Aims

To assess the accuracy of posterior and anterolateral methods of injection into the subacromial space (SAS) of the shoulder.

To assess outcomes following a radical approach to cases of compartment syndrome in which a significant degree of muscle necrosis is found, 4 paediatric and adolescent patients with a delayed diagnosis of compartment syndrome in which muscle necrosis in single or multiple compartments were treated by radical debridement of necrotic tissue and reconstruction of the anterior compartment through transfer of peroneus brevis to extensor digitorum and hallucis longus tendons. Where suitable, a free vascularised and innervated gracilis muscle transfer to the tibialis anterior tendon stump was carried out with anastomosis of the nerve to gracilis to the deep peroneal nerve.

Free gracilis muscle transfer was functional in one of the two patients whilst peroneus brevis transfer to extensor digitorum and hallucis tendons was functional in all three patients. In one patient, radical debridement resulted in loss of the entire anterior compartment requiring permanent ankle foot orthosis. All others had recovery of protective foot sensation and at minimum follow-up of 12 months were walking unaided. Infection was not seen in any patient.

Prompt fasciotomy, debridement and reconstruction for late diagnosis of compartment syndrome proved limb-saving in our patients.

Aim: The purpose of this study was to evaluate the results of transphyseal ACL reconstruction technique in skeletally immature patients.

Material & Methods: Between 2002 and 2008, twenty knees in twenty skeletally immature patients with a mean chronological age of 13.2 years (range, 7 to 16.2 years) underwent transphyseal reconstruction of the anterior cruciate ligament with use of an autogenous quadrupled hamstrings-tendon graft with metaphyseal fixation. Ten knees had additional meniscal surgery. The functional outcome, graft survival, radiographic outcome, and any growth disturbance were evaluated at a mean of 2.2 years (range, 1.0 to 5.9 years) after the surgery.

Results: No patient underwent revision anterior cruciate ligament reconstruction. The mean International Knee Documentation Committee subjective knee score (SD) was 90.5 (10.0) points and the mean Lysholm knee score was 92.2 (10.0) points. The result of the Lachman examination was normal in 18 knees and nearly normal in two; it was not abnormal or severely abnormal in any knee. The mean increase in total height was 7.2 cm (range, 1.2 to 20.4 cm) from the time of surgery to the time of final follow-up. No angular deformities of the lower extremity were measured radiographically, and no lower-extremity length discrepancies were measured clinically. Complications included one case of knee stiffness requiring physiotherapy, one case of persistent pain leading to medial menisectomy for tear and one case of re-injury five months post ACL reconstruction requiring medial meniscus repair.

Conclusion: Excellent functional outcome was noted in skeletally immature patients after transphyseal reconstruction of the anterior cruciate ligament with use of an autogenous quadrupled hamstrings-tendon graft with metaphyseal fixation. There were very few complications and no growth disturbance.

Aim: The purpose of the study was to report the outcome of Flexible elastic nailing for femoral shaft fractures in children

Materials and Methods: Sixty-three femoral shaft fractures in 62 children treated with titanium flexible elastic nailing over a 10 year period (1998–2007). There were 44 boys and 18 girls aged 7.4 to 15.6 yrs (mean 11.2 yrs). Their body weight ranged from 22 to 64.80 kg (mean 40.99 kg). The right side was involved in 36 and the left in 27 children (including 1 bilateral fracture). The mechanism of injury varied from Road traffic accidents (RTA) in 42, Sports in 2 and Falls in 18 children. The proximal third shaft was involved in 3, middle third in 50 and distal third in 10 children. The fracture pattern varied from Transverse in 28, Oblique in 21, Spiral in 12 and Comminuted in 2 children.

Results: All fractures united with a mean union time of 15 weeks (range 6 to 30 weeks). The average follow-up was 72 weeks (range 52–104 weeks). Outcome assessment using the Titanium Elastic Nailing (TEN) Score showed 63% excellent, 32% satisfactory and 5% poor results. The minor complications varied from transient knee stiffness in 8 children, prominent nail ends in 7 children, extensor lag in 2 children, and acceptable facture angulation in 2 children. The major complications were fracture malunion, non-union, delayed union in 1 child each and re-fracture at different level in one child. The mean leg length discrepancy after union was 8mm (range 0–13 mm). There were no cases of infection. This method of treatment provided stable fixation, early mobilization and discharge.

Conclusion: We found that good surgical technique with attention to surgical details resulted in 95% excellent to satisfactory outcome.

Spinal anaesthetic (SA) with intrathecal diamorphine and general anaesthetic (GA) with blocks and/or patient control analgesia (PCA) are commonly used in hip and knee replacement surgery. Drop in blood pressure, feeling light-headed and drowsiness, itching are known early complications respectively. This causes delay in patient mobilization post operatively. Our study examines the use of a local anaesthetic infuser device (LAID) (pain buster pump) for post operative pain relief after total hip or knee replacement surgery.

Forty six patients (25) THRs and (21) TKRs were included in this study. Each were given a LAID which consisted of 0.25% bupivicaine infused at 4ml/hr via an elastometric pump over 48 hours. 100mls of 0.1% bupivicaine with 0.5mg adrenaline was infiltrated locally into the wound at closure. All patients were prescribed regular analgesic as per the multimodal pain regime and an hourly pain score maintained. Rescue opioids were prescribed if pain score crossed 5. Patient satisfaction score was recorded as excellent, some or no pain relief. Eleven patients were given general anaesthetic and 25 patients were given spinal anaesthetic.

26% were able to sit out of bed within 6 hours of surgery and 65% (30 patients) were sitting out by the first post operative day. Average length of stay was 6.15 days, decreased to 4 days for patients mobilised on day zero and compared to eight days prior to this study. 21% had excellent result, 29% had some pain and 6% had poor result. 90% needed oral rescue analgesia within the first 48 hours.

LAID allowed some patients to be mobilised within 6 hours of surgery. The use of LAID helps avoids the need for PCA or diamorphine and hence its associated complications though some amount of oral rescue analgesia was necessary. Patient compliance was satisfactory. The early results are encouraging and further studies are been conducted at our hospital.

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.

Aim: The dorsal flange stem was introduced following reports of stem fracture using the Charnley “flat-back” stem. This retrospective study reports the outcome using the Flanged Charnley stem in total hip replacement.

Materials and methods: Between January 1983 to December 1996, 1170 cemented total hip replacements (915 patients) were performed using the flanged Charnley stem. The main indications were osteoarthritis, rheumatoid arthritis and avascular necrosis. There were 532 females and 383 males aged 32 to 83 years (average 70.2 years). 612 patients were alive at an average follow-up of 16.6 years (9 to 22 years). All operations were performed by the trans-trochanteric or antero-lateral approach. Patients were evaluated using the Charnley’s modification of Merle d’Aubigne system.

Results: All patients had an improvement in function following the operation. Aseptic loosening of the stem was noted in 32 patients. Survivorship to revision of the femoral stem was 94% at 10 years (95% CI, 89%–99%) and 90% (95% CI, 81%–99%) at 15 years. The common complications included dislocation, wire breakage and trochanteric non-union. Femoral stem fracture resulted in 1 patient requiring stem revision.

Conclusion: The use of the Flanged Charnley stem in total hip replacement gives good long term outcome.

Introduction: We previously reported our results of 98 Charnley Low-Friction Arthroplasty in 76 patients with Paget’s disease of the hip at an average follow-up of 10.4 years. The current report presents the outcome of this procedure at 15 to 30 years.

Methods: A total of 98 Charnley low-friction arthroplasties were performed on 76 patients, 27 men (37 hips) and 49 women (61 hips) with an average age of 67.4 years (range 51–79 years). All operations were performed by the trans-trochanteric or antero-lateral approach.

Results: When component revision was used as the endpoint, the survivorship of the acetabular component was 93% at 15 years (CI, 81% to 98%), 83% at 20 years (CI, 59% to 93%), 72% at 25 years (CI, 41% to 89%) and 36% at 30 years (CI, 2% to 78%). The survival of the femoral component was 91% at 15 years (CI, 80% to 96%), 84% at 20 years (CI, 60% to 94%), 84% at 25 years (CI, 60% to 94%) and 72% at 30 years (CI, 38% to 89%). The survival of both components was 89% at 15 years (CI, 76% to 95%), 81% at 20 years (CI, 56% to 92%), 81% at 25 years (CI, 56% to 92%) and 81% at 30 years (CI, 56% to 92%).

When component failure was used as the endpoint, the survivorship of the acetabular component was 78% at 15 years (CI, 64% to 87%), 66% at 20 years (CI, 48% to 80%), 43% at 25 years (CI, 21% to 62%) and 12% at 30 years (CI, 2% to 32%). The survival of the femoral component was 76% at 15 years (CI, 62% to 85%), 67% at 20 years (CI, 48% to 80%), 47% at 25 years (CI, 25% to 67%) and 7% at 30 years (CI, 1% to 26%). The survival of both components was 74% at 15 years (CI, 59% to 83%), 64% at 20 years (CI, 44% to 78%), 43% at 25 years (CI, 20% to 64%) and 7% at 30 years (CI, 1% to 27%).

Discussion and Conclusion: Long term results using Charnley’s Low Friction Arthroplasty achieved in this patient group are comparable to general arthroplasty population.

(Previous report: Charnley low-friction arthroplasty for Paget’s disease of the hip.

J Arthroplasty. 2000 Feb;15(2):210–9).

Aim: The aim of this study was to evaluate management of non-articular distal tibial fractures.

Materials & Methods: Between January 2000–December 2004, we treated 25 children with a non-articular distal tibia fracture. All fractures were isolated high velocity injuries (11-Road traffic accidents; 14-Sports injuries) without neurovascular compromise. Only 2 out of 25 were open (grade I) fractures. There were 19 males and 6 females aged 7–16 years (average 11.4 years). On radiography, the fracture patternsvaried from transverse-7 patients, spiral-8 patients, short oblique-7 patients, and communited-3 patients.16 patients had an associated fibula fracture. 20 of the 25 fractures were primarily treated in a cast while the remaining 5 were primarily treated by external fixator (3-Orthofix; 2-Ilizarov) as closed reduction was unstable. The average period in cast/external fixator was 8.4 weeks and the average follow-up 6.2 months.

Results: On early follow-up, 8 of the 20 fractures (40%) that were initially treated in a cast needed intervention (plaster wedging-5; external fixator-3) because of displacement/angulation of the fracture. 7 (28%) of the 8 fractures needing intervention were short oblique fractures. There was no correlation between open injury/associated fibula fracture and displacement/angulation.

Conclusion: Short oblique fractures had a high failure rate with cast treatment. We recommend close monitoring with weekly radiographs for cast treated fractures or alternately primary external fixation of unstable, short oblique fractures.

Introduction and Aim: While displaced metaphyseal and diaphyseal fractures in children with severe spastic cerebral palsy have been reported in literature, there is no reference to epiphyseal separations in this group. Physeo-epiphyseal injuries have been reported in meningomyelocoele patients, but these injuries differ significantly in their etiology and natural history.

Method and Results: We report nine epiphyseal separations involving the distal femur and proximal humerus in four severely handicapped children with spastic cerebral palsy, and find scurvy to be the major cause of such epiphyseal slips. These epiphyseal slips have a good prognosis unlike those reported in MMC children. Treatment with vitamin C and splintage, without any attempt at reduction, resulted in rapid healing with excellent remodelling. Scurvy should be considered a potential cause for an epiphyseal slip in a child suffering from severe cerebral palsy.

Conclusion: We recommend routine vitamin C dietary supplementation in this group of malnourished, non-ambulant children.