The traditional techniques involving an oblique
tunnel or triangular wedge resection to approach a central or mixed-type
physeal bar are hindered by poor visualisation of the bar. This
may be overcome by a complete transverse osteotomy at the metaphysis
near the growth plate or a direct vertical approach to the bar.
Ilizarov external fixation using small wires allows firm fixation
of the short physis-bearing fragment, and can also correct an associated angular
deformity and permit limb lengthening. We accurately approached and successfully excised ten central-
or mixed-type bars; six in the distal femur, two in the proximal
tibia and two in the distal tibia, without damaging the uninvolved
physis, and corrected the associated angular deformity and leg-length
discrepancy. Callus formation was slightly delayed because of periosteal
elevation and stretching during resection of the bar. The resultant
resection of the bar was satisfactory in seven patients and fair
in three as assessed using a by a modified Williamson–Staheli classification. Cite this article:
The accurate assessment of skeletal maturity
is essential in the management of orthopaedic conditions in the growing
child. In order to identify the time of peak height velocity (PHV)
in adolescents, two systems for assessing skeletal maturity have
been described recently; the calcaneal apophyseal ossification method
and the Sanders hand scores. The purpose of this study was to compare these methods in assessing
skeletal maturity relative to PHV. We studied the radiographs of
a historical group of 94 healthy children (49 females and 45 males),
who had been followed longitudinally between the ages of three and
18 years with serial radiographs and physical examination. Radiographs
of the foot and hand were undertaken in these children at least
annually between the ages of ten and 15 years. We reviewed 738 radiographs
of the foot and 694 radiographs of the hand. PHV was calculated
from measurements of height taken at the time of the radiographs. Prior to PHV we observed four of six stages of calcaneal apophyseal
ossification and two of eight Sanders stages. Calcaneal stage 3
and Sanders stage 2 was seen to occur about 0.9 years before PHV,
while calcaneal stage 4 and Sanders stage 3 occurred approximately
0.5 years after PHV. The stages of the calcaneal and Sanders systems can be used in
combination, offering better assessment of skeletal maturity with
respect to PHV than either system alone. Cite this article:
Developmental dysplasia of the hip (DDH) should
be diagnosed as early as possible to optimise treatment. The current
United Kingdom recommendations for the selective screening of DDH
include a clinical examination at birth and at six weeks. In Northern
Ireland babies continue to have an assessment by a health visitor
at four months of age. As we continue to see late presentations
of DDH, beyond one year of age, we hypothesised that a proportion had
missed an opportunity for earlier diagnosis. We expect those who
presented to our service with Tonnis grade III or IV hips and decreased
abduction would have had clinical signs at their earlier assessments. We performed a retrospective review of all patients born in Northern
Ireland between 2008 and 2010 who were diagnosed with DDH after
their first birthday. There were 75 856 live births during the study
period of whom 645 children were treated for DDH (8.5 per 1000).
The minimum follow-up of our cohort from birth, to detect late presentation,
was four years and six months. Of these, 32 children (33 hips) were
diagnosed after their first birthday (0.42 per 1000). With optimum application of our selective screening programme
21 (65.6%) of these children had the potential for an earlier diagnosis,
which would have reduced the incidence of late diagnosis to 0.14
per 1000. As we saw a peak in diagnosis between three and five months
our findings support the continuation of the four month health visitor
check. Our study adds further information to the debate regarding
selective Cite this article:
This retrospective study was designed to evaluate
the outcomes of re-dislocation of the radial head after corrective osteotomy
for chronic dislocation. A total of 12 children with a mean age
of 11 years (5 to 16), with further dislocation of the radial head
after corrective osteotomy of the forearm, were followed for a mean
of five years (2 to 10). Re-operations were performed for radial
head re-dislocation in six children, while the other six did not
undergo re-operation (‘non-re-operation group’). The active range
of movement (ROM) of their elbows was evaluated before and after
the first operation, and at the most recent follow-up. In the re-operation group, there were significant decreases in
extension, pronation, and supination when comparing the ROM following
the corrective osteotomy and following
re-operation (p <
0.05). The children who had not undergone re-operation achieved a better
ROM than those who had undergone re-operation. There was a significant difference in mean pronation (76° Cite this article:
A retrospective study was performed in 18 patients
with achondroplasia, who underwent bilateral humeral lengthening
between 2001 and 2013, using monorail external fixators. The mean
age was ten years (six to 15) and the mean follow-up was 40 months
(12 to 104). The mean disabilities of the arm, shoulder and hand (DASH) score
fell from 32.3 (20 to 40)
pre-operatively to 9.4 (6 to 14) post-operatively (p = 0.037). A
mean lengthening of 60% (40% to 95%) was required to reach the goal
of independent perineal hygiene. One patient developed early consolidation,
and fractures occurred in the regenerate bone of four humeri in
three patients. There were three transient radial nerve palsies. Humeral lengthening increases the independence of people with
achondroplasia and is not just a cosmetic procedure. Cite this article:
Pelvic obliquity is a common finding in adolescents
with cerebral palsy, however, there is little agreement on its measurement
or relationship with hip development at different gross motor function
classification system (GMFCS) levels. The purpose of this investigation was to study these issues in
a large, population-based cohort of adolescents with cerebral palsy
at transition into adult services. The cohort were a subset of a three year birth cohort (n = 98,
65M: 33F, with a mean age of 18.8 years (14.8 to 23.63) at their
last radiological review) with the common features of a migration
percentage greater than 30% and a history of adductor release surgery. Different radiological methods of measuring pelvic obliquity
were investigated in 40 patients and the angle between the acetabular
tear drops (ITDL) and the horizontal reference frame of the radiograph
was found to be reliable, with good face validity. This was selected
for further study in all 98 patients. The median pelvic obliquity was 4° (interquartile range 2° to
8°). There was a strong correlation between hip morphology and the
presence of pelvic obliquity (effect of ITDL on Sharpe’s angle in
the higher hip; rho 7.20 (5% confidence interval 5.59 to 8.81, p
<
0.001). This was particularly true in non-ambulant adolescents
(GMFCS IV and V) with severe pelvic obliquity, but was also easily
detectable and clinically relevant in ambulant adolescents with mild
pelvic obliquity. The identification of pelvic obliquity and its management deserves
closer scrutiny in children and adolescents with cerebral palsy. Cite this article:
Controversy remains whether the contralateral
hip should be fixed in patients presenting with unilateral slipped capital
femoral epiphysis (SCFE). This retrospective study compares the
outcomes and cost of those patients who had prophylactic fixation
with those who did not. Between January 2000 and December 2010 a total of 50 patients
underwent unilateral fixation and 36 had prophylactic fixation of
the contralateral hip. There were 54 males and 32 females with a
mean age of 12.3 years (9 to 16). The rate of a subsequent slip
without prophylactic fixation was 46%. The risk of complications
was greater, the generic health measures (Short Form-12 physical
(p <
0.001) and mental (p = 0.004) summary scores) were worse.
Radiographic cam lesions in patients presenting with unilateral
SCFE were only seen in patients who did not have prophylactic fixation.
Furthermore, prophylactic fixation of the contralateral hip was
found to be a cost-effective procedure, with a cost per quality
adjusted life year gained of £1431 at the time of last follow-up. Prophylactic fixation of the contralateral hip is a cost-effective
operation that limits the morbidity from the complications of a
further slip, and the diminished functional outcome associated with
unilateral fixation. Cite this article:
Hip displacement, defined in this study as a
migration percentage (MP) of more than 40%, is a common, debilitating complication
of cerebral palsy (CP). In this prospective study we analysed the
risk of developing hip displacement within five years of the first
pelvic radiograph. All children with CP in southern and western Sweden are invited
to register in the hip surveillance programme CPUP. Inclusion criteria
for the two groups in this study were children from the CPUP database
born between 1994 and 2009 with Gross Motor Function Classification
System (GMFCS) III to V. Group 1 included children who developed
hip displacement, group 2 included children who did not develop
hip displacement over a minimum follow-up of five years. A total
of 145 children were included with a mean age at their initial pelvic
radiograph of 3.5 years (0.6 to 9.7). The odds ratio for hip displacement was calculated for GMFCS-level,
age and initial MP and head-shaft angle. A risk score was constructed
with these variables using multiple logistic regression analysis.
The predictive ability of the risk score was evaluated using the
area under the receiver operating characteristics curve (AUC). All variables had a significant effect on the risk of a MP >
40%. The discriminatory accuracy of the CPUP hip score is high (AUC
= 0.87), indicating a high ability to differentiate between high-
and low-risk individuals for hip displacement. The CPUP hip score
may be useful in deciding on further follow-up and treatment in
children with CP. Cite this article:
The recognition of hips at risk of displacement
in children with cerebral palsy (CP) is a difficult problem for
the orthopaedic surgeon. The Gross Motor Function Classification
System (GMFCS) and head–shaft angle (HSA) are prognostic factors
for hip displacement. However, reference values for HSA are lacking.
This study describes and compares the development of HSA in normal
hips and children with CP. We selected 33 children from a retrospective cohort with unilateral
developmental dysplasia of the hip (DDH) (five boys, 28 girls) and
50 children (35 boys, 15 girls) with CP with GMFCS levels II to
V. HSA of normal developing hips was measured at the contralateral
hip of unilateral DDH children (33 hips) and HSA of CP children
was measured in both hips (100 hips). Measurements were taken from
the radiographs of the children at age two, four and seven years.
The normal hip HSA decreased by 2° per year (p <
0.001). In children
with CP with GMFCS levels II and III HSA decreased by 0.6° (p =
0.046) and 0.9° (p = 0.049) per year, respectively. The HSA did
not alter significantly in GMFCS levels IV and V. Between the ages of two and eight years, the HSA decreases in
normal hips and CP children with GMFCS level, II to III but does
not change in GMFCS levels IV to V. As HSA has a prognostic value
for hip displacement, these reference values may help the orthopaedic
surgeon to predict future hip displacement in children with CP. Cite this article:
The aim of this prospective study was to investigate
prematurity as a risk factor for developmental dysplasia of the hip
(DDH). The hips of 221 infants (88 female, 133 male, mean age 31.11
weeks; standard deviation ( These results suggests that prematurity is not a predisposing
factor for DDH. Cite this article:
We report the results of Vulpius transverse gastrocsoleus
recession for equinus gait in 26 children with cerebral palsy (CP),
using the Gait Profile Score (GPS), Gait Variable Scores (GVS) and
movement analysis profile. All children had an equinus deformity
on physical examination and equinus gait on three-dimensional gait
analysis prior to surgery. The pre-operative and post-operative
GPS and GVS were statistically analysed. There were 20 boys and
6 girls in the study cohort with a mean age at surgery of 9.2 years
(5.1 to 17.7) and 11.5 years (7.3 to 20.8) at follow-up. Of the
26 children, 14 had spastic diplegia and 12 spastic hemiplegia.
Gait function improved for the cohort, confirmed by a decrease in
mean GPS from 13.4° pre-operatively to 9.0° final review (p <
0.001). The change was 2.8 times the minimal clinically important
difference (MCID). Thus the improvements in gait were both clinically and
statistically significant. The transverse gastrocsoleus recession
described by Vulpius is an effective procedure for equinus gait
in selected children with CP, when there is a fixed contracture
of the gastrocnemius and soleus muscles. Cite this article:
End caps are intended to prevent nail migration
(push-out) in elastic stable intramedullary nailing. The aim of
this study was to investigate the force at failure with and without
end caps, and whether different insertion angles of nails and end caps
would alter that force at failure. Simulated oblique fractures of the diaphysis were created in
15 artificial paediatric femurs. Titanium Elastic Nails with end
caps were inserted at angles of 45°, 55° and 65° in five specimens
for each angle to create three study groups. Biomechanical testing
was performed with axial compression until failure. An identical
fracture was created in four small adult cadaveric femurs harvested
from two donors (both female, aged 81 and 85 years, height 149 cm and
156 cm, respectively). All femurs were tested without and subsequently
with end caps inserted at 45°. In the artificial femurs, maximum force was not significantly
different between the three groups (p = 0.613). Push-out force was
significantly higher in the cadaveric specimens with the use of
end caps by an up to sixfold load increase (830 N, standard deviation
(SD) 280 These results indicate that the nail and end cap insertion angle
can be varied within 20° without altering construct stability and
that the risk of elastic stable intramedullary nailing push–out
can be effectively reduced by the use of end caps. Cite this article:
The management of children’s fractures has evolved
as a result of better health education, changes in lifestyle, improved
implant technology and the changing expectations of society. This
review focuses on the changes seen in paediatric fractures, including
epidemiology, the increasing problems of obesity, the mechanisms
of injury, non-accidental injuries and litigation. We also examine
the changes in the management of fractures at three specific sites:
the supracondylar humerus, femoral shaft and forearm. There has
been an increasing trend towards surgical stabilisation of these
fractures. The reasons for this are multifactorial, including societal
expectations of a perfect result and reduced hospital stay. Reduced hospital
stay is beneficial to the social, educational and psychological
needs of the child and beneficial to society as a whole, due to
reduced costs. Cite this article:
We describe our experience in the reduction of
dislocation of the hip secondary to developmental dysplasia using ultrasound-guided
gradual reduction using flexion and abduction continuous traction
(FACT-R). During a period of 13 years we treated 208 Suzuki type
B or C complete dislocations of the hip in 202 children with a mean
age of four months (0 to 11). The mean follow-up was 9.1 years (five
to 16). The rate of reduction was 99.0%. There were no recurrent
dislocations, and the rate of avascular necrosis of the femoral
head was 1.0%. The rate of secondary surgery for residual acetabular
dysplasia was 19.2%, and this was significantly higher in those
children in whom the initial treatment was delayed or if other previous
treatments had failed (p = 0.00045). The duration of FACT-R was significantly
longer in severe dislocations (p = 0.001) or if previous treatments
had failed (p = 0.018). This new method of treatment is effective and safe in these difficult
cases and offers outcomes comparable to or better than those of
standard methods. Cite this article:
We undertook a retrospective comparative study
of all patients with an unstable slipped capital femoral epiphysis presenting
to a single centre between 1998 and 2011. There were 45 patients
(46 hips; mean age 12.6 years; 9 to 14); 16 hips underwent intracapsular
cuneiform osteotomy and 30 underwent pinning Pinning Non-emergency intracapsular osteotomy may have a protective effect
on the epiphyseal vasculature and should be undertaken with a delay
of at least two weeks. The place of emergency pinning Cite this article:
We present the validation of a translation into
Danish of the Oxford ankle foot questionnaire (OxAFQ). We followed the
Isis Pros guidelines for translation and pilot-tested the questionnaire
on ten children and their parents. Following modifications we tested
the validity of the final questionnaire on 82 children (36 boys
and 45 girls) with a mean age of 11.7 years (5.5 to 16.0) and their
parents. We tested the reliability (repeatability (test–retest),
child–parent agreement, internal consistency), feasibility (response
rate, time to completion, floor and ceiling effects) and construct
validity. The generic child health questionnaire was used for comparison.
We found good internal consistency for the physical and the school
and play domains, but lower internal consistency for the emotional domain.
Overall, good repeatability was found within children and parents
as well as agreement between children and parents. The OxAFQ was
fast and easy to complete, but we observed a tendency towards ceiling
effects in the school and play and emotional domains. To our knowledge
this is the first independent validation of the OxAFQ in any language.
We found it valid and feasible for use in the clinic to assess the
impact on children’s lives of foot and/or ankle disorders. It is
a valuable research tool. Cite this article:
Over a 15-year prospective period, 201 infants
with a clinically unstable hip at neonatal screening were subsequently
reviewed in a ‘one stop’ clinic where they were assessed clinically
and sonographically. Their mean age was 1.62 weeks (95% confidence
interval (CI) 1.35 to 1.89). Clinical neonatal hip screening revealed
a sensitivity of 62% (mean, 62.6 95%CI 50.9 to 74.3), specificity
of 99.8% (mean, 99.8, 95% CI 99.7 to 99.8) and positive predictive value
(PPV) of 24% (mean, 26.2, 95% CI 19.3 to 33.0). Static and dynamic
sonography for Graf type IV dysplastic hips had a 15-year sensitivity
of 77% (mean, 75.8 95% CI 66.9 to 84.6), specificity of 99.8% (mean,
99.8, 95% CI 99.8 to 99.8) and a PPV of 49% (mean, 55.1, 95% CI
41.6 to 68.5). There were 36 infants with an irreducible dislocation
of the hip (0.57 per 1000 live births), including six that failed
to resolve with neonatal splintage. Most clinically unstable hips referred to a specialist clinic
are female and stabilise spontaneously. Most irreducible dislocations
are not identified from this neonatal instability group. There may
be a small subgroup of females with instability of the hip which
may be at risk of progression to irreducibility despite early treatment
in a Pavlik harness. A controlled study is required to assess the value of neonatal
clinical screening programmes. Cite this article:
We investigated the incidence and risk factors
for the development of avascular necrosis (AVN) of the femoral head in
the course of treatment of children with cerebral palsy (CP) and
dislocation of the hip. All underwent open reduction, proximal femoral
and Dega pelvic osteotomy. The inclusion criteria were: a predominantly
spastic form of CP, dislocation of the hip (migration percentage,
MP >
80%), Gross Motor Function Classification System, (GMFCS) grade
IV to V, a primary surgical procedure and follow-up of >
one year. There were 81 consecutive children (40 girls and 41 boys) in
the study. Their mean age was nine years (3.5 to 13.8) and mean
follow-up was 5.5 years (1.6 to 15.1). Radiological evaluation included
measurement of the MP, the acetabular index (AI), the epiphyseal
shaft angle (ESA) and the pelvic femoral angle (PFA). The presence
and grade of AVN were assessed radiologically according to the Kruczynski
classification. Signs of AVN (grades I to V) were seen in 79 hips (68.7%). A
total of 23 hips (18%) were classified between grades III and V. Although open reduction of the hip combined with femoral and
Dega osteotomy is an effective form of treatment for children with
CP and dislocation of the hip, there were signs of avascular necrosis
in about two-thirds of the children. There was a strong correlation
between post-operative pain and the severity of the grade of AVN. Cite this article:
A small proportion of children with Gartland
type III supracondylar humeral fracture (SCHF) experience troubling limited
or delayed recovery after operative treatment. We hypothesised that
the fracture level relative to the isthmus of the humerus would
affect the outcome. We retrospectively reviewed 230 children who underwent closed
reduction and percutaneous pinning (CRPP) for their Gartland type
III SCHFs between March 2003 and December 2012. There were 144 boys
and 86 girls, with the mean age of six years (1.1 to 15.2). The
clinico-radiological characteristics and surgical outcomes (recovery
of the elbow range of movement, post-operative angulation, and the
final Flynn grade) were recorded. Multivariate analysis was employed
to identify prognostic factors that influenced outcome, including
fracture level. Multivariate analysis revealed that a fracture below
the humeral isthmus was significantly associated with poor prognosis
in terms of the range of elbow movement (p <
0.001), angulation
(p = 0.001) and Flynn grade (p = 0.003). Age over ten years was also
a poor prognostic factor for recovery of the range of elbow movement (p
= 0.027). This is the first study demonstrating a subclassification system
of Gartland III fractures with prognostic significance. This will
guide surgeons in peri-operative planning and counselling as well
as directing future research aimed at improving outcomes. Cite this article:
In 11 paediatric patients (seven girls and four
boys, from 12 to 15 years old) with unilateral obligatory patellar dislocation
and ligamentous laxity vastus medialis advancement, lateral release,
partial patellar ligament transposition and Galeazzi semitendinosus
tenodesis was undertaken to stabilise the patella. The diagnostic criterion
for ligamentous laxity was based on the Beighton scale. Outcomes
were evaluated radiologically and functionally by measurement of
the range of knee movement and isokinetic testing. The evaluation
also included the Lysholm knee scale. Follow-up studies took place
at a mean of 8.1 years (5 to 15) post-operatively. Normal patellar tracking without any recurrence of dislocation
was obtained in ten out of 11 patients. Pain related to vigorous
activity was reported by nine patients. Compared with the opposite
normal side, the isokinetic tests revealed a statistically significant
decrease in the maximal torque values for the affected quadriceps
muscle (p = 0.003 and p = 0.004), but no difference between the
knee flexors (for angular velocities of 60°/s and 180°/s) (p = 0.858
and p = 0.79). The applied surgical technique generally prevents the recurrence
of the disorder in children with habitual patellar dislocation and
ligamentous laxity. Quadriceps muscle weakness can be expected to
occur post-operatively, Cite this article: