Introduction:

This study evaluates the mid-term results of first metatarsophalangeal joint replacement (MTPJR) for hallux rigidus using the Toefit-Plus™ prosthesis.

The lateral pillar classification (LPC) is a widely used tool in determining prognosis and planning treatment in patients who are in the fragmentation stage of Perthes disease. The original classification has been modified to help increase the accuracy of the classification system by the Herring group. The purpose of our study was to independently assess this modified Herring classification.

35 standardized 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. The degrees of agreement were as follows: poor, fair, moderate, good and very good.

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 study highlights the lack of agreement between senior clinicians when applying the modified LPC. This has clinical implications when applying the classification to the decision making process in treating patients at risk of developing adverse outcomes from the disease. To our knowledge, this is the first time the modified LPC has been independently tested for its reproducibility by another specialist paediatric orthopaedic unit.

This study was designed to assess the utility of the scarf osteotomy in the management of symptomatic adolescent hallux valgus.

Purpose of this study

This study was designed to assess the utility of the scarf osteotomy in the management of symptomatic adolescent hallux valgus.

The purpose of our study was to independently assess the modified Herring lateral pillar classification.

Aim

To assess the risk of hip dislocations in children with cerebral palsy (CP) attending special schools, and the effects of preventative soft tissue surgery (psoas and adductor tenotomy).

Osteoarthritis (OA) is a common degenerative disease associated with aging thatas yet has no cure. Glucosamine (Gln) is a naturally produced amino sugar that forms part of the cartilage matrix and is taken by millions of OA sufferers in the hope of alleviating their symptoms. Apart from alleviating pain, there is evidence in the literature that Gln may also be a chondroprotective drug in OA and some clinical trials have shown reduced joint space narrowing in patients taking 1mg Gln per day. However, the mechanisms by which Gln might have its beneficial effects are still uncertain.

We wanted to determine whether Gln has any influence on the aberrant gene expression that takes place in OA chondrocytes. To this end, we cultured healthy articular chondrocytes and induced aberrant gene expression with TNF-α /OSM. Healthy human chondrocytes were isolated from the cartilage of the femoral head obtained after hemiarthroplasty from four patients who had fractured the neck of their femur. Each sample was divided in to 4 groups prior the monolayer culture:

Control culture,

At confluency (~ 2 weeks) RNA was extracted for analysis of mRNA expression by RT-PCR. The impact of Gln on the expression if the inflammatory cytokine IL-1b and the protease MMP-13 was determined by conventional RT-PCR.

No expression of IL-1b was found in control cultures and Gln on its own did not induce expression. As expected, TNF-a/OSM induced the expression of IL-1b in all four patients. When Gln was present together with TNF-a/OSM, IL-1b expression was prevented in two patients and considerably reduced in the other two patients. With respect to MMP-13, expression was present in 3/4 cultured controls and Gln did not influence this expression. TNF-α /OSM increased expression of IL-1b, and the cytokine-induced expression was slightly reduced by Gln in 2/4 patients.

These results suggest that Gln prevents the TNF-α /OSM-induced expression of IL-1b, but has limited direct influence on MMP-13 expression, at least in vitro. If the data are applicable to the in vivo situations, the results support the proposed chondroprotective effect of glucosamine at the cellular level.

Aim: To assess the ease of use and reliability of PICC lines for the delivery of intravenous antibiotics in children with septic joints.

Method: Over a twelve month period 22 children with septic joints were prospectively recruited. All received open arthrotomy and washout prior to commencing antibiotic treatment. At the time of surgery, a PICC line was inserted. All children were given intravenous antibiotics for two weeks then oral antibiotics for four weeks. Inflammatory blood markers were reviewed regularly. Upon removal of the PICC line the tip was sent for microbiological testing.

Results: All 22 children made a full recovery with a minimum of twelve months follow up (range 12–20 months). All PICC line tips were negative for microbiological culture after 48 hours.

Conclusion: Peripheral cannulation for intravenous access in children can be challenging. Younger children have chubby limbs and often fragile veins. Even with the use of topical analgesics the procedure can be traumatic for a young child. A PICC line inserted at the time of the surgical washout of the infected joint seems an ideal solution. PICC lines are safe, reliable and allow for at least two weeks of intravenous access, avoiding the need for regular re-cannulation of children.

Purpose: To alert the Orthopaedic fraternity that smoking needs to be considered in the Paediatric population and highlight it’s adverse effect on bone healing index.

Method: During assessment of Paediatric patients who had undergone limb reconstruction surgery, a sub-population was found to have a prolonged time to consolidation of the regenerate to norm. Screening for contributing factors, we were surprised to learn that this subgroup were active smokers. Revisiting their radiographs, it was felt that the quality of the regenerate appeared to differ from non-smokers.

Results: We identified 12 patients who were active smokers. 2 also had parents who smoked. They all exhibited a prolonged time to regenerate consolidation. We calculated their bone healing indices to compare with non smokers and found significant differences.

Conclusion: Smoking has adverse effects on bone healing in children as well as adults. We have drawn up an advise sheet to make patients and their parents aware of the adverse effects of active and passive smoking on bone healing.

Introduction: Prophylactic pinning of an asymptomatic hip in SCFE is controversial. Bone age has been used as evidence of future contralateral slip risk and used as an indication for such intervention. The efficacy of bone age assessment at predicting contralateral slip was tested in this study.

Patients and Methods: 18 Caucasian children prospectively had bone age assessment using wrist and hand x-rays when presenting with a unilateral SCFE. Patients and parents were informed about the chance of con-tralateral slip and risks of prophylactic fixation, and advised to attend hospital immediately on development of symptoms in contralateral hip. After in-situ fixation of the affected side prospective monitoring in outpatient department was performed. Surgical intervention was undertaken if the contralateral hip was symptomatic.

Results: Three children (2 boys) went on to develop to a contralateral slip at a mean of 20 months from initial presentation. 6 children (5 boys) were deemed at risk of contralateral slip due to a bone age below 12.5 years for boys and 10.5 for girls. Only one from this group developed a contralateral slip. The relative risk of proceeding to contralateral slip when the bone age is below the designated values was 1 (95% confidence interval of 0.1118 to 8.95). The sensitivity and specificity were 33% and 66% respectively. With positive predictive value of 15% and diagnostic efficiency of 61%.

Conclusion: Delayed bone age by itself is not a good predictor of future contralateral slip at initial presentation. Routine prophylactic pinning is not justified based on bone age alone, with the risks of surgical fixation it carries. Prospective long term longitudinal study is required.

Introduction: Prophylactic pinning of an asymptomatic hip in SCFE is controversial. Bone age has been used as evidence of future contralateral slip risk and used as an indication for such intervention. The efficacy of bone age assessment at predicting contralateral slip was tested in this study.

Patients and Methods: 18 Caucasian children prospectively had bone age assessment using wrist and hand x-rays when presenting with a unilateral SCFE. Patients and parents were informed about the chance of con-tralateral slip and risks of prophylactic fixation, and advised to attend hospital immediately on development of symptoms in contralateral hip. After in-situ fixation of the affected side prospective monitoring in outpatient department was performed. Surgical intervention was undertaken if the contralateral hip was symptomatic.

Results: Three children (2 boys) went on to develop to a contralateral slip at a mean of 20 months from initial presentation. 6 children (5 boys) were deemed at risk of contralateral slip due to a bone age below 12.5 years for boys and 10.5 for girls. Only one from this group developed a contralateral slip. The relative risk of proceeding to contralateral slip when the bone age is below the designated values was 1 (95% confidence interval of 0.1118 to 8.95). The sensitivity and specificity were 33% and 66% respectively. With positive predictive value of 15% and diagnostic efficiency of 61%.

Conclusion: Delayed bone age by itself is not a good predictor of future contralateral slip at initial presentation. Routine prophylactic pinning is not justified based on bone age alone, with the risks of surgical fixation it carries. Prospective long term longitudinal study is required.

To assess the reliability of the pre-operative measurement methods used in the management of the hallux valgus deformity, five observers assessed 50 pre-operative standing foot radiographs on two occasions in order to assess the reliability of radiological hallux valgus assessment using the inter-metatarsal angle (IMA), hallux valgus angle (HVA) and joint congruency. Five published methods of angle measurements described by Hawkins, Venning and Hardy, Mitchell, Miller and Nestor were used.

Kappa statistics were used to assess the reliability of the diagnosis of congruency. Regarding IMA and HVA, mean values between the methods were assessed by one-way ANOVA. The differences between the methods and observers were assessed by two-way ANOVA.

Results: Diagnosis of congruency showed good agreement (k=0.608) over two occasions, although this did vary by observer.

The mean IMA and HVA measurements varied significantly between methods on both occasions (p< 0.0001). Mitchell’s method had the lowest and Miller’s the highest mean values.

Analysis of variance showed both method and observer variations were significant for IMA. But HVA measurements differed significantly only by observers.

Conclusion: The reliability of IMA and HVA measurements is poor whichever measuring method is used and these methods are not interchangeable. Study papers should state the measurement method used. For the pre- and post-operative assessment the same method should be used.

Introduction: Prophylactic pinning of an asymptomatic hip in SCFE is controversial. Bone age has been used as evidence of future contralateral slip risk and used as an indication for such intervention. The efficacy of bone age assessment at predicting contralateral slip was tested in this study.

Patients and Methods: 18 Caucasian children prospectively had bone age assessment using wrist and hand x-rays when presenting with a unilateral SCFE. Patients and parents were informed about the chance of contralateral slip and risks of prophylactic fixation, and advised to attend hospital immediately on development of symptoms in contralateral hip. After in-situ fixation of the affected side prospective monitoring in outpatient department was performed. Surgical intervention was undertaken if the contralateral hip was symptomatic.

Results: Three children (2 boys) went on to develop to a contralateral slip at a mean of 20 months from initial presentation. 6 children (5 boys) were deemed at risk of contralateral slip due to a bone age below 12.5 years for boys and 10.5 for girls. Only one from this group developed a contralateral slip. The relative risk of proceeding to contralateral slip when the bone age is below the designated values was 1 (95% confidence interval of 0.1118 to 8.95).

Conclusion: Delayed bone age by itself is not a good predictor of future contralateral slip at initial presentation. Routine prophylactic pinning is not justified based on bone age alone, with the risks of surgical fixation it carries. Prospective long term longitudinal study is required.

Aims: To assess the reliability and repeatability of the þve described methods of measuring hallux valgus (HVA) and intermetatarsal angles (IMA). The diagnosis of congruency of þrst MTP joint was also assessed. Methods: Five Orthopaedic staff analysed 50 pre-operative standing foot radiographs on two occasions. ANOVA was used to examine the difference between the þve methods and between the þve observers, for both IMA and HVA. Kappa test was used to measure agreement in diagnosing congruency between two occasions. Results: The mean IMA and HVA varied signiþcantly between some of the methods (p< 0.00001). The ANOVA model showed that both method and observer variations (p=0.0264 and p< 0.001 respectively) were signiþcant for IMA and there was no signiþcant difference between measurement methods (p=0.7882) for HVA. The intraobserver reliability of congruency was good (k=0.608) but the interobserver reliability was only fair (k=0.261). A second IMA measurement will lie between 4.2û less and 4.6û more than the þrst IMA measurement 95% of the time. A second HVA measurement will lie between 6û less and 5.6û more than the þrst HVA measurement 95% of the time. Conclusions: This study shows that the different methods give signiþcantly different results. The methods are, therefore, not interchangeable. There was no advantage to any of the method in terms of reliability. All methods had considerable inter- and intra- observer variability that makes these measurements unreliable.

The five different methods of measuring hallux valgus (HVA) and intermetatarsal angles (IMA) and the diagnosis of congruency of first MTP joint were studied on 50 pre-operative standing foot radiographs, to test if these methods were reliable and the results reproducible enough to be used in a treatment algorithm for hallux valgus.

Analysis of variance (ANOVA) was used to examine the difference between the five methods and between the five observers. Kappa test was used to measure agreement in diagnosing congruency between two occasions.

The mean IMA and HVA varied significantly (p< 0.00001). The ANOVA model showed that method and observer variations were both significant for IMA; there was no significant difference between measurement methods for HVA. Congruency had good (k=0.608) intraobserver and fair (k=0.261) interobserver reliability. A second IMA measurement will lie between 4.2° less and 4.6° more than the first IMA measurement 95% of the time. A second HVA measurement will lie between 6° less and 5.6° more than the first HVA measurement 95% of the time.

Overall, there was no advantage to any of the measurement methods, although some observers were better than others. All methods had considerable inter- and intra-observer variability that makes these measurements unreliable.

We followed up 82 patients who under went 92 Furlong Hydroxyapatite coated uncemented femoral stem, and threaded acetabular component. All hips had a 28mm ceramic heads.

These hips were inserted between the periods 1989–1992. The mean age of the patients at the time of surgery was 54(31–67).

At the ten year follow up there were 64 patients with 70 hips. 5 hips were revised. 3 for acetabular component loosening, 2 for infection. 8 patients died from unrelated causes, 3 refused to attend but filled in the Oxford hip score by mail, 2 were lost to follow up.

At 10 years follow-up the mean age was 64(41–77) years. The Oxford, and the Harris hip scores were used to Asses the patients clinically, and a standard AP pelvis X-Ray showing both hips was performed

Clinically we found that the mean Harris hip score was 90 (51 – 100), the mean Oxford hip score 20 (12 – 45).

Radiographic assessment showed good component fixation with uniform bone growth around the components. The average angle of the Acetabular component was 52 (40– 60). 21 hips showed polyethylene wear in the acetabular component, 5 had more than 2mm wear, and 1 had more than 3mm of poly wear.

36 (52%) of the hips showed proximal calcar remodelling.

We conclude that the Furlong HA coated THR is an excellent THR for the young patient who has a higher activity demand with a cumulative survival rate of 94.29% (CI ±5.2).