Temperature data was available for 48 patients, with a mean of 38.2 degrees Celsius at presentation. The mean ESR was 55.8. 28 patients (40%) grew an organism on culture of the hip fluid. The most common organism was Staphylococcus Aureus (64% of positive cultures). 66% (n=16) of patients in the <
1 year old group developed complications relating to growth arrest and leg length discrepancy. Seven of these patients (43%) underwent further surgery to correct deformity at a later date. In contrast, only 4.3% of patients in the >
1 year old group developed complications. The mean delay to surgery in patients who developed complications was 6.3 days with a mean delay to surgery of 3.1 days in patients who did not develop complications (p = 0.03, student’s T-Test).
Gradual correction of periarticular deformities has necessitated the application of external fixators to accomplish the task. By contrast, such deformities when treated by acute correction are most often stabilised using internal fixation. Hemi-epiphyseal arrest, by stapling or transphyseal screw is a disadvantage by being an irreversible process which has to be delayed until later childhood. This study describes the preliminary results of using an alternative internal device which corrects angular deformity by acting as a tension band on one side of the growth plate. Twenty nine consecutive patients with significant coronal plane deformities in the lower limb were treated using the guided growth technique. This was accomplished through the extra-periosteal application of a 2-hole plate and screws (the 8-plate, Orthofix SRL, Verona). The plate was left in-situ and the patient monitored at regular intervals until the desired correction of the mechanical axis was accomplished. Plate removal was undertaken if the child was not skeletally mature at completion of treatment. Eighteen males and 11 females completed treatment and had their plates removed. The age of patients ranged from 5 to 14 years (average 11.5 years). There were 23 patients with genu valgum deformity with an average deformity of 9.8 degrees, and 6 patients with genu varum deformity with an average deformity of 29.9 degrees. The follow up period averaged 12.5 months from plate removal. The average duration of correction was 15.8 months. The overall rate of correction was 0.87 degrees per month. Two complications were recorded: plate migration in one patient and deep infection in another patient. We had one case of rebound deformity. The guided growth technique using the 8-plate is a simple and safe procedure for the treatment of lower limb angular deformity which produces temporary physeal arrest.
Primary pyomyositis is increasing in incidence in the western world. Although a commonly encountered condition in the tropics it was not described in the USA until 1971 and the UK until 1998. The reason for the increasing incidence is not understood. Typically pyomyositis affects the muscles around the hip and may present in a variety of ways to orthopaedic or general surgeons – occasionally leading to unnecessary operative intervention. We sought to identify the experience gained, of this condition, within a UK paediatric tertiary referral unit. A retrospective review of cases of pyomyositis, from our institution, since 1998 was undertaken to identify demographics, presentation, diagnosis and management. Thirteen cases of pyomyositis were identified. Obturator internus was most commonly affected (n = 7). Trauma was implicated in three cases and group A staphylococcus was cultured in nine cases. Male:Female ratio ~ 3: 2. Initial working diagnosis at presentation was septic joint in eight cases, appendicitis in three cases and soft tissue abscess in two cases. Ten cases settled with antibiotics alone. One diagnostic retroperitoneal exploration was performed which may have been avoided with greater preoperative awareness of this condition. On reflection, all cases were identified by CT or MRI. To our knowledge, this is the first UK series of pyomyositis, reflecting its increasing incidence in the western world. Its presentation is similar to other common paediatric surgical emergencies, yet its management is very different – often not requiring surgery. A greater awareness of this emerging condition is therefore essential to both general and orthopaedic surgeons in order to prevent misdiagnosis and unnecessary surgical intervention.
Elastic stable Intramedullary nailing (ESIN) is a method of treating femoral fractures in older children. The purpose of this study is to report our results over a 9 year period. Between 1998 and 2007, 62 children with femoral shaft fracture were managed at our institution with flexible titanium nailing. There were 44 boys and 18 girls with a mean age of 12.4 years (range 6 to 16 years). The mechanism of injury varied from RTA, falls and sports. The right side was involved in 41 and the left in 23. Two children had bilateral fractures. The fracture was in the proximal one third in 3, middle third in 51 and the distal third of the diaphysis in 8 children. The fracture pattern varied from transverse in 33, oblique in 15, spiral in 10 and comminuted in 4 patients. 11 children had associated injuries and 2 had mild osteogenesis imperfecta and another 3 sustained pathological fractures (fibrous dysplasia - 1 patient; simple bone cyst -1 patient; aneurismal bone cyst – 1 patient). The surgical procedure was retrograde except in one child with a mid third oblique fracture where this technique failed and hence an ante grade insertion was performed. All fractures united at an average follow-up of 18 months (range 12–24 months). The mean union time was 3.8 months (range 1.2 to 7.2 months). All patients were followed until the implant was removed and the mean insertion to removal interval was 13 months (5 to 29 months). The complications noted in our series were knee discomfort with stiffness (8 patients), pain from prominent nails (2 patients), malunion (1 patient), delayed union (1 patient), peri-prosthetic fracture (1 patient). There were no cases of infection. In conclusion, the results of our series showed that Elastic stable Intramedullary nailing gives satisfactory outcome in management of femoral shaft fractures in children.
Complete data was available for the full period under review except for the year 2003.
Eleven cases (68.8%) improved with conservative management and a further three cases improved following a local anaesthetic/steroid injection. Two cases (12.5%) who did not improve with these measures underwent surgical decompression with subsequent improvement in symptoms. No side effects were reported from the either the steroid injection or surgical decompression.
Investigations include MRI for one patient and CT for another USG was done for the remaining four. There was no post op complication for any of them. None of them have shown any recurrence during the follow-up.
Cytogenetic evaluation often shows chromosomal anomalies of tumour cells like abnormalities of the long arm of chromosome 8, leading the rearrangement of the PLAG1 gene. Biopsy of the lesion is recommended, as clinical and radiological diagnoses can be misleading. These tumours tend to spread locally and may recur in case of incomplete resection; metastatic potential has not been reported. Differential diagnosis includes myxoid liposarcoma, welldiffrentiated liposarcoma, spindle cell lipoma, typical lipoma and soft tissue sarcoma.
Aprotinin has been shown to reduce blood loss in a number of surgical specialities. Patients with Duchenne Muscular Dystrophy (DMD) bleed more during surgical procedures than patients without this condition. The aim of this study was to evaluate the effect of aprotinin in reducing blood loss in scoliosis correction surgery in patients with DMD. A retrospective analysis of case notes was performed. Thirty two patients diagnosed with DMD who underwent surgical correction for scoliosis over the last 25 years were included. All patients underwent posterior spinal fusion and instrumentation, between the levels T3 and L3. All procedures were carried out by the same lead surgeon. Patient age, body weight, length of procedure, and estimated blood loss were recorded. Blood loss as a percentage of total circulating volume was calculated and compared between patients who had not received aprotinin (seven patients), and those who did (25 patients). Blood loss as a percentage of total circulating volume in the group of patients with aprotinin (range 37% – 107% mean 67%) was significantly lower (P<
0.05) than the group without aprotinin (range 67% – 157% mean 111%). There was found to be no statistically significant relationship between blood loss and length of procedure. There was no statistically significant difference in the duration of the procedure between the two groups of patients. Despite the small number of patients this study shows a beneficial effect for aprotinin in reducing blood loss during scoliosis correction surgery in patients with DMD.
The standard protocol described by Ponseti was used for treatment. Mean period of follow up was 12 months (6– 30 months). Evaluation was by the Pirani club foot score.
Average number of casts required were 6. Tenotomy was required in 80% of feet. At the latest follow up approximately 15% of feet recurred following treatment and were managed surgically. Poor compliance was noted to be the main cause of failure in these patients. We have recently modified our splint and hope this will address some of the reasons for poor compliance. There was also a smaller subgroup of patients (approximately 5%) which failed to respond to the treatment regime and could not be brought to the point were tenotomy would be appropriate.
The commonest complication (25%) was skiin irritation around the entry site, which invariably resolved after implant removal. Delayed union occurred in 2 femoral and 2 tibial fractures (all healed following bone marrow injection). 2 tibial fractures mal-united and 1 tibial fracture was complicated with compartment syndrome. The average nail removal time was 9 months. The nails could not be removed in 4 cases.
This study shows the efficacy of The Pavlik harness for the treatment of Development Dysplasia of Hip using ultrasonographic monitoring. Between March 1995 and February 2000 we treated 149 dysplastic hips in 117 babies. According to the Graf’s classification 90 were dysplastic type IIB, IIC,IID hips; 59 were dislocated Type IIIA, IIIB and IV hips. Babies were regularly monitored using ultrasound until the age of 26 weeks and radiographs there after for bony roof angle. The Pavlik harness was abandoned if there was persistent dislocation of hip at the end of 3 weeks of treatment. The average full time harness treatment was 12.2 ( range 6–20 ) weeks. The average follow up was 55 ( range 30–90 ) months. The harness failed to reduce 14 hips ( 9.5 % of total hips). These required arthrogram and closed or open reductions. Late presentation beyond 12 weeks and a higher grade on the Graf’s classification reduces the success rate of the pavlik harness treatment. Two cases continue to show a small femoral ossific nuclei at 30 months follow up. The hips treated successfully showed no significant difference in acetabular index from the normal values at follow up radiographs. We conclude that using our protocol, successful initial treatment of Developmental Dysplasia of Hip with the Pavlik harness appears to restore normal development of the hip. We continue to monitor patients by regular radiological surveillance up to 3 years in dysplastic hips and 5 years in unstable and dislocated hips.
Introduction: It is commonly believed that markedly increased femoral anteversion is a primary abnormality and a consistent feature of hip dysplasia. It is also considered to be one of the main factors leading to redislocation. Apart from limited cadaveric studies, the true normal range of anteversion in infants is largely unknown. We measured femoral anteversion in infants using ultrasound. We are presenting our results measuring the femoral anteversion in both normal and DDH hips. Methods and materials: Anteversion measurements are taken at the time of routine ultrasound screening for Developmental Dysplacia of Hip. This method was previously validated. We measured femoral anteversion in 76 infants with normal hips. We measured femoral ante-version in 27 hips with DDH. The mean femoral ante-version in normal babies is compared to the value in the babies with hip dysplasia using unpaired t-test. Results: The mean value of femoral anteversion in normal babies in our series was 46.75° with 95% reference interval of 36.34° to 57.17°. The mean femoral anteversion in dysplastic hips was 50.39° with a 95% reference interval of 34.88° to 65.89°. The difference between normal and dysplastic hips was statistically significant (p value −0.0095 and 95% CI of 6.36° to 0.90°). This showed a small increase of femoral anteversion in the dysplastic hips. Conclusion: We established reference ranges of femoral anteversion in normal and dysplastic hips. Our series showed only a small increase of femoral anteversion in the dysplastic hips. We showed that the markedly increased femoral anteversion was not a primary abnormality in hip dysplasia.