The use of serial casting in the management of early onset scoliosis (EOS) has been well described. Our aim was to evaluate outcomes of plaster jacket therapy in patients with EOS from a tertiary referral centre.

A retrospective review of hospital records and PACS images of 27 patients to identify patients treated with serial casting over a five year period. The primary outcome measure was the need for surgical intervention, with change in Cobb angle used as a secondary outcome measure

Mean age at presentation was 14 months (range 10 – 42), including 14 male and 13 female patients, with an average follow-up of 34 months. Curves were categorised according to aetiology: 16 idiopathic, 6 syndromic, 3 congenital and 2 neuromuscular curves. The mean Cobb angle at diagnosis was 43.7° (range 22 – 115) and mean rib vertebral angle difference (RVAD) was 22.2° (8 – 70). Duration of treatment was 9.9 months (range 3 – 27), with an average of two plaster jacket changes per child. At the time of review, patients fell into one of three groups. Group one (10 patients) failed conservative treatment due no improvement in Cobb angle (mean 48.4° compared with pre-op 53.9°, p value 0.55) and either had insertion of growing rods or had been listed for this procedure, at a mean age of 51.8 months. Group two (12 patients) had a mean Cobb angle of 38.9° pre-treatment which improved to 23.5° (p value <0.05) and were either treated in a brace or had discontinued treatment. The mean RVAD at initial diagnosis was 36.6° in group 1 compared with 13.8° in group 2 (p<0.05). All patients in group one requiring surgical treatment had an RVAD of greater than 20°. Serial casting is on-going for five patients (group three). Complications occurred in 30% of patients including pressure sores, chest infection and respiratory compromise requiring intubation.

Current NICE guidance recognises that serial casting ‘rarely corrects scoliosis’ but recommends it may be used ‘to allow growth before a more permanent treatment is offered’. In our experience, serial casting did not allow any patients with a progressive scoliosis (determined by an RVAD of greater than 20°), to reach a single definitive fusion. However serial casting appeared to halt to curve progression until the child was suitable for the insertion of a growing rod system.

The aim of the study was to assess the rate of greater tuberosity non union in reverse shoulder arthroplasty performed for proximal humerus fractures and to assess if union is related to type of fracture or the intraoperative reduction of the greater tuberosity.

All cases of reverse shoulder arthroplasty for proximal humerus fractures at our institution over a three year period were retrospectively reviewed from casenotes and radiologically and the position of the greater tuberosity was documented at immediate post op, 6 months and 12 months. Any malunion or non union were noted.

A total of 27 cases of reverse shoulder arthroplasty for proximal humeral fractures were identified. 4 cases did not have complete follow up xrays and were excluded from analysis. The average age at operation of the cohort of the 23 remaining patients was 79 years (range 70–91). The greater tuberosity was anatomically well positioned intraoperatively in 17 of the 23 cases.

At the end of 12 months there were 4 cases of tuberosity non union (17%), all except one occurring in poorly intraoperatively positioned greater tuberosity. 50% (3 out of 6) of greater tuberosities displaced further and remained ununited if the intraoperative position was poor. Only 6% (1 out of 17) greater tuberosities did not unite if the greater tuberosities was reduced anatomically. Intra operatively position of the greater tuberosity was strongly associated with their union (Fischer's exact test p<0.05). Union of greater tuberosity was not statistically associated with fracture pattern (Fischer's exact test p=0.48).

Our case series show a low rate of tuberosity malunion after reverse shoulder arthroplasty for proximal humerus fracture. Good positioning and fixation of the greater tuberosity intra operatively is a strong predictor of their uneventful union to shaft.

Aims: Osteomyelitis after open injuries or internal fixation of forearm fractures is uncommon. Established chronic infections do not respond fully to antibiotic suppression or limited debridement. We describe a two-stage treatment of segmental chronic osteomyelitis where wide excision of the affected area was followed by spanning external fixation and supplementary local and systemic antibiotic delivery. The bony defect was subsequently filled by vascularised fibula transfer, held by internal or external fixation.

Methods: Eleven male patients (mean age 41 years) with post-traumatic segmental chronic osteomyelitis were reviewed. There were 6 radii and 5 ulnas; the mean post-debridement defect was 7.7cm (range 5–11cm). The first stage involved wide excision and metalwork removal, followed by application of a spanning external fixator to restore distal radio-ulnar congruency. Gradual distraction was needed in some cases with long standing subluxation. ‘Dead-space’ management used gentamicin beads or gentamicin-loaded calcium sulphate, supplemented with systemic antibiotics according to tissue culture results.

A second stage reconstruction was performed after 4–6 weeks, using a free vascularised fibular graft, fixed using internal and/or external fixation.

Results: The mean follow-up period was 42.4 months. There was no recurrence of infection and union occurred at both graft-host junctions in all patients. The mean period to radiographic bone union was 4.4 months (range 4–6 months).

Patients gained an average of 46° forearm rotation (range 0–105°) with wrist or elbow motion significantly improved in 3 patients. At last review, all patients had a pain-free stable forearm with unhindered hand functions of grasp, hook and pinch. SF-36 assessment showed varied results, although mean values for the physical components of the survey were lower than general population values, while mental/emotional scores were as good.

Conclusions: Staged reconstruction, as described, is a suitable treatment strategy for this challenging problem and produces a good functional outcome.

Background: Mini-incision surgery (MIS) for total hip replacement (THR) typically uses incisions of 10cm or less and therefore may offer a better cosmetic appearance. Reported advantages of MIS include decreased blood loss, less tissue trauma and decreased pain, all of which are equivocal by six weeks post-surgery, when compared with standard incisions. The aim of this study was to compare patient scar satisfaction and identify potential long-term benefits of this incision when used in the posterior approach for THR.

Methods: Two groups of patients who underwent primary THR were reviewed. Group 1 consisted of 43 patients who underwent THR via a mini-incision, with a mean incision length of 9.44cm. Group 2 consisted of 51 patients who had a posterior standard incision, with a mean length of 15.3cm. The average length of follow-up was 12.8 months (range 2 – 48 months). There were no wound complications in either group. Scars were assessed using the validated Manchester Scar Proforma (MSP) and Visual Analogue Scales (VAS), and patients completed a Patient Scar Assessment Scale.

Results: The mean combined MSP and VAS scores for Group 1 and Group 2 were 7.2 and 7.1 respectively. The mean Patient Scar Assessment Scale score was 8.8 in group 1, and 10.4 in Group 2. The single parameter that scored highest in the Patient Scar Assessment Scale was the colour of the scar. This did not vary between the two groups of patients. There was no statistical significance in any of the parameters measured.

Conclusion: There does not appear to be any cosmetic benefit from MIS, when performing THR via the posterior approach. The length of wound was of little concern to patients, while the colour of the scar was the highest-scoring factor in the Patient Scar Assessment Scale. We therefore conclude that there is no long-term benefit from mini-incision surgery for THR via the posterior approach.