Prophylactic stabilisation with internal fixation of the asymptomatic hip in unilateral slipped capital femoral epiphysis is controversial. The incidence of bilaterality varies from 20–80% depending on the length of follow-up. The opposite hip has 2335 times higher incidence of developing a slip in cases of a unilateral slip at presentation and there is no chemical, anatomic or radiological feature which can predict a slip. The arguments regarding prophylactic fixation are based on risks of AVN, chondrolysis, and problems with implant removal and joint penetration We present a retrospective analysis of sixty-five patients who had prophylactic fixation of the uninvolved hip at the same time as their opposite slipped femoral physis. None had an underlying systemic or endocrine disorder and the average age was 12.5 years (range 11–15 years).A single 7.0 mm cannulated screw was used in all cases. The average time to fusion was 18 months (range 6 to 36 months) and duration of follow up ranged from 3–8 years (mean 4.5 years). None of the patients had implant removal and at latest review did not show any evidence of chondrolysis, avascular necrosis, premature physeal arrest or secondary arthrosis in the prophylactically fixed hip. There were a couple of cases of inadvertent wire penetration into joint, which were recognised and rectified immediately, and a correct length screw inserted. Both these patients had an uneventful post-operative course with no problems of chondrolysis etc at latest follow-up (5 years). One patient (1.5%) developed a superficial wound infection, which cleared up with antibiotics.
The treatment of acetabular dysplasia in adolescents (age>
12) is difþcult and various complex pelvic osteotomies have been described. The aim of surgery being improvement in pain and to delay the onset of secondary osteoarthrosis.
Children with osteogenesis imperfecta(OI) have multiple long bone fractures with subsequent deformities. The mainstay of treatment is correction with multiple osteotomies and intramedullary fixation. The Shefffield intramedullary telescoping rod system has been successful in the treament of long bone fractures and deformities (Wilkinson et al ,JBJS-B,1998) Bisphosphonates (Pamidronate -1- 1.5mg/kg/day)have been used as adjuvant therapy in the treatment of OI since the last five years. The perceived benefits include reduction in fracture frequency, improvement in bone density and a general feeling of well being. We present our experience of five cases of OI who developed infections around thier Sheffield telescoping rods while on Pamidronate therapy. There was only one case of sepsis over a ten year period(over eighty patients)in a previously reported series from our centre. The time interval between the start of Pamidronate therapy and the diagnosis of infection varied between 12–36 months ie. between 4–12 cycles of Pamidronate (parenteral administration over a three day period at three month intervals). All patients had their intramedullary rods in situ from anywhere between 2–7 years. The infections were low grade with a 2–3 month period of dull ache prior to actual presentation. Intrestigly though all patients had multiple rods in situ, only one of their femoral rods was affected and they did not have any other infective focus at the time of diagnosis. Three patients presented with thigh abcesses while the other two presented with ipsilateral knee pain and effusion. All had raised inflammatory markers, radiological signs of sepsis with Staph Aureus the commonest infecting organism. Those cases presenting with abcesses were treated by drainage and rod removal, however only antibiotics were sufficient in the rest. The relationship between Pamidronate therapy and these infections is not absolutely clear and has not been reported previously. The possible links are discussed and a high degree of suspicion is recommended for those cases of OI on bisphosphonate
Craniovertebral tuberculosis accounts for 5% of all cases of tuberculosis and is the commonest infective pathology affecting this region. There are very few published reports discussing the presentation and management of this complex pathology. 30 cases of craniovertrebral tuberculosis treated between 1989–97 were reviewed retrospectively. The average age was 24 years (range 6 – 42 years) with a follow up of 41 months (range 36 – 48 months). Two main groups on the basis of atlantoaxial stability. 18 (60%) had an unstable atlantoaxial articulation and of these 12 (66%) had a fully reducible AAD in extension. 17 patients (56%) had varying degrees of neurological deficit with lower limb spasticity being the commonest. Antituberculous chemotherapy, skeletal traction in extension and prolonged bracing with moulded philadelphia collar were main stays of conservative treatment. Surgery in the form of posterior occipito cervical arthrodesis was needed in 13 patients (43%) and indications included incompletely reduced AAD, non resolving neurological deficit and persistent instability despite 6 weeks in traction. There was 93% success rate with resolution of infection (range 4 – 8 months) and improvement in neurological deficit 2 patients had incomplete neurological recovery and required 2nd stage anterior transoral odontoidectomy. Management strategies based on the presence or absence of instability and neurological deficit can give a very satisfactory outcome with judicious combination of drug therapy, bracing and surgical decompression with fusion.
