Aims

The aim of this study was to reassess the rate of neurological, psoas-related, and abdominal complications associated with L4-L5 lateral lumbar interbody fusion (LLIF) undertaken using a standardized preoperative assessment and surgical technique.

The October 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: Outcomes of open reduction in children with developmental hip dislocation: a multicentre experience over a decade; A torn discoid lateral meniscus impacts lower-limb alignment regardless of age; Who benefits from allowing the physis to grow in slipped capital femoral epiphysis?; Consensus guidelines on the management of musculoskeletal infection affecting children in the UK; Diagnosis of developmental dysplasia of the hip by ultrasound imaging using deep learning; Outcomes at a mean of 13 years after proximal humeral fracture during adolescence; Clubfeet treated according to Ponseti at four years; Controlled ankle movement boot provides improved outcomes with lower complications than short leg walking cast.

Aims

This study investigated the effects of transcatheter arterial embolization (TAE) on pain, function, and quality of life in people with early-stage symptomatic knee osteoarthritis (OA) compared to a sham procedure.

Aims

Open tibial fractures are limb-threatening injuries. While limb loss is rare in children, deep infection and nonunion rates of up to 15% and 8% are reported, respectively. We manage these injuries in a similar manner to those in adults, with a combined orthoplastic approach, often involving the use of vascularised free flaps. We report the orthopaedic and plastic surgical outcomes of a consecutive series of patients over a five-year period, which includes the largest cohort of free flaps for trauma in children to date.

Aims

To evaluate the perioperative complications associated with total en bloc spondylectomy (TES) in patients with spinal tumours, based on the extent and level of tumour resection.

Aims

Dual plating of distal femoral fractures with medial and lateral implants has been performed to improve construct mechanics and alignment, in cases where isolated lateral plating would be insufficient. This may potentially compromise vascularity, paradoxically impairing healing. This study investigates effects of single versus dual plating on distal femoral vascularity.

Objectives

As well as debridement and irrigation, soft-tissue coverage, and osseous stabilization, systemic antibiotic prophylaxis is considered the benchmark in the management of open fractures and considerably reduces the risk of subsequent fracture-related infections (FRI). The direct application of antibiotics in the surgical field (local antibiotics) has been used for decades as additional prophylaxis in open fractures, although definitive evidence confirming a beneficial effect is scarce. The purpose of the present study was to review the clinical evidence regarding the effect of prophylactic application of local antibiotics in open limb fractures.

Aims

This multicentre, retrospective study aimed to improve our knowledge of primary pyogenic spinal infections in children by analyzing a large consecutive case series.

Aims. Despite the expansion of arthroscopic surgery of the shoulder, the open deltopectoral approach is increasingly used for the fixation of fractures and arthroplasty of the shoulder. The anatomy of the terminal branches of the posterior circumflex humeral artery (PCHA) has not been described before. We undertook an investigation to correct this omission. Patients and Methods. The vascular anatomy encountered during 100 consecutive elective deltopectoral approaches was recorded, and the common variants of the terminal branches of the PCHA are described. Results. In total, 92 patients (92%) had a terminal branch that crossed the space between the deltoid and the proximal humerus and which was therefore vulnerable to tearing or avulsion during the insertion of the blade of a retractor during the deltopectoral approach to the shoulder. In 75 patients (75%) there was a single vessel, in 16 (16%) a double vessel and in one a triple vessel. Conclusion. The relationship of these vessels to the landmark of the tendon of the insertion of pectoralis major into the proximal humerus is described. Damage to these previously undocumented branches can cause persistent bleeding leading to prolonged surgery and post-operative haematoma and infection, as well as poor visualisation during the procedure. Cite this article: Bone Joint J 2016;98-B:1395–8

Introduction. The vascular anatomy of the femoral head and neck has been previously reported, with the primary blood supply attributed to the deep branch of the Medial Femoral Circumflex Artery (MFCA). This understanding has led to development of improved techniques for surgical hip dislocation for multiple intra-capsular hip procedures including Hip Resurfacing Arthroplasty (HRA). However, there is a lack of information in the literature on quantitative analysis of the contributions of the Lateral Femoral Circumflex Artery (LFCA) to femoral head and neck. Additionally, there is a lack of detailed descriptions in the literature of the anatomic course of the LFCA from its origin to its terminal branches. Materials & Methods. Twelve fresh-frozen human pelvic cadaveric specimens were studied (mean age 54.3 years, range 28–69). One hip per specimen was randomly assigned as the experimental hip, with the contralateral used as a control. Bilateral vascular dissection was performed to cannulate the MFCA and LFCA. Specimens were assigned as either LFCA-experimental or MFCA-experimental. All specimens underwent a validated quantitative-MRI protocol: 2mm slice thickness with pre- and post- MRI contrast sequences (Gd-DTPA diluted with saline at 3:1). In the LFCA-experimental group 15ml of MRI contrast solution was injected into the LFCA cannula. In the MFCA-experimental group 15ml of contrast solution was injected into the MFCA cannula. On the control hip contrast solution was injected into both MFCA and LFCA cannulas, 15ml each (30ml total for the control hip). Following MRI, the MFCA and LFCA were injected with polyurethane compound mixed with barium sulfate (barium sulfate only present in either MFCA or LFCA on each hip). Once polymerization had occurred, hips underwent thin-slice CT scan to document the extra- and intra-capsular course of the LFCA and MFCA. Gross dissection was performed to visually assess all intra-capsular branches of both the MFCA and LFCA and assess for extravasation. Quantitative-MRI analysis was performed based on Region of Interest (ROI) assessment. Femoral heads were osteotomized at the level of the largest diameter proximal to the articular margin and perpendicular to the femoral neck, for placement of a 360° scale. Measurements using the 360° scale were recorded. For data processing, we used right-side equivalents and integrated our 360° data into the more commonly used imaginary clock face. Results. Quantitative analysis of contributions of the MFCA and LFCA are detailed (Table 1). Thin slice CT scan graphical analysis of the LFCA provided (Figure 1). Topographic 360° scale (and imaginary clock face) results are also detailed in a diagram (Figure 2). Discussion. This study provides the first comparative results for quantitative assessment of arterial contributions from both the MFCA and LFCA for the femoral head and neck. The MFCA is the dominant vessel for both the femoral head and neck, supplying 82% of the femoral head and 67% of the femoral neck. The LFCA plays its largest role in the inferoanterior femoral neck (with a 48% arterial contribution). This finding highlights the importance of protecting the LFCA in addition to the MFCA during intra-capsular hip procedures including Hip Resurfacing Arthroplasty

Aims

This retrospective cohort study compared the results of vascularised and non-vascularised anterior sliding tibial grafts for the treatment of osteoarthritis (OA)of the ankle secondary to osteonecrosis of the talus.

A new method of vascularised tibial grafting has been developed for the treatment of avascular necrosis (AVN) of the talus and secondary osteoarthritis (OA) of the ankle. We used 40 cadavers to identify the vascular anatomy of the distal tibia in order to establish how to elevate a vascularised tibial graft safely. Between 2008 and 2012, eight patients (three male, five female, mean age 50 years; 26 to 68) with isolated AVN of the talus and 12 patients (four male, eight female, mean age 58 years; 23 to 76) with secondary OA underwent vascularised bone grafting from the distal tibia either to revascularise the talus or for arthrodesis. The radiological and clinical outcomes were evaluated at a mean follow-up of 31 months (24 to 62). The peri-malleolar arterial arch was confirmed in the cadaveric study. A vascularised bone graft could be elevated safely using the peri-malleolar pedicle. The clinical outcomes for the group with AVN of the talus assessed with the mean Mazur ankle grading scores, improved significantly from 39 points (21 to 48) pre-operatively to 81 points (73 to 90) at the final follow-up (p = 0.01). In all eight revascularisations, bone healing was obtained without progression to talar collapse, and union was established in 11 of 12 vascularised arthrodeses at a mean follow-up of 34 months (24 to 58). MRI showed revascularisation of the talus in all patients. . We conclude that a vascularised tibial graft can be used both for revascularisation of the talus and for the arthrodesis of the ankle in patients with OA secondary to AVN of the talus. Cite this article: Bone Joint J 2015; 97-B:802–8

The use of joint-preserving surgery of the hip has been largely abandoned since the introduction of total hip replacement. However, with the modification of such techniques as pelvic osteotomy, and the introduction of intracapsular procedures such as surgical hip dislocation and arthroscopy, previously unexpected options for the surgical treatment of sequelae of childhood conditions, including developmental dysplasia of the hip, slipped upper femoral epiphysis and Perthes’ disease, have become available. Moreover, femoroacetabular impingement has been identified as a significant aetiological factor in the development of osteoarthritis in many hips previously considered to suffer from primary osteoarthritis.

As mechanical causes of degenerative joint disease are now recognised earlier in the disease process, these techniques may be used to decelerate or even prevent progression to osteoarthritis. We review the recent development of these concepts and the associated surgical techniques.

Cite this article: Bone Joint J 2014;96-B:5–18.

Despite the expansion of arthroscopic surgery of the shoulder, the open deltopectoral approach to the shoulder is still frequently used, for example in fracture fixation and shoulder replacement. However, it is sometimes accompanied by unexpected bleeding. The cephalic vein is the landmark for the deltopectoral interval, yet its intimate relationship with the deltoid artery, and the anatomical variations in that structure, have not previously been documented. In this study the vascular anatomy encountered during 100 consecutive elective deltopectoral approaches was recorded and the common variants described. Two common variants of the deltoid artery were encountered. In type I (71%) it crosses the interval and tunnels into the deltoid muscle without encountering the cephalic vein. However, in type II (21%) it crosses the interval, reaches the cephalic vein and then runs down, medial to and behind it, giving off several small arterial branches that return back across the interval to the pectoralis major. Several minor variations were also seen (8%). These variations in the deltoid artery have not previously been described and may lead to confusion and unexpected bleeding during this standard anterior surgical approach to the shoulder. Cite this article: Bone Joint J 2013;95-B:657–9

The Delto-pectoral approach is the workhorse of the shoulder surgeon, but surprisingly the common variants of the cephalic vein and deltoid artery have not been documented. The vascular anatomy encountered during one hundred primary elective delto-pectoral approaches was documented and common variants described. Two common variants are described. A type I (71%), whereby the deltoid artery crosses the interval and inserts directly in to the deltoid musculature. In this variant the surgeon is unlikely to encounter any vessels crossing the interval apart from the deltoid artery itself. In a type II pattern (21%) the deltoid artery runs parallel to the cephalic vein on the deltoid surface and is highly likely to give off medial branches (95%) that cross the interval, as well as medial tributaries to the cephalic vein (38%). Knowledge of the two common variants will aid the surgeon when dissecting the delto-pectoral approach and highlights that these vessels crossing the interval are likely to be arterial, rather than venous. This study allows the surgeon to recognize these variations and reproduce bloodless, safe and efficient surgery

Aims. Meningococcal septicaemia can result in growth arrest and angular deformities. The aim of this case series was to review the pattern of involvement in the lower leg. Patients and Methods. The notes and radiographs of all patients presenting with a growth arrest or deformity affecting the lower leg following meningococcal septicaemia between 1995 and 2010 were reviewed. There were fourteen patients, eight girls and six boys. The mean age of the patients at the time of presentation was 9.6 years. Results. There was a variety of deformities with some patients exhibiting several deformities in the same limb and/or bilateral deformities. Some of the deformities were complex. Nine patients had a lower limb length discrepancy (mean 4.8cms, range: 1 to 13cms). There were a total of 27 lower limb deformities; three patients had bilateral lower limb deformities. In 14 the proximal tibia was involved causing genu varum in 12 cases and genu valgum in two cases. Seven distal tibia deformities all resulted in varus deformity. In all cases, the fibula was spared. Discussion. In this series involvement of the tibial physeal growth plates was frequently asymmetric and with two exceptions resulted in a varus deformity. The medial and anterior proximal tibial physis seems particularly susceptible to the sequelae of meningococcal septicaemia whereas the fibula physeal plates were always spared. These observations confirm the work of other authors and this characteristic pattern of involvement is likely to reflect the vascular anatomy of the physeal plates. The fibula may be protected from damage because of the nature of its blood supply. Modern limb reconstruction techniques, particularly the Spatial frame now permit correction of these complex and difficult deformities

Shoulder girdles of 20 cadavers (68–94yrs) were harvested. The anterior (ACHA) and posterior circumflex humeral arteries (PCHA) were injected with ink and the extra and intraosseous courses of the dyed vasculature dissected through the soft tissues and bone to the osteotendinous junctions of the rotator cuff. The ink injection and bone dissection method was newly developed for the study. Rates of cross-over at the osteotendinous juntion were 75% in the supraspinatus, 67% in subscapularis, 33% in infraspinatus and 20% in teres minor. The supraspinatus and subscapularis insertions were vascularised by the arcuate artery, a branch of the ACHA. The insertions of the infraspinatus and teres minor were supplied by an unnamed terminal branch of the PCHA. The insertions of the rotator cuff receive an arterial supply across their OTJ's in 50% of cases. This may explain observed rates of AVN in comminuted proximal humeral fractures. The terminal branch of the PCHA supplying the infraspinatus and teres minor insertions was named the “Posterolateral Artery”. Finally, the new method employed for this study which allowed for direct visualisation of intraosseous vasculature, will enhance our understanding of skeletal vascular anatomy and have clinical applications in orthopaedic and reconstructive surgery

Vascular injury associated with hip surgery is a rare but serious complication. Hip surgeons need to understand the vascular anatomy around the acetabulum to avoid vascular injury. The aim of this study was to visualize the pelvic vascular structures thorough the osseous acetabulum using 3DCT angiography and to describe the three-dimensional relationship between the vessels and the acetabulum. A total of 100 patients who took 3DCT with intravenous contrast for intra-pelvic neoplastic disease were randomly chosen. Those patients with hip disease were excluded. Three examinations were performed. First, dual-phase helical CT data were transferred to a workstation (M900;Zio,Tokyo,Japan) and 3D visualizations of the vascular structures through the pelvis were reconstructed. Second, location of the external iliac, femoral and obturator vessels were investigated in axial CT images. Finally, influence of the age factor on the anatomical courses of the external iliac vessels was assessed. Reconstructed 3D images were able to provide spatial relationship between courses of the pelvic vascular structures and the acetabulum. We could visualize the pelvic vascular structures thorough the pelvis from similar operative viewpoints. Axial CT examinations revealed the external iliac vessels locate very closely to the pelvis as they exit the pelvic cavity. Especially, the left side vessels and vein were closer to the pelvis. The femoral vessels became closer to the acetabular edge with traveling distally. At the distal half of the acetabulum, the femoral vessels located just ventrally to the anterior acetabular edge. The obturator vessels courses inferiorly along the quadrilateral surface behind the acetabulum, they became very close to the inner cortex or the acetabulum. Straight type of the anatomical course of the external iliac vessels was the most common configuration in young patients, curved and the tortuous types were present in older patients. The results of this study are useful to understand the anatomical orientation of the vessels around the acetabulum. To avoid vascular injuries in hip surgery, knowledge of the vascular orientation is of critical importance for the hip surgeon