Objective

To compare the effectiveness of arthrodiastasis with shelf acetabuloplasty for Perthes' disease in older children, by assessing the radiological outcome in matched pairs of children at skeletal maturity.

Aim

To assess if Osteoset (CaSO4) improves graft incorporation after shelf procedure and whether spica immobilisation is necessary

Aim: To assess the outcome for Perthes disease in children over eight treated by observation, varus osteotomy, abduction plasters and acetabular augmentation.

Methods and results: A retrospective case note review of prospectively collected data for 44 children (48) hips with Catterall grades 2, 3 or 4 Perthes’ disease with onset age eight or older and followed to maturity was performed. The groups were demographically similar. For all groups combined 60% had a satisfactory Stulberg grade I to III outcome. Poorer outcomes (as assessed by Stulberg, centre edge angle and Reimer’s migration index) were associated with increasing age, greater initial head deformity and greater head involvement. Initial head deformity did not remodel for any treatment group. Indeed, progressive head deformity occurred despite plaster treatment or varus osteotomy but not after acetabular augmentation. Hips managed by acetabular augmentation also had better outcomes than the other groups for Stulberg, Reimer’s index and centre-edge angle.

Conclusions: Whatever the treatment the outcome for Perthes’ disease in children over eight is poorer with increasing age. No treatment offers the prospect of a good result in the older child with significant head involvement or significant initial deformity but acetabular augmentation seems to improve Stulberg, Reimer’s migration and centre-edge angle outcomes and prevents progressive femoral head deformity compared with observation, varus osteotomy and plaster treatment.

Femoral head deformity with flattening and lateral protrusion can occur secondary to epiphyseal dysplasia or avascular necrosis of any aetiology in childhood. This causes painful impingement of the lateral femoral head on the acetabular lip, a phenomenon known as hinge abduction. We aimed to review our experience of valgus extension osteotomy in the treatment of hinge abduction in children and young adults with avascular necrosis.

Twenty patients undergoing valgus osteotomy for hinge abduction performed by a single specialist were clinically and radiologically reviewed. The aetiology was Perthes disease in 16 patients and treatment of DDH in 4 patients. The indication for the procedure was pain and limited abduction. The mean follow-up was 4.5 years. Patients were assessed using modified Iowa hip scores at final follow-up. The procedure corrected some leg shortening and improved the abduction range of the affected hip. Overall 80 % of patients did well. The mean Iowa hip score in Perthes group was 84 at final follow-up.

Four patients preoperatively had cysts/ defects in their femoral head. These were seen to fill up during their postoperative follow-up. Poorer outcome was associated with preoperative hip stiffness and surgery before stabilisation of the avascular process.

Conclusion: Valgus osteotomy is an effective procedure for relieving hinge abduction with associated additional benefits including improvement of leg shortening and improvement in hip abduction. The procedure should be avoided in stiff hips.

Introduction: There is paucity of literature describing complex lateral condylar mass (LCM) fractures of the elbow in children, which we define as a LCM fracture occurring concurrently with another fracture or dislocation in the same elbow. The aim of this study was to evaluate the management, outcome and complication rate of 26 complex LCM fractures and to analyse difference in the outcome between the isolated and complex LCM fractures.

Materials and methods: Between 1990 and 2005, we identified 26 complex LCM fractures in the departmental database (1% of 2502 elbow/humeral injuries). Information was collected from theatre-charts, casenotes and radiographs. The mean follow-up was 5.9 months (range, 6 weeks to 4 years).

Results: These were complex because of their association with elbow dislocation (n=12; mean age 8.2 years), olecranon fracture (n=8; mean age 4.1 years) and medial condylar fracture (n=6; mean age 8 years). Nine were treated conservatively. The remaining 17 were fixed with K-wires (9), a screw (7) or both (1). A concomitant elbow dislocation was managed by closed reduction followed by open K-wiring or screw fixation of the LCM fracture. An associated olecranon fracture was treated non-operatively for minimally displaced fractures, although one needed internal fixation. All displaced T-condylar fractures required open reduction and internal fixation. There were no complications of non-union, mal-union, avascular necrosis, cubitus valgus or tardy ulnar palsy. Healing and return of normal function occurred in all, although six patients had minor loss of extension.

Conclusion: We found no obvious difference in the outcome between the isolated displaced LCM fractures described in the literature and our complex LCM group. However the importance of careful assessment of the preoperative radiographs and testing of elbow stability by examination under anaesthesia is stressed.

Introduction: The aim of this paper was to test the hypothesis that for hips affected with Legg-Calve-Perthes’ (LCP) disease under the age of 8 years, surgery does not affect the outcome.

Methods: We performed a retrospective paired study of patients, who were diagnosed with LCP disease before the age of 8 years, to compare the radiological results after treatment between conservatively and surgicallytreated groups. One patient was selected from each group to create the pairs for this study. Each pair was strictly matched for gender, body mass index, age at onset, and stage at the first visit, Catterall and Herring grading and radiological at-risk signs. Each pair was assessed by comparing the values of five radiological measurements.

Results: From a cohort of 345 hips diagnosed with LCP disease 14 pairs (28 hips) fitted the criteria. The radiological measurements, which showed a statistically better result in the surgical groups, were Mose’s method (p = 0.019), the Acetabular-Head Index (p = 0.034). There were no statistical differences in the Slope of the Acetabular Roof (p = 0.37), Articulotrochanteric distance (p = 0.17) and Stulberg grading (p = 0.2). 5 pairs had a better Stulberg result in the operative group. Three of these 5 pairs were less than 6.5 years at the time of their surgical procedure. Three pairs had a better Stulberg result in the conservative group. Six pairs had no difference between the groups.

Discussion: We conclude that surgical treatment can improve the sphericity of the femoral head and provide greater acetabular cover than conservative treatment in hips of patients less than 8 years at the onset of LCP disease. However, the Stulberg grading was not affected. Our study supports the hypothesis that for hips affected with LCP disease under the age of 8 years, surgery does not affect the outcome.

Stickler’s syndrome, also called Hereditary Progressive Arthro-Ophthalmopathy, is an autosomal dominant connective tissue disorder with strong expressivity, characterised by ocular, orofacial, skeletal, cardiac, and auditory features.

We describe a case of valgus slipped capital femoral epiphysis in a 13 year-old boy with Stickler’s syndrome. He presented at routine rheumatology clinic follow-up with a 1-month history of progressively worsening right hip pain, which radiated to the knee. He underwent insitu cannulated screw fixation of the right slipped capital femoral epiphysis.

Joint pains are a common manifestation in Stickler’s syndrome and this might delay the diagnosis of slipped capital femoral epiphysis. Valgus slipped capital femoral epiphysis is a rare entity. Obesity and the increased femoral anteversion are predisposing factors. Insitu fixation with a single cannulated screw is the treatment of choice.

Introduction: The aim of this paper was to present a profile of Legg-Calve-Perthes’ (LCP) disease and test the hypothesis of an association between LCP disease and poverty.

Methods: We examined demographic data on a group of 240 children (263 hips) presenting with LCP disease in Greater Glasgow, where the mean deprivation scores are substantially greater than in the rest of Scotland, to see if this association applies or whether other clues to the aetiology of LCP could be divined.

Results: There were 197 males and 43 females. The majority presented in the sclerosis phase with much smaller numbers in the other phases. 70 % (184 cases of LCP) were Catterall grades 3 or 4. 16.25% had a family history of LCP. Bone age in our series is heavily skewed towards the lower centiles. The number of siblings in the family averaged 1.9, with 13 % being an only child. The maternal age at birth of the index child showed no preponderance to older age. Maternal smoking during and after pregnancy was noted in 55 %, which compares with 52% reported in the population of Greater Glasgow in general. Bone age in our series was heavily skewed towards the lower centiles. Birth weight showed a definite shift to the left, height a weaker shift to the left. 25 % of the children in our series are in social class IV and V, although this accounts for more than 50 % of the population of the Greater Glasgow.

Discussion: There is no significant evidence of a preponderance of LCP disease in the most deprived groups (p=0.9). The aetiology of LCP disease is likely to be multifactorial and may include a genetic or deprivation influence causing low bone age, hyperactivity and a high pain threshold.