The management of developmental hip dysplasia requiring open reduction between 12 and 18 months of age is controversial. We compare the outcome of medial approach open reduction (MAOR) versus anterior open reduction with Salter osteotomy (delayed until the child is of sufficient size) in such patients. 19 consecutive patients who underwent MAOR aged 12-22 months were reviewed at a mean follow-up of 3.5 years (range: 1.0-6.2). This group was compared to 14 patients who underwent anterior reduction and Salter osteotomy aged 18-23 months (mean follow-up 4.1 years).Purpose of study
Patients and methods
Albania is one of the poorest countries in Western European with a GDP per capita standing at 26 percent of the EU average in 2010. Whilst there is government-funded universal free provision of healthcare, it is accepted that delivery is patchy, not accessible to all and lacking expertise for more complex paediatric orthopaedic conditions. With the sponsorship of a UK-based charity, we have set up and completed 5 visits to Albania (3 assessment and 2 operative) to provide additional expertise for paediatric orthopaedic disorders running parallel to and utilising currently available local services. We present the results of this treatment and training programme to date. Between 2008 and 2011, we assessed 204 children and adolescents with paediatric orthopaedic disorders in Tirana and Durres on 3 separate visits. Of these, 28 were listed for surgical procedures whilst the rest were treated non-operatively. Of the listed patients, 14 patients underwent surgical intervention (total of 18 procedures).Introduction
Patients and methods
A description of a procedure to stabilize symptomatic complete discoid menisci with medium term results. Children with mechanical symptoms of lateral meniscal instability were assessed by MRI scan. In those with a lateral discoid meniscus an arthroscopic examination was performed to identify the presence of tears and confirm the radiological diagnosis. No incomplete or Wrisberg variant types were encountered. An antero-lateral arthrotomy was performed. The anterior horn of the meniscus was mobilized and traction sutures inserted. Flexion and extension of the knee whilst traction was applied led to delivery of the anterior horn into the wound. After confirmation of position with image intensifier a groove was fashioned in the anterior aspect of the cartilaginous portion of the proximal tibial epiphysis. Typically three titanium bone anchors with non absorbable sutures were placed in the base of the groove. The anterior horn of the meniscus was drawn into the groove and anchored with sutures. Active range of motion exercises were encouraged but a canvas knee immobilizer was employed whilst walking for the first six weeks. Four boys and three girls underwent meniscopexy performed at a mean age of 9.4 years (range 5.7 to 12.4 years). Follow up was at a mean of 4.9 years. At last follow up no patient reported symptoms of locking or pain. No patient has required revision surgery but one girl had a subsequent meniscopexy procedure on the opposite knee. Five of the children have had Lysholm scores performed at last follow up averaging 93.5 (80 to 100 points).Purpose of Study
Methods and Results
A retrospective study was undertaken to evaluate and compare the results of telescoping (group I) versus non-telescoping rods (group II) in the treatment of osteogenesis imperfecta. Thirty-three lower limb segments in ten patients were studied (14 segments in group I and 19 segments in group II). The surgical techniques of Sofield and Miller (1959) and Lang-Stevenson and Sharrard (1984) for rod insertion were used. All cases were assessed clinically regarding mobility status, growth and limb-length, refracture, and infection. They were also assessed radiologically regarding rod migration, bone outgrowing the rod, incorrect T-piece placement, breakage and bending of rods.Aim
Materials and Methods
Septic arthritis of the hip in the newborn baby can result in severe long term sequelae in the form of dislocation of the hip, loss of movement and growth disturbance with leg length discrepancy. Reconstructive procedures for this difficult problem have not been satisfactory. This series comprises eight patients with septic hip sequelae . All of them had old septic hip and leg length discrepancy ranging from 4 cm to 15 cm. all underwent hip stabilization by pelvic support osteotomy and simultaneous limb lengthening and angular deformities correction using the Ilizarov frame. The age at the operation range from 8 years to 19 years, with an average follow up 4 years.Introduction
Patient and methods
To define the orthopaedic problems associated with pseudoachondroplasia (PSACH) and their functional impact. We reviewed the medical records of 12 consecutive patients presenting to our unit. Radiographic analysis of deformity included assessment of mechanical axis and dysplasia at hip, knee and ankle measured by acetabular index (AI), Reimer's migration percentage (MP), neck-shaft angle, distal lateral femoral (aDFLA) and proximal (mMPTA) and distal tibial angles. The paediatric/adolescent PODCI questionnaires and the SF36 were used to assess quality of life issues.Purpose
Methods
Unicameral bone cysts (UBCs) are difficult to treat and have a high recurrence rate. Their pathogenesis is unknown making targeted therapies difficult. Attributed causes include venous and interstitial fluid obstruction, oxygen free radicals, lysosomal enzymes, prostaglandins and genetic factors. Skeletal stem cells (SSCs) are osteoblast precursors critical to bone formation and cyst fluid may influence their growth, however the association between SSCs and cyst fluid has never been investigated. To investigate the effect of UBC fluid on SSC growth.Background
Aim
To determine the consistency with which specialist orthopaedic surgeons rate the importance of criteria for the diagnosis of DDH which had previously been generated in a BSCOS and EPOS multi national study. 163 members of BSCOS received a questionnaire containing 37 criteria that, in a previous study, had been found to be important for the diagnosis of DDH in infants under 8 weeks. A visual analogue scale was used to rate the importance of each criterion in the diagnosis of DDH. We determined the consistency using the intra-class correlation coefficient (values > .80 are anticipated). Analyses were preformed for all members of BSCOS and for geographic regions.Purpose of the study
Methods
The purpose of this study was to determine the oblique plane deformity in slipped upper femoral epiphysis. A retrospective radiographic review was undertaken in patients admitted with a slipped upper femoral epiphysis between March 2008 and October 2010. Patients in whom a CT scan had been performed in addition to plain radiographs were assessed further. Angular deformity in the coronal and sagittal planes were measured by the angle formed between the femoral neck and a line perpendicular to the physis on the AP pelvic radiograph and the axial CT scan respectively. The magnitude and direction of the resultant deformity was defined in the oblique plane. Additional demographic data (gender, age, side, procedure and complications) was collected. Seven girls, average age of 12 (range 10 – 13) and 6 boys, average age of 13 (range 10 – 15) were identified. The slip was bilateral in 2, left sided in 6 and right sided in 5 cases. Two patients were pinned in situ, 8 had surgical dislocation performed to facilitate reduction prior to pinning and 3 patients had secondary procedures performed following in situ pinning. The average angulation in the oblique posteroinferior plane (25 degrees) was less than in the coronal (30 degrees) and the sagittal planes (62 degrees). The average magnitude was 67mm (range 31 – 88). CT is useful adjunct particularly when a frog legged lateral view is not possible because of pain or the fear of further displacement. Determination of the deformity in the oblique plane may aid in positioning of the screw during in situ pinning and may be helpful in identifying patients in whom pinning maybe difficult.
To assess if prolonged use of Bisphosphonates in Osteogenesis Imperfecta alters the pattern of femoral fractures. Osteogenesis Imperfecta (OI) has been treated with Bisphosphonates for many years with some clear clinical benefits. In adult cohorts there are reports of a new pattern of atraumatic subtrochanteric fractures seen with Bisphosphonate treatment. This study assesses the location of femoral fractures in a cohort of 176 OI patients treated with Bisphosphonates over a two year period and compares it to a historical control group of 45 managed prior to the advent of this specific treatment.PURPOSE OF THE STUDY
SUMMARY OF METHODS
The aim of this retrospective study was to review the outcome of patients treated with Fassier-Duval (FD) rods and highlight some of the complications found during treatment. Between April 2006 and August 2010 we inserted 24 FD rods in 13 patients. 17 rods for osteogenesis imperfecta (OI), 2 for fractures and deformity associated with cerebral palsy, 1 for fracture associated with muscular dystrophy, 1 for fibrous dysplasia and 3 for centralisation of single bone forearms. In the upper limb one patient required revision for proximal migration of the male component and another patient is waiting for revision for the same problem. In the lower limb, a tibial nail was revised because of proximal migration of the male component. A femoral nail was adjusted because of loss of the proximal fixation. One of the OI patients fell, fractured the femur and bent a femoral nail. This awaits revision at a later date. A second OI patient fell on 2 separate occasions bending both a tibial and a femoral nail respectively. These were both revised to trigen intramedullary nails. In all the other cases there were no complications. In summary the Fassier Duval system provides a versatile way of providing intramedullary stabilisation for growing bones through a single entry point. However in our experience we have a 33% complication rate most notably bending of the rods. We advocate careful patient selection and using as high a diameter nail as is feasible.
To report the experience and evolution of treatment of Congenital Pseudarthrosis of the Tibia in a single surgeon, consecutive series of 19 patients. A retrospective case series review, with radiological assessment and functional outcome scores including the Activity Scale for Kids (ASK) and the Oxford Ankle Foot Questionnaire (OAFQ) Child & Teenager version. Patients were classified as per Boyd & Andersen. Alteration in the Tibial mechanical axis was compared pre-treatment and at last review.PURPOSE
METHODS
We present a retrospective study of bilateral CDH. We analysed the correlation of complications to the confounding factors. We reviewed all bilateral CDH patients treated by the same surgeon at Southampton between 1988-2006. The patient recruitment was carried out as follows:
Group A – failed Pavlik harness; Group B – late presentations not treated in Pavlik harness.AIMS
MATERIAL AND METHODS
The purpose of our study was to independently assess the modified Herring lateral pillar classification. 35 standardised true antero-posterior radiographs of children in various stages of fragmentation were independently assessed by 6 senior observers on 2 separate occasions (6 weeks apart). Kappa analysis was used to assess the inter and intraobserver agreement between observations made. Intraobserver analysis revealed at best only moderate agreement for two observers. 3 observers showed fair consistency, whilst 1 remaining observer showed poor consistency between repeated observations (p<0.01). The highest scores for interobserver agreement varying between moderate to good could only be established between 2 observers. For the remaining observers results were just fair (p<0.01). This stdy highlights the lack of agreement between senior clinicians when applying the modified LPC. This clearly has clinical implications. To our knowledge this is the first time the modified lateral pillar classification has been independently tested for its reproducibility by a specialist orthopaedic unit.Methods and results
Conclusion
To document the success rate of closed reduction and soft tissue release in the treatment of bilateral true dislocation in developmental dysplasia of the hip (DDH). Case-note review of 22 children (44 hips) with idiopathic bilateral hip dislocation referred to a tertiary centre before walking age. The management protocol was as follows:
Examination under general anaesthesia, arthrogram, closed reduction and appropriate soft tissue release (adductors/psoas), application of a ‘frog’ cast. CT scan at 2 weeks to confirm reduction. Change of cast and arthrogram at 6 weeks to confirm improving position and stability. Cast removal at 12 weeks, and application of an abduction brace for 6 weeks. Treatment failure could occur on day 1 (failure of reduction), at week 2 (failure to maintain reduction), at week 6, or after cast removal.Purpose
Methods
We describe two recent cases of intraosseous (IO) access resulting in amputation in critically ill infants and make contemporary recommendations on the safe practice of this technique. This is a retrospective case series of two children transferred from peripheral hospitals to our unit. One child (5 months) was resuscitated after cardiorespiratory decompensation due to diaphragmatic hernia. The other child (18 months) deteriorated during presentation with purpura fulminans two days after a scald injury. Both children underwent emergent bilateral tibial IO access using power driven needle systems. Initial resuscitation included large volumes of 0.9% normal saline. One child received doses of adrenaline and 8.4% sodium bicarbonate, whole blood and an initial dopamine infusion; the other received 8.4% sodium bicarbonate, 10% calcium gluconate and whole blood. Total infused volumes were 400mL and 730 ml respectively. Progressive lower limb tension became evident in both children after 12 hours; bilateral posterior tibial fractures were noted in one child. Ultimately, both children underwent surgical fasciotomy, but extensive necrosis necessitated unilateral below knee amputation at days 12 and 13 respectively.Purpose
Methods/results
The purpose of this study was to calculate the dislocation rate following open or closed reduction for developmental dysplasia of the hip (DDH) in our unit. In addition we evaluated the posterior neck line as a method of determining hip relocation and assessed the morphology of the dysplastic acetabulum on single slice CT scan. We retrospectively assessed all patients operated on for either open or closed reduction for DDH between August 2007 and August 2009 and evaluated their notes, CT scans and radiographs. The immediate post-operative dislocation rate was calculated, as was the subsequent re-dislocation rate and late subluxation rate. The acetabular morphology was assessed to determine whether the acetabulae were “S” shaped or “C” shaped. A novel method for confirming hip reduction was also appraised.Aims
Method
A review of the role of external fixators in paediatric trauma at The Royal London Hospital Trauma and Orthopaedic Department. Retrospective study between 2004 and 2010 reviewing traumatic bone injuries that required initial management with an external fixator. Information was collected through the patients' medical documents and radiographs.Purpose
Methods
Our experience with Taylor Spatial Frame correction of complex foot deformities in children. Persistent foot deformity in congenital talipes equinovarus is a challenge. Open surgery is associated with complications including difficulty in achieving acute corrections in stiff, scarred feet. Gradual correction using the Ilizarov circular frame has been described as an alternative and we present the experience using a computer assisted hexapod gradual frame correction with the Taylor Spatial Frame (TSF). A retrospective audit of sequential patients treated by TSF was performed. Technique, outcome, complications and key learning points were recorded. 21 paediatric patients underwent 27 treatments with a Taylor Spatial frame for complex foot deformity correction. Average age 11 years with majority diagnosis of congenital talipes equinovarus. The deformities severity meant acute correction would result in either neurovascular or soft tissue compromise. Plantigrade feet with good function was achieved in 22 feet. 3 feet were deemed as failures. 2 feet have residual deformity but acceptable function. According to Paley's classification, there were 4 complications, 7 obstacles and 35 difficulties (pin tract infection and pain management). Complications did contribute to poorer outcomes. The key learning points were: protection of the ankle joint and distal tibial physis; staged osteotomy reduces swelling and complication rates; and consideration of further procedures at frame removal is important. Finally a thorough preoperative counselling programme should be instituted and patients warned of the time commitment and high difficulty rates associated with treatment. Managing patient expectation with goals is as important as meticulous surgery. Although complication rates were high, the majority of treatment goals were met, therefore the TSF is valid in the treatment of complex deformities in the foot. Most patients with severe deformity can achieve a plantigrade functional foot but residual stiffness and need for minor orthotics is almost universal.Statement of Purpose
CRUS is difficult to treat. Many techniques have been tried in an effort to restore forearm rotation; however, they have not been successful. It is inadvisable by many authors to perform any operation with the hope of obtaining pronation and supination. Eleven children; 3 - 8 years old with CRUS, Wilkie type I, with fixed full pronation deformity were managed by the new ALLAM'S OPERATION which is a one stage intervention including separation of the bony fusion, special cementation technique of the ulnar (or radial) side of the osteotomy, double osteotomy of the radius and a single osteotomy of the ulna (all of the 3 osteotomies were done percutaneously) with intramedullary K. wire fixation of osteotomies at the mid-prone position and above elbow cast application for 6 weeks.Background
Patients and Methods
Statement of purpose of study: To determine how effective Flexible Intramedullary Nails are in treating tibial and femoral fractures in adolescents. Summary of Methods used: Retrospective review of consecutive adolescent patients treated over a seven year period with Flexible Intramedullary Nails for tibial and femoral fractures. Statement of Conclusion: We conclude that the higher than expected rates of malunion and delayed union suggest that other treatments should be considered when treating adolescents with unstable tibial or femoral fractures. Introduction Flexible intramedullary nails (FIN) are increasingly used in the management of paediatric tibial and femoral fractures. Recently, concerns have been raised regarding the use of FIN in older children. The aim of this study was to determine how effective FIN's are in treating tibial and femoral fractures in adolescents. Methods Hospital records were used to identify all patients aged 11 years or older under going FIN for tibial and femoral fractures between 2003 and 2009. Radiographs and case notes were reviewed to identify complications. Results 35 consecutive adolescent patients underwent FIN for tibial (n=21) and femoral fractures (n=15) with a mean age of 12.9 years. 2 femoral and 9 tibial fractures were open. Eight patients sustained multiple injuries. Mean radiographic follow up was 29 weeks. 60% (n=9) and 38% (n=9) of femoral and tibial fractures respectively malunited. Fracture severity was associated with increased malunion for both tibial and femoral fractures (P=0.046 and P=0.044 respectively). There were no cases of non-union. 2 femoral fractures took longer than 20 weeks to unite and 7 tibial fractures took longer than 16 weeks to unite. One patient developed post operative compartment syndrome, one patient developed deep infection and two patients were treated with post operative traction for loss of fracture position. Discussion Previous publications from multiple centres, including ours, have demonstrated excellent results of FIN for tibial and femoral fractures in the general paediatric population. However, concerns have recently been raised about the use of FIN in older, heavier children and with unstable fracture patterns. This is the first published series of adolescent patients undergoing FIN. We conclude that the higher than expected rates of malunion and delayed union suggest that other treatments should be considered when treating adolescents with unstable tibial or femoral fractures.
To determine whether radiographically demonstrated femoral neck irregularities (pistolgrip-deformity, focal prominences or lytic defects) are associated with positive clinical impingement tests. The 1989 Bergen birth cohort (n=4004) was invited to a population-based follow-up including clinical examination and two pelvic radiographs. 2081 (52%) were enrolled. Associations between clinical and radiographic findings were examined using chi-squared or Fischer's exact test.Purpose
Methods
Early results of Ponseti treatment in 14 children (17 feet) aged between 2 and 10 years at the start of treatment are assessed. Method and Results 14 children aged between 2 and 10 years (mean 5.4) presented with relapsed or under- corrected club feet. All had previous treatment with strapping and bebax or pedro boots. 8 had subsequently undergone posterior release of the Achilles tendon, ankle and subtalar joint through a longitudinal posterior incision. All patients presented with absent heel strike, walking on the lateral border of the foot. 14 feet had a varus heel and 15 had an internal foot progression angle. Mean Pirani score was 2.14. Photographs and videos were taken. Ponseti casting was implemented. 15 feet required an Achilles tenotomy, and 15 feet had a tibialis anterior transfer to help maintain the correction. Pirani scores improved from a mean of 2.64 to 0.21 in the group that had had previous surgery, and 1.64 to 0.07 in those that had had previous conservative treatment. All patients achieved a heel strike and ceased to walk on the lateral border of the foot. Heel varus corrected in 11/14 and partially corrected in 3. Internal foot progression resolved in 12/15 and improved in 3. At latest follow up (16 months- 20 months), all transfers were working and all patients walked with heel strike and a plantargrade foot. 2 patients required further casting for relapse in forefoot adductus, and one for recurrent posterior tightness. Conclusions The Ponseti method has been successful in the under corrected or relapsed club foot in children aged between 2 and 10 years in this series, including those with previous surgical intervention.
Meningococcal septicaemia from meningococcal infection is a devastating illness affecting children. Advances in medical management have reduced the mortality rate to approximately 15 to 20% and children who survive can develop late orthopaedic sequelae from growth plate arrests with resultant complex deformities. Our aim in this study was to review and analyze the case histories of a series of patients with late orthopaedic sequelae, all treated by the senior author. We describe a treatment strategy to address the multiple deformities that may occur in these patients. Methods & Results Between 1990 and 2009, 12 patients were treated for late orthopaedic sequelae after meningococcal septicaemia by the senior author. There were 8 girls and 4 boys. All patients had lower limb involvement. 1 patient had involvement of the upper limb requiring treatment. Each patient had had a mean of 3 operations (range from 2 to 9). Methods of treatment included a combination of angular deformity correction, limb lengthening and epiphysiodesis. At final follow-up 9 of the 12 patients were skeletally mature. In 9 patients limb length discrepancy in the lower limb was corrected to within 1 cm, with normalization of the lower limb mechanical axis. Conclusion Meningococcal septicaemia can lead to late orthopaedic sequelae due to growth plate arrests. Central growth plate arrests leads to limb length discrepancy, and partial growth plate arrests leads to an angular deformity. In addition, limb amputations may occur and there may be altered growth of the stump requiring further surgery. In cases of central growth arrest with limb shortening alone, limb equalisation is performed with limb lengthening procedures. In cases of partial growth arrests, angular correction is performed together with ablation of the affected growth plate. We recommend ablation of the affected growth plates at the initial surgery to prevent recurrence of angular deformity. Angular correction can be performed acutely, with a dome or transphyseal osteotomy; or gradually, with application of Ilizarov or Taylor Spatial frames. Severe deformities of the tibial plateau are treated by plateau elevation with bone graft augmentation. With the appropriate strategy deformities can be corrected and further lengthening procedures can be undertaken if necessary. Long-term follow-up of these patients is essential to recognise and treat any recurrence of deformity.
To investigate the effect of soft tissue release (STR) and the length of postoperative immobilisation on the long term outcomes of closed reduction (CR) of the hip for developmental dysplasia of the hip. 77 hips (72 patients) who had undergone closed reduction (CR) between 1977-2005 were studied retrospectively to review their outcome (Severin grade), identify the reasons for failure and to assess factors associated with residual dysplasia. Particular attention was paid to the use of a STR at the time of CR (to improve initial hip stability) and the duration of postoperative immobilisation.Purpose
Materials
Purpose This was an observational study to determine the prevalence of 25-hydroxyvitamin D (25[OH]D deficiency in our paediatric orthopaedic patient population. Methods We have measured serum 25(OH)D levels in 44 paediatric patients who presented with bone pain. None of these patients had a pre-existing diagnosis of 25(OH)D deficiency. The age of patients ranged from 11 months to 16.5 years. There were 23 female and 21 male patients. The range of diagnoses included hip pain/irritable hip (4), Blount's disease (4), developmental hip dysplasia (7), genu valgum (3), Legg Calve Perthes’ disease (6), slipped capital femoral epiphysis (11), knee pain (3), other (6). Those found to be 25(OH)D deficient underwent further biochemical investigation and were referred for paediatric endocrinology review with a view to vitamin D supplementation. Results We found 9 patients (20%) with serum 25(OH)D levels of <20ng/mL indicating 25(OH)D deficiency. 17 patients (39%) had serum 25(OH)D levels in the range 20-30ng/mL indicating possible deficiency. The remaining 18 patients (41%) had a normal level of 25(OH)D. There was no association between low serum 25(OH)D level and any specific diagnosis, nor with gender or age of patient. There was, however, a statistically significant difference between the serum 25(OH)D level in those patients with unexplained joint pain (mean 22.5ng/mL) and those with other diagnoses (mean 30.7ng/ml) (P<0.05). Conclusion Our results are consistent with other recent prevalence studies showing a concerning level of 25(OH)D deficiency among the paediatric population, and may suggest an increasing burden of disease in the coming years arising from the problem.
In cerebral palsy patients, while upper limb function is acknowledged as being important, it has traditionally taken a back seat to lower limb function. This is partly due to inexperience and partly due to difficulty deciding on the best way of improving upper limb function. In Swansea since June 2008 we have been offering a multi-disciplinary service for the assessment and treatment of upper limb problems in cerebral palsy. The core team consists of a consultant orthopaedic surgeon, a consultant plastic surgeon with a special interest in CP upper limb problems, a consultant paediatric neurologist, a community paediatric physiotherapist and a community paediatric occupational therapist. Upon referral, the physiotherapist and occupational therapist carry out initial functional assessment of the patient. This is followed by a joint assessment by the whole team in a special clinic held every 3 months. If required, the child is offered surgery, botox injections or both. Further follow-up is in the special clinic until the child is suitable for follow-up in a normal clinic. We present our initial experience with this multi-disciplinary approach, the problems encountered in setting up the service and our plans for the future.
Habitual hip subluxation and dislocation is a potentially disabling feature of Trisomy 21 and we describe long-term outcomes following the precise use of femoral varus derotation osteotomy. 16 consecutive hips, 9 children, with Trisomy 21 aged =10 years, were identified from hospital databases. Clinical notes and radiographs from presentation to final follow-up were reviewed.Purpose
Methods
To report the difference in the rates of avascular necrosis (AVN) of the femoral head following change in the hip abduction angle in the hip spica. Up until 2002, following closed and medial open reduction of the dislocated hip, the joint was immobilised in a 90° of flexion, 60° of abduction and 10-20° of internal rotation hip spica. The practice was changed after 2002 to 45° of hip abduction in the spica with other parameters remaining same. We audited the rates of radiologic AVN in these two groups of children. Group A, before 2002, had 20 children and in group B, after 2002 till Aug 2007, had 53 children. AVN was quantified on 2 year radiograph by the classification described by Salter and noted its progression on serial radiographs.Purpose of the study
Methods
The results clinically & statistically of a 14 year longitudinal study comparing the traditional ‘stretch & strap’ method (1994-2002) with the Ponseti technique (2002-2008) A 14 year prospective longitudinal comparative study was undertaken into management and outcome of CTEV. There were 114 feet (80 patients), 64 feet (45 patients) treated traditionally and 50 feet (35 Patients) with the Ponseti technique. Patient demographics, the Harold & Walker Classification, and associated risk factors for CTEV were analysed. If conservative treatment failed a radical sub-talar release operation (RSR) was undertaken. The incidence of fixed CTEV was 1.6 per 1000 live births with a male to female ratio of 2.8 to 1. Idiopathic CTEV was present in 77.5% of patients, (22.5% with a primary aetiology). Mean time to RSR was comparable: 37.43 weeks (CI: 33.65 to 41.21) and 46 weeks (CI: 39.18 to 52.82) for the traditional and Ponseti groups respectively. In the traditional group 65.6% (CI: 53.4 to 76.1%) of feet underwent RSR surgery compared to just 25.5% (CI: 15.8 to 38.3%) in the Ponseti group, When idiopathic CTEV was analysed separately these rates reduce to 56.5% (CI: 42.3 to 69.8%) and 15.8% (CI: 7.4 to 30.4%) respectively. The Relative Risk of requiring RSR surgery in traditional compared to Ponseti groups was 2.58 (CI: 1.59 to 4.19) for all patients and 3.58 (CI: 1.65 to 7.78) for idiopathic CTEV (statistically significant). The results of the Ponseti method improved with time suggesting a learning curve.Purpose of study
Methods & Results
We have reviewed the complication rate over a ten year period for removal of screws placed for slipped capital femoral epiphysis (SCFE) and have surveyed the views of orthopaedic surgeons with an adult hip practice in Scotland on leaving the metalwork in situ. Whilst screw removal is favoured by many orthopaedic surgeons, a recent review of the literature reported that the complication rate for removal of implants placed for SCFE was 34%. Between 1998 and 2007 84 patients had insertion of screws for SCFE. Of these 54 patients had screws removed, 51 of these records were available. The median duration between insertion and removal of screws was 2 yrs 7 months. Of the 51 children, overall five (9.8%) had complications - three (5.9%) major and two (3.9%) minor. Two screws could not be removed; one patient sustained a fracture after screw removal and two developed an infection. We assessed the attitudes of adult hip surgeons on this topic using an electronic questionnaire which was completed by 29 out of 40 recipients. 78.6% of respondents support routine removal and 21.4% favour leaving the screw permanently in place. 82.2% had needed to remove metalwork from a hip requiring arthroplasty in a patient whose metalwork was inserted during childhood; and described their experience of this including the complications encountered. We have identified a lower complication rate following screw removal inserted for SCFE than in published series. Most adult hip surgeons support routine removal once the physis is closed but studies regarding the long-term outcome of retained orthopaedic implants are needed since even with this lower complication rate the question of routine removal remains unclear.
To assess if Osteoset (CaSO4) improves graft incorporation after shelf procedure and whether spica immobilisation is necessary 49 patients with acetabular dysplasia treated by shelf procedure were reviewed retrospectively. Group 1 (19 children) and group 2 (12 adults) had shelf acetabuloplasty using autogenous bone graft and CaSO4. Group 3 (18 children) underwent shelf acetabuloplasty using autogenous bone graft alone. Group 2 was assessed separately to avoid age bias. Within group 3 we compared 10 patients managed in plaster for six weeks with 8 mobilized on crutches post operatively. Total shelf and graft area, total shelf length, extra-osseous shelf length and speed of graft incorporation were measured radiologically. There was no difference in shelf indices between patients treated in plaster and those mobilized on crutches. Use of CaSO4 significantly enlarged shelf volume by 3 months post-operative with less resorption, which was maintained throughout follow-up. In contrast the non-CaSO4 group showed a steady decrease in shelf volume. The extra-osseous shelf length was initially similar in groups 1 & 3. By 6 weeks the group 1 extra-osseous shelf was significantly greater than for group 3 and was maintained throughout follow-up. Graft incorporation was faster in group 1. Shelf area and extra-osseous shelf length improved significantly in group 2. However total shelf length decreased slightly by 6 months.Aim
Methods/results
The long term results of closed reduction of the hip for DDH were reviewed to determine if the presence of the ossific nucleus had an effect on outcome. The clinical and radiological outcome of a single-surgeon series of closed reduction for DDH was assessed in a strictly defined group of 48 hips in 42 patients with an average of 11.1 years follow up. In 50% of cases, the ossific nucleus was absent. 100% of patients had an excellent or good result (Severin classification) at final follow-up. 8.3% (4 hips) demonstrated evidence of avascular necrosis. Three were Kalamchi & MacEwen Type I and one was type II. Two of the AVN cases did not demonstrate an ossific nucleus at closed reduction, and both developed type I AVN. 6 hips underwent further surgery. The acetabular index and center-edge angle were not significantly different between the affected and unaffected hip at final follow-up. There was no relationship between the presence or absence of an ossific nucleus at the time of closed reduction and the final outcome. In this well defined group, closed reduction is safe and provides excellent results in the long-term. The absence of an ossific nucleus is not detrimental to the final outcome.
To determine the effect of the femoral head ossific nucleus on the development of avascular necrosis (AVN) after reduction of a dislocated hip. We included consecutive patients treated for a dislocated hip secondary to DDH with either closed or open reduction under the age of 30 months (mean, 9.6□4.8) in this retrospective cohort study. 85 patients or 100 hips were included. Radiographs were analysed for the presence of the ossific nucleus at the time of hip reduction, and for the presence of AVN at 9.2□3.4 years after hip reduction by 3 blinded assessors. There was no significant effect of the femoral head ossific nucleus on the development of osteonecrosis, with 16/40 (40%) cases of osteonecrosis in infants with an ossific nucleus absent compared with 18/60 (30%) in the group with an ossific nucleus (adjusted relative risk = 0.83; 95% CI = 0.38 to 1.83; p=0.65). When only radiographic changes of grade II or worse were considered osteonecrosis, the association remained statistically insignificant (adjusted relative risk = 0.84; 95% CI = 0.35 to 2.00; p=0.69). Our study reports the longest follow-up addressing the question of a potential protective effect of the ossific nucleus on the development of AVN. We could not demonstrate such an effect. Strategies aimed at delaying the treatment of a dislocated hip in the absence of the ossific nucleus cannot be recommended as they will not affect the risk for subsequent AVN.Purpose
Conclusion
Results clinically & statistically of a 10 year prospective observational longitudinal study of the effects of sonographic screening for ‘risk’ factors in DDH. From 1997 to 2006 the project analysed the results of a sonographic screening programme for clinical instability & ‘risk factors’ in Blackburn (modified Graf system). ‘Risk factors’ included: breech presentation, strong family history, foot deformities & oligohydramnios. Statistically 95% confidence intervals, relative risk, sensitivity, specificity PPV & NPV were calculated. The outcome measure was irreducible dislocation of the hip joint. There was a birth population of 37,510, of which 2693 were ‘at risk’ & 132 clinically unstable. Three subsections: The overall irreducible dislocation rate was 0.51 per 1000 live births. ‘Risk factors’: mGraf Type III/IV/ Irreducible: Narrow 95% CI for Breech, CTCV & CTEV Wide 95% CI for Family history, oligohydramnios & TEV (postural) 95% CI (RR) for Oligohydramnios & TEV not significant. RR for clinical hip instability was 983.6 Percentage female 34.15% of clinically unstable hip joints had a ‘risk factor’Purpose of study
Methods & Results
1. Clinically unstable hips (birth)
2 irreducible dislocations
2. ‘At risk’
6 irreducible dislocations
3. Secondary referral (GP screening)
11 irreducible dislocations
CTCV:
1: 13.8
RR = 26.5
Family history:
1:18.5
RR = 23.3
Breech:
1:35
RR = 14.8
Oligohydramnios
1:99.5
TEV (postural)
1:202
CTEV (fixed)
0.0
18/19 irreducible hips
94.74%
64/92 Type IV hips
69.56%
26/30 Type III hips
86.66%
To assess the radiological outcomes of medial screw epiphyseodesis of the proximal femoral physis in the management of lateral growth arrest following treatment of developmental dysplasia of the hip. We identified 10 patients noted to have lateral growth disturbance of the proximal femoral physis, 9 of which were managed with medial screw epiphyseodesis. Serial radiographs were reviewed. A new technique was employed to monitor progression of lateral growth arrest and also to assess the role of screw epiphyseodesis in preventing further deterioration or indeed allowing for improvement. This method involved calculating the tilt angle (angle formed between a horizontal reference line and a line joining medial and lateral points of physis) and following its progression with increasing age.Purpose of Study
Methods
We aimed to examine the true incidence of DDH in our area, and to investigate both known and unknown risk factors for the condition. Data were prospectively recorded on all live births in the Exeter area from January 1998 to December 2008. The data included the baby's gestational age, sex, demographic details of parents, maternal age and parity, geographic and socioeconomic data, mode of presentation and delivery, and family history of DDH. Data were also collected prospectively on all treated cases of DDH (Graf 2c and above) for the same period. Using the population live birth data as controls, odds ratios (OR) and confidence intervals were calculated.Aims
Methods
To document the incidence and nature of complications associated with hemiepiphysiodesis using a screw and plate device (8-plate, Orthofix). We reviewed case notes and radiographs of 71 children (130 segments) with lower limb deformities treated with temporary hemiepiphyseal arrest using the 8-plate. 96% of deformities were in the coronal plane, 4% sagittal. 72% of coronal deformities demonstrated valgus malalignment. We defined three types of complications: complications Complications were related to variables of patient age, gender, diagnosis, location of deformity and associated surgery.Purpose
Methods
This study aimed to determine the major diagnoses and needs of children in Rwanda with musculoskeletal conditions to enable the Rwandan government to begin to plan orthopaedic and rehabilitation services. When faced with developing orthopaedic services for children in Sub-Saharan Africa, there is little objective evidence-based data on the magnitude and type of services needed. Rwanda is a small country that is in the process of developing orthopaedic and rehabilitation services, and its Ministry of Health supported a survey that would provide information necessary for planning such services. A national survey of musculoskeletal impairment (MSI) prevalence was undertaken. Of a population of 8.4 million, 8368 people were enumerated. Four thousand one hundred thirty-four were aged 16 years or less. Cases who failed a screening test for MSI were examined, allocated a diagnostic category, and assessed as to treatment needed.BACKGROUND
METHODS
To determine whether hemiplegia causes abnormal torsion of the radius of the affected compared with the unaffected limb as demonstrated by MRI measurements, and to assess whether this correlates with the passive range of movement as measured clinically. 27 patients who fit the inclusion criteria were recruited from an existing database of hemiplegic patients into our prospective cohort study. A clinical assessment was made of each subject to determine the range of active and passive upper limb movements. A functional assessment of the children's upper limbs was made using the validated House score. Subsequent MRI scans of both upper limbs were then performed. A single radiologist (blinded as to the affected limb) then measured the torsional profiles of both radii using a method validated by Bindra et al.Purpose of study
Methods
Purpose We report the long term outcome of a minimally invasive technique avoiding the risks associated with open reduction and bone grafting in paediatric lateral condyle fracture non-unions. Methods The Toronto Hospital for Sick Children's radiology database was searched to isolate all those who sustained a lateral condyle elbow fracture and had developed a non-union between the years 1998 and 2008. This identified 16 patients who had undergone percutaneous fixation for the treatment of their non union. Each individuals clinical notes and radiographs were reviewed from presentation to final follow-up. Results Median age at injury was 5.1 (3.2, 7.2) in the successful and 2.8 (2.1, 4.7) in the unsuccessful groups (p=0.18). 11 patients (68.7%) had been initially managed non-operatively. Median time from injury to non-union diagnosis was 15.7 weeks in the successful, and 225.5 weeks in the unsuccessful group (p=0.039). Mean time to union post fixation was 16.2 weeks (+/- 6.74) and mean time to surgery was 5.2 weeks (+/- 4.11). Surgery was successful, defined as radiological and clinical union, in 12 of 16 patients (75%). 43.8% had metalwork removal and no cases of avascular necrosis were reported. Conclusion We have demonstrated this technique to be successful in those non-unions addressed within 16 weeks from initial injury to diagnosis. We had 4 failures, these occurred in patients whose non-unions were diagnosed more than 31 weeks from the time of injury (31; 68; 383; 427 weeks). Each of these failures had been managed non-operatively as part of their primary treatment plan. Percutaneous fixation is feasible and safe. Patients not achieving union were diagnosed significantly later. There was a trend towards successfully treated patients being younger.
To determine the impact of sonographic information on surgeons' diagnostic thinking and decision-making in the management of infants with clinically suspicious hip dysplasia. Four experienced consultant surgeons examined 66 hips referred for possible hip dysplasia and reported for each hip ( The ultrasound led to a change in diagnosis in 34/66 (52%) hips. However, the management plan only changed in 21/66 (32%) hips. The mean gain in reported diagnostic confidence was 19.37 (95% CI = 17.27, 21.47). If the treatment plan did not change, there still was a gain in diagnostic confidence but this gain was small with a mean value of 8 (95% CI = 5.29, 10.70). However, if the ultrasound led to a change of the treatment plan, the mean gain in diagnostic confidence was much higher with 46 (95% CI = 30.53, 60.79). The difference was -37.67 ( In this study, the sonographic information only led to a modest gain in diagnostic confidence. Ultrasound was particularly helpful for surgeons in clarifying hips with limited abduction or signs of leg length difference.Purpose
Conclusion
To evaluate the results of using external fixation to stabilise femoral derotation osteotomy involved in DDH surgery. A retrospective analysis was performed on 44 patients undergoing 48 femoral osteotomies for DDH surgery between the years 2001 and 2009 by a single surgeon (senior author MC). The external fixator was used either during the primary procedure involving femoral shortening to aid in hip reduction (4 patients) or to correct femoral malrotation in a reduced hip as a secondary procedure(40 patients). As the external fixator frame was within the hip spica it was not a cause of concern to the parents or the child. There was no evidence of any pin tract infection and all patients eventually progressed to satisfactory bony union. One patient had delayed union which was treated successfully with conservative management and one patient had a malunion requiring a further osteotomy and extended treatment with the external fixator.Purpose of Study
Methods and results
Clinical coding is used to record information from patient admissions in the form of coded data used for monitoring the provision of health services and trends, research, audit and NHS financial planning. A sample of 105 cases admitted to Southampton General paediatric orthopaedic department from 2006-9 was used. 31 admissions were grouped using HRG4 and the remaining 74 using HRG3.5. Accuracy of coding was calculated by establishing correct discharge coding and comparing them with coding records. The correct codes were run through HRG 3.5 and 4 payment groupers and their outcomes were compared financially to the HRG codes these admissions were actually grouped under.Purpose
Method
We describe a new technique of talar dome osteotomy in the treatment of fixed equinovalgus deformity of the foot in patients with Fibular Hemimelia and successfully applied it in two patients. Fibular Hemimelia is a congenital absence or hypoplasia of fibula with associated fixed equinovalgus deformity of the foot. Treatment for this deformity ranges from corrective osteotomy of the tibia, calcaneum to Syme's amputation.Purpose of the study
Background
