This study sought to determine if treatment of resistant clubfeet by the Ilizarov method influenced the pattern of recurrence. Forty-seven children were identified as having undergone treatment by the Ilizarov method. Inclusion criteria for treatment with the Ilizarov method were clubfeet belonging to diagnostic categories that had recognised tendencies for resistance to standard methods of clubfoot management or a previous history of soft tissue releases performed adequately but accompanied by rapid relapse.

There were 60 feet with a mean follow-up of 133 months (46-224). Diagnoses included 34 idiopathic types, 7 arthrogryposis, 1 cerebral palsy, and 5 other. Summary statistics and survival analysis was used; failure was deemed as a recurrence of fixed deformity necessitating further correction. This definition parallels clinical practice where attainment of ‘normal’ feet in this group remains elusive, and mild to moderate relapses that remain passively correctable are kept under observation.

Soft tissue releases were common primary or secondary procedures. The mean time to revision surgery, if a soft tissue release was undertaken as a primary procedure, was 36 months (SD 22), and 39 (SD 23) months if undertaken for the second time. This compares with 52 months (SD 32) if Ilizarov surgery was used. Using survival analysis, there is a 50% chance of a relapse sufficiently marked to need corrective surgery after 44 months following the first soft tissue release, 47 months if after the second soft tissue procedure and 120 months after the Ilizarov technique.

We conclude that resistant club feet, defined as those belonging to diagnostic categories with known poor prognoses or those that succumb to an early relapse despite adequate soft tissue surgery, may have longer relapse-free intervals if treated by the Ilizarov method.

To assess outcomes following a radical approach to cases of compartment syndrome in which a significant degree of muscle necrosis is found, 4 paediatric and adolescent patients with a delayed diagnosis of compartment syndrome in which muscle necrosis in single or multiple compartments were treated by radical debridement of necrotic tissue and reconstruction of the anterior compartment through transfer of peroneus brevis to extensor digitorum and hallucis longus tendons. Where suitable, a free vascularised and innervated gracilis muscle transfer to the tibialis anterior tendon stump was carried out with anastomosis of the nerve to gracilis to the deep peroneal nerve.

Free gracilis muscle transfer was functional in one of the two patients whilst peroneus brevis transfer to extensor digitorum and hallucis tendons was functional in all three patients. In one patient, radical debridement resulted in loss of the entire anterior compartment requiring permanent ankle foot orthosis. All others had recovery of protective foot sensation and at minimum follow-up of 12 months were walking unaided. Infection was not seen in any patient.

Prompt fasciotomy, debridement and reconstruction for late diagnosis of compartment syndrome proved limb-saving in our patients.

Background: Knee stiffness from peri-articular fractures, arthroplasty or limb lengthening surgery, if intractable after an extensive programme of physiotherapy, may be resolved by quadricepsplasty. We describe the recovery of knee function in a cohort of 12 patients who underwent a Judet quadricepsplasty for loss of knee flexion.

Material and Methods: 12 adult patients underwent a Judet quadricepsplasty for recovery of knee flexion range. The causes of stiffness were trauma, arthroplasty, infection and limb lengthening surgery. A protocol of continuous passive knee movement under epidural analgesia was maintained after surgery. Continuous passive motion was continued at home for a further 4–6 weeks together with regular out-patient physiotherapy attendances. Outcome measures were range of movement, extensor lag, a modified WOMAC score for physical function, KINCOM data (with the contralateral limb as control), SF-36 and complications of surgery.

Results: There were 11 male patients and 1 female. The mean age was 30 years (20–71). The median period of follow-up was 3 years (0.8–7 years). The difference between pre-operative and final knee motion ranges was statistically significant (p=0.0048). The medians for flexion before surgery was 41 degrees (SD=18; at surgery 110 degrees (SD =15); final follow-up 105 degrees (SD=20). Extensor lag after surgery was 27.5 degrees (SD18) reducing 3.5 degrees (SD=3.5) finally. KINCOM data against a contralateral control showed a highly significant difference (p< 0.001) in quads strength. The medians for the WOMAC score was 38; PCS of the SF36 34.7 (SD13) and the MCS 53.7 (SD 13). Wound complications occurred in 7 patients and three needed further surgery.

Conclusion: Improvement in knee flexion after a Judet quadricepsplasty is maintained at one year. Extensor lag is common after the procedure but recovers. Most patients found the improvement beneficial but objective measures of knee function showed a return to normal had not been achieved.

Gradual correction of periarticular deformities has necessitated the application of external fixators to accomplish the task. By contrast, such deformities when treated by acute correction are most often stabilised using internal fixation. Hemi-epiphyseal arrest, by stapling or transphyseal screw is a disadvantage by being an irreversible process which has to be delayed until later childhood. This study describes the preliminary results of using an alternative internal device which corrects angular deformity by acting as a tension band on one side of the growth plate.

Twenty nine consecutive patients with significant coronal plane deformities in the lower limb were treated using the guided growth technique. This was accomplished through the extra-periosteal application of a 2-hole plate and screws (the 8-plate, Orthofix SRL, Verona). The plate was left in-situ and the patient monitored at regular intervals until the desired correction of the mechanical axis was accomplished. Plate removal was undertaken if the child was not skeletally mature at completion of treatment.

Eighteen males and 11 females completed treatment and had their plates removed. The age of patients ranged from 5 to 14 years (average 11.5 years). There were 23 patients with genu valgum deformity with an average deformity of 9.8 degrees, and 6 patients with genu varum deformity with an average deformity of 29.9 degrees. The follow up period averaged 12.5 months from plate removal. The average duration of correction was 15.8 months. The overall rate of correction was 0.87 degrees per month. Two complications were recorded: plate migration in one patient and deep infection in another patient. We had one case of rebound deformity.

The guided growth technique using the 8-plate is a simple and safe procedure for the treatment of lower limb angular deformity which produces temporary physeal arrest.

Fibular hemimelia is associated with equinovalgus deformity of the ankle and hind foot and antero-medial bowing of tibia. A wedge shaped distal epiphysis of the tibia and tight posterolateral soft tissues play an important role in the pathogenesis of ankle valgus and lateral subluxation of foot. Tethering effect of fibular anlage may contribute to the deformities in the tibia and ankle. Lengthening procedures are associated with progression of these deformities.

The purpose of this study is to determine whether Exner Osteotomy and Excision of Fibular anlage will correct the valgus deformity of the ankle and antero-medial bowing of tibia. A bending osteotomy through the distal tibial physis as described by Exner and excision of Fibular Anlage was performed in six limbs in five children (4 boys, 1 girl) with fibular hemimelia. Histology of Excised Fibular anlage was studied under light microscopy. The mean age at the time of surgery was twenty two months (range: 8 months to 5 years).

The mean follow-up was two years and two months (13 months to 4 years and 8 months). Full Correction of ankle valgus and tibial bowing was achieved in three feet where, a cortical strut graft was used in the open wedge osteotomy. In two feet synthetic bone substitute was used. In these, tibial bowing corrected but slight ankle valgus remained. In one foot where synthetic bone substitute was used and the postoperative compliance with AFO was poor, bowing of tibia improved but ankle valgus recurred. Premature fusion of growth plate did not occur in any of the cases. Histology of fibular anlage showed replacement of bone tissue by mature collagen bundles surrounded by fibroconnective tissue.

Exner Osteotomy and Excision of Fibular Anlage in Fibular Hemimelia corrects the ankle valgus and antero-medial bowing of tibia.

Sub-muscular plating is an established technique in the management of long-bone fractures and reconstruction. In the femur, the presence of the vascular structures medially favours the lateral approach and as such, the technique of medial femoral sub-muscular plating has not, to the authors knowledge, been previously described.

We report a series of 5 patients employing the medial approach to femoral sub-muscular plating. The indications and limitations of the technique are discussed with particular reference to reducing external fixation times, avoidance of stress risers and areas of previously traumatised or infected tissues. The surgical technique for medial femoral sub-muscular plating with emphasis on the role of vastus medialis in the protection of the vascular structures, together with cross sectional anatomy is described.

Medial femoral sub-muscular plating is a useful technique in specific indications and can be performed safely with an understanding of the relevant anatomy.

Introduction: The treatment of femoral nonunions remains challenging despite modern surgical techniques and adjuncts to fracture healing. We present a series of 14 patients in whom a bifocal treatment technique has been used in order to achieve bony union and correct limb length.

Methods: Patients were identified from theatre records and their hospital notes and x-rays were retrospectively reviewed. All patients underwent bifocal treatment for femoral nonunions – debridement and internal fixation (single or double plating) of the nonunion and lengthening at the opposite end of the bone to correct limb length discrepancy. Initially the procedures were staged, with treatment of the non-union then subsequent lengthening. However, our technique has evolved to perform all procedures in a single stage. All lengthening procedures were done with a monolateral (Orthofix LRS) fixator.

Results: 11 patients had distal and 3 proximal femoral nonunions. 13 patients were male and 1 female. The non-union united with the index procedure in 13 patients, 1 is still undergoing treatment. Limb length discrepancy range 2–5 cm was fully corrected in all patients with no axial deviation of the regenerate. There were no pin site problems.

Discussion: Femoral nonunions are challenging due to multiple previous procedures, insecure grip on the smaller fragment and bone loss. Successful union can be achieved by ORIF with bone grafting, but this does not restore length. Treatment by the Ilizarov method alone is associated with significant morbidity, particularly knee stiffness. A bifocal strategy provides stable internal fixation of the non-union to allow bone healing, and any consequent loss of length is safely restored. We believe this to be a safe and effective technique to treat femoral nonunions.

Introduction: Lengthening for congenital femoral hypoplasia is associated with a significant refracture rate and problems in recovery of knee motion. We present a series of 7 patients where two techniques of lengthening were used and recovery of knee motion compared.

Methods: This is a retrospective study. The outcome of interest was recovery of knee motion. All children were diagnosed to have congenital femoral hypoplasia. In two patients (group A), conventional metaphyseal osteotomies of the femur and tibia, with ankle and knee bridging fixators were applied. In the remaining five (group B), a combination of soft tissue releases, patella ‘capture’, a modified external fixator configuration and early conversion to internal fixation was used. Osteotomies of tibia and femur were performed in the mid-shaft and lengthening progressed at 0.75 mm per day. At 4 months, before regenerate consolidation, both femur and tibia were plated using a submuscular technique. The limb was supported in a cast, which was replaced by a brace at 3 weeks and knee motion exercises started. Lengthening was kept to within 15% in both groups.

Results: Recovery in knee flexion to greater than 90 degrees was accomplished by 4 of the 5 Group B patients by 4 months. One patient failed to attend for physiotherapy and did not progress with knee motion recovery. One patient sustained a fracture proximal to the submuscular plate which needed revision surgery. This did not hinder progress with knee motion recovery. In comparison, patients in group A reached 90 degrees of flexion at 12 months with one patient not exceeding 85 degrees at final follow up and subsequently needing a quadricepsplasty.

Conclusion: Recovery of knee motion may be assisted by soft tissue releases in combination with early conversion to internal fixation.

Introduction: The subtrochanteric area of the femur is subject to large tensile and compressive forces. The rate of nonunion following operative fixation of such fractures is about 7–20%. Revision surgery to obtain union is difficult because of the small size of the proximal fragment, muscle forces acting in 2 planes, and bone loss.

We present the results of a series of 9 consecutive patients with subtrochanteric non-unions treated by double plates.

Methods: Retrospective analysis of 9 consecutive subtrochanteric nonunions treated with double plates and additional osteoinduction (bone graft, or BG+BMP-7).

Results: There were 5 male and 4 female patients, with ages from 50–82 years (mean 65). All were treated in a single-stage procedure by implant removal, a lateral plate and a separate anterior plate. One patient had had a previous unsuccessful revision procedure with an intra-medullary device.

One patient with liver cirrhosis died 5 days postoperatively. Two patients are currently 8 weeks post surgery. All the others healed in a mean of 5.1 months (range 4–6 months).

Two patients underwent distal femoral lengthening to compensate for bone loss.

Discussion: The high muscle forces around the proximal femur require a sound mechanical environment for bone healing to occur. This is particularly marked in nonunions. The small size of the proximal fragment can result in suboptimal fixation. The addition of the anterior plate provides better fixation and also neutralizes the sagittal forces.

We believe that double plating neutralizes all the forces around the proximal femur, providing the best mechanical environment. Given the limits of the small numbers and the retrospective nature of the study, we believe that this method of treatment offers a sound surgical strategy, reflected by our success rate.

We have carried out a retrospective review of 20 patients with segmental fractures of the tibia who had been treated by circular external fixation. We describe the heterogeneity of these fractures, their association with multiple injuries and the need for multilevel stability with the least compromise of the biology of the fracture segments. The assessment of outcome included union, complications, the measurement of the functional IOWA knee and ankle scores and the general health status (Short-form 36).

The mean time to union was 21.7 weeks (12.8 to 31), with no difference being observed between proximal and distal levels of fracture. Complications were encountered in four patients. Two had nonunion at the distal level, one a wire-related infection which required further surgery and another shortening of 15 mm with 8° of valgus which was clinically insignificant. The functional scores for the knee and ankle were good to excellent, but the physical component score of the short-form 36 was lower than the population norm. This may be explained by the presence of multiple injuries affecting the overall score.

A total of 25 children (37 legs and 51 segments) with coronal plane deformities around the knee were treated with the extraperiosteal application of a flexible two-hole plate and screws. The mean age was 11.6 years (5.5 to 14.9), the median angle of deformity treated was 8.3° and mean time for correction was 16.1 months (7 to 37.3). There was a mean rate of correction of 0.7° per month in the femur (0.3° to 1.5°), 0.5° per month in the tibia (0.1° to 0.9°) and 1.2° per month (0.1° to 2.2°) if femur and tibia were treated concurrently. Correction was faster if the child was under 10 years of age (p = 0.05). The patients were reviewed between six and 32 months after plate removal. One child had a rebound deformity but no permanent physeal tethers were encountered.

The guided growth technique, as performed using a flexible titanium plate, is simple and safe for treating periarticular deformities of the leg.

Aim: The aim of this study was to evaluate management of non-articular distal tibial fractures.

Materials & Methods: Between January 2000–December 2004, we treated 25 children with a non-articular distal tibia fracture. All fractures were isolated high velocity injuries (11-Road traffic accidents; 14-Sports injuries) without neurovascular compromise. Only 2 out of 25 were open (grade I) fractures. There were 19 males and 6 females aged 7–16 years (average 11.4 years). On radiography, the fracture patternsvaried from transverse-7 patients, spiral-8 patients, short oblique-7 patients, and communited-3 patients.16 patients had an associated fibula fracture. 20 of the 25 fractures were primarily treated in a cast while the remaining 5 were primarily treated by external fixator (3-Orthofix; 2-Ilizarov) as closed reduction was unstable. The average period in cast/external fixator was 8.4 weeks and the average follow-up 6.2 months.

Results: On early follow-up, 8 of the 20 fractures (40%) that were initially treated in a cast needed intervention (plaster wedging-5; external fixator-3) because of displacement/angulation of the fracture. 7 (28%) of the 8 fractures needing intervention were short oblique fractures. There was no correlation between open injury/associated fibula fracture and displacement/angulation.

Conclusion: Short oblique fractures had a high failure rate with cast treatment. We recommend close monitoring with weekly radiographs for cast treated fractures or alternately primary external fixation of unstable, short oblique fractures.

Aim : To evaluate our initial experience using the Ponseti method for the treatment of clubfoot .

Materials and Methods: 85 feet in 56 patients treated at Alder Hey Hospital, Liverpool between Nov 2002 – Dec 2004 were included in the study. The standard protocol described by Ponseti was used for treatment. Mean period of follow up was 12 months (6– 30 months). Evaluation was by the Pirani club foot score.

Results : Results were evaluated in terms of the number of casts applied, the need for tenotomy and the recurrence of deformity. Average nuber of casts required were 6. Tenotomy was required in 80% of feet. At the latest follow up approximately 15% of feet recurred following treatment and were managed surgically. Poor compliance was noted to be the main cause of failure in these patients. We have recently modified our splint and hope this will address some of the reasons for poor compliance. There was also a smaller subgroup of patients (approximately 5%) which failed to respond to the treatment regime and could not be brought to the point were tenotomy would be appropriate.

Conclusion: In our hands the ponseti technique has proved to be a very effective treatment method for the management of CTEV but like all treatment methods does have some limitations.

Two protocols for the operative technique and care of the pin-site with external fixation were compared prospectively. There was a total of 120 patients with 46 in group A and 74 in group B. Infection was defined as an episode of pain or inflammation at a pin site, accompanied by a discharge which was either positive on bacterial culture or responded to a course of antibiotics.

Patients in group B had a lower proportion of infected pin sites (p = 0.003) and the time to the first episode of infection was longer (p < 0.001). The risk of pin-site infection is lower if attention is paid to avoiding thermal injury and local formation of haematoma during surgery and if after-care includes the use of an alcoholic antiseptic and occlusive pressure dressings.

Aim: To evaluate the initial experience of using the Ponseti Method in the management of idiopathic clubfoot and to identify learning curve problems.

Materials and Methods: A retrospective analysis undertaken of 57 feet in 39 patients with CTEV treated by the Ponseti method. The standard protocol described by Ponseti was followed. Pirani’s clubfoot score was used to assess the deformity and the results of treatment. The follow-up in the study ranged from 3 months to 35 months. Denis Brown splints were used full-time for 3 months and at night for 1 year.

Results: 47 out of 57 feet had good results with no evidence of recurrence. 10 feet had recurrence and underwent further surgery. If compliance was poor with the Denis Brown splints or if there was a severe initial deformity there was an increased risk of recurrence. 20% had problems with the plaster of Paris cast and the foot slipped out of the Denis Brown splint in 14%. It was noted there were 2 cases of bruising and swelling associated with the removal of the cast and the application of Denis Brown boots which had not previously been reported.

Conclusion: This is only a preliminary study and therefore the long-term outcome cannot be assessed. It was noted that attention to detail and appropriate regular follow-up is important in achieving satisfactory results.

Introduction

This study has evaluated the results of plantar fascia release through a plantar incision.

Materials and Methods

A 4cm curved incision on the plantar surface of the heel, was used to release the plantar fascia in children. The incision allowed complete visualisation of the entire origin of the plantar fascia. The procedure was performed as part of treatment for pes cavus or resistant clubfoot.

There were 27 feet in 17 patients. The ages ranged from three to sixteen years. The minimum follow up was six months after surgery. The wound was assessed for pain, numbness, and problem scarring as well as heel pad symptoms. A modified functional score was used. (American Orthopaedic Foot and Ankle Society Ankle/ Hindfoot Scale)

Results

All wounds healed within two weeks. The scar was clearly visible in seven patients, and visible only on close inspection in 10 patients. None had heel tenderness, hypersensitivity or numbness and there were no signs of pad atrophy. Fifteen patients had no pain, while two had minimal pain score of two on the visual analogue scale. The functional score was more than 90. All the patients were satisfied with the cosmetic appearance of the scar.

Conclusion

The plantar incision is safe, effective and provides excellent visualisation of the plantar fascia for complete release with minimal morbidity.