mg band implantation has revealed 80%

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 RESORBABLE MAGNESIUM SCREWS IN CHILDREN

Fig.4 Radiographs taken at three months postoperatively show healing of the fracture and initial signals of magnesium screws
resorption, with mild gas formation.

of nitrogen, 5.6% carbon dioxide, 6.5% oxygen, 7.3% taining Mg alloy (WE43) rod implanted in Sprague-Daw-
hydrogen. In addition, Verbrugge38 found all the Mg cor- ley rats, with respect to standard Ti control. Moreover,
rosion product to be non-toxic and non-irritant. tested Mg rods showed significantly higher bone-implant
On the other hand, rapid corrosion leading to implant contact and bone volume per tissue volume. Systemic
failure before fracture healing was a concern and limited inflammatory response in tested animals was ruled out
clinical application. Moreover, controlling degradation with blood sample analysis.15 Cheng et al (2016)15 have
rate is of utmost importance because fast degradation demonstrated that tendon graft fixed with a high purity
produces a great amount of gas, inhibits osteogene- Mg interference screw exhibited superior biomechanical
sis and eventually destroys the near physis.39 Too slow properties and higher expression of collagen II as com-
a resorption rate may result in increased inflammatory pared with the classic Ti screw, in a rabbit model of ACL
response and fibrosis.1 Thus, a great number of different rupture.
Mg alloys have been proposed and tested and studies are MgYREZr is a biodegradable, mainly made of WE43,
still ongoing. Al-free and REEs-containing Mg alloy and is the first Mg
Mg-based biodegradable materials may be divided into biocompatible alloy approved for clinical use in orthopae-
four groups: 1) pure Mg; 2) aluminum (Al) containing dic surgery. While there is apparent controversy between
alloys; 3) Rare Earth Elements (REEs) containing alloys; stimulating and toxic effect of REEs on humans, recent
4) Al-free alloys.36 Every alloying element has a different studies have proposed a reconciliating point of view
contribution to improve mechanical properties, corrosion according to the hormesis phenomenon. According to this
resistance or both. Al, Calcium (Ca), Manganese (Mn) and model, rare elements have got stimulating effects at low
Lithium (Li) all improve corrosion resistance at various concentrations and inhibitory or toxic effects at increasing
concentratio.40,41 Zinc (Zn), Zirconium (Zr) and Yttrium (Y) doses.36 Currently, MgYREZr is used to produce standard
improve both corrosion resistance and mechanical prop- Herbert screws, pins and cortical bone screws with differ-
erties.42,43 ent length and diameter.
Castellani et al (2011) has demonstrated highly signifi- Only a few but promising studies are currently available
cantly greater maximum push-out force, ultimate shear on clinical application of these implants. The MgYREZr
strength and energy absorption to failure in a REEs-con- screw demonstrated similar efficacy in functional and

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RESORBABLE MAGNESIUM SCREWS IN CHILDREN

Fig. 5 Clinical results at 18 months: a) and b) complete range of movement with painless full flexion and full extension; c) anteroposterior
standing view of the lower limbs.

radiological outcomes in modified Chevron osteotomy in 14 different procedures, as described in Table 1, ranging
hallux valgus,23 medial malleolar fracture44 and good clini- from orthopaedics to traumatology. Our series included
cal outcome in other isolated reports.29,33 All these studies, apophyseal avulsion, epiphyseal fractures, OCD, dis-
indeed, are conducted in adult populations, with the only placed osteochondral fragment and tendon transposition
exception being Jungesblut et al21, reporting on an aver- using an interference screw. In all these cases Mg screws
age age of 13.7 years. Nonetheless, according to inclusion guaranteed stable fixation, without implant failure, with
criteria we cannot tell if some of the patients had already good clinical and radiological results. Implant corrosion
reached skeletal maturity. was evident after two months, with minimum radiolucent
Our clinical department started using Mg screws in space around the screws, as previously reported.21,30 None
paediatric procedures after positive experiences with of the patients developed local pain, swelling or other
the treatment of intercondylar eminence fracture of the clinical signs of discomfort or intolerance to the implant,
knee.17 Since 2018, MAGNEZIX screws have been used in thus there was no need for second surgery in any of the

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Table 2 Main results from clinical studies included in our review

Author Design of study Type of lesion Patients Procedure Follow-up, Results

mths

Windhagen et al RCT Hallux valgus CO 13 vs 13 CSF: Mg vs Ti 6 No SRD

(2013) 23
Jungesblut et al Retrospective case UOCD/OCF 19 (mean age Fixation with Mg pins 6 to 20 One revision for intraarticular
(2020)21 series 13.7 yrs) loose pin; 12 radiological
healing
Turan et al (2020)24 Case report Radial styloid fr 2 CSF 24 Healing; no complications
Acar et al (2020)25 Retrospective C-C MM O 11 vs 11 CSF: Mg vs Ti 20.7 (sd 8.9) No SRD; one Ti group IR
study
Atkinson et al (2019)26 Retrospective C-C Hallux valgus CO 11 vs 25 CSF: Mg vs Ti 19 (median) No SRD
study
Aktan et al (2018) 27
Case report Distal epiphysis 1 CSF with Mg 4 Healing; no complications
humeral fr
Acar et al (2018) 14
Retrospective C-C Hallux valgus CO 16 vs 15 CSF: Mg vs Ti 19.0 (sd 6.8) No SRD
study
Gigante et al (2018)17 Retrospective case Intercondylar 3 CSF with Mg 12 Healing; no complications
series eminence fr
Klauser et al (2019)28 Retrospective C-C Hallux valgus CO 100 vs 100 CSF: Mg vs Ti 3 No SRD
study
Choo et al (2019)13 Retrospective C-C Hallux valgus CO 24 vs 69 CSF: Mg vs Ti 12 No SRD
study
Acar et al (2018)29 Case reports Isolated LM fr 1 CSF with Mg 24 Healing; no complications
Kose et al (2018)30 Retrospective, MM fr 11 CSF with Mg 17.3 (sd 4.1) Healing; no complications
case series
Plaass et (2018)31 Retrospective C-C Hallux valgus CO 13 vs 13 CSF: Mg vs Ti 36 No SRD; one lost to FU, 11
study partial FU
Plaass et al (2016)32 Retrospective case Hallux valgus CO 40 CSF with Mg 21.4 (mean) One revision, six minor
series displacement
Biber et al (2016)33 Case report Capitulum humeri 1 CSF with Mg 12 Healing; no complications
fr.
Wichelhaus et al Case report STT arthrodesis 1 CSF with Mg 1.5 Revision due to osteolysis and
(2016)22 implant loosening
Zhao et al (2016)16 RCT ONFH 24 vs 24 VBG + Mg screw vs 12 HHS > in Mg group; normal Mg,
VBG without fixation Ca, P levels
Yu et al (2015) 34
Retrospective case Femoral neck fr 19 CSF with Ti + iliac bone 8 to 24 One nonunion, 14 HHS > 90; three
series autograft fixed with Mg HHS > 80; one HHS < 80; no AVN

RCT, randomized control trial; CO, chevron osteotomy; CSF, compression screw fixation; Mg, magnesium; Ti, titanium; SRD, statistically relevant difference;
UOCD, undisplaced osteochondritis dissecans; OCF, osteochondral fragment; fr, fracture; C-C, case-control; MM, medial malleolar; O, osteotomy; IR, implant
removal; LM, lateral malleolar; FU, follow-up; STT, scapho-trapezo-trapezoideal; ONFH, osteonecrosis of the femoral head; VBG, vascularized bone graft; HHS,
Harris hip score; Ca, Calcium; P, Phosphate; AVN, avascular necrosis

patients. It is worth underlining that implant removal rep- many potential applications for this relatively new tech-
resents nearly 35% of the annual surgical burden of our nique and clinical and radiological FU is long enough to
centre. assess healing of the lesions without implant-related com-
In patient number 5, six months after surgery there plications in all patients. Moreover, the systematic review
was evidence of a loose screw fragment beside the medial pointed out that, while in recent years evidence is grow-
epicondyle of the elbow, perhaps corresponding to one ing in the adult setting, only one level IV study has been
of the screw head not completely tightening inside the conducted among skeletally immature patients. Indeed, it
cortical bone (Fig. 6). The patient was completely asymp- is mandatory to add new evidence in this latter clinical set-
tomatic, and this was just an incidental finding on a rou- ting, in order to transfer the promising results underlined
tine control radiograph. Nonetheless, this could have in the present review.
been a major problem if the fragment were loose into In conclusion, this study confirmed that Mg resorbable
an articular space, probably requiring surgical removal. screws are safe and effective for selected orthopaedic pro-
On the other hand, the screw fragmentation confirms cedures in skeletally immature subjects, at least at short-
that the corrosion process is ongoing. Thus, we suggest term FU. No patient in our series required second surgery,
that great attention be paid not to leave any part of these or developed local or systemic signs of implant-related
screws outside the cortical bone, especially in intraarticu- adverse reaction. This implant demonstrated safety
lar procedures. towards the physis when implanted nearby. However,
This manuscript presents a series of heterogeneous when inserted through the physis it displays the potential
cases treated with the same fixation device. The short to bridge bone through it, leading to complete or partial
FU of some patients, the absence of a control group and epiphysiodesis. These would open to new potential appli-
the heterogeneity of cases included in the series are lim- cations in orthopaedic procedures of guided growth in
itations. Nonetheless, this study is the first to present so developmental deformities.

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RESORBABLE MAGNESIUM SCREWS IN CHILDREN

VC: Surgical procedures, Editing of the manuscript.

DF: Surgical procedures, Editing of the manuscript.
ES: Data collection, Revision of the databases.
APG: Editing and revision of the manuscript.

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