Ambulating children with bilateral spastic cerebral palsy (BSCP) demonstrate atypical posture and gait due to abnormal muscle and skeletal growth when compared to typically–developing (TD) children. Normal postural alignment in standing facilitates many of the tasks of daily living because it allows a stable base of support without requiring significant muscular effort. Similarly, increasing gait abnormality is associated with poorer functional capacity. Our aims were to compare the standing posture of TD children and children with BSCP using the Standing Profile Score and identify if any abnormality in standing is correlated with abnormality in walking in children with BSCP using the Gait Profile Score index. We retrospectively compared 44 typically-developing children to 74 age-matched children with BSCP (GMFCS I & II). We performed 3D Gait Analysis during long-standing (10seconds) and in gait after application of 16 retro-reflective markers on anatomical landmarks of the lower limb and pelvis. Analysis of all kinematics was performed for movements in the sagittal, coronal and axial planes. The Gait Profile score (GPS) is a validated index of overall gait pathology. The Standing Profile Score (SPS) was developed using the same calculations for GPS but during static trials. A significant correlation was observed between the Standing Profile Score (SPS) and Gait Profile Score (GPS) in children with BSCP (p<0.001). Significant differences were exhibited in GPS between the two groups, across all parameters, except the pelvic obliquity (p<0.05). A significant positive correlation existed for hip rotation in both groups, however the correlations observed at hip flexion and ankle dorsiflexion were significantly greater in the BSCP group compare to the TD group (p<0.01). We have shown that posture during gait (GPS) is predictable from standing posture (SPS) in patients with BSCP. This biomechanical relationship can aid surgical decision-making.
The aim was to assess contemporary management of slipped capital femoral epiphysis (SCFE) by surveying members of the British Society of Children's Orthopaedic Surgery (BSCOS). A questionnaire with 5 case vignettes was used. Two questions examined the timing of surgery for an acute unstable SCFE in a child presenting at 6 hours and at 48 hours after start of symptoms. Two further questions explored the preferred method of fixation in mild and severe stable SCFE. The final question examined the management of the contralateral normal hip. Responses were entered into an Excel spreadsheet and the data w analysed using a chi-squared test. The response rate was 56% (110/196). 88.2% (97/110) responded that if a child presented with an acute unstable SCFE within 6 hours, they would treat it within 24 hours of presentation, compared with 40.9% (45/110) for one presenting 48 hours after the onset of symptoms (P<0.0001). 52.6% (58/110) of surveyed BSCOS members would offer surgery for an unstable SCFE between 1 and 7 days after onset of symptoms. Single screw fixation in situ was advocated by 96.4% (106/110) and 70.9% (78/110) while corrective osteotomy was preferred by 1.8% (2/110) and 26.4% (29/110) of respondents for the mild and the severe stable slips respectively (P<0.0001). Surgeons preferring osteotomy are more likely to perform an intracapsular technique. Prophylactic fixation of the contralateral normal hip was performed by 27.3% (30/110) of participants. There are significant differences in opinions between BSCOS members as to the optimal management of SCFE in children. This reflects the variable recommendations and quality in the current scientific literature. Further research is therefore required to determine best practice and enable consensus to be reached.
A femoral fracture in an adolescent is a significant injury. It is generally agreed that operative fixation is the treatment of choice and rigid intramedullary nailing is a surgical treatment option. We present on experience of treating adolescent femoral fractures using a lateral entry intramedullary nail. We reviewed 15 femoral fractures in 13 children who we treated in our unit between 2011 and 2014. Two patients had bilateral fractures (non-simultaneous). Data collected included patient demographics, mechanism of injury, type of fracture, associated injuries, size of nail, time to unite and complications. The mean age of the patients at time of surgery was 12 years (range 10–15). There were 7 male and 6 female. 10 fractures were caused by a fall whilst 5 were due to road traffic collisions (RTC). 8 fractures involved the middle third, 2 of theses were open fractures and were caused by a RTC. The remaining 7 involved the proximal third of the femur. The mean time to radiological union was 3.4 months (range 2.5–5) in 14 fractures. One patient had a delayed union that required bone grafting and united fully at 7.5 months post injury. The only other complications were a broken proximal locking screw in one patient and an undisplaced femoral neck fracture in another patient. These complications did not compromise the outcome. No patients had infection or developed avascular necroses at the latest follow up. Intramedullary nailing of adolescent femoral fractures using the lateral entry point is safe and effective
A retrospective review of patients with spinal growing rods in a single institution. Demographic data including age at first surgery, diagnosis, pre- and post-operative cobb angles from erect standardised radiographs were collected. The type of construct used i.e. spine to rib or spine to spine was noted along with the type of growing mechanism used (magnetic or cassette). Any complications were collated for each technique. Our results include 26 patients who had growing rod insertion, 12 in the spine - spine group and 14 in rib - spine group. Pre-operative cobb angles of 71 and 78 degrees respectively with a correction to 36 and 35 degrees. Mean age at surgery was 63 months in spine to spine group and 67 months in rib to spine group. Spine to spine group had 2 proximal pull out of hooks and the rib spine group had one pull out of hook. The correction achieved by the new technique is comparable to the spine – spine constructs. Complications are seen in both groups. The perceived benefit of the new technique is the proximal spine is not violated so there is a reduced risk of mass fusion. The canal and pedicles are not included proximally, so there will be no effect on the growing diameter of the canal. Biomechanically the construct is more robust and should allow greater control of the curve. Further follow up and analysis of this new technique is warranted.
The purpose of the study was to investigate the incidence of surgical site infection following elective paediatric orthopaedic surgery. A pro forma adopted from a pilot study was filled out preoperatively for each elective operation performed during the study period. Each patient was then followed up for six weeks postoperatively to record any SSI that developed. Data collected included patient demographics, type of operation, grade of Surgeon, type of procedure, wound length, skin preparations, use of tourniquet, any antibiotic prophylaxis and length of operation. This study collated data on 334 operations with 410 procedural sites over a six month period. Infection were recorded in 19 sites equivalent to a SSI rate of 4.63%. None of the patients developed long-term complications. The mean age of the participants in the study was 11 years (range 0.5 to 17 years), 57% were males and 43% were females. The infection were detected between 1 and 38 days after surgery. The outcome was not compromised in any of the patients as none of them required long-term treatment. Statistical analysis was undertaken. The study proves that the surgical site infection after elective paediatric orthopaedic surgery is low and serve as a bases for consenting patients for surgery.
This retrospective matched cohort study tested the hypothesis that an incomplete periacetabular acetabuloplasty, as an added step to delayed open reduction, diminishes the risk of developing acetabular dysplasia. 29 hips from 23 patients with idiopathic DDH that underwent intentionally delayed open reduction and acetabuloplasty at our institution from 2003 to 2010 were matched for age at presentation and bilaterality to historic controls. These were 29 hips from 26 patients, treated with open reduction alone from 1989 to 2003. Residual dysplasia treated with pelvic osteotomy, AVN grade II-IV, and rate of re-intervention were the outcome measures. The mean ages at diagnosis and at surgery were 8.62 weeks and 12.97 months, respectively. At latest follow-up, 27 hips in the acetabuloplasty group and 22 in the open reduction alone group had satisfactory radiographic outcome (Severin class Ia, Ib or II) (p=0.16). 18 of the 58 hips (31.0%) had AVN, 7 (24.14%) in the case group and 11(37.93%) in the control group. Further surgery was required in 15 of the 29 hips in the open reduction alone group. These included 2 revision of open reductions, 5 pelvic osteotomies, 3 varus derotation osteotomies, and 5 apo or epiphysiodesis whilst only one patient in the acetabuloplasty group required a medial screw epiphysiodesis for late lateral growth arrest. There is a positive association between the need for further surgery and open reductions alone: the odds ratio is 14.00 and the 95% confidence interval (1.97, 99.63), p=0.0017. The five hips in the open reduction alone group that required a pelvic osteotomy were intervened at an average of 31.45 (±9.07) months. The addition of an incomplete periacetabular periacetabuloplasty to all hips undergoing open reduction eliminated residual acetabular dysplasia in this cohort whilst it does not appear to have deleterious effects, as evidenced by the similar Severin and McKay scores.
The purpose of the study was to identify risk factors that are associated with re-displacement of the hip after surgical reconstruction in cerebral palsy. Retrospective review of children with cerebral palsy who had hip reconstruction with proximal femoral varus derotation osteotomy (VDRO) and Dega-type pelvic osteotomy, between 2005–2012, at a UK and European institution, was performed. Patient demographics, GMFCS, clinical and radiological outcome were assessed as well as the presence of pelvic obliquity and significant scoliosis (Cobb angle > 10 degrees). Redisplacement was defined as Reimer's Migration Index (MI) >30% at final follow-up. Logistic regression analysis was used to assess which factors were predictive of redisplacement and adjusted for clustered variables (α = 0.05). Eighty hips were identified in 61 patients. The mean age at surgery was 8.8 years (± 3.3). Mean MI pre-op was 68% (± 23%) and post-op was 8% (± 12%). At a mean follow-up, of 3.2 years (± 2.0), 23 hips had a MI >30%. Of these; five were symptomatic, and one had required a salvage procedure. Metalwork removal was undertaken in 14 hips. Logistic regression demonstrated that the pre-operative MI and the percentage of acute correction were significant predictors of re-displacement. If the pre-operative MI was greater than 65 percent, the odds ratio (OR) for redisplacement was 5.99 (p = 0.04). If correction of the MI was less than 90% of the pre-operative MI, the OR for re-displacement was 4.6 (p = 0.03). Age at the time of surgery, GMFCS, pelvic obliquity and scoliosis were not predictive of re-displacement. These results, firstly, highlight the importance of hip surveillance in children with cerebral palsy to allow timely intervention to ensure adequate radiological outcomes. Secondly, as in developmental hip dysplasia, full concentric reduction is essential to reduce the risk of re-displacement, with its associated clinical consequences.
The disadvantages of hip spica casts following hip surgery for cerebral palsy include fractures, plaster sores, soiling and general inconvenience. In this series, 56 hips in 31 children aged 4 to 16 years (mean 8) were treated for hip displacement in keeping with the recommendations of others (eg Miller et al 1997) between 2005 and 2008 by one consultant. There were 29 open reductions for a Reimer's migration index (RMI) greater than 50%. A blade plate was used for the femoral osteotomy, and an acetabuloplasty was performed for 22 hips. No casting or immobilisation of any sort was used. The average length of stay was 5 days. The results at 5 the year follow-up were chosen so that all patients were at the same stage. The average RMI pre-operatively for displaced hips was 76.9 +/− 21.3. At follow-up it was 18.8 +/− 19.7. 18 patients had pain prior to hip surgery; 6 had pain during follow-up, and 4 of these responded to removal of metal; and one required a proximal femoral resection. There were 3 complications: one re-dislocation in the immediate post-operative period, one mal-union because the blade plate cut out; and one of the three walking children fractured below the blade plate 2 ½ months after surgery. There were no infections. The radiographic and clinical outcomes of hip reconstruction without hip spica immobilisation are good, reproducible and long-lasting. The child may be nursed free post-operatively and discharged in his or her own chair. As a result of studying these patients, since 2009 we have introduced locking plates for better fixation, and pre- and post-operative Paediatric Pain Profiles and CPCHILD questionnaires.
The aim of this study was to determine the effectiveness of intra-operative tranexamic acid in children with osteogenesis imperfecta, who have been shown to have increased bleeding tendency, in deformity correction surgery. We retrospectively reviewed all cases of lower limb intramedullary rodding in patients with osteogenesis imperfecta treated in our unit from 2000–2013 in whom a pre and post- operative full blood count was available (n=69). Case notes were reviewed and patients were grouped according to the use of tranexamic acid. Peri-operative change in haemoglobin (Hb), haematocrit (HCT) and requirement for blood transfusion was assessed. Of 69 operations performed, 62.3% were in female patients, 78.3% were femoral, and 43.5% were bilateral cases (19 femur, 11 tibia). In the non-tranexamic acid group there was a mean drop in Hb of 28.9 g/L (range 0–62), mean HCT drop of 8.8 (range 2.2–19.4) and 3 patients required red cell transfusion. In the tranexamic acid group there was a mean Hb drop of 22.5 g/L (range 1–49), mean HCT drop of 7.35 (range −0.8–16.7) and one patient required red cell transfusion. There was a significant decrease in Hb drop (p=0.0287) in the tranexamic acid group. Tranexamic acid seems to decrease the drop in haemoglobin during lower limb intramedullary rodding in patients with osteogenesis imperfecta, with little associated risk. Protocols should be established for future use a further review undertaken.
The unwell child with an acutely irritable hip poses a diagnostic dilemma. Recent studies indicate that pericapsular myositis may be at least as common as joint infection in the septic child. MRI might therefore be a critical first step to avoid unnecessary hip drainage surgery in the septic child with hip symptoms. We reviewed our own experience with MR imaging in this setting. We searched our PACS system to retrieve MRI scans performed for children with suspected hip sepsis from August 2008 to August 2014 using the following terms: hip, septic arthritis, osteomyelitis, mysositis, abscess, femur, acetabulum. 56 cases fulfilled inclusion criteria that included acute presentation with hip symptoms and 2 or more Kocher criteria for septic arthritis. Recent unsuccessful hip washout was not a contra-indication. 56 patients presented with acute infection around the hip. 47 (84%) had MRI scans before any surgical intervention and 9 (16%) had scans promptly following unsatisfactory hip washout with failure to improve. 20 (36%) were found to have pericapsular myositis. In this group, the infection commonly involved the iliopsoas (4), gluteal (4), piriformis (5) or obturator (7) muscles. 15 (27%) children had proximal femoral or acetabular osteomyelitis and 8 (14%) were diagnosed with septic arthritis. The 13 (23%) remaining scans did not show infection around the hip. This study confirms a high rate of extracapsular foci in septic children presenting with hip irritability. Less than 20% had actual septic arthritis in this series. While drainage of a septic joint should never be delayed in the face of a large joint effusion with debris on US, there is a clear role for MRI scanning in the acute setting when the diagnosis is less certain.
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:
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:
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:
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:
There is controversy whether congenital foot
abnormalities are true risk factors for pathological dysplasia of
the hip. Previous United Kingdom screening guidelines considered
congenital talipes equinovarus (CTEV) to be a risk factor for hip
dysplasia, but present guidelines do not. We assessed the potential
relationship between pathological dysplasia of the hip and fixed
idiopathic CTEV. We present a single-centre 21-year prospective longitudinal observational
study. All fixed idiopathic CTEV cases were classified (Harrold
and Walker Types 1 to 3) and the hips clinically and sonographically
assessed. Sonographic Graf Type III, IV and radiological irreducible
hip dislocation were considered to be pathological hip dysplasia. Over 21 years there were 139 children with 199 cases of fixed
idiopathic CTEV feet. Sonographically, there were 259 normal hips,
18 Graf Type II hips, 1 Graf Type III hip and 0 Graf Type IV hip.
There were no cases of radiological or sonographic irreducible hip
dislocation. Fixed idiopathic CTEV should not be considered as a significant
risk factor for pathological hip dysplasia. This conclusion is in
keeping with the current newborn and infant physical examination
guidelines in which the only risk factors routinely screened are
family history and breech presentation. Our findings suggest CTEV
should not be considered a significant risk factor in pathological
dysplasia of the hip. Cite this article:
Assessment of skeletal age is important in children’s
orthopaedics. We compared two simplified methods used in the assessment
of skeletal age. Both methods have been described previously with
one based on the appearance of the epiphysis at the olecranon and
the other on the digital epiphyses. We also investigated the influence
of assessor experience on applying these two methods. Our investigation was based on the anteroposterior left hand
and lateral elbow radiographs of 44 boys (mean: 14.4; 12.4 to 16.1
) and 78 girls (mean: 13.0; 11.1 to14.9) obtained during the pubertal
growth spurt. A total of nine observers examined the radiographs
with the observers assigned to three groups based on their experience (experienced,
intermediate and novice). These raters were required to determined
skeletal ages twice at six-week intervals. The correlation between
the two methods was determined per assessment and per observer groups. Interclass
correlation coefficients (ICC) evaluated the reproducibility of
the two methods. The overall correlation between the two methods was r = 0.83
for boys and r = 0.84 for girls. The correlation was equal between
first and second assessment, and between the observer groups (r ≥ 0.82).
There was an equally strong ICC for the assessment effect (ICC ≤ 0.4%)
and observer effect (ICC ≤ 3%) for each method. There was no significant
(p <
0.05) difference between the levels of experience. The two methods are equally reliable in assessing skeletal maturity.
The olecranon method offers detailed information during the pubertal
growth spurt, while the digital method is as accurate but less detailed,
making it more useful after the pubertal growth spurt once the olecranon
has ossified. Cite this article:
In 1994 a cerebral palsy (CP) register and healthcare
programme was established in southern Sweden with the primary aim
of preventing dislocation of the hip in these children. The results from the first ten years were published in 2005 and
showed a decrease in the incidence of dislocation of the hip, from
8% in a historical control group of 103 children born between 1990
and 1991 to 0.5% in a group of 258 children born between 1992 and
1997. These two cohorts have now been re-evaluated and an additional
group of 431 children born between 1998 and 2007 has been added. By 1 January 2014, nine children in the control group, two in
the first study group and none in the second study group had developed
a dislocated hip (p <
0.001). The two children in the first study
group who developed a dislocated hip were too unwell to undergo
preventive surgery. Every child with a dislocated hip reported severe pain,
at least periodically, and four underwent salvage surgery. Of the
689 children in the study groups, 91 (13%) underwent preventive
surgery. A population-based hip surveillance programme enables the early
identification and preventive treatment, which can result in a significantly
lower incidence of dislocation of the hip in children with CP. Cite this article:
We present the long-term results of open surgery
for internal shoulder rotational deformity in brachial plexus birth palsy
(BPBP). From 1997 to 2005, 207 patients (107 females, 100 males, mean
age 6.2 (0.6 to 34)) were operated on with subscapularis elongation
and/or latissimus dorsi to infraspinatus transfer. Incongruent shoulder
joints were relocated. The early results of these patients has been
reported previously. We analysed 118 (64 females, 54 males, mean
age 15.1 (7.6 to 34)) of the original patient cohort at a mean of
10.4 years (7.0 to 15.1) post-operatively. A third of patients with
relocated joints had undergone secondary internal rotational osteotomy
of the humerus. A mixed effects models approach was used to evaluate the effects
of surgery on shoulder rotation, abduction, and the Mallet score.
Independent factors were time (pre-and post-surgery), gender, age,
joint category (congruent, relocated, relocated plus osteotomy)
and whether or not a transfer had been performed. Data from a previously published
short-term evaluation were reworked in order to obtain pre-operative
values. The mean improvement in external rotation from pre-surgery to
the long-term follow-up was 66.5° (95% confidence interval (CI)
61.5 to 71.6). The internal rotation had decreased by a mean of
22.6° (95% CI -18.7 to -26.5). The mean improvement in the three-grade
aggregate Mallet score was 3.1 (95% CI 2.7 to 3.4), from 8.7 (95%
CI 8.4 to 9.0) to 11.8 (11.5 to 12.1). Our results show that open subscapularis elongation achieves
good long-term results for patients with BPBP and an internal rotation
contracture, providing lasting joint congruency and resolution of
the trumpet sign, but with a moderate mean loss of internal rotation. Cite this article:
Salter innominate osteotomy is an effective reconstructive
procedure for the treatment of developmental dysplasia of the hip
(DDH), but some children have a poor outcome at skeletal maturity.
In order to investigate factors associated with an unfavourable
outcome, we assessed the development of the contralateral hip. We retrospectively
reviewed 46 patients who underwent a unilateral Salter osteotomy
at between five and seven years of age, with a mean follow-up of
10.3 years (7 to 20). The patients were divided into three groups
according to the centre–edge angle (CEA) of the contralateral hip
at skeletal maturity: normal (>
25°, 22 patients), borderline (20°
to 25°, 17 patients) and dysplastic (<
20°, 7 patients). The
CEA of the affected hip was measured pre-operatively, at eight to
nine years of age, at 11 to 12 years of age and at skeletal maturity.
The CEA of the affected hip was significantly smaller in the borderline
and dysplastic groups at 11 and 12 years of age (p = 0.012) and
at skeletal maturity (p = 0.017) than in the normal group. Severin
group III was seen in two (11.8%) and four hips (57.1%) of the borderline
and dysplastic groups, respectively (p <
0.001). Limited individual development of the acetabulum was associated
with an unfavourable outcome following Salter osteotomy. Cite this article:
We report the effect of introducing a dedicated
Ponseti service on the five-year treatment outcomes of children
with idiopathic clubfoot. Between 2002 and 2004, 100 feet (66 children; 50 boys and 16
girls) were treated in a general paediatric orthopaedic clinic.
Of these, 96 feet (96%) responded to initial casting, 85 requiring
a tenotomy of the tendo-Achillis. Recurrent deformity occurred in
38 feet and was successfully treated in 22 by repeat casting and/or
tenotomy and/or transfer of the tendon of tibialis anterior, The
remaining 16 required an extensive surgical release. Between 2005 and 2006, 72 feet (53 children; 33 boys and 20 girls)
were treated in a dedicated multidisciplinary Ponseti clinic. All
responded to initial casting: 60 feet (83.3%) required a tenotomy
of the tendo-Achillis. Recurrent deformity developed in 14, 11 of
which were successfully treated by repeat casting and/or tenotomy
and/or transfer of the tendon of tibialis anterior. The other three
required an extensive surgical release. Statistical analysis showed that children treated in the dedicated
Ponseti clinic had a lower rate of recurrence (p = 0.068) and a
lower rate of surgical release (p = 0.01) than those treated in
the general clinic. This study shows that a dedicated Ponseti clinic, run by a well-trained
multidisciplinary team, can improve the outcome of idiopathic clubfoot
deformity. Cite this article:
Previous studies have identified clinical and
demographic risk factors for recurrence in the treatment of idiopathic clubfoot
(congenital talipes equinovarus). Evertor muscle activity is not
usually considered amongst them. This study aimed to evaluate whether
recurrence could be predicted by demographic, clinical and gait
parameters. From a series of 103 children with clubfeet, 67 had
completed a follow-up of two years: 41 male and 26 female, 38 with idiopathic
and 29 with non-idiopathic deformities. The mean age was 3.2 years
(2.1 to 6.3). Primary correction was obtained in all 38 children
(100%) with an idiopathic deformity, and in 26 of 29 patients (90%)
with a non-idiopathic deformity. Overall, 60 children (90%) complied
with the abduction brace regime. At a mean follow-up of 31.4 months (24
to 62), recurrence was noted in six children (15.8%) in the idiopathic
and 14 children (48.3%) in the non-idiopathic group. Significant
correlation was found between poor evertor activity and recurrence
in both groups. No statistically significant relationship was found
between the rate of recurrence and the severity of the initial deformity,
the age at the time of treatment, the number of casts required or
the compliance with the brace. After correction of idiopathic and non-idiopathic clubfoot using
the Ponseti method, only poor evertor muscle activity was statistically
associated with recurrence. The identification of risk factors for
recurrent deformity allows clinicians to anticipate problems and
advocate early additional treatment to improve muscle balance around
the ankle. Cite this article:
Two types of fracture, early and late, have been
reported following limb lengthening in patients with achondroplasia (ACH)
and hypochondroplasia (HCH). We reviewed 25 patients with these conditions who underwent 72
segmental limb lengthening procedures involving the femur and/or
tibia, between 2003 and 2011. Gender, age at surgery, lengthened
segment, body mass index, the shape of the callus, the amount and
percentage of lengthening and the healing index were evaluated to determine
predictive factors for the occurrence of early (within three weeks
after removal of the fixation pins) and late fracture (>
three weeks
after removal of the pins). The Mann‑Whitney U test and Pearson’s
chi-squared test for univariate analysis and stepwise regression
model for multivariate analysis were used to identify the predictive factor
for each fracture. Only one patient (two tibiae) was excluded from
the analysis due to excessively slow formation of the regenerate,
which required supplementary measures. A total of 24 patients with
70 limbs were included in the study. There were 11 early fractures in eight patients. The shape of
the callus (lateral or central callus) was the only statistical
variable related to the occurrence of early fracture in univariate
and multivariate analyses. Late fracture was observed in six limbs
and the mean time between removal of the fixation pins and fracture
was 18.3 weeks (3.3 to 38.4). Lengthening of the tibia, larger healing
index, and lateral or central callus were related to the occurrence
of a late fracture in univariate analysis. A multivariate analysis
demonstrated that the shape of the callus was the strongest predictor
for late fracture (odds ratio: 19.3, 95% confidence interval: 2.91
to 128). Lateral or central callus had a significantly larger risk
of fracture than fusiform, cylindrical, or concave callus. Radiological monitoring of the shape of the callus during distraction
is important to prevent early and late fracture of lengthened limbs
in patients with ACH or HCH. In patients with thin callus formation,
some measures to stimulate bone formation should be considered as
early as possible. Cite this article:
The aim of this study was to determine whether
an osteoplasty of the femoral neck performed at the same time as an
intertrochanteric Imhäuser osteotomy led to an improved functional
outcome or increased morbidity. A total of 20 hips in 19 patients
(12 left, 8 right, 13 male, 6 female), who underwent an Imhäuser
intertrochanteric osteotomy following a slipped capital femoral
epiphysis were assessed over an eight-year period. A total of 13
hips in 13 patients had an osteoplasty of the femoral neck at the
same time. The remaining six patients (seven hips) had intertrochanteric
osteotomy alone. The mean age was 15.3 years (13 to 20) with a mean
follow-up of 57.8 months (15 to 117); 19 of the slips were severe
(Southwick grade III) and one was moderate (grade II), with a mean
slip angle of 65.3° (50° to 80°); 17 of the slips were stable and
three unstable at initial presentation. The mean Non-Arthritic Hip Scores
(NAHS) in patients who underwent osteoplasty was 91.7 (76.3 to 100)
and the mean NAHS in patients who did not undergo osteoplasty was
76.6 (41.3 to 100) (p = 0.056). Two patients required a subsequent
arthroplasty and neither of these patients had an osteoplasty. No
hips developed osteonecrosis or chondrolysis, and there was no increase
in complications related to the osteoplasty. We recommend that for
patients with a slipped upper femoral epiphysis undergoing an intertrochanteric
osteotomy, the addition of an osteoplasty of the femoral neck should
be considered. Cite this article:
Proximal femoral varus osteotomy improves the
biomechanics of the hip and can stimulate normal acetabular development
in a dysplastic hip. Medial closing wedge osteotomy remains the
most popular technique, but is associated with shortening of the
ipsilateral femur. We produced a trigonometric formula which may be used pre-operatively
to predict the resultant leg length discrepancy (LLD). We retrospectively
examined the influence of the choice of angle in a closing wedge
femoral osteotomy on LLD in 120 patients (135 osteotomies, 53% male,
mean age six years, (3 to 21), 96% caucasian) over a 15-year period
(1998 to 2013). A total of 16 of these patients were excluded due
to under or over varus correction. The patients were divided into
three age groups: paediatric (<
10 years), adolescent (10 to
16 years) and adult (>
16 years). When using the same saw blades
as in this series, the results indicated that for each 10° of angle
of resection the resultant LLD equates approximately to multiples
of 4 mm, 8 mm and 12 mm in the three age groups, respectively. Statistical testing of the 59 patients who had a complete set
of pre- and post-operative standing long leg radiographs, revealed
a Pearson’s correlation coefficient for predicted This study identified a geometric model that provided satisfactory
accuracy when using specific saw blades of known thicknesses for
this formula to be used in clinical practice. Cite this article:
Congenital Talipes Equinovarus (CTEV) is one
of the most common congenital limb deformities. We reviewed the records
of infants who had received treatment for structural CTEV between
1 January 2007 and 30 November 2012. This was cross-referenced with
the prenatal scans of mothers over a corresponding period of time.
We investigated the sensitivity, specificity, and positive and negative
predictive values of the fetal anomaly scan for the detection of CTEV
and explored whether the publication of Fetal Anomaly Screening
Programme guidelines in 2010 affected the rate of detection. During the study period there were 95 532 prenatal scans and
34 373 live births at our hospital. A total of 37 fetuses with findings
suggestive of CTEV were included in the study, of whom 30 were found
to have structural CTEV at birth. The sensitivity of screening for
CTEV was 71.4% and the positive predictive value was 81.1%. The negative
predictive value and specificity were more than 99.5%. There was
no significant difference between the rates of detection before
and after publication of the guidelines (p = 0.5). We conclude that a prenatal fetal anomaly ultrasound screening
diagnosis of CTEV has a good positive predictive value enabling
prenatal counselling. The change in screening guidance has not affected
the proportion of missed cases. This information will aid counselling
parents about the effectiveness and accuracy of prenatal ultrasound
in diagnosing CTEV. Cite this article:
In this study we evaluated the results of midtarsal
release and open reduction for the treatment of children with convex
congenital foot (CCF) (vertical talus) and compared them with the
published results of peritalar release. Between 1977 and 2009, a
total of 22 children (31 feet) underwent this procedure. In 15 children
(48%) the CCF was isolated and in the remainder it was not (seven
with arthrogryposis, two with spinal dysraphism, one with a polymalformative
syndrome and six with an undefined neurological disorder). Pre-operatively, the mean tibiotalar angle was 150.2° (106° to
175°) and the mean calcaneal pitch angle was -19.3° (-72° to 4°).
The procedure included talonavicular and calcaneocuboid joint capsulotomies,
lengthening of tendons of tibialis anterior and the extensors of
the toes, allowing reduction of the midtarsal joints. Lengthening
of the Achilles tendon was necessary in 23 feet (74%). The mean follow-up was 11 years (2 to 21). The results, as assessed
by the Adelaar score, were good in 24 feet (77.4%), fair in six
(19.3%) and poor in one foot (3.3%), with no difference between
those with isolated CCF and those without. The mean American Orthopaedic
Foot and Ankle Society midfoot score was 89.9 (54 to 100) and 77.8
(36 to 93) for those with isolated CCF and those without, respectively.
At the final follow-up, the mean tibiotalar (120°; 90 to 152) and
calcaneal pitch angles (4°; -13 to 22) had improved significantly
(p <
0.0001). Dislocation of the talonavicular and calcaneocuboid
joints was completely reduced in 22 (70.9%) and 29 (93.6%) of feet,
respectively. Three children (five feet) underwent further surgery
at a mean of 8.5 years post-operatively, three with pes planovalgus
and two in whom the deformity had been undercorrected. No child
developed avascular necrosis of the talus. Midtarsal joint release and open reduction is a satisfactory
procedure, which may provide better results than peritalar release.
Complications include the development of pes planovalgus and persistent
dorsal subluxation of the talonavicular joint. Cite this article:
Cubitus varus is the most frequent complication
following the treatment of supracondylar humeral fractures in children.
We investigated data from publications reporting on the surgical
management of cubitus varus found in electronic searches of Ovid/MEDLINE
and Cochrane Library databases. In 894 children from 40 included
studies, the mean age at initial injury was 5.7 years (3 to 8.6)
and 9.8 years (4 to 15.7) at the time of secondary correction. The four
osteotomy techniques were classified as lateral closing wedge, dome,
complex (multiplanar) and distraction osteogenesis. A mean angular
correction of 27.6º (18.5° to 37.0°) was achieved across all classes
of osteotomy. The meta-analytical summary estimate for overall rate
of good to excellent results was 87.8% (95% CI 84.4 to 91.2). No technique
was shown to significantly affect the surgical outcome, and the
risk of complications across all osteotomy classes was 14.5% (95%
CI 10.6 to 18.5). Nerve palsies occurred in 2.53% of cases (95%
CI 1.4 to 3.6), although 78.4% were transient. No one technique
was found to be statistically safer or more effective than any other. Cite this article:
Proximal femoral resection (PFR) is a proven
pain-relieving procedure for the management of patients with severe cerebral
palsy and a painful displaced hip. Previous authors have recommended
post-operative traction or immobilisation to prevent a recurrence
of pain due to proximal migration of the femoral stump. We present
a series of 79 PFRs in 63 patients, age 14.7 years (10 to 26; 35
male, 28 female), none of whom had post-operative traction or immobilisation. A total of 71 hips (89.6%) were reported to be pain free or to
have mild pain following surgery. Four children underwent further
resection for persistent pain; of these, three had successful resolution
of pain and one had no benefit. A total of 16 hips (20.2%) showed
radiographic evidence of heterotopic ossification, all of which
had formed within one year of surgery. Four patients had a wound
infection, one of which needed debridement; all recovered fully.
A total of 59 patients (94%) reported improvements in seating and
hygiene. The results are as good as or better than the historical results
of using traction or immobilisation. We recommend that following
PFR, children can be managed without traction or immobilisation,
and can be discharged earlier and with fewer complications. However,
care should be taken with severely dystonic patients, in whom more
extensive femoral resection should be considered in combination
with management of the increased tone. Cite this article:
The medial approach for the treatment of children
with developmental dysplasia of the hip (DDH) in whom closed reduction
has failed requires minimal access with negligible blood loss. In
the United Kingdom, there is a preference for these children to
be treated using an anterolateral approach after the appearance
of the ossific nucleus. In this study we compared these two protocols,
primarily for the risk of osteonecrosis. Data were gathered prospectively for protocols involving the
medial approach (26 hips in 22 children) and the anterolateral approach
(22 hips in 21 children) in children aged <
24 months at the
time of surgery. Osteonecrosis of the femoral head was assessed
with validated scores. The acetabular index (AI) and centre–edge
angle (CEA) were also measured. The mean age of the children at the time of surgery was 11 months
(3 to 24) for the medial approach group and 18 months (12 to 24)
for the anterolateral group, and the combined mean follow-up was
70 months (26 to 228). Osteonecrosis of the femoral head was evident
or asphericity predicted in three of 26 hips (12%) in the medial approach
group and four of 22 (18%) in the anterolateral group (p = 0.52).
The mean improvement in AI was 8.8° (4° to 12°) and 7.9° (6° to
10°), respectively, at two years post-operatively (p = 0.18). There
was no significant difference in CEA values of affected hips between
the two groups. Children treated using an early medial approach did not have
a higher risk of developing osteonecrosis at early to mid-term follow-up
than those treated using a delayed anterolateral approach. The rates
of acetabular remodelling were similar for both protocols. Cite this article:
Children with congenital vertical talus (CVT)
have been treated with extensive soft-tissue releases, with a high
rate of complications. Recently, reverse Ponseti-type casting followed
by percutaneous reduction and fixation has been described, with
excellent results in separate cohorts of children with CVT, of either
idiopathic or teratological aetiology. There are currently no studies
that compare the outcome in these two types. We present a prospective cohort
of 13 children (21 feet) with CVT of both idiopathic and teratological
aetiology, in which this technique has been used. Clinical, radiological
and parent-reported outcomes were obtained at a mean follow-up of
36 months (8 to 57). Six children (nine feet) had associated neuromuscular
conditions or syndromes; the condition was idiopathic in seven children
(12 feet). Initial correction was achieved in all children, with significant
improvement in all radiological parameters. Recurrence was seen
in ten feet. Modification of the technique to include limited capsulotomy
at the initial operation may reduce the risk of recurrence. The reverse Ponseti-type technique is effective in the initial
correction of CVT of both idiopathic and teratological aetiology.
Recurrence is a problem in both these groups, with higher rates
than first reported in the original paper. However, these rates
are less than those reported after open surgical release. Cite this article:
The incidence of clinically significant avascular
necrosis (AVN) following medial open reduction of the dislocated
hip in children with developmental dysplasia of the hip (DDH) remains
unknown. We performed a systematic review of the literature to identify
all clinical studies reporting the results of medial open reduction
surgery. A total of 14 papers reporting 734 hips met the inclusion
criteria. The mean follow-up was 10.9 years (2 to 28). The rate
of clinically significant AVN (types 2 to 4) was 20% (149/734).
From these papers 221 hips in 174 children had sufficient information
to permit more detailed analysis. The rate of AVN increased with
the length of follow-up to 24% at skeletal maturity, with type 2
AVN predominating in hips after five years’ follow-up. The presence
of AVN resulted in a higher incidence of an unsatisfactory outcome
at skeletal maturity (55% Cite this article:
We report the radiological outcomes, and short-term clinical results, of 47 periacetabular osteotomies undertaken through both the traditional bikini incision, and a minimally invasive approach. 47 periacetabular osteotomies have been undertaken in 45 patients, by the senior author, between 2005 and 2013. There were 10 male and 35 female patients. The mean age at operation was 28.2 years. Since 2010 surgery has been performed through a 7-cm skin incision (31 hips), an incision coined as minimally invasive by Søballe et al when they described their trans-sartorial approach for acetabular surgery. Clinical data was collected prospectively; primary outcome measures included the young adult hip score and the hip disability and osteoarthritis outcome score. Pre- and post-operative radiographs were analysed for achieved acetabular reorientation. At the time of follow-up the median young adult hip score had improved significantly from pre-operative values. Mean scores were 35.4 pre-operatively, and 64.25 post-operatively. Improvement in the anterior and lateral centre-edge angle was 32 and 32.9 degrees respectively through a traditional incision, and 27.1 and 30 degrees through the minimally invasive approach (p>0.05). No major complications occurred in any patient. Four patients complained of lateral cutaneous nerve hypoaesthesia, in two patients there was delayed union of the pubic osteotomy and in one non-union. Two patients have gone on to total hip replacement. The minimally invasive approach is safe and allows for accurate reorientation of the acetabulum whilst minimizing tissue damage. The scar is cosmetically appealing to patients, especially the predominantly female group treated with this condition. We did not see the evidence of reduced surgical stay that has been reported by other groups utilizing a minimally invasive approach. Level of evidence: II
To examine the feasibility of surgical outcome measures for a children's orthopaedic surgeon when compared with other specialties. Details of procedure codes for 2726 inpatient episodes were used to examine the distribution of procedures and the breadth of diagnoses dealt with by a variety of orthopaedic sub-specialists. The author's practice included 199 surgical cases and was compared with two arthroplasty surgeons (n=971); a spinal surgeon (n=256); a foot and ankle surgeon (n=341) and an upper limb surgeon (n=393). Arthroplasty surgeons can report 50% of their outcomes as primary knee or hip replacements the index procedure for the author is metalwork removal (14.5%). My upper limb colleague could be judged on 25% of his cases (carpal tunnel decompression) and my spinal surgical colleague on 20% of his cases (primary posterior decompression of spinal cord). Only my foot and ankle colleague compared in terms of diversity with 9% of his cases consisting of first metatarsal osteotomy and the next 9% consisting of 1st MTPJ arthrodesis. The proportion of multiple procedures also varies between sub-specialists with 66% of my cases being multiple compared with 38% for the arthroplasty surgeons and 42% for the upper limb surgeons. Foot and ankle has a high rate of multiple procedures (62%) and the spinal surgeons code different procedures at each level in the spine giving the high rates of multiple procedures.Purpose:
Methods & Results:
A cooled, side cutting burr designed for use in adult foot surgery has been used as a primary bone cutting device in children to facilitate a truly percutaneous method of performing osteotomies. Stabilisation of the femur was using a percutaneous locked nail and for the tibia percutaneous K-wires. The author describes the advantages and disadvantages of this method with results from the first cohort of patients treated. Patients under going osteotomy of the femur, tibia and fibula using a 2 mm × 20 mm side cutting burr were followed prospectively and assessed for scar size, bone healing time and complications.Purpose of the Study
Method
To determine the rate of recurrence of coronal plane deformity in children treated with ‘guided growth’ using 8-plates, from the time of implant removal to skeletal maturity. Over a consecutive 5 year period between April 2008 and April 2013 we analysed our results of guided growth treatment using 8-plates to correct coronal plane lower limb deformity. Patients with neuromuscular disorders such as cerebral palsy were excluded. Deformity planning was performed using standardised techniques. Our standard practice is to remove the 8-plate and screws once deformity is corrected both clinically and radiologically. Patients were followed up until either skeletal maturity or recurrence, which necessitated reapplication of the 8-plate. We are aware of no study in which children treated with guided growth using 8-plates are followed up to skeletal maturity.Aim
Methods
An assessment of the relationship between pathological Developmental Dysplasia of the Hip (DDH) and Congenital Talipes Equinovarus (CTEV). Traditional UK guidelines consider abnormalities of the foot to be a risk factor for DDH1,2. Currently, there is controversy whether congenital foot abnormalities are true risk factors for pathological DDH3,4. There is a relationship between CTCV and hip dysplasia though the relationship between CTEV and pathological DDH is less clear5. In a previous 11 year prospective longitudinal study no case of Graf Types III, IV or irreducible hip dislocation were associated with CTEV5. Subsequent correspondence and case histories have challenged this view6Aim:
Introduction:
This purpose of this study was to investigate whether prophylactic pinning of the contralateral hip in unilateral slipped upper femoral epiphysis affects subsequent femoral morphology. To determine the effect of prophylactic pinning on growth we compared contralateral hip radiographs of 24 proximal femora prophylactically pinned with 26 cases observed, in a cohort of patients with unilateral SUFE. Validated measurements were used to determine hip morphology; the articulo-trochanteric distance (ATD) and the ratio of the trochanteric-trochanteric distance (TTD) to articulo-trochanteric distance (TTD:ATD) in addition to direct measurement of the femoral neck length. Post-operative radiographs were compared to radiographs taken at a 12–84 months follow-up. Comparing pinned and unpinned hips the neck length was shorter (mean 5.1 mm vs 11.1 mm) and the ATD was lower (p=0.048). The difference between initial and final radiograph TTD:ATD ratio for each case was calculated. The average was 0.63 in the prophylactically pinned group and 0.25 in the unpinned group (p=0.07). When hips of the same patient were compared on final radiographs, there was a smaller difference in TTD:ATD between the two sides when the patient had been prophylactically pinned (0.7) as opposed to observed (1.47). This was not statistically significant (p=0.14). Universal prophylactic pinning of the contralateral hip in slipped upper femoral epiphysis is controversial and alteration of the proximal femoral morphology is one reason for this. Our results show that prophylactic pinning does not stop growth but does alter subsequent proximal femoral morphology by causing a degree of coxa vara and breva. Some loss of growth in the prophylactically pinned hip contributes to reduction in leg length inequality at skeletal maturity which is advantageous. No iatrogenic complications were observed with single cannulated screw fixation. Prophylactic pinning prevents the potential catastrophe of a subsequent slip, is safe and the effect on growth is, if anything, beneficial. Level of evidence: III
A 15 year prospective, observational cohort study was undertaken to assess selective screening of DDH in males and females referred with risk factors only. Individuals born breech or with evidence of a strong family history for DDH were the ‘risk factors’ studied. All were clinically examined and sonographically screened by one Consultant Paediatric Orthopaedic surgeon. Irreducible hip dislocation rate was the primary outcome measure. From a cohort of 64670 live births, 2,984 neonates/infants, 46.1 per 1000 live births [95% CI 44.6 to 47.8 per 1000 live births] were referred and sonographically screened with ‘pure’ risk factors of breech presentation and/or family history, with clinical stability. 1360 were male, of which 4 were identified as having ‘pathological’ DDH; an incidence of 1 in 333 of those males referred [95 CI 0.001, 0.008]. 1624 were female, of which 45 were identified as having ‘pathological’ DDH; an incidence of 1 in 36 of those females referred [95% CI 0.021, 0.037]. There was a significant difference in the number of female individuals sonographically diagnosed as having ‘pathological’ DDH compared to males (p<0.001). Four individuals were diagnosed with irreducible hip dislocation, 0.06 per 1000 live births [95% CI 0.24, 0.159 per 1000 live births]. All were in females. Additionally, there were 2 female individuals; both with family history of DDH (1st cousin splinted and sister splinted, respectively) as a risk factor, referred late. Our study suggests that there is a significant difference between the incidence of female and male individuals diagnosed with ‘pathological’ DDH, in those referred purely with risk factors (breech and family history). These findings question the current screening policy for ultrasound examination of males with risk factors in the absence of clinical instability, and may influence future DDH screening programme policy. Level of evidence: II
To establish the early outcome, satisfaction and complications of sinus tarsi implants in the management of symptomatic flexible flatfeet for a paediatric population We included all patients aged 18 years or less who were treated for flexible flatfeet with a sinus tarsi implant between January 2010 and June 2012. We excluded patients who had a history of clubfeet or tarsal coalition. 34 patients had 59 implants. The mean age at surgery was 13.7 yrs (9–17 yrs), with mean follow-up of 22 months (range 10–35). Mean AOFAS improved from 65.7 to 87.9 (p<0.001), with an improvement in AOFAS pain scores (p=0.0001). Radiographic correction occurred in all feet, with average improvement of the anteroposterior talar-second metatarsal angle of 16 degrees, and the lateral talar-first metatarsal angle of 9 degrees. Implant placement satisfaction rate was 86%, with 81% claiming that they would have the procedure again. Complications included peroneal spasm (8%), extrusion (7%), revision (5%), and removal (5%). Peroneal spasm was recalcitrant in 3 of the 5 cases, and those with spasm had a higher average forefoot abduction measurement (35 degrees) than the remaining treated cases (25 degrees).Purpose
Methods and results
The aim of this study was to validate the SENIAM recommendations for surface electromyography placement(sEMG) over rectus femoris(RF) muscle in healthy children and in children with cerebral palsy(CP) during gait analysis and compare placement using these guidelines to using ultrasonography. The study included 10 healthy children volunteers and 10 CP children volunteers, aged 8–12. All the CP children had spastic diplegia, were GMFCS levels I–II and had not previously undergone surgery. RF electrodes were placed following SENIAM recommendations. RF was then identified by ultrasound. The distance between the lateral edge of RF and the position of the sEMG electrode as per SENIAM guidelines and the width of RF was measured, to the nearest millimetre. We considered ‘ideal electrode’ position to be at halfway between the edges of RF (i.e. 50%). The mean percentage difference in distance from the ‘ideal electrode’ position as measured by ultrasound to electrode placement following SEMIAN guidelines was 2.7% in the healthy children group compared with 19.5% in the CP group. By performing unpaired SENIAM recommendations for sEMG electrode placement over RF muscle were validated in 10 healthy children. We showed that ultrasonography improved the accuracy of sEMG electrode placement in children with CP, who can exhibit anatomical variation due to their condition. Accurate electrode placement will ensure that a more accurate signal is recorded which may have a direct clinical bearing on the decision to proceed with surgical intervention. Level of evidence: IIMethods & Results:
Conclusion:
We describe the technique and results of medial
submuscular plating of the femur in paediatric patients and discuss its
indications and limitations. Specifically, the technique is used
as part of a plate-after-lengthening strategy, where the period
of external fixation is reduced and the plate introduced by avoiding
direct contact with the lateral entry wounds of the external fixator
pins. The technique emphasises that vastus medialis is interposed
between the plate and the vascular structures. A total of 16 patients (11 male and five female, mean age 9.6
years (5 to 17)), had medial submuscular plating of the femur. All
underwent distraction osteogenesis of the femur with a mean lengthening
of 4.99 cm (3.2 to 12) prior to plating. All patients achieved consolidation
of the regenerate without deformity. The mean follow-up was 10.5 months
(7 to 15) after plating for those with plates still Placing the plate on the medial side is advantageous when the
external fixator is present on the lateral side, and is biomechanically
optimal in the presence of a femoral defect. We conclude that medial
femoral submuscular plating is a useful technique for specific indications
and can be performed safely with a prior understanding of the regional
anatomy. Cite this article:
To review the natural history of upper limb osteochondromas and assess their functional effect. We performed a retrospective casenote review of a consecutive patient cohort presenting between 1997–2012 with upper limb osteochondromas. Indications for surgical intervention were noted and considered to be cosmetic, functional (including pain relief) and ‘prophylactic’ in terms of deformity prevention. All patients were invited to complete questionnaires for the PODCI, DASH, OSS and MHS scores.Aim
Materials
Risk factors for developmental dysplasia of the hip (DDH) in early infancy have never been validated from basic principles; their relevance remains controversial. To determine risk factors for DDH using newly developed diagnostic criteria based on international consensus.Introduction:
Purpose:
Shoulder; dislocation; instability; skeletal immaturity; arthroscopic Bankart repair; outcomes Non-operative management of traumatic shoulder instability in children has a recurrence rate of up to 100%. Short-term outcomes of surgery in adults results has a quoted recurrence rates of around 10%. The aim of this study was to examine the surgical outcomes of adolescent patients (aged 13 to 18 years) undergoing arthroscopic stabilisation for shoulder instability.Keywords
Introduction
A randomised clinical trial was undertaken to find out if treatment time and failure rate in children treated by the Ponseti method differed between below-knee vs above-knee cast groups. Eligible children with idiopathic clubfoot, treated using the Ponseti method, were randomised to either below knee or above knee plaster of Paris casting. Outcome measures were total treatment time and the occurrence of failure, defined as two slippages or a treatment time above eight weeks. Twenty-six children (33 feet) were entered into the trial, with a mean age of 17 days (range 1–40) in the above knee and 11 days (range 5–20) in the below knee group. Because of six failures in the below knee group (38%), the trial was stopped early for ethical reasons. Failure rate was significantly higher in the below-knee group (P 0.039). The median treatment times of six weeks in the below knee and four weeks in the above knee group differed significantly (P 0.01).Statement of purpose:
Methods and Results:
Congenital vertical talus (CVT) is a rare deformity of the foot. It has been historically treated with extensive soft tissue releases with significant associated complications. Recently, reverse Ponseti-type casting followed by minimally invasive or percutaneous reduction and fixation has been described with excellent results in separate cohorts of either idiopathic or teratologic cases of CVT. There are currently no studies that compare the outcomes between the two types. We present a prospective cohort of 13 patients (21 feet) in which this technique has been used in both idiopathic and teratologic associated cases of CVT. Clinical, radiographic and parent-reported outcomes were obtained at a mean follow up of 36 months (range 8–57). Clinical and radiographic scoring was according to the system of Adelaar and parent-reported outcomes were assessed using the POSNA paediatric outcomes data collection instrument (PODCI).Background
Methods
To assess the success rate of closed reduction after failing Pavlik harness for treatment of DDH. It was a retrospective review of prospectively collected data. Patient's notes/computerised records were reviewed. Radiological investigations were also reviewed. Microsoft excel used for descriptive stats.Aims:
Methods:
Femoral head deformity can be a devastating outcome in a small percentage of patients with Perthes' disease. Deformities usually start during the fragmentation stage. In this study, we aimed to determine the effects of Vitamin D deficiency on the natural history of Perthes' disease. Patients with Perthes' disease and Vitamin D deficiency presenting to our unit in the last 3 years were identified. All X-rays were reviewed retrospectively to determine the duration of the fragmentation and ossification stages. Treatment methods were obtained from the notes. Late presenters (i.e. after fragmentation stage) were excluded. In our unit, Vitamin D deficiency is diagnosed if levels <72 nmol/L. Fifteen patients (17 hips) with Perthes' disease were found to be Vitamin D deficient. Levels ranged from (18–71 nmol/L). The mean length of the fragmentation stage was 15.7 months which is significantly higher than quoted literature figures (8 months). Ossification stage duration was 18.8 months which was comparable to quoted figures. However, patients with severe Vitamin D deficiency (< 52 nmol/L) were found to have longer ossification stage (20.6 months) compared with patients with mild deficiency (52–72 nmol/L) (16.4 months). Seven out of 16 patients (44%) required surgical containment which is significantly higher than the usually low rates of surgical intervention. The critical fragmentation stage in Vitamin D deficiency is significantly longer putting the femoral head at higher risk of deformity and extrusion. This leads to higher rates of surgical containment. Also the severity of Vitamin D deficiency might be an important determinant of the period of time required for ossification and healing. Vitamin D level is an important prognostic factor and must be measured in all patients with Perthes' disease. Prescribing Vitamin D supplements is advisable in this group of patients. However, the effects of these supplements on the course of the disease requires further research. Level of evidence: III
Audit of the outcome of subcapital osteotomy for a series of cases of severe unstable slipped capital femoral epiphysis. 57 cases of unstable severe slipped capital femoral epiphysis were operated on by a single surgeon between 2000 and 2011. The procedure was performed through the anterior abductor sparing approach. Patients have been followed up prospectively and the results are presented at average follow up is 6.4 years with a minimum of 18 month follow to include all risks of avn.Aim:
Method:
Our goal was to evaluate the use of Ponseti’s
method, with minor adaptations, in the treatment of idiopathic clubfeet
presenting in children between five and ten years of age. A retrospective
review was performed in 36 children (55 feet) with a mean age of
7.4 years (5 to 10), supplemented by digital images and video recordings
of gait. There were 19 males and 17 females. The mean follow-up
was 31.5 months (24 to 40). The mean number of casts was 9.5 (6
to 11), and all children required surgery, including a percutaneous
tenotomy or open tendo Achillis lengthening (49%), posterior release
(34.5%), posterior medial soft-tissue release (14.5%), or soft-tissue
release combined with an osteotomy (2%). The mean dorsiflexion of
the ankle was 9° (0° to 15°). Forefoot alignment was neutral in
28 feet (51%) or adducted (<
10°) in 20 feet (36%), >
10° in
seven feet (13%). Hindfoot alignment was neutral or mild valgus
in 26 feet (47%), mild varus (<
10°) in 19 feet (35%), and varus
(>
10°) in ten feet (18%). Heel–toe gait was present in 38 feet
(86%), and 12 (28%) exhibited weight-bearing on the lateral border
(out of a total of 44 feet with gait videos available for analysis).
Overt relapse was identified in nine feet (16%, six children). The
parents of 27 children (75%) were completely satisfied. A plantigrade foot was achieved in 46 feet (84%) without an extensive
soft-tissue release or bony procedure, although under-correction
was common, and longer-term follow-up will be required to assess
the outcome. Cite this article:
We investigated whether, in the management of
stable paediatric fractures of the forearm, flexible casts that
can be removed at home are as clinically effective Cite this article:
We undertook a randomised clinical trial to compare
treatment times and failure rates between above- and below-knee
Ponseti casting groups. Eligible children with idiopathic clubfoot,
treated using the Ponseti method, were randomised to either below-
or above-knee plaster of Paris casting. Outcome measures were total
treatment time and the occurrence of failure, defined as two slippages
or a treatment time above eight weeks. A total of 26 children (33 feet) were entered into the trial.
The above-knee group comprised 17 feet in 13 children (ten boys
and three girls, median age 13 days (1 to 40)) and the below-knee
group comprised 16 feet in 13 children (ten boys and three girls,
median age 13 days (5 to 20)). Because of six failures (37.5%) in
the below-knee group, the trial was stopped early for ethical reasons.
The rate of failure was significantly higher in the below-knee group
(p = 0.039). The median treatment times of six weeks in the below-knee
and four weeks in the above-knee group differed significantly (p
= 0.01). This study demonstrates that the use of a below-knee plaster
of Paris cast in conjunction with the Ponseti technique leads to
unacceptably high failure rates and significantly longer treatment
times. Therefore, this technique is not recommended. Cite this article:
Recent reports have suggested an increase in
the number of anterior cruciate ligament (ACL) injuries in children, although
their true incidence is unknown. The prognosis of the ACL-deficient knee in young active individuals
is poor because of secondary meniscal tears, persistent instability
and early-onset osteoarthritis. The aim of surgical reconstruction
is to provide stability while avoiding physeal injury. Techniques
of reconstruction include transphyseal, extraphyseal or partial
physeal sparing procedures. In this paper we review the management of ACL tears in skeletally
immature patients. Cite this article:
We evaluated results at one year after surgical
correction of internal rotation deformities in the shoulders of
270 patients with obstetric brachial plexus palsy. The mean age
at surgery was 6.2 years (0.6 to 35). Two techniques were used:
open subscapularis elongation and latissimus dorsi to infraspinatus
transfer. In addition, open relocation was performed or attempted
in all patients with subluxed or dislocated joints. A mixed effects
model approach was used to evaluate the effects of surgery on internal
and external rotation, abduction, flexion and Mallet score. Independent
factors included operative status (pre- or post-operative), gender,
age, the condition of the joint, and whether or not transfer was
performed. The overall mean improvement in external rotation following
surgery was 84.6° (95% confidence interval (CI) 80.2 to 89.1) and
the mean Mallet score improved by 4.0 (95% CI 3.7 to 4.2). There was
a mean decrease in internal rotation of between 27.6° and 34.4°
in the relocated joint groups and 8.6° (95% CI 5.2 to 12.0) in the
normal joint group. Abduction and flexion were unchanged following
surgery. Adding a latissimus dorsi transfer did not result in greater
improvement in the mean external rotation compared with elongation
of the subscapularis alone. Cite this article:
Supracondylar humeral fractures are common in
children, but there are no classification systems or radiological parameters
that predict the likelihood of having to perform an open reduction.
In a retrospective case–control study we evaluated the use of the
medial spike angle and fracture tip–skin distance to predict the
mode of reduction (closed or open) and the operating time in fractures
with posterolateral displacement. A total of 21 patients (4.35%) with
a small medial spike angle (<
45°) were identified from a total
of 494 patients, and 42 patients with a medial spike angle of >
45° were randomly selected as controls. The medial spike group had
significantly smaller fracture tip–skin distances (p <
0.001),
longer operating times (p = 0.004) and more complications (p = 0.033)
than the control group. There was no significant difference in the
mode of reduction and a composite outcome measure. After adjustments
for age and gender, only fracture tip–skin distance remained significantly
associated with the operating time (β = -0.724, p = 0.042) and composite
outcome (OR 0.863 (95% confidence interval 0.746 to 0.998); p = 0.048). Paediatric orthopaedic surgeons should have a lower threshold
for open reduction when treating patients with a small medial spike
angle and a small fracture tip–skin distance. Cite this article:
Fractures of the forearm (radius or ulna or both)
in children have traditionally been immobilised in plaster of Paris (POP)
but synthetic cast materials are becoming more popular. There have
been no randomised studies comparing the efficacy of these two materials.
The aim of this study was to investigate which cast material is
superior for the management of these fractures. We undertook a single-centre
prospective randomised trial involving 199 patients with acute fractures
of the forearm requiring general anaesthesia for reduction. Patients
were randomised by sealed envelope into either a POP or synthetic
group and then underwent routine closed reduction and immobilisation
in a cast. The patients were reviewed at one and six weeks. A satisfaction
questionnaire was completed following the removal of the cast. All
clinical complications were recorded and the cast indices were calculated.
There was an increase in complications in the POP group. These complications
included soft areas of POP requiring revision and loss of reduction
with some requiring re-manipulation. There was an increased mean
padding index in the fractures that lost reduction. Synthetic casts
were preferred by the patients. This study indicates that the clinical outcomes and patient satisfaction
are superior using synthetic casts with no reduction in safety. Cite this article:
The development of tibiofemoral angle in children has shown ethnic
variations. However this data is unavailable for our population. We measured the tibiofemoral angle (TFA) and intercondylar and
intermalleolar distances in 360 children aged between two and 18
years, dividing them into six interrupted age group intervals: two
to three years; five to six years; eight to nine years; 11 to 12
years; 14 to 15Â years; and 17 to 18 years. Each age group comprised
30 boys and 30 girls. Other variables recorded included standing
height, sitting height, weight, thigh length, leg length and length
of the lower limb.Objectives
Methods
Congenital pseudarthrosis of the tibia (CPT)
is a rare but well recognised condition. Obtaining union of the pseudarthrosis
in these children is often difficult and may require several surgical
procedures. The treatment has changed significantly since the review
by Hardinge in 1972, but controversies continue as to the best form
of surgical treatment. This paper reviews these controversies. Cite this article:
We compared the accuracy of the growth remaining
method of assessing leg-length discrepancy (LLD) with the straight-line
graph method, the multiplier method and their variants. We retrospectively
reviewed the records of 44 patients treated by percutaneous epiphysiodesis
for LLD. All were followed up until maturity. We used the modified Green–Anderson
growth-remaining method (Method 1) to plan the timing of epiphysiodesis.
Then we presumed that the other four methods described below were
used pre-operatively for calculating the timing of epiphysiodesis. We
then assumed that these four methods were used pre-operatively.
Method 2 was the original Green–Anderson growth-remaining method;
Method 3, Paley’s multiplier method using bone age; Method 4, Paley’s
multiplier method using chronological age; and Method 5, Moseley’s
straight-line graph method. We compared ‘Expected LLD at maturity
with surgery’ with ‘Final LLD at maturity with surgery’ for each
method. Statistical analysis revealed that ‘Expected LLD at maturity
with surgery’ was significantly different from ‘Final LLD at maturity
with surgery’. Method 2 was the most accurate. There was a significant
correlation between ‘Expected LLD at maturity with surgery’ and
‘Final LLD at maturity with surgery’, the greatest correlation being
with Method 2. Generally all the methods generated an overcorrected
value. No method generates the precise ‘Expected LLD at maturity
with surgery’. It is essential that an analysis of the pattern of
growth is taken into account when predicting final LLD. As many
additional data as possible are required. Cite this article:
Permanent growth arrest of the longer bone is
an option in the treatment of minor leg-length discrepancies. The
use of a tension band plating technique to produce a temporary epiphysiodesis
is appealing as it avoids the need for accurate timing of the procedure
in relation to remaining growth. We performed an animal study to
establish if control of growth in a long bone is possible with tension
band plating. Animals (pigs) were randomised to temporary epiphysiodesis
on either the right or left tibia. Implants were removed after ten
weeks. Both tibiae were examined using MRI at baseline, and after
ten and 15 weeks. The median interphyseal distance was significantly shorter
on the treated tibiae after both ten weeks (p = 0.04) and 15 weeks
(p = 0.04). On T1-weighted images the metaphyseal water
content was significantly reduced after ten weeks on the treated
side (p = 0.04) but returned to values comparable with the untreated
side at 15 weeks (p = 0.14). Return of growth was observed in all
animals after removal of implants. Temporary epiphysiodesis can be obtained using tension band plating.
The technique is not yet in common clinical practice but might avoid
the need for the accurate timing of epiphysiodesis. Cite this article:
Most centres in the United Kingdom adopt a selective
screening programme for developmental dysplasia of the hip (DDH)
based on repeated clinical examination and selective ultrasound
examination. The Newborn Infant Physical Examination protocol implemented
in 2008 recommends a first examination at birth and then a second
and final examination at six to ten weeks of age. Due to concerns
over an increase in late presentations we performed a retrospective
review of our 15-year results to establish if late presentation
increases treatment requirements. Of children presenting before
six weeks of age, 84% were treated successfully with abduction bracing,
whereas 86% of children presenting after ten months eventually required
open reduction surgery. This equates to a 12-fold increase in relative
risk of requiring open reduction following late presentation. Increasing
age at presentation was associated with an increase in the number
of surgical procedures, which are inevitably more extensive and complex,
with a consequent increased in cost per patient. The implementation
of an opportunistic examination at three to five months could help
to reduce the unintended consequences of the Newborn Infant Physical Examination
programme. Cite this article:
Symptoms of obstetric brachial plexus injury (OBPI) vary widely
over the course of time and from individual to individual and can
include various degrees of denervation, muscle weakness, contractures,
bone deformities and functional limitations. To date, no universally
accepted overall framework is available to assess the outcome of patients
with OBPI. The objective of this paper is to outline the proposed
process for the development of International Classification of Functioning,
Disability and Health (ICF) Core Sets for patients with an OBPI. The first step is to conduct four preparatory studies to identify
ICF categories important for OBPI: a) a systematic literature review
to identify outcome measures, b) a qualitative study using focus
groups, c) an expert survey and d) a cross-sectional, multicentre
study. A first version of ICF Core Sets will be defined at a consensus
conference, which will integrate the evidence from the preparatory
studies. In a second step, field-testing among patients will validate this
first version of Core Sets for OBPI.Background
Methods
Slipped capital femoral epiphysis (SCFE) is uncommon
in India and we routinely look for associated metabolic or endocrine
abnormalities. In this study we investigated a possible association
between vitamin D deficiency and SCFE. All children presenting with
SCFE during the study period had their 25-hydroxyvitamin D levels
measured as part of an overall metabolic, renal and endocrine status
evaluation, which included measurement of body mass index (BMI).
Vitamin D status was compared with age-, gender- and habitat-matched
controls with acute trauma or sepsis presenting to our emergency
department. A total of 15 children (12 boys and three girls) with a mean
age of 13 years ( Cite this article:
Congenital Talipes Equinovarus (CTEV) has been excluded from the standards set by the NHS fetal anomaly screening programme (NHS FASP) for the 18+0–20+6 week fetal ultrasound scan (USS). Whilst adhering to NHS FASP guidelines, the antenatal ultrasound department at our centre performs “incidental screening” for CTEV; parents are informed if CTEV is noted incidentally during the scan and referral made to the fetal medicine department. Our aim was to investigate the effectiveness of incidental antenatal screening for structural CTEV. The database of the antenatal ultrasound department was interrogated for all suspected cases of CTEV on the 18+0–20+6 week USS, between August 2006 and June 2012. Terminations, stillbirths and outside referrals were excluded. Our Ponseti-service database was searched to identify all patients treated for structural CTEV between January 2007 and November 2012. Cases were excluded if the mother did not receive antenatal-care at our centre. Results from the two searches were cross-referenced, and statistical analysis performed.Aim
Method
Iliopsoas tendinopathy occurs due to friction of the iliopsoas tendon on the iliopectineal bar or the hip capsule causing pain and snapping of the hip. In adolescent cases this condition is generally treated conservatively with physiotherapy, stretching and NSAIDs. Our aim was to study the outcome of non-operative management of iliopsoas tendinopathy. A retrospective 4-year study identified adolescent patients with a clinical diagnosis of psoas tendinopathy managed non-operatively. These patients were followed up by postal questionnaire, which included functional assessment using the Non-Arthritic Hip Score (NAHS). A custom study questionnaire assessed current symptoms and the effects of physiotherapy. All patients not treated conservatively were removed from the study.Aim
Method
The Pelvic Support Osteotomy (PSO) or Ilizarov Hip Reconstruction(IHR) is well described for the treatment of septic sequelae of infancy. The purpose of this study was to clinically, functionally and radiographically assess our short-term results of this procedure. 25 patients (16 boys, 9 girls) who had undergone an IHR using the Ilizarov/TSF construct over a period of 10 years for a variety of pathologies were reviewed.Aim
Method
To compare outcomes for children treated for idiopathic clubfeet with the Ponseti regimen before (2002–2004) and after (2005–2006) implementation of a dedicated Ponseti service. A retrospective analysis of outcomes for all patients with idiopathic clubfeet treated in the 2 years before and after implementation of a dedicated Ponseti service was undertaken. Results were statistically analysed using Fisher's exact t-test.Aim
Method
Since 2008 we have been using third generation Fassier Duval (FD) telescopic rods for children with complex and severe osteogenesis imperfecta (sOI). We present our experience with the technique. 8 children with sOI have undergone rodding of 16 lower limb long bones; 6 tibial, 10 femoral. 3 were revision procedures, exchanging previous Sheffield rods that had been implanted with the female portion only. Indications were recurrent fracture and/or progressive deformity. Age range and follow up are 2–12 and 0.4–4.75 years respectively. All but one of the procedures were performed by a single surgeon.Aim
Method
The current literature indicates that hip arthroscopy is safe in both adolescents and adults with good early outcomes but there are no available studies that directly compare the outcomes of this procedure for mixed indications between these two groups. This was a prospective cohort study of 102 consecutive supine hip arthroscopies in 96 patients (48 adolescent (<18) hips, mean age 13.9 years and 54 adult (>18 hips), mean age 33.8 years) at a tertiary referral paediatric and adult university hospital followed-up for a minimum of two years. Patient demographics, indications for surgery, Modified Harris Hip (MHHS) and Non-Arthritic Hip (NAHS) scores, operative interventions and complications were recorded.Aim
Method
Historically, surgeons have focused on isolated simple coalition resection in symptomatic tarsal coalition with concomitant rigid flat foot. However, recent evidence suggests that coalitions with severe preoperative planovalgus malposition treated with resection alone are associated with continued disability and deformity. We believe that concomitant severe flatfoot should be considered as much as a pathological component and pain generator as the coalition itself. Our primary hypothesis is that simple resection of middle facet tarsal coalitions and simultaneous flat foot reconstruction can improve clinical outcomes. We identified eleven children (13 feet) who had resections of middle facet tarsal coalitions with or without complex foot reconstruction (calcaneal lengthening, medial cuneiform osteotomy) for concurrent severe planovalgus between 2003 and 2011. Clinical examination, American Orthopaedic Foot and Ankle Society (AOFAS) hind-foot scores, and radiographic assessments were evaluated after resection of middle facet tarsal coalitions with simultaneous flat foot reconstruction.Aim
Method
To review the infants in our district general hospital receiving delayed treatment for DDH i.e. those infants who had more than one ultrasound scan prior to diagnosis and treatment. In this group all scans were abnormal at the time of treatment but the scans at first presentation were normal for age when reviewed by our senior radiologist. An audit was performed of all the children attending our institution from 2008–2011 for treatment of DDH following diagnosis with clinical examination and dynamic ultrasound. A senior radiologist and consultant orthopaedic surgeon independently assessed the scans. Two questions were asked (a) were the scans at the time of treatment normal or abnormal and (b) in those who were treated following a repeat scan, was the initial scan normal.Aim
Method
To compare the rate and severity of avascular necrosis following medial open and closed reduction in developmental hip dysplasia and the resulting influence on femoral and acetabular development. The radiographs and hospital records of 118 patients with dislocation of the hip were reviewed. 57 patients (66 hips) underwent medial open reduction and 61 patients (75 hips) underwent closed reduction. Mean follow-up was 10.9 years (5 years to 17.4 years). Avascular necrosis (AVN) was recorded according to the Bucholz and Ogden classification. The acetabular index was measured pre-operatively, at 1 and 4 years following surgery. The final radiograph was assigned a Severin grade. Sharp and centre-edge angles were recorded at final follow-up. A Severin grade I or II was considered a satisfactory result and a grade III to V an unsatisfactory result. Initial non-operative measures, such as Pavlik harness treatment and traction were documented. Additional surgical interventions were noted.Aim
Method
Forearm fractures in children have a tendency
to displace in a cast leading to malunion with reduced functional
and cosmetic results. In order to identify risk factors for displacement,
a total of 247 conservatively treated fractures of the forearm in
246 children with a mean age of 7.3 years ( Fractures of both forearm bones in children have a strong tendency
to displace even in an above-elbow cast. Severe fractures of the
non-dominant arm are at highest risk for displacement. Radiographs
at set times during treatment might identify early displacement,
which should be treated before malunion occurs, especially in older children
with less potential for remodelling. Cite this article:
To inform a working group of UK paediatric surgeons (the UK SCFE Study Group) convened to design pertinent trials in slipped capital femoral epiphysis (SCFE), three centres (Bristol, Newcastle and Barts and The London) reviewed the demographics and management of children with SCFE presenting between 2007 and 2012. At all contributing centres with digital PACS records for a minimum of 5 years, a search for the following terms was made of PACS reports: slipped capital femoral epiphysis, slipped upper femoral epiphysis, SCFE and SUFE. From the results, radiographs and electronically stored clinic letters were assessed to confirm the diagnosis and ascertain age at presentation, incidence of bilaterality, chronicity, stability (Loder criteria), management and complications.Aim
Method
Kite manipulation and casting for congenital talipes equinovarus (CTEV) was noted to require a subsequent posteromedial release (PMR) in almost all of the children treated, with variable outcomes including overcorrection and stiffness. Introduction of the Ponseti serial manipulation and casting technique dramatically reduced the need for PMR. This study assesses the medium term outcomes in these two treatment groups. We retrospectively identified patients treated for idiopathic CTEV between 1997 and 2007 under a single surgeon. Two cohorts with a minimum 4 years' follow-up were treated with Kite (1997–2001) and Ponseti (2002–2007) manipulation and casting. The entire Kite cohort (14 patients) and none of the Ponseti cohort (16 patients) required PMR. All patients were assessed by clinical and functional examination, questionnaire and medical notes review. There was a total of 40 feet (10 bilateral and 20 unilateral) with 20 feet in each cohort.Aim
Methods
With the link between obesity and Slipped Upper Femoral Epiphysis (SUFE) well established and a rising number of paediatric orthopaedic patients presenting with vitamin D deficiency, the aim of our study was to establish the incidence of vitamin D deficiency in SUFE patients and whether low vitamin D levels increases the time to proximal femoral physeal fusion post surgical fixation. All paediatric patients presenting to the orthopaedic department at University Hospital Southampton with a SUFE and tested for vitamin D between June 2007 to present day and who were subsequently found to have low levels of vitamin D, were eligible for inclusion in the study. A deficient level of vitamin D (25-(OH)D) was determined as < 52 nmols/L and insufficiency between 52–72 nmols/L. Levels > 72 nmols/L were considered to be normal. The normal time for 50% of physeal fusion on anteroposterior radiograph quoted in the literature is 9 months.Aim
Method
The objective was to assess whether late presentation of DDH leads to an increase in treatment magnitude and cost. This was a retrospective review of prospectively collected data from our hip instability clinic database. All patients presenting to our hip instability clinic that required any form of treatment for DDH between 1990 and 2005 were included. Children were grouped according to age at presentation and then treatment requirements were reviewed. Average costs were calculated based on procedures performed.Aim
Method
Of 48 consecutive children with Gartland III
supracondylar fractures, 11 (23%) had evidence of vascular injury,
with an absent radial pulse. The hand was pink and warm in eight
and white and cold in the other three patients. They underwent colour-coded
duplex scanning (CCDS) and ultrasound velocimetry (UV) to investigate
the patency of the brachial artery and arterial blood flow. In seven
patients with a pink pulseless hand, CCDS showed a displaced, kinked
and spastic brachial artery and a thrombosis was present in the
other. In all cases UV showed reduced blood flow in the hand. In
three patients with a white pulseless hand, scanning demonstrated
a laceration in the brachial artery and/or thrombosis. In all cases,
the fracture was reduced under general anaesthesia and fixed with
Kirschner wires. Of the seven patients with a pink pulseless hand
without thrombosis, the radial pulse returned after reduction in
four cases. The remaining three underwent exploration, along with
the patients with laceration in the brachial artery and/or thrombosis. We believe that the traditional strategy of watchful waiting
in children in whom the radial pulse remains absent in spite of
good peripheral perfusion should be revisited. Vascular investigation
using these non-invasive techniques that are quick and reliable
is recommended in the management of these patients. Cite this article:
To establish the incidence of clinically significant avascular necrosis (AVN) and the resultant influence on radiological outcome following medial open reduction for DDH. A systematic review of the literature was performed using Medline and Embase, from 1946 to 2012, to identify all relevant clinical studies. We excluded papers with a mean follow-up under 5 years. The effect of length of follow-up, outcome according to Severin, age at surgery, and type of growth disturbance were reviewed.Aim
Method
10 years after the introduction of the Ponseti casting regimen as standard treatment for idiopathic clubfoot at Alder Hey Children's Hospital, we reviewed the mid-term outcomes of the initial 2-year cohort (treated from 2002–2004) 100 feet were treated in 66 patients. 61 of the 100 feet have been prospectively reviewed on an annual/ bi-annual basis since successful correction, with outcomes of the remaining feet obtained by retrospective analysis.Aim
Method
Shelf acetabuloplasty is part of the armamentarium for the treatment of Legg-Perthes-Calve disease. Surgeons have used it to increase the anterolateral cover of the deformed head in advanced stages of the disease. However, others, including the senior author, advocate its use for containment of the diseased femoral head earlier in the disease, for both the prevention of further femoral head extrusion and as an aid in the remodelling process. The current study presents the results of this procedure performed from August 1999 to February 2010. Full sets of x-rays were available for 44 patients (45 hips). Three other bilateral cases were treated with a unilateral shelf.Aim
Method
Differentiation between bone infarction and bone infection in sickle cell disease has traditionally been difficult, even with modern imaging techniques, and widespread antibiotic use is common. Early differentiation between the two conditions would enable more appropriate targeting of radiological investigations, antibiotics and surgery, and avoid un-necessary antibiotic usage. At our tertiary paediatric sickle cell centre, we have developed a sequencing protocol to be able to accurately differentiate between infection and infarction in sickle cell children using Magnetic Resonance (MR) Imaging. We have undertaken a preliminary retrospective study to analyse clinical and laboratory parameters in these children to see whether earlier differentiation prior to MR imaging is possible.Aim
Method
Following successful adoption of the Ponseti method for clubfoot treatment, a team of physiotherapists and orthotists and one surgeon in Jalalabad, Afghanistan have begun to treat Congenital Vertical Talus (CVT) by the technique described by Dodds et al, adapted to locally available resources. We have reviewed the outcome. Since 2010, 38 feet in 31 patients have been treated. Diagnosis of CVT is confirmed with a stress radiograph. The underlying conditions are diverse. The technique involves serial passive stretches and plaster of Paris casts. Once the talo-navicular joint is judged to be reduced, the joint if fixed with a percutaneous pin under local anaesthetic and an Achilles tenotomy performed. Post-operative treatment is as per the Iowa technique with night-time bracing and an AFO for ambulant patients.Aim
Method
At our institution surgical correction of symptomatic
flat foot deformities in children has been guided by a paradigm in
which radiographs and pedobarography are used in the assessment
of outcome following treatment. Retrospective review of children
with symptomatic flat feet who had undergone surgical correction
was performed to assess the outcome and establish the relationship
between the static alignment and the dynamic loading of the foot. A total of 17 children (21 feet) were assessed before and after
correction of soft-tissue contractures and lateral column lengthening,
using standardised radiological and pedobarographic techniques for
which normative data were available. We found significantly improved static segmental alignment of
the foot, significantly improved mediolateral dimension foot loading,
and worsened fore-aft foot loading, following surgical treatment.
Only four significant associations were found between radiological
measures of static segmental alignment and dynamic loading of the foot. Weakness of the plantar flexors of the ankle was a common post-operative
finding. Surgeons should be judicious in the magnitude of lengthening
of the plantar flexors that is undertaken and use techniques that
minimise subsequent weakening of this muscle group. Cite this article:
This pilot study aimed to identify the important symptomatic, functional and psychosocial aspects of hip disorders from the perspective of adolescent patients and their families in order to begin developing a patient-focused instrument (Bridging Adolescent Self-Reported Hip – BASH - score). This was a qualitative patient-centred study at a tertiary paediatric orthopaedic centre involving 50 adolescents aged 13–17 years, composed of five groups of 10 adolescents with slipped capital femoral epiphysis (SCFE), hip dysplasia (DDH), labral tears undergoing arthroscopic treatment, lower limb trauma and a miscellaneous group with conditions including Perthes' disease. A control group of 100 adolescents were also interviewed from a local school. Adolescent and separate concurrent parent groups underwent an ‘open’ phase face-to-face or telephone interview (theme development). This involved agreeing or disagreeing with statements, and open exploration of ideas related to the ‘day in the life’ of an adolescent with hip problems in order to generate and specify themes. This was followed by ranking and finally, scoring and testing.Aim
Methods
We investigated the predictive value of intra-operative
neurophysiological investigations in obstetric brachial plexus injuries.
Between January 2005 and June 2011 a total of 32 infants of 206
referred to our unit underwent exploration of the plexus, including
neurolysis. The findings from intra-operative electromyography,
sensory evoked potentials across the lesion and gross muscular response
to stimulation were evaluated. A total of 22 infants underwent neurolysis
alone and ten had microsurgical reconstruction. Of the former, one
was lost to follow-up, one had glenoplasty and three had subsequent
nerve reconstructions. Of the remaining 17 infants with neurolysis,
13 (76%) achieved a modified Mallet score >
13 at a mean age of
3.5 years (0.75 to 6.25). Subluxation or dislocation of the shoulder
is a major confounding factor. The positive predictive value and
sensitivity of the intra-operative EMG for C5 were 100% and 85.7%,
respectively, in infants without concurrent shoulder pathology.
The positive and negative predictive values, sensitivity and specificity
of the three investigations combined were 77%, 100%, 100% and 57%, respectively. In all, 20 infants underwent neurolysis alone for C6 and three
had reconstruction. All of the former and one of the latter achieved
biceps function of Raimondi grade 5. The positive and negative predictive
values, sensitivity and specificity of electromyography for C6 were
65%, 71%, 87% and 42%, respectively. Our method is effective in evaluating the prognosis of C5 lesion.
Neurolysis is preferred for C6 lesions. Cite this article:
Redisplacement is the most common complication
of immobilisation in a cast for the treatment of diaphyseal fractures
of the forearm in children. We have previously shown that the three-point
index (TPI) can accurately predict redisplacement of fractures of
the distal radius. In this prospective study we applied this index
to assessment of diaphyseal fractures of the forearm in children
and compared it with other cast-related indices that might predict
redisplacement. A total of 76 children were included. Their ages,
initial displacement, quality of reduction, site and level of the
fractures and quality of the casting according to the TPI, Canterbury
index and padding index were analysed. Logistic regression analysis
was used to investigate risk factors for redisplacement. A total
of 18 fractures (24%) redisplaced in the cast. A TPI value of >
0.8 was the only significant risk factor for redisplacement (odds
ratio 238.5 (95% confidence interval 7.063 to 8054.86); p <
0.001). The TPI was far superior to other radiological indices, with
a sensitivity of 84% and a specificity of 97% in successfully predicting
redisplacement. We recommend it for routine use in the management
of these fractures in children. Cite this article:
Matrix metalloproteinases (MMPs), responsible
for extracellular matrix remodelling and angiogenesis, might play
a major role in the response of the growth plate to detrimental
loads that lead to overuse injuries in young athletes. In order
to test this hypothesis, human growth plate chondrocytes were subjected
to mechanical forces equal to either physiological loads, near detrimental
or detrimental loads for two hours. In addition, these cells were
exposed to physiological loads for up to 24 hours. Changes in the
expression of MMPs -2, -3 and -13 were investigated. We found that expression of MMPs in cultured human growth plate
chondrocytes increases in a linear manner with increased duration
and intensity of loading. We also showed for the first time that
physiological loads have the same effect on growth plate chondrocytes
over a long period of time as detrimental loads applied for a short
period. These findings confirm the involvement of MMPs in overuse injuries
in children. We suggest that training programmes for immature athletes
should be reconsidered in order to avoid detrimental stresses and
over-expression of MMPs in the growth plate, and especially to avoid
physiological loads becoming detrimental. Cite this article:
McFarland fractures of the medial malleolus in
children, also classified as Salter–Harris Type III and IV fractures,
are associated with a high incidence of premature growth plate arrest.
In order to identify prognostic factors for the development of complications
we reviewed 20 children with a McFarland fracture that was treated
surgically, at a mean follow-up of 8.9 years (3.5 to 17.4). Seven
children (35%) developed premature growth arrest with angular deformity.
The mean American Orthopaedic Foot and Ankle Society Ankle-Hindfoot
Scale for all patients was 98.3 (87 to 100) and the mean modified
Weber protocol was 1.15 (0 to 5). There was a significant correlation
between initial displacement (p = 0.004) and operative delay (p
= 0.007) with premature growth arrest. Both risk factors act independently
and additively, such that all children with both risk factors developed
premature arrest whereas children with no risk factor did not. We
recommend that fractures of the medial malleolus in children should
be treated by anatomical reduction and screw fixation within one
day of injury. Cite this article:
We present our experience of the modified Dunn
procedure in combination with a Ganz surgical dislocation of the hip
to treat patients with severe slipped capital femoral epiphysis
(SCFE). The aim was to prospectively investigate whether this technique
is safe and reproducible. We assessed the degree of reduction, functional
outcome, rate of complications, radiological changes and range of
movement in the hip. There were 28 patients with a mean follow-up
of 38.6 months (24 to 84). The lateral slip angle was corrected
by a mean of 50.9° (95% confidence interval 44.3 to 57.5). The mean
modified Harris hip score at the final follow-up was 89.1 ( Cite this article:
Although non-union is a devastating and costly consequence of trauma for the child, family and society it is felt to be a rare complication in children. Currently there is no data available in the literature regarding its incidence either per fracture or per head of population. Should we be taking paediatric fracture non-union more seriously regarding research, resource allocation and informed consent? Our aim was to determine the incidence of non-union per child and per fracture. In Scotland Information Services Division (NHS Scotland) records every inpatient admission by ICD-10 diagnosis. As almost all fracture non-unions require intervention ISD provides accurate non-union figures by site and age. However, many fractures are treated as outpatients. Using local data of overall fracture numbers we were able to calculate a ratio of inpatient to total fracture numbers and apply this nationally.Aim
Method
The purpose of this study was to quantify the number of children treated with ESIN (elastic stable intra-medullary nails) at our institution and to determine what proportion of these nails have been removed and the time and difficulty taken to do so. Patients treated with ESIN between 2000 and 2005 were identified by database search. Their notes were reviewed to record patient and initial nailing details, and timing, difficulty and length of metalwork removal procedures. Complications leading to premature removal or following nail extraction were noted.Aim
Methods
To compare the effectiveness of arthrodiastasis with shelf acetabuloplasty for Perthes' disease in older children, by assessing the radiological outcome in matched pairs of children at skeletal maturity. Retrospective observational study case series.Objective
Design