BACKGROUND

Most closed tibial fractures in children can be treated conservatively. On the occasions that surgical intervention is required, there are various options available to stabilise the fracture. We would like to present our experience of using monolateral external fixators in the management of closed tibial fractures.

The aim was to assess the value of the GP 6–8 week hip examination.

In a 15-year prospective observational longitudinal cohort study, every infant referred by the GP with suspected pathological developmental dysplasia of the hip (DDH) had their hip joints clinically and sonographically examined in a specialist hip screening clinic. Graf Type IV and dislocated hips were classified as pathological. Screening failures were defined as those who had not been identified by the 6–8 week check and presented with late instability. Secondary univariate and multivariable analysis was performed to determine which clinical findings are predictive of instability.

64,518 infants underwent the 6–8 week GP check. Of 176 referrals, 5 had pathological hips. 13 screening failures, presented between the ages of 17 and 80 weeks. The 6–8 week check has a sensitivity of 28% and a specificity of 99.7%.

Univariate analysis revealed positive Ortolani tests and patients referred as ‘unstable hip’ to be significant predictors of hip pathology. Clicky hips, asymmetric skin creases, and leg length inequality were not predictive of pathological hips. A multivariable model showed a positive Ortolani test to be the sole independent predictor of instability at 6–8 weeks.

This is the first attempt to test the validity of the 6–8 week GP clinical hip check. A low rate of hip pathology was identified. The high rate of false negatives raises questions about the value of screening at this age. At 6–8 weeks, clinical signs of hip instability are unreliable as hips become irreducible and stiff.

Based on our findings, we recommend that at 6–8 weeks, referrals are only made if the Ortolani test is positive. We advocate the reintroduction of the 8-month check, including an assessment for limited hip abduction, which may improve the detection rate of those missed by initial screening.

We report our early experience with distracting external fixation used to offload the hip after avascular necrosis (AVN) of the femoral head secondary to severe slipped upper femoral epiphysis (SUFE).

A case series of five patients treated in a tertiary centre is reported. Electronic case records and radiographs were reviewed. Data recorded included demographics, initial presentation, timing of head collapse, timing and duration of distraction and outcome including referral to adult arthoplasty services.

Mean age at presentation was 12 years (range 12–15). 4 were females. Initial treatment in 4 cases was a delayed cuneiform osteotomy and pinning, one patient underwent serendipitous reduction and percutaneous pinning. Mean duration to initial surgery was 10 days (range 5–16). All patients had femoral head collapse at a mean of 148 days from time of presentation. 2 patients required backing out of screws due to intra-articular protrusion. All patients underwent distraction at a mean 193 days from presentation. Average distraction achieved was 10 mm and duration of application was 125 days (range 91–139)

All patients experienced improvement or resolution of pain but persistence of poor function, characterised by fixed adduction and limb length discrepancy. 3 patients were referred to adult arthroplasty services.

This may be an effective treatment option for pain associated with AVN post SUFE. However, in our experience normal anatomy and function of the hip is not restored if performed after collapse of the femoral head. Consideration should be given to application of the distractor either at the time of initial fixation or prior to femoral head collapse. Authors believe that timing of the application of the distractor is critical for a successful outcome and recommend a prospective study with large numbers.

Aims:

To assess the success rate of closed reduction after failing Pavlik harness for treatment of DDH.

This study sought to determine if treatment of resistant clubfeet by the Ilizarov method influenced the pattern of recurrence. Forty-seven children were identified as having undergone treatment by the Ilizarov method. Inclusion criteria for treatment with the Ilizarov method were clubfeet belonging to diagnostic categories that had recognised tendencies for resistance to standard methods of clubfoot management or a previous history of soft tissue releases performed adequately but accompanied by rapid relapse.

There were 60 feet with a mean follow-up of 133 months (46-224). Diagnoses included 34 idiopathic types, 7 arthrogryposis, 1 cerebral palsy, and 5 other. Summary statistics and survival analysis was used; failure was deemed as a recurrence of fixed deformity necessitating further correction. This definition parallels clinical practice where attainment of ‘normal’ feet in this group remains elusive, and mild to moderate relapses that remain passively correctable are kept under observation.

Soft tissue releases were common primary or secondary procedures. The mean time to revision surgery, if a soft tissue release was undertaken as a primary procedure, was 36 months (SD 22), and 39 (SD 23) months if undertaken for the second time. This compares with 52 months (SD 32) if Ilizarov surgery was used. Using survival analysis, there is a 50% chance of a relapse sufficiently marked to need corrective surgery after 44 months following the first soft tissue release, 47 months if after the second soft tissue procedure and 120 months after the Ilizarov technique.

We conclude that resistant club feet, defined as those belonging to diagnostic categories with known poor prognoses or those that succumb to an early relapse despite adequate soft tissue surgery, may have longer relapse-free intervals if treated by the Ilizarov method.

Introduction: Lengthening for congenital femoral hypoplasia is associated with a significant refracture rate and problems in recovery of knee motion. We present a series of 7 patients where two techniques of lengthening were used and recovery of knee motion compared.

Methods: This is a retrospective study. The outcome of interest was recovery of knee motion. All children were diagnosed to have congenital femoral hypoplasia. In two patients (group A), conventional metaphyseal osteotomies of the femur and tibia, with ankle and knee bridging fixators were applied. In the remaining five (group B), a combination of soft tissue releases, patella ‘capture’, a modified external fixator configuration and early conversion to internal fixation was used. Osteotomies of tibia and femur were performed in the mid-shaft and lengthening progressed at 0.75 mm per day. At 4 months, before regenerate consolidation, both femur and tibia were plated using a submuscular technique. The limb was supported in a cast, which was replaced by a brace at 3 weeks and knee motion exercises started. Lengthening was kept to within 15% in both groups.

Results: Recovery in knee flexion to greater than 90 degrees was accomplished by 4 of the 5 Group B patients by 4 months. One patient failed to attend for physiotherapy and did not progress with knee motion recovery. One patient sustained a fracture proximal to the submuscular plate which needed revision surgery. This did not hinder progress with knee motion recovery. In comparison, patients in group A reached 90 degrees of flexion at 12 months with one patient not exceeding 85 degrees at final follow up and subsequently needing a quadricepsplasty.

Conclusion: Recovery of knee motion may be assisted by soft tissue releases in combination with early conversion to internal fixation.

Aim: To assess whether use of the Pavlik harness for the management of developmental dysplasia of the hip (DDH) can safely be discontinued without weaning.

Method: The study group comprised babies diagnosed with DDH at the Royal Liverpool Children’s hospital over a 10 year period, between January 1995 and August 2004. The decision to instigate treatment with a Pavlik harness was based upon the Graf grade. We used Graf IIB or worse as our treatment threshold for the use of the Pavlik harness. In our practice the harness was removed when the hips were ultrasonographically and clinically normal, without a period of weaning.

Results: There were 368 hips (273 babies) for analysis, 178 cases of unilateral DDH (128 left hips and 50 right hips) and 95 bilateral cases. Mean age at diagnosis was 59 days (range 1 – 187 days) with twenty-six patients presenting late after the usual 120 day time limit. Treatment with the Pavlik harness was successful in normalising 323 hips (87.8%). The Pavlik harness was unsuccessful in reducing 45 dislocations (12.2%). Patients were followed-up for a mean of 4.1 ± 2.7 years with no deterioration of acetabular indices on plane radiographs, according to the Tonnis classification. There were 4 hips with possible grade I avascular necrosis. To date there have been no cases of late dysplasia.

Conclusions: Although many units remove the harness after a period of gradual weaning, practice is varied. Since we did not encounter any negative outcome despite not weaning we conclude that that weaning is unnecessary.

Introduction: Propionibacterium acnes (P. acnes), a common anaerobic skin commensal, has been implicated in biomaterial-related infections (BRI). Bacteria can adhere to biomaterial surfaces and grow as a bio-film held together by exopolymer, exhibiting increased antimicrobial resistance. To our knowledge, images of P. acnes biofilms have not previously been published. We have demonstrated the ability of P. acnes to adhere to surgical steel and to develop a biofilm on this material. However its ability to adhere to and develop a biofilm on titanium, a commonly used surgical implant material, has not been fully investigated.

Aims:

To determine the quantitative adherence and biofilm development of P. acnes on titanium compared to surgical steel.

Method: Six clinical isolates of P. acnes were assayed for adherence to materials with and without plasma glycoprotein conditioning film by chemiluminescence and culture. Biofilm development was assessed by chemiluminescence, fluorescence microscopy, environmental (ESEM) and scanning electron microscopy (SEM). Mature biofilms were exposed to plasma concentrations of penicillin and quantified by chemiluminescence and culture. Unpaired student’s t tests and univariate linear regression models were calculated using SPSS software (version 12).

Results: Univariate linear regression showed that P. acnes adherence to titanium was 18% (p=0.001) greater than to steel. Adherence was reduced by the presence of the conditioning film on titanium by 28% (p=0.001), but this made no significant difference to P. acnes adherence to steel. P. acnes biofilms were clearly demonstrated, along with bacterial expolymer, showing an interesting similarity to biofilms of S. epidermidis. P. acnes grows as a thick biofilm on both materials held together by exopolymer and our preliminary results suggest that biofilms on titanium might be less susceptible to antimicrobials after 24 hours of penicillin treatment; a reduction of 94% on steel and 81% on titanium (p=0.057, p=0.39 resp).

Conclusions: P. acnes adheres to steel and titanium, a crucial first step in BRI. Greater numbers of P. acnes adhere to titanium than to steel. The naked surface of titanium is microporous, assisting adhesion. A conditioning film reduces P. acnes adherence to titanium but not to steel. P. acnes develops as a biofilm on steel and titanium. Results indicate that pathogenesis of P. acnes infection on titanium is more successful than on steel. P. acnes biofilms on titanium may be harder to eradicate with antimicrobial agents.

Aims: This study shows the efþcacy of The Pavlik harness for the treatment of Development Dysplasia of hip (DDH) using ultrasonographic monitoring. Methods: Between 1995–2000 we treated 149 dysplastic hips in 117 babies. According to the Grafñs classiþcation 90 were dysplastic type IIB, IIC, IID hips; 59 were dislocated Type IIIA, IIIB and IV hips. Babies were regularly monitored using ultrasound unto 26 weeks and radiographs up to 5 years in dislocated hips for bony roof angle. Results: The average full time harness treatment was 12.2 (range 6–20) weeks, average follow up was 55 (range 30–90) months. The harness failed to reduce 14 hips (9.5% of total hips). Two cases continue to show a small femoral ossiþc nuclei at 30 months follow up. The hips showed no signiþcant difference in acetabular index from the normal values at follow up radiographs. Conclusions: We conclude that using this protocol, successful initial treatment of DDH with the Pavlik harness appears to restore normal development of the hip.

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.