Aim: To report our experience and early results with the Ilizarov pelvic support realignment lengthening osteotomy for complex hip pathology in children.

Material & Methods: Between 1997 & 2004, seven children were treated with this technique and five have completed treatment. The treatment was undertaken for sequelae of DDH in 4 patients and septic arthritis in 1 patient. The median age of the patients was 13(10–17). There were 3 boys and 2 girls. The outcome assessment was performed using the Harris hip score, clinical and radiological parameters.

Results: 4 patients presented with hip instability, shortening of the lower limb, pain and restricted motion. The remaining patient presented with a nonfunctional ankylosis with shortening. The median time between the onset of symptoms and the operation was 3 years (2–5). The median preoperative leg-length discrepancy was 3 cm (2–4.5). The median fixator time was 5 months (3–6). The median follow-up was 24 months (9–72).

Patients had improvement of pain, posture, hip instability, walking ability and limb length discrepancy. The median lengthening of the femur was 3 cm (2–5). The mechanical axis was realigned in all patients. All patients were satisfied with the outcome. Planned secondary contra lateral epiphyseodesis was required to equalise leg length in 2 patients. Complications included a stiff knee (1) that required a Judet quadricepsplasty, premature consolidation (1) that required reosteotomy and knee subluxation (1) that required cross knee stabilisation.

Conclusion: This is a safe and reliable alternative option to joint replacement, Colonna arthroplasty and arthrodesis for the reconstruction of multiply operated complex hip pathology in children.

Purpose: The aim of this part retrospective and part prospective study was to establish the incidence of pinsite infections and assess evolution of changes in practice

Methods: Data was collected retrospectively and prospectively for pin site infections from the inception of limb reconstruction service viz. 1985 to January 2002. There were 812 patients, 1042 limb segments, and 9935 pins. The various external fixators used were limb reconstruction system (LRS) 549; Ilizarov 397; Sheffield ring fixator (SRF); Dynamic axial fixator (DAF) 35; LRS/Sequoia 8; LRS/Garche 7; and Pennig 5.

Results: The pin site infections were graded from 0 to 6 ( Saleh & Scott). There were no infections in 206 segments. The infection grade is shown below:

We changed our pin tract care practice from 1996. We had a significant decrease in pin tract infections since then (p< 0.0001). We also found that using Ilizarov wires had significantly less infections than with half pins used with monolateral fixators (p< 0.0001; linear trend, p= 0.0338). There were 48 patients that required hospital admissions for IV antibiotics. and of these 10 patients required debridement. There were no residual long lasting infections or chronic osteomyelitis.

Conclusion: Attention to detail in insertion of wires and half pins is crucial to avoid pin site infections. This audit supports the fact that external fixation is a safe method from the point of view of infection contrary to general belief.

Aim: To report our experience and early results with flexible nailing for unstable or irreducible displaced proximal humeral fractures in children.

Material & methods: Between 1997 & 2004, 15 children with unstable or irreducible displaced fractures of the proximal humerus were treated with closed/open reduction and flexible IM nailing. There were 10 boys and 5 girls. The median age of the patients was 12.5 years (9–15). Thirteen children had a Salter – Harris II, Neer grade III/IV fracture and 2 children had metaphyseal fractures. The outcome assessment was performed using the shoulder score, clinical and radiological parameters.

Results: All fractures united. None of the patients had a clinically significant malunion/shortening. Three patients had irritation at the nail insertion site. One patient had a transient radial nerve neurapraxia. There were no other operative or postoperative complications. The flexible nails were removed at a median time of 6 months (1.5–10) in 12 patients and 3 patients are awaiting removal. At a median follow-up of 30 months (4–66) all patients had a normal or near normal glenohumeral motion, full strength and all reported regaining full pre-injury functional use of the involved extremity.

Conclusion: Flexible nailing can be used safely to maintain reduction in unstable or irreducible displaced fractures of the proximal humerus and allows early return to normal activities and function with minimal complications. This treatment is also useful in older children who have minimal remodelling potential.

Introduction: Planovalgus is a clinical deformity on weightbearing. Extra-articular calcaneal lengthening osteotomy, is a recognised surgical treatment for symptomatic flat feet. The aim of this study was to assess the difference in pedal pressures and radiographic parameters in the assessment of patients undergoing lateral column lengthening for planovalgus deformity.

Methods: Operative records of one surgeon were reviewed over a 5 year period to identify those who had undergone a lateral column lengthening procedure. 10 patients, 14 feet were identified. Patients were recalled for post-operative pedobarography and pre- and post-operative X-rays were identified. Peak plantar pressures were measured at 8 sites and a line plotted to show maximum deviation of pressure progression from the anatomical axis of the foot. 5 angles on X-rays were measured by 2 observers on 2 occasions.

Results: Difference in pressure under the 3^rd metatarsal head (p=0.0004), hallux (p=0.02) and medial midfoot (0.001) suggested a highly significant change. Results for the first (p=0.41) and second (p=0.91) metatarsal heads showed no change. The centre of pressure maximum deviation, plotted using a line drawn between the second toe and the rear of the heel was found to be highly significant postoperatively (p=0.00051) indicating that load bearing shifted from medial to lateral. Changes in X-ray angles of the lateral talo-1^st metatarsal angle(p=0.006), calcaneal pitch(p=0.002), AP talocalcaneal angle(0.0001) and talonavicular coverage(p=0.003) were all highly significant.

Discussion: Lateral lengthening in adolescent feet changes the pedal pressures in an advantageous way.

Introduction and Aims: To review the existing classifications in characterising the pathologic morphology of congenital lower limb deficiencies (CLLLD) and their usefulness in planning limb reconstruction.

Method: Ninety-five patients undergoing limb reconstruction were classified using existing classifications. Predominantly femoral deficiencies were classified using Aitken, Amstutz, Hamanishi, Gillespie and Torode, Fixsen and Lloyd-Roberts, Kalamchi, and Pappas systems and fibular deficiencies were classified using Coventry and Johnston, Achterman and Kalamchi, and Birch systems.

Results: All patients with predominant deficiency of one segment (femoral or fibular) also had associated shortening of the other segment in the same limb. Acetabular dysplasia, knee instability due to cruciate insufficiency and lateral femoral condylar hypoplasia were found in both femoral and fibular deficiencies. None of the existing classification systems were able to represent the complete pathologic morphology in any given patient. Due consideration of alignment, joint stability and length discrepancy of affected limb as a whole at the planning stage of reconstruction could not be ascertained using these classification systems. Instead, it was useful to characterise the morphology of the involved limb using the following method:

Acetabulum: Dysplastic/Non-dysplastic

Conclusion: Existing classifications do not represent the complete morphology of the entire involved lower limb in CLLLD and therefore a systematic method of characterising the morphology of the lower limb is more useful in planning limb reconstruction.

Aim: To evaluate our results of articulated hip distraction in children with a painful, stiff hip.

Materials & Methods: Between 1988 & 2003, 10 children underwent hip distraction and 7 have completed treatment. The diagnoses were varied, though the presentations were those of pain & stiffness of the hip, poor posture and gait. The Orthofix articulated hip device was used in all patients. The outcome assessment was performed by clinical and radiological review.

Results: The mean age of the patients was 13.7 years (Range 12–17 years). The primary diagnosis was SUFE- 3, Perthes-4, trauma-1, septic arthritis -1, chemotherapy induced -1. The mean fixator time was 12 weeks (range 10–14 weeks). The follow-up period ranged from 4–183 months. Soft tissue releases and joint debridement were done in 6 and 2 patients respectively. Results were good in one, fair in five and poor in one patient. Patients with non-functional ankylosis gained functional position with some increase in range of motion. Grade 2 pin tract infections were noted in 4 patients.

Conclusion: Early results with hip distraction in this difficult, complicated group of patients are promising clinically and radiologically.

Introduction We have reviewed the clinical outcome and complications of Monofocal and Bifocal Callotasis for lower limb lengthening in children with Achondroplasia.

Methods Between August 1986 and January 1999, 57 children with Achondroplasia had lower limb lengthening. Monofocal callotasis had been carried out in 147 Segments of 44 children and bifocal callotasis in 38 segments of 17 children. Complications were noted and final outcomes recorded.

Results The 29 children who completed the programme gained an average of 20 cms in height. For all patients, the mean length gained per segment was roughly nine centimetres. Average Bone Healing Index in the mono-focal lengthening group was 39.9 days/cm and in the bifocal lengthening group 33.6 days/cm. Complications were staged and graded and the average was 2.8 complications per lengthened segment. Most were pin-site related and occurred during stage of distraction. Twenty percent of the segments required further axis corrections. Most patients regained their pre-operative range of motion. Serious irreversible complications were seen in only two patients and included a physeal bar and psychological disturbances. Functional outcome analyses are planned.

Conclusions Limb lengthening for short stature due to Achondroplasia can be confidently undertaken with favourable results in most cases. Bifocal lengthening is an alternative technique with quicker consolidation time.

Aims: To review the results of reconstruction of pseudoarthrosis and/or significant varus with retroversion of proximal femur in congenital longitudinal lower limb deficiencies. Methods: 23 of 95 patients had proximal femoral reconstruction. 7 had pseudoarthrosis of the neck of femur and the remaining had significant coxa vara with retroversion of femur. 3 patients with pseudoarthroses were treated with valgus derotation osteotomy and cancellous bone grafting, 2 with fibular strut grafts, 1 King’s procedure and 1 with excision of fibrous tissue and valgus derotation osteotomy. Remaining patients underwent valgus derotation osteotomies. A variety of internal fixation devices and external fixators were used. Results: All patients with pseudoarthroses underwent multiple procedures to achieve union. 3 with cancellous bone grafting underwent repeat osteotomies to correct residual varus and 2 had grafting repeated twice. 2 patients achieved union after fibular strut grafting. One patient, who underwent excision of pseudoarthrosis, achieved union but had to undergo further valgus osteotomy. The remaining 17 patients with coxa vara and retroversion of femur also had valgus osteotomies repeated more than once (average 2.3) for recurrence of varus deformity. There were significant numbers of implant failures. Average initial neck-shaft angle of 72 degrees improved to 115 degrees after reconstruction. Conclusion: Achieving union of pseudoarthrosis and early axis correction using valgus derotation osteotomy with a view to later lengthening is important in limb reconstruction. Recurrence may require repeated osteotomies and pseudoarthrosis may need more aggressive surgery to achieve union. Muscle slides and soft tissue releases decrease the stress on implant and maintain correction.

Aims: To review the results of limb lengthening and deformity correction in fibular hemimelia. Methods: Fifty-five patients with fibular hemimelia underwent limb reconstruction at Sheffield Children’s Hospital. According to Achterman and Kalamchi classification, twenty-six were classified as Type IA, six as Type IB and twenty-three as Type II fibular hemimelia. All patients had at least some shortening of ipsilateral femur but forty-nine had significant femoral deficiency. Lengthening of tibia and in significant cases femur was done using either De Bastiani, Vilarrubias or Ilizarov methods. Ankle valgus and heel valgus were corrected through osteotomies either in the supramalleolar region or heel. Equinus was corrected by lengthening of tendoachelis with posterior soft tissue release and in severe cases using Ilizarov technique. Results: The average length gained was 4.2 cm (range 1 to 8) and the mean percentage of length increase was 15.82 (range 4.2 to 32.4). Mean bone healing index was 54.23 days/cm. Significant complications included knee subluxation, transient common paroneal nerve palsy, and recurrence of equinus and valgus deformity of foot. Overall alignment and ambulation improved in all patients. Knee stiffness due to cruciate deficient subluxations needed prolonged rehabilitation. Presence of 3-ray foot gives a better functional result and cosmetic acceptance by patients. The Ilizarov frame has the advantage to cross joints and lengthen at the metaphysis. Conclusion: Limb reconstruction in fibular hemimelia using limb lengthening and deformity correction techniques improve functional status of involved lower limb.

Aims: To test the hypothesis that there is a trend to over correction in patients who demonstrate signs of generalised joint laxity.

Patients and methods: 41 patients with an average age of 6.5yrs (3–15) were examined for generalised joint laxity using the Biro score. This gave 52 feet (11 bilateral) for clinical assessment using the podoscope and graded based on Tachdijans flat foot score.

Results: The results were assessed and the patients divided into 2 groups depending on whether or not they had joint laxity. This left 15 patients with 18 feet in the non-lax group and 26 patients with 34 feet in the lax group. The 2 groups were then compared to see if there was a difference in flat foot grade. In the non-lax group 2 patients showed evidence of over-correction whereas in the lax group 25 patients were over corrected to some extent. Using the fisher’s exact test there was a significant difference between the 2 groups with a trend towards over correction in those with generalised joint laxity (p = 0.002).

Conclusion: Based on the findings of this study there is a correlation between generalised joint laxity and over correction in congenital talipes equino-varus.

Aims: To review the hip subluxations or dislocations occurring during femoral lengthening in patients with congenital longitudinal lower limb deficiencies. Methods: Sixty-three patients with congenital longitudinal lower limb deficiencies underwent femoral lengthening using either De Bastiani, Villarubias or Ilizarov technique. Acetabular index, medial joint space, CE angle of Wiberg, acetabular angle of Sharp and neck-shaft angle were measured on anteroposterior radiographs of hip before, during and after lengthening. Acetabulum was considered dysplastic when the Sharp angle was more than 45 degrees. Hip was considered to be subluxed when the medial joint space increased during lengthening. Results: During femoral lengthening, eleven hips subluxed as measured by the increase in medial joint space and one hip dislocated. All these hips had a pre-operative acetabular index more than 25 degrees, CE angle less than 20 degrees and Sharp angle more than 45 degrees. The average neck-shaft angle was 75 degrees. Following subluxation, lengthening was stopped and the hips were reduced in hip spica after adductor and sartorius tenotomies. In one patient femoral shortening and acetabuloplasty had to be done to reduce the sub-luxation. No case of avascular necrosis or chondrolysis was noted. Conclusions: Hip subluxation during femoral lengthening of congenital longitudinal lower limb deficiencies tends to occur when there is associated ace-tabular dyplasia and femoral coxa vara. Careful preoperative assessment, if need be hip reconstruction prior to lengthening and close monitoring during lengthening is recommended.

Aims: To review the presentation, progression, treatment, and outcome of congenital posteromedial bow of tibia. Methods: Seventeen patients were studied using radiographs and medical records retrospectively. The time period was from 1989 to 2002. Data was collected with special reference to deformity correction and lengthening. Complications were analysed. Results: Eight of the patients were male and nine female; eleven of them had deformity correction and lengthening, whereas two are awaiting surgery, two underwent contralateral epiphysiodeses and one, periosteal stripping. Twelve were treated with the Ilizarov device, seven with LRS. The range of discrepancy pre – operatively was from 3 to 8.8 cm. Mean length gained was 3.7 cm with residual discrepancy within 0.6 cm. Complications noted were minor grades of infection and 3 patients required further corrective surgery. The bone-healing index was 62 days per cm. There was some decrease in ankle movement noted, this was unchanged or improved post-operatively. Conclusion: Successful simultaneous deformity correction and lengthening for this condition is possible. The Ilizarov frame provided more benefits in reducing complications. This is the largest series of lengthening and correction of this deformity published and the residual deformity and initial length discrepancy is greater than previously stated.

Aim: To assess the outcome of operative treatment of joint deformities using circular external fixators in arthrogryposis

Materials and Methods: 16 cases were identified in 9 children, who underwent application of Ilizarov external fixation from 1989 to 2000 at the Sheffield Children’s Hospital for progressive correction of knee and foot deformities. This treatment modality was combined with either a soft tissue release, soft tissue distraction or a bony correction. Clinical outcomes were assessed, and comparisons were made between the different treatment modalities. Results: Three fixed flexion deformities of the knee treated with progressive correction and soft tissue distraction all achieved initial correction, but recurred some time after removal of fixators. Out of five club-feet treated with an Ilizarov frame with progressive soft tissue distraction alone, three deformities recurred despite long term splinting. The remaining eight club-foot deformities were treated with a bony procedure combined with gradual correction in the circular frame, and all corrections were maintained at follow up. The average treatment time in the fixator was 17 weeks (12–50 weeks), and the average follow up time was 36 months. Complications included 4 pin track sepses, 1 osteitis requiring a sequestrectomy, 1 transient neurapraxia and 1 fracture following removal of the fixator.

Conclusion: The treatment of joint deformities in arthrogryposis remains challenging and difficult, and complications do occur. Combining the Ilizarov device with a bony procedure seems to have superior results and less recurrence of deformities than pure progressive soft tissue correction.

Aims: To test the hypothesis that there is a trend to over correction in talipes patients who demonstrate signs of generalised joint laxity.

Patients and Methods: 45 patients with an average age of 6.9yrs(3–16) were examined for generalised joint laxity using the Biro score. This gave 65 feet (20 bilateral) for clinical assessment using the podoscope and graded based on Tachdijans flat foot score.

Results: The results were assessed and the patients divided into 2 groups depending on whether or not they had joint laxity. This left 19 patients with 26 feet in the non-lax group and 26 patients with 39 feet in the lax group. The 2 groups were then compared to see if there was a difference in flat foot grade. In the non-lax group 2 patients showed evidence of over-correction whereas in the lax group 18 patients(25 feet)were over corrected to some extent. Using the fisher’s exact test there was a significant difference between the 2 groups with a trend towards over correction in those with generalised joint laxity (p=. 002).

Conclusion: Based on the findings of this study there is a correlation between generalised joint laxity and over correction in congenital talipes equinovarus.

Objective: To review the existing classifications in characterizing the pathological morphology of congenital lower limb deficiencies and their usefulness in planning limb reconstruction.

Methods: Ninety-five patients undergoing limb reconstruction were classified using existing classifications. Predominantly femoral deficiencies were classified using Aitken,Amstutz,Hamanishi,Gillespie andTorode,Fixsen and Lloyd-Roberts, Kalamchi, and Pappas systems and fibular deficiencies were classified using Coventry and Johnston, Achterman and Kalamchi, and Birch systems.

Results: All patients with predominantly femoral deficiencies also had associated shortening of ipsilateral tibia and fibula. Similarly, most patients with predominantly fibular deficiencies also had some associated shortening ipsilateral femur. Acetabular dysplasia, knee instability due to cruciate insufficiency and lateral femoral condylar hypoplasia were found in both femoral and fibular deficiencies. None of the existing classification systems were able to represent the complete pathologic morphology in any given patient. Due consideration of alignment, joint stability and length discrepancy of affected limb as a whole at the planning stage of reconstruction could not be ascertained using these classification systems. Instead, it was useful to characterize the morphology of the involved limb using the following method:

Acetabulum: Dysplastic/ Non-dysplastic (AC index, Sharp’s angle, CE angle)

Conclusion: Congenital longitudinal lower limb deficiency is a spectrum of disorder involving the entire lower limb. Existing classifications do not represent the complete morphology of the entire involved lower limb and therefore a systematic method of characterizing the morphology of the lower limb is more useful in planning limb reconstruction.

Objective: To review the hip subluxations or dislocations occurring during femoral lengthening in patients with congenital longitudinal lower limb deficiencies.

Methods: Sixty-three patients with congenital longitudinal lower limb deficiencies underwent femoral lengthening using either De Bastiani, Villarubias or Ilizarov technique. Acetabular index, medial joint space, CE angle of Wiberg, acetabular angle of Sharp and neck-shaft angle were measured on anteroposterior radiographs of hip before, during and after lengthening. The Acetabulum was considered dysplastic when the Sharp angle was more than 45 degrees. Hip was considered to be subluxed when the medial joint space increased during lengthening.

Results: During femoral lengthening, eleven hips sub-luxed as measured by the increase in medial joint space and one hip dislocated. All these hips had a preoperative acetabular index more than 25 degrees, CE angle less than 20 degrees and Sharp angle more than 45 degrees. The average neck-shaft angle was 75 degrees. Following subluxation, lengthening was stopped and the hips were reduced in hip spica after adductor and sartorius tenotomies. In one patient femoral shortening and acetabulo-plasty had to be done to reduce the subluxation. No case of avascular necrosis was noted.

Conclusion: Hip subluxation during femoral lengthening of congenital longitudinal lower limb deficiencies tends to occur when the acetabular index is more than 25 degrees, Sharp angle is more than 45 degrees, CE angle is less than 20 degrees and when there is associated femoral coxa vara. Careful preoperative assessment is required, and if need be hip reconstruction prior to lengthening. Close monitoring during lengthening is recommended.

Increased incidence of complications has been reported when lengthening limbs with underlying bone disorders such as dysplasias and metabolic bone diseases. There is a paucity of literature on limb lengthening in Osteogenesis Imperfecta (OI), probably due to the concern that the bone containing abnormal collagen may not tolerate the external fixators for a long term and there may not be adequate regenerate formation from this abnormal bone.

We performed limb lengthening and deformity correction of nine lower limb long bones in six children with OI. Four children were type I and two were type IV OI as per Sillence classification. The mean age was 14.7 years. All six children had lengthening for femoral shortening and three of them also had lengthening for tibial shortening on the same side. Angular deformities were corrected during lengthening. Five limb segments were treated using a monolateral external fixator and four limb segments were treated using an Ilizarov external fixator. In three children, previously inserted femoral intramedullary nails were left in situ during the course of femoral lengthening. The average lengthening achieved was 6.26 cm. Limb length discrepancies were corrected to within 1.5 cm of the length of the contralateral limb in five children. In one child with fixed pelvic obliquity and spinal scoliosis, functional leg length was achieved. The mean healing index was 33.25 days/cm of lengthening. Among the complications significant ones included, one deep infection, one fracture through the midshaft of the femur, and development of anterior angulation deformity after the removal of the fixator in one tibia. Abnormal bone of OI tolerated the external fixator throughout the period of lengthening without any incidence of migration of wires and screws through the soft bone when distraction forces were applied. The regenerate bone formed within the time that is normally expected in limb lengthening procedures performed for other conditions. We conclude that despite abnormal bone characteristics, limb reconstruction to correct limb length discrepancy and angular deformity can be done safely in children with OI.

We reviewed the outcome of 30 patients treated with an Ilizarov frame for resistant clubfoot deformity. Each patient was assessed using objective and subjective outcome measures. We used clinical examination, X-ray analysis, pedobarography and gait analysis and the Activities Scale for Kids questionnaire, developed and validated by The Hospital for Sick Children, Toronto, Canada.

The average questionnaire score was 83. This suggested a good subjective outcome when compared to the average score of 38 achieved by children with untreated clubfoot. Patients were into 2 groups using this score. Patients scoring over 75 were considered to have a good outcome and those scoring less than 75 were considered to have a bad outcome. The objective results were then compared.

We found no difference between the 2 groups using clinical examination and X-ray. Pedobarography showed lower pressures in the bad subjective group, in particular virtually no pressure was generated under the heel when walking.

The pressure distribution also showed the bad group to have the pressure balance towards the front of the foot over the 5^th metatarsal head.

Gait analysis showed differences. The bad group had increased pelvic obliquity and increased pelvic movement suggesting an inefficient gait, increased hip abduction in swing, hyperextension of the knee on loading and decreased dorsiflexion of the ankle in swing when compared to the good group.

Our conclusions were that subjectively this group of patients did well after surgical treatment using an Ilizarov frame.

Clinical examination can show significant intra- and inter-observer error and X-ray is unreliable in children whose feet are congenitally deformed. Pedobarography and gait analysis seem to correlate better with subjective outcome. We know that a good foot is a functional foot and it may be that functional assessment is a more appropriate means of assessing results of treatment in these patients.

The aim was to study the use of limb reconstruction techniques in the management of Ollier’s Dysplasia over a period of 25 years.

This was a retrospective review of case records and radiographs of patients who had lower limb reconstruction for deformity and limb length discrepancy. There were a total of 9 patients of whom 7 had reached maturity and four of these were still under follow up.

The major aims of surgery were to correct lower limb length discrepancy and deformity. A total of twenty segments were operated upon. These were 11 femurs and 9 tibiae. In some segments repeated surgery was required. 41 index and 54 secondary procedures were necessary giving an average of 10.5 procedures per patient. The most common problems were difficulty in fixation in abnormal bone, premature consolidation reflecting the rich osteogenic potential and growth related recurrence of deformities and discrepancy. The mean length gained was 13.8 cms per patient. Healing of regenerate occurred with radiologically normal appearance even in chondro-dysplastic areas. All patients who had completed treatment had a satisfactory mechanical axis and the mean length discrepancy was 1.7 cms.

Patients with Ollier’s dysplasia appear to respond well to limb reconstructive surgery. It is possible to correct severe limb length discrepancies and angular deformities. Surgeons should be aware of the possibility of premature healing and should consider faster lengthening rates of up to 1.5 mms per day. Distraction should begin early by day 5 or less. Immature patients should be warned about the possibility of recurrence of deformity and possible need for repeated surgery.