Complex tibial fractures are difficult to treat. The costs associated with hospitalization can be substantial, yet it is unknown how these vary depending upon the type of implant used. There have been multiple studies on economics of tibial fractures but none of these studies actually focussed on costing of illizarov and taylor spatial frames. We discuss the cost analysis of 200 tibial fractures treated with illizarov or taylor spatial frames. The purpose of this study was to compare the cost of treatment of complex tibial fractures with reimbursement given to the hospital in treating such injuries. We evaluated the economical data of 200 patients with complex tibial fractures treated with illizarov frame or taylor spatial frame from May 2005 to May 2010. Demographic data, fracture classification and method of surgical treatment along with the length of hospital stay were recorded in detail. The total cost calculated was then compared to the range of reimbursement price based on HRG (human Resource Group) coding. The implant cost was determined from the buying cost of institution.Background
Methods
We report 3 cases from different centres of infantile tibia vara in which the deformity was due to slippage of the proximal tibial epiphysis on the metaphysis; the aim of this study was to define the features of this previously unreported condition, and their implications for management. Three cases of tibia vara secondary to atraumatic slippage of the upper tibial epiphysis on the metaphysis were identified from three different centres. The case notes and imaging studies were retrospectively reviewed to distinguish common clinical and radiographic features.Introduction
Method
The present study was conducted to evaluate the cost of physiotherapy both for inpatient and outpatient services. Significant physiotherapy resources are required to rehabilitate patients with an Ilizarov or Taylor Spatial Frame (TSF). Within Hull and East Yorkshire Hospitals NHS Trust Physiotherapy department the average number of outpatient treatment sessions per routine patient is 6. In comparison, the average number of treatment sessions required for a patient with an ilizarov (or TSF) is 24 for a trauma patient and 33 for a patient undergoing an elective procedure. Seventy three (73) patients received physiotherapy treatment with an Ilizarov frame or a Taylor spatial frame between April 2008 and April 2010. Physiotherapy input was recorded (in minutes) for the patients identified. This included treatment received as an inpatient as well as an outpatient (if the patient received their treatment within Hull and East Yorkshire NHS trust). Data collection was divided into either trauma or elective procedure for analytical purposes. The average cost of physiotherapy treatment to Hull and East Yorkshire Hospitals NHS Trust for an inpatient with an ilizarov frame is £121.82 per case (trauma) and £133.15 per case (elective). The average cost of physiotherapy treatment to Hull and East Yorkshire Hospitals NHS Trust for an outpatient for a trauma case was calculated as £404.65 and £521.41for an average elective case. This is in comparison to a routine patient costing the service £60.29 (when treated by a Band 7 physiotherapist). The present study gives valuable data for future business planning and assistance with the setting of local or national tariffs for the treatment of this patient group.
The specific methods of skeletal reconstruction of massive bone loss remains a topic of controversy. The problem increased in case of massive bone loss, extensive soft tissue scar, vascular compromise, and short tibial remnants. We evaluate the use of fibula in association of Ilizarov external fixator in management of massive post traumatic bone loss of tibial shaft.Abstract
Aim of the work
The aim of this retrospective study is to compare the different anaesthetic techniques in children undergoing circular frame application for lengthening and deformity correction. Data was collected from 68 cases on severe pain episodes, postoperative duration of analgesia, requirement for top-up analgesia, complications and side-effects and number of osteotomies. The three analgesic methods used were morphine infusion (M), epidural analgesia (E) and continuous peripheral nerve blocks (CPNB). There was a significant difference between the number of episodes of severe pain experienced by the patients receiving a morphine infusion when compared to the epidural and CPNB groups (M vs. E p<0.0001, M vs. CPNB p=0.018). CPNB were associated with the lowest incidence of severe pain episodes and top-up analgesia requirements. The difference in the incidence of nausea and vomiting between the methods was approaching significance (p=0.06). A significant difference was found when comparing epidural and morphine infusions (p=0.05). Epidural analgesia was associated with significantly more nausea and vomiting (p=0.023), and motor blockade (p<0.01) than CPNB. The results show the most effective method of post-operative analgesia for our paediatric patients, in light of pain episodes and associated side-effects, is sciatic nerve catheterisation with continuous infusion.
The aim of the study was to characterise gait in patients with achondroplasia post lengthening. Full kinematic and kinetic lower limb gait analysis was performed at the Sheffield Children's Hospital gait laboratory, Sheffield, using a Vicon system (6 cameras working at 50Hz) and processed using Plug In Gait modelling software. The lengthened Achondroplasia group (n=11, mean age = 24.5 ± 6.1) had previously undergone surgical lengthening of the legs. The lengthened Achondroplasia group was compared to a control group of 11 adult normal subjects.Aim
Patients/Materials and Methods
The purpose of this study was to assess the accuracy of three-dimensional camera technology when monitoring deformity correction by an Ilizarov frame and to compare it to manual measurements. A model consisting of an Ilizarov frame built around an artificial tibia and fibula was used with retro-reflective markers placed on the frame and bones to allow for the positions of each to be detected by the camera system. Measurements made by the camera system were compared to measurements taken manually. In the assessment of frame lengthening, the camera system average error was 2% (SD 2%) compared to 7% (SD 6%) for manual measurement. In the assessment of bone lengthening, the camera system average error was 4% (SD 4%) compared to 34% (SD 8%) for manual measurement. The technology also demonstrated good accuracy in the measurement of angular deformity changes.Purpose
Methods and Results
To examine the effect of limb lengthening on the quality of life of people who have disproportionate short stature (DSS). Thirteen previous patients, completed the SF-36, the Derriford Appearance Scale and participated in face to face semi structured interviews to establish the impact on their physical and social functioning, their present situation including employment, education, housing and leisure activities and their thoughts about whether they felt the treatment had been worthwhile. To increase understanding about the patient and family experience of limb lengthening, participants were asked about their memories of the procedure and the treatment period.Purpose
Method
Fractures of the femoral neck in children are
rare, high-energy injuries with high complication rates. Their treatment has
become more interventional but evidence of the efficacy of such
measures is limited. We performed a systematic review of studies
examining different types of treatment and their outcomes, including
avascular necrosis (AVN), nonunion, coxa vara, premature physeal
closure (PPC), and Ratliff’s clinical criteria. A total of 30 studies
were included, comprising 935 patients. Operative treatment and
open reduction were associated with higher rates of AVN. Delbet
types I and II fractures were most likely to undergo open reduction
and internal fixation. Coxa vara was reduced in the operative group,
whereas nonunion and PPC were not related to surgical intervention. Nonunion
and coxa vara were unaffected by the method of reduction. Capsular
decompression had no effect on AVN. Although surgery allows a more
anatomical union, it is uncertain whether operative treatment or
the type of reduction affects the rate of AVN, nonunion or PPC,
because more severe fractures were operated upon more frequently.
A delay in treatment beyond 24 hours was associated with a higher
incidence of AVN. Cite this article:
Perthes’ disease is an osteonecrosis of the juvenile
hip, the aetiology of which is unknown. A number of comorbid associations
have been suggested that may offer insights into aetiology, yet
the strength and validity of these are unclear. This study explored
such associations through a case control study using the United
Kingdom General Practice Research database. Associations investigated
were those previously suggested within the literature. Perthes’ disease has a significant association with congenital
genitourinary and inguinal anomalies, suggesting that intra-uterine
factors may be critical to causation. Other comorbid associations
may offer insight to support or refute theories of pathogenesis.
A total of 35 children with Erb’s palsy and shoulder
abduction of <
90° underwent transfer of teres major. In 18 cases (group
1) a trapezius transfer was added (combined procedure). In 17 cases
(group 2) teres major transfer was carried out in isolation (single
procedure). The mean gain in abduction was 67.2° (60° to 80°) in
group 1 and 37.6° (20° to 70°) in group 2, which reached statistical
significance (p <
0.001). Group 2 was further divided into those who had deltoid power
of <
M3 (group 2a) and those with deltoid power ≥ M3 (group 2b).
The difference in improvement of abduction between groups 2a and
group 2b was statistically significant (p <
0.001) but the difference
between group 2b and group 1 was not (p = 0.07). We recommend the following protocol of management: in children
with abduction ≥ 90° a single procedure is indicated. In children
with abduction <
90°: a combined procedure is indicated if deltoid
power is <
M3 and a single procedure is indicated if deltoid
power is ≥ M3. If no satisfactory improvement is achieved, the trapezius
can be transferred at a later stage.
We undertook a retrospective analysis of 306
procedures on 233 patients, with a mean age of 12 years (1 to 21),
in order to evaluate the use of somatosensory evoked potential (SSEP)
monitoring for the early detection of nerve compromise during external
fixation procedures for limb lengthening and correction of deformity.
Significant SSEP changes were identified during 58 procedures (19%).
In 32 instances (10.5%) the changes were transient, and resolved
once the surgical cause had been removed. The remaining 26 (8.5%)
were analysed in two groups, depending on whether or not corrective
action had been performed in response to critical changes in the
SSEP recordings. In 16 cases in which no corrective action was taken,
13 (81.2%, 4.2% overall) developed a post-operative neurological
deficit, six of which were permanent and seven temporary, persisting
for five to 18 months. In the ten procedures in which corrective
action was taken, four patients (40%, 1.3% overall) had a temporary
(one to eight months) post-operative neuropathy and six had no deficit. After appropriate intervention in response to SSEP changes, the
incidence and severity of neurological deficits were significantly
reduced, with no cases of permanent neuropathy. SSEP monitoring
showed 100% sensitivity and 91% specificity for the detection of
nerve injury during external fixation. It is an excellent diagnostic
technique for identifying nerve lesions when they are still highly
reversible.
We describe three cases of infantile tibia vara
resulting from an atraumatic slip of the proximal tibial epiphysis
upon the metaphysis. There appears to be an association between
this condition and severe obesity. Radiologically, the condition
is characterised by a dome-shaped metaphysis, an open growth plate
and disruption of the continuity between the lateral borders of
the epiphysis and metaphysis, with inferomedial translation of the
proximal tibial epiphysis. All patients were treated by realignment
of the proximal tibia by distraction osteogenesis with an external
circulator fixator, and it is suggested that this is the optimal
method for correction of this complex deformity. There are differences
in the radiological features and management between conventional
infantile Blount’s disease and this ‘slipped upper tibial epiphysis’
variant.
Although equinus gait is the most common abnormality
in children with spastic cerebral palsy (CP) there is no consistency
in recommendations for treatment, and evidence for best practice
is lacking. The Baumann procedure allows selective fractional lengthening
of the gastrocnemii and soleus muscles but the long-term outcome
is not known. We followed a group of 18 children (21 limbs) with
diplegic CP for ten years using three-dimensional instrumented gait
analysis. The kinematic parameters of the ankle joint improved significantly
following this procedure and were maintained until the end of follow-up.
We observed a normalisation of the timing of the key kinematic and
kinetic parameters, and an increase in the maximum generation of
power of the ankle. There was a low rate of overcorrection (9.5%,
n = 2), and a rate of recurrent equinus similar to that found with
other techniques (23.8%, n = 5). As the procedure does not impair the muscle architecture, and
allows for selective correction of the contracted gastrocnemii and
soleus, it may be recommended as the preferred method for correction
of a mild fixed equinus deformity.
Analyze the results of reconstruction of post osteomyelitic bone defect using non-vascularised fibula graft in children and correlation of results with magnitude of defect. 11 boys and 15 girls (mean age 6.8±2.33 years) were prospectively enrolled in the study. All had primary acute hematogeneous osteomyelitis with diaphyseal sequestration and active discharging sinuses. 7 femur, 12 tibia, 3 humerus, 3 radius and 1 ulna were the bone involved. As first step a radical debridement and sequestrectomy was performed. Second step was considered after a ‘dry’ period judged clinically and by normalized CRP. A subperiosteal resection of fibula was done and used as graft to fill in the diaphyseal defect. Graft was stabilized using intramedullary ‘K’ wires and supported by post-operative casts. Weight-bearing was started on radiological evidence of union.Purpose
Methods
To assess the initial rise in inflammatory markers in paediatric patients presenting with long bone osteomyelitis and whether this is comparable with that in septic arthritis, and diagnostic. All radiologically confirmed cases of long bone osteomyelitis without septic arthritis, joint effusion or abscess, in paediatric patients, presenting to one hospital over an eighteen-month period were included. These patients were compared with all culture positive septic arthritides presenting to the same hospital within the same period. Inflammatory markers taken on the day of admission were studied.Purpose
Methods
This study was designed to assess the utility of the scarf osteotomy in the management of symptomatic adolescent hallux valgus. This is a consecutive case series of 30 patients (38 feet) with a mean follow up of 38.2 months (range 6-60 months). The mean age at the time of surgery was 14.2 years (range 10-17 years). American Orthopaedic Foot and Ankle Society scores (AOFAS) were collected at final follow up, along with a rating of the overall satisfaction. Any complications were recorded.Purpose of this study
Methods
We report the results of a retrospective review of patients that underwent distal tibial deformity correction with transphyseal or supramalleolar osteotomy with or without tibial lengthening. The aims of the procedures performed were to obtain equal leg length, restore the alignment of the ankle joint and tibio—fibular relationship. Supramalleolar osteotomy enables deformity correction, can be combined with lengthening and is appropriate where the tibio—fibular relationship is normal. When the tibio—fibular relationship is abnormal, as is often the case with bone dysplasias, differential tibio—fibular lengthening can be performed. If physeal arrest has occurred, for example after sepsis, deformity correction can be achieved with a transphyseal osteotomy allowing correction and ensuring epiphysiodesis. When the fibular length is excessive, transphyseal osteotomy can be combined with a fibular shortening. Our review encompassed 12 patients over a period of 10 years with 5 having deformity after previous meningococcal septicaemia, 4 with fibular hemimelia, 2 with a history of previous trauma and 1 with deformity occurring after a compartment syndrome as a consequence of snake bite. Seven transphyseal osteotomies were performed in 5 patients (2 bilateral), 4 with deformity secondary to meningococcal septicaemia and 1 with deformity secondary to previous trauma. After 1 transphyseal osteotomy there was recurrent distal tibial deformity (14%) which occurred within 1 year requiring a later supramalleolar dome osteotomy. Of the other 6 transphyseal osteotomies all healed with no residual leg—length inequality or deformity. Seven patients underwent supramalleolar osteotomies with all healing and recurrent deformity occurring in 1 patient (14%). Future lengthening is required in 2 patients and 1 patient will undergo a subtalar joint arthrodesis for a painful valgus hindfoot. Distal tibial deformity correction is challenging but our results show that providing the stated principles are adhered to, successful management with an acceptable recurrent deformity rate is possible.
This study is to determine the survival and outcomes of the Birmingham Interlocking Triple Pelvic Osteotomy. A dysplastic hip predisposes to early arthritis. The Triple Pelvic Osteotomy (TPO) is a joint-preserving option for the treatment of young adults with hip dysplasia. The long term success of the procedure is not known. The senior author has been performing Birmingham Interlocking Triple Pelvic Osteotomies for 18 years. The outcomes of the first 100 patients (117 TPOs) were reviewed using postal questionnaires, telephone interviews and radiograph review. The primary outcome measure of the study was the Kaplan—Meier survival curve for the TPO. Hip replacement or resurfacing were taken as failure points. The Oxford Hip Score (OHS) and University of California, Los Angeles (UCLA) score were used as secondary outcome measures for the surviving osteotomies. The pre-and post-operative acetabular index and centre-edge angles were measured from surviving radiographs.Purpose of study
Patients and methods
Between 2005 and 2010 ten consecutive children
with high-energy open diaphyseal tibial fractures were treated by early
reduction and application of a programmable circular external fixator.
They were all male with a mean age of 11.5 years (5.2 to 15.4),
and they were followed for a mean of 34.5 months (6 to 77). Full
weight-bearing was allowed immediately post-operatively. The mean
time from application to removal of the frame was 16 weeks (12 to
21). The mean deformity following removal of the frame was 0.15°
(0° to 1.5°) of coronal angulation, 0.2° (0° to 2°) sagittal angulation,
1.1 mm (0 to 10) coronal translation, and 0.5 mm (0 to 2) sagittal
translation. All patients achieved consolidated bony union and satisfactory
wound healing. There were no cases of delayed or nonunion, compartment
syndrome or neurovascular injury. Four patients had a mild superficial
pin site infection; all settled with a single course of oral antibiotics.
No patient had a deep infection or re-fracture following removal
of the frame. The time to union was comparable with, or better than,
other published methods of stabilisation for these injuries. The
stable fixator configuration not only facilitates management of
the accompanying soft-tissue injury but enables anatomical post-injury
alignment, which is important in view of the limited remodelling
potential of the tibia in children aged >
ten years. Where appropriate
expertise exists, we recommend this technique for the management
of high-energy open tibial fractures in children.
To assess the risk of early re—dislocation following closed reduction (CR) of the hip for idiopathic developmental dysplasia of the hip (DDH). Review of case notes and radiographs of all who underwent CR for DDH between January 2005 and January 2010 was undertaken. Parameters recorded included sex, side of dysplasia, age at the time of attempted reduction and concomitant complications. The main outcome measure was clinical and radiographic evidence of successful reduction. Early failure of reduction was regarded as loss of concentric reduction requiring an open procedure within a year of CR. CR was performed via a standardised protocol under general anaesthetic, with arthrographic control, adductor tenotomy as required and hip spica application. Post procedure reduction was confirmed with MRI and the spica was maintained for 12 weeks.Purpose of study
Methods
To evaluate the efficacy of Kocher's criteria to differentiate between transient synovitis and septic arthritis in children. All children with a presentation of ‘atraumatic limp’ and a proven effusion on hip ultrasound between 2004 and 2009 were included. Patient demographics, details of the clinical presentation and laboratory investigations were documented to identify a response to each of the four variables (Weight bearing status, WCC >12,000 cells/m3, CRP >20mg/L and Temperature >38.5°C). SA was defined based upon culture and microscopy of the operative findings. 311 hips were included within the study. Of these 282 were considered to have transient synovitis. 29 patients met criteria to be classified as SA based upon laboratory assessment of the synovial fluid. The introduction of CRP eliminated the need for a four variable model as the prediction for two variables (CRP and weight bearing status) was of similar efficacy. Treating individuals who were non-weight-bearing and a CRP >20mg/L as SA correctly classified 94.8% individuals, with a sensitivity of 75.9%, specificity of 96.8%, positive predictive value of 71.0%, and negative predictive value of 97.5%. CRP was a significant independent predictor of septic arthritis.Purpose
Methods and results
The purpose of this study was to comprehensively evaluate syndactyly correction. Patient selection, complexity, technique and aftercare are compared with scar quality, web-creep, hand function and patient satisfaction. 49 syndactyly releases (in 32 patients between 1999-2010) attended evaluation clinics. Demographics, surgical technique (island web transfer, graft vs graftless) aftercare and complications were identified from case notes. Patient satisfaction was obtained via questionnaire. Function was assessed by grip and pincer strength, range of motion, and age of developmental milestones. Where appropriate this was compared to the contralateral side.Introduction
Methods
The management of developmental hip dysplasia requiring open reduction between 12 and 18 months of age is controversial. We compare the outcome of medial approach open reduction (MAOR) versus anterior open reduction with Salter osteotomy (delayed until the child is of sufficient size) in such patients. 19 consecutive patients who underwent MAOR aged 12-22 months were reviewed at a mean follow-up of 3.5 years (range: 1.0-6.2). This group was compared to 14 patients who underwent anterior reduction and Salter osteotomy aged 18-23 months (mean follow-up 4.1 years).Purpose of study
Patients and methods
Albania is one of the poorest countries in Western European with a GDP per capita standing at 26 percent of the EU average in 2010. Whilst there is government-funded universal free provision of healthcare, it is accepted that delivery is patchy, not accessible to all and lacking expertise for more complex paediatric orthopaedic conditions. With the sponsorship of a UK-based charity, we have set up and completed 5 visits to Albania (3 assessment and 2 operative) to provide additional expertise for paediatric orthopaedic disorders running parallel to and utilising currently available local services. We present the results of this treatment and training programme to date. Between 2008 and 2011, we assessed 204 children and adolescents with paediatric orthopaedic disorders in Tirana and Durres on 3 separate visits. Of these, 28 were listed for surgical procedures whilst the rest were treated non-operatively. Of the listed patients, 14 patients underwent surgical intervention (total of 18 procedures).Introduction
Patients and methods
A description of a procedure to stabilize symptomatic complete discoid menisci with medium term results. Children with mechanical symptoms of lateral meniscal instability were assessed by MRI scan. In those with a lateral discoid meniscus an arthroscopic examination was performed to identify the presence of tears and confirm the radiological diagnosis. No incomplete or Wrisberg variant types were encountered. An antero-lateral arthrotomy was performed. The anterior horn of the meniscus was mobilized and traction sutures inserted. Flexion and extension of the knee whilst traction was applied led to delivery of the anterior horn into the wound. After confirmation of position with image intensifier a groove was fashioned in the anterior aspect of the cartilaginous portion of the proximal tibial epiphysis. Typically three titanium bone anchors with non absorbable sutures were placed in the base of the groove. The anterior horn of the meniscus was drawn into the groove and anchored with sutures. Active range of motion exercises were encouraged but a canvas knee immobilizer was employed whilst walking for the first six weeks. Four boys and three girls underwent meniscopexy performed at a mean age of 9.4 years (range 5.7 to 12.4 years). Follow up was at a mean of 4.9 years. At last follow up no patient reported symptoms of locking or pain. No patient has required revision surgery but one girl had a subsequent meniscopexy procedure on the opposite knee. Five of the children have had Lysholm scores performed at last follow up averaging 93.5 (80 to 100 points).Purpose of Study
Methods and Results
We present our early experience of arthroscopic
reduction of the dislocated hip in very young infants with developmental
dysplasia of the hip (DDH). Eight dislocated hips, which had failed attempts at closed reduction,
were treated by arthroscopy of the hip in five children with a mean
age of 5.8 months (4 to 7). A two-portal technique was used, with
a medial sub-adductor portal for a 2.7 mm cannulated system with
a 70° arthroscope and an anterolateral portal for the instruments. Following
evaluation of the key intra-articular structures, the hypertrophic
ligamentum teres and acetabular pulvinar were resected, and a limited
release of the capsule was performed prior to reduction of the hip.
All hips were reduced by a single arthroscopic procedure, the reduction
being confirmed on MRI scan. None of the hips had an inverted labrum.
The greatest obstacle to reduction was a constriction of the capsule.
At a mean follow-up of 13.2 months (9 to 24), all eight hips remained
stable. Three developed avascular necrosis. The mean acetabular index
decreased from 35.5° (30° to 40°) pre-operatively to 23.3° (17°
to 28°). This study demonstrates that arthroscopic reduction is feasible
using two standardised portals. Longer follow-up studies are necessary
to evaluate the functional results.
A retrospective study was undertaken to evaluate and compare the results of telescoping (group I) versus non-telescoping rods (group II) in the treatment of osteogenesis imperfecta. Thirty-three lower limb segments in ten patients were studied (14 segments in group I and 19 segments in group II). The surgical techniques of Sofield and Miller (1959) and Lang-Stevenson and Sharrard (1984) for rod insertion were used. All cases were assessed clinically regarding mobility status, growth and limb-length, refracture, and infection. They were also assessed radiologically regarding rod migration, bone outgrowing the rod, incorrect T-piece placement, breakage and bending of rods.Aim
Materials and Methods
Septic arthritis of the hip in the newborn baby can result in severe long term sequelae in the form of dislocation of the hip, loss of movement and growth disturbance with leg length discrepancy. Reconstructive procedures for this difficult problem have not been satisfactory. This series comprises eight patients with septic hip sequelae . All of them had old septic hip and leg length discrepancy ranging from 4 cm to 15 cm. all underwent hip stabilization by pelvic support osteotomy and simultaneous limb lengthening and angular deformities correction using the Ilizarov frame. The age at the operation range from 8 years to 19 years, with an average follow up 4 years.Introduction
Patient and methods
To define the orthopaedic problems associated with pseudoachondroplasia (PSACH) and their functional impact. We reviewed the medical records of 12 consecutive patients presenting to our unit. Radiographic analysis of deformity included assessment of mechanical axis and dysplasia at hip, knee and ankle measured by acetabular index (AI), Reimer's migration percentage (MP), neck-shaft angle, distal lateral femoral (aDFLA) and proximal (mMPTA) and distal tibial angles. The paediatric/adolescent PODCI questionnaires and the SF36 were used to assess quality of life issues.Purpose
Methods
Unicameral bone cysts (UBCs) are difficult to treat and have a high recurrence rate. Their pathogenesis is unknown making targeted therapies difficult. Attributed causes include venous and interstitial fluid obstruction, oxygen free radicals, lysosomal enzymes, prostaglandins and genetic factors. Skeletal stem cells (SSCs) are osteoblast precursors critical to bone formation and cyst fluid may influence their growth, however the association between SSCs and cyst fluid has never been investigated. To investigate the effect of UBC fluid on SSC growth.Background
Aim
To determine the consistency with which specialist orthopaedic surgeons rate the importance of criteria for the diagnosis of DDH which had previously been generated in a BSCOS and EPOS multi national study. 163 members of BSCOS received a questionnaire containing 37 criteria that, in a previous study, had been found to be important for the diagnosis of DDH in infants under 8 weeks. A visual analogue scale was used to rate the importance of each criterion in the diagnosis of DDH. We determined the consistency using the intra-class correlation coefficient (values > .80 are anticipated). Analyses were preformed for all members of BSCOS and for geographic regions.Purpose of the study
Methods
The purpose of this study was to determine the oblique plane deformity in slipped upper femoral epiphysis. A retrospective radiographic review was undertaken in patients admitted with a slipped upper femoral epiphysis between March 2008 and October 2010. Patients in whom a CT scan had been performed in addition to plain radiographs were assessed further. Angular deformity in the coronal and sagittal planes were measured by the angle formed between the femoral neck and a line perpendicular to the physis on the AP pelvic radiograph and the axial CT scan respectively. The magnitude and direction of the resultant deformity was defined in the oblique plane. Additional demographic data (gender, age, side, procedure and complications) was collected. Seven girls, average age of 12 (range 10 – 13) and 6 boys, average age of 13 (range 10 – 15) were identified. The slip was bilateral in 2, left sided in 6 and right sided in 5 cases. Two patients were pinned in situ, 8 had surgical dislocation performed to facilitate reduction prior to pinning and 3 patients had secondary procedures performed following in situ pinning. The average angulation in the oblique posteroinferior plane (25 degrees) was less than in the coronal (30 degrees) and the sagittal planes (62 degrees). The average magnitude was 67mm (range 31 – 88). CT is useful adjunct particularly when a frog legged lateral view is not possible because of pain or the fear of further displacement. Determination of the deformity in the oblique plane may aid in positioning of the screw during in situ pinning and may be helpful in identifying patients in whom pinning maybe difficult.
A delay in the diagnosis of paediatric acute
and subacute haematogenous osteomyelitis can lead to potentially devastating
morbidity. There are no definitive guidelines for diagnosis, and
recommendations in the literature are generally based on expert
opinions, case series and cohort studies. All articles in the English literature on paediatric osteomyelitis
were searched using MEDLINE, CINAHL, EMBASE, Google Scholar, the
Cochrane Library and reference lists. A total of 1854 papers were
identified, 132 of which were examined in detail. All aspects of
osteomyelitis were investigated in order to formulate recommendations. On admission 40% of children are afebrile. The tibia and femur
are the most commonly affected long bones. Clinical examination,
blood and radiological tests are only reliable for diagnosis in
combination. Most studies were retrospective and there is a need for large,
multicentre, randomised, controlled trials to define protocols for
diagnosis and treatment. Meanwhile, evidence-based algorithms are
suggested for accurate and early diagnosis and effective treatment.
We present a retrospective study of bilateral CDH. We analysed the correlation of complications to the confounding factors. We reviewed all bilateral CDH patients treated by the same surgeon at Southampton between 1988-2006. The patient recruitment was carried out as follows:
Group A – failed Pavlik harness; Group B – late presentations not treated in Pavlik harness.AIMS
MATERIAL AND METHODS
The purpose of our study was to independently assess the modified Herring lateral pillar classification. 35 standardised true antero-posterior radiographs of children in various stages of fragmentation were independently assessed by 6 senior observers on 2 separate occasions (6 weeks apart). Kappa analysis was used to assess the inter and intraobserver agreement between observations made. Intraobserver analysis revealed at best only moderate agreement for two observers. 3 observers showed fair consistency, whilst 1 remaining observer showed poor consistency between repeated observations (p<0.01). The highest scores for interobserver agreement varying between moderate to good could only be established between 2 observers. For the remaining observers results were just fair (p<0.01). This stdy highlights the lack of agreement between senior clinicians when applying the modified LPC. This clearly has clinical implications. To our knowledge this is the first time the modified lateral pillar classification has been independently tested for its reproducibility by a specialist orthopaedic unit.Methods and results
Conclusion
To assess if prolonged use of Bisphosphonates in Osteogenesis Imperfecta alters the pattern of femoral fractures. Osteogenesis Imperfecta (OI) has been treated with Bisphosphonates for many years with some clear clinical benefits. In adult cohorts there are reports of a new pattern of atraumatic subtrochanteric fractures seen with Bisphosphonate treatment. This study assesses the location of femoral fractures in a cohort of 176 OI patients treated with Bisphosphonates over a two year period and compares it to a historical control group of 45 managed prior to the advent of this specific treatment.PURPOSE OF THE STUDY
SUMMARY OF METHODS
The aim of this retrospective study was to review the outcome of patients treated with Fassier-Duval (FD) rods and highlight some of the complications found during treatment. Between April 2006 and August 2010 we inserted 24 FD rods in 13 patients. 17 rods for osteogenesis imperfecta (OI), 2 for fractures and deformity associated with cerebral palsy, 1 for fracture associated with muscular dystrophy, 1 for fibrous dysplasia and 3 for centralisation of single bone forearms. In the upper limb one patient required revision for proximal migration of the male component and another patient is waiting for revision for the same problem. In the lower limb, a tibial nail was revised because of proximal migration of the male component. A femoral nail was adjusted because of loss of the proximal fixation. One of the OI patients fell, fractured the femur and bent a femoral nail. This awaits revision at a later date. A second OI patient fell on 2 separate occasions bending both a tibial and a femoral nail respectively. These were both revised to trigen intramedullary nails. In all the other cases there were no complications. In summary the Fassier Duval system provides a versatile way of providing intramedullary stabilisation for growing bones through a single entry point. However in our experience we have a 33% complication rate most notably bending of the rods. We advocate careful patient selection and using as high a diameter nail as is feasible.
To report the experience and evolution of treatment of Congenital Pseudarthrosis of the Tibia in a single surgeon, consecutive series of 19 patients. A retrospective case series review, with radiological assessment and functional outcome scores including the Activity Scale for Kids (ASK) and the Oxford Ankle Foot Questionnaire (OAFQ) Child & Teenager version. Patients were classified as per Boyd & Andersen. Alteration in the Tibial mechanical axis was compared pre-treatment and at last review.PURPOSE
METHODS
Elastic stable intramedullary nailing (ESIN)
is generally acknowledged to be the treatment of choice for displaced diaphyseal
femoral fractures in children over the age of three years, although
complication rates of up to 50% are described. Pre-bending the nails
is recommended, but there are no published data to support this.
Using synthetic bones and a standardised simulated fracture, we
performed biomechanical testing to determine the influence on the
stability of the fracture of pre-bending the nails before implantation.
Standard ESIN was performed on 24 synthetic femoral models with
a spiral fracture. In eight cases the nails were inserted without
any pre-bending, in a further eight cases they were pre-bent to
30° and in the last group of eight cases they were pre-bent to 60°. Mechanical
testing revealed that pre-bending to 60° produced a significant
increase in the stiffness or stability of the fracture. Pre-bending
to 60° showed a significant positive influence on the stiffness
compared with unbent nails. Pre-bending to 30° improved stiffness
only slightly. These findings validate the recommendations for pre-bending,
but the degree of pre-bend should exceed 30°. Adopting higher degrees
of pre-bending should improve stability in spiral fractures and
reduce the complications of varus deformity and shortening.
To document the success rate of closed reduction and soft tissue release in the treatment of bilateral true dislocation in developmental dysplasia of the hip (DDH). Case-note review of 22 children (44 hips) with idiopathic bilateral hip dislocation referred to a tertiary centre before walking age. The management protocol was as follows:
Examination under general anaesthesia, arthrogram, closed reduction and appropriate soft tissue release (adductors/psoas), application of a ‘frog’ cast. CT scan at 2 weeks to confirm reduction. Change of cast and arthrogram at 6 weeks to confirm improving position and stability. Cast removal at 12 weeks, and application of an abduction brace for 6 weeks. Treatment failure could occur on day 1 (failure of reduction), at week 2 (failure to maintain reduction), at week 6, or after cast removal.Purpose
Methods
We describe two recent cases of intraosseous (IO) access resulting in amputation in critically ill infants and make contemporary recommendations on the safe practice of this technique. This is a retrospective case series of two children transferred from peripheral hospitals to our unit. One child (5 months) was resuscitated after cardiorespiratory decompensation due to diaphragmatic hernia. The other child (18 months) deteriorated during presentation with purpura fulminans two days after a scald injury. Both children underwent emergent bilateral tibial IO access using power driven needle systems. Initial resuscitation included large volumes of 0.9% normal saline. One child received doses of adrenaline and 8.4% sodium bicarbonate, whole blood and an initial dopamine infusion; the other received 8.4% sodium bicarbonate, 10% calcium gluconate and whole blood. Total infused volumes were 400mL and 730 ml respectively. Progressive lower limb tension became evident in both children after 12 hours; bilateral posterior tibial fractures were noted in one child. Ultimately, both children underwent surgical fasciotomy, but extensive necrosis necessitated unilateral below knee amputation at days 12 and 13 respectively.Purpose
Methods/results
The outcome of 56 children (61 shoulders) treated
surgically at the Rizzoli Institute between April 1975 and June 2010
for congenital elevation of the scapula is reported. There were
31 girls and 25 boys with a mean age at surgery of 6.4 years (2
to 15). The deformity involved the right shoulder in 20 cases, the
left in 31 and was bilateral in five. The degree of the deformity
was graded clinically and radiologically according to the classifications
of Cavendish and Rigault, respectively. All patients underwent a
modified Green procedure combined, in selected cases, with resection
of the superomedial portion of the scapula and excision of any omovertebral
connection. After a mean follow-up of 10.9 years (1 to 29.3), there
was cosmetic improvement by at least one Cavendish grade in 54 shoulders (88.5%).
The mean abduction of the shoulder improved from 92° (50° to 155°)
to 112° (90° to 170°) and the mean flexion improved from 121° (80°
to 160°) to 155° (120° to 175°). The unsatisfactory cosmetic result
in seven shoulders was due to coexistent scoliosis in two cases
and insufficient reduction of the scapular elevation in the other
five. An incomplete upper brachial plexus palsy occurred post-operatively
in three patients but resolved within seven months. We suggest that a modified Green procedure combined with resection
of the superomedial portion of the scapula provides good cosmetic
and functional results in patients with Sprengel’s shoulder.
The purpose of this study was to calculate the dislocation rate following open or closed reduction for developmental dysplasia of the hip (DDH) in our unit. In addition we evaluated the posterior neck line as a method of determining hip relocation and assessed the morphology of the dysplastic acetabulum on single slice CT scan. We retrospectively assessed all patients operated on for either open or closed reduction for DDH between August 2007 and August 2009 and evaluated their notes, CT scans and radiographs. The immediate post-operative dislocation rate was calculated, as was the subsequent re-dislocation rate and late subluxation rate. The acetabular morphology was assessed to determine whether the acetabulae were “S” shaped or “C” shaped. A novel method for confirming hip reduction was also appraised.Aims
Method
A review of the role of external fixators in paediatric trauma at The Royal London Hospital Trauma and Orthopaedic Department. Retrospective study between 2004 and 2010 reviewing traumatic bone injuries that required initial management with an external fixator. Information was collected through the patients' medical documents and radiographs.Purpose
Methods
Our experience with Taylor Spatial Frame correction of complex foot deformities in children. Persistent foot deformity in congenital talipes equinovarus is a challenge. Open surgery is associated with complications including difficulty in achieving acute corrections in stiff, scarred feet. Gradual correction using the Ilizarov circular frame has been described as an alternative and we present the experience using a computer assisted hexapod gradual frame correction with the Taylor Spatial Frame (TSF). A retrospective audit of sequential patients treated by TSF was performed. Technique, outcome, complications and key learning points were recorded. 21 paediatric patients underwent 27 treatments with a Taylor Spatial frame for complex foot deformity correction. Average age 11 years with majority diagnosis of congenital talipes equinovarus. The deformities severity meant acute correction would result in either neurovascular or soft tissue compromise. Plantigrade feet with good function was achieved in 22 feet. 3 feet were deemed as failures. 2 feet have residual deformity but acceptable function. According to Paley's classification, there were 4 complications, 7 obstacles and 35 difficulties (pin tract infection and pain management). Complications did contribute to poorer outcomes. The key learning points were: protection of the ankle joint and distal tibial physis; staged osteotomy reduces swelling and complication rates; and consideration of further procedures at frame removal is important. Finally a thorough preoperative counselling programme should be instituted and patients warned of the time commitment and high difficulty rates associated with treatment. Managing patient expectation with goals is as important as meticulous surgery. Although complication rates were high, the majority of treatment goals were met, therefore the TSF is valid in the treatment of complex deformities in the foot. Most patients with severe deformity can achieve a plantigrade functional foot but residual stiffness and need for minor orthotics is almost universal.Statement of Purpose
CRUS is difficult to treat. Many techniques have been tried in an effort to restore forearm rotation; however, they have not been successful. It is inadvisable by many authors to perform any operation with the hope of obtaining pronation and supination. Eleven children; 3 - 8 years old with CRUS, Wilkie type I, with fixed full pronation deformity were managed by the new ALLAM'S OPERATION which is a one stage intervention including separation of the bony fusion, special cementation technique of the ulnar (or radial) side of the osteotomy, double osteotomy of the radius and a single osteotomy of the ulna (all of the 3 osteotomies were done percutaneously) with intramedullary K. wire fixation of osteotomies at the mid-prone position and above elbow cast application for 6 weeks.Background
Patients and Methods
This study evaluated the effect of limb lengthening
on longitudinal growth in patients with achondroplasia. Growth of
the lower extremity was assessed retrospectively by serial radiographs
in 35 skeletally immature patients with achondroplasia who underwent
bilateral limb lengthening (Group 1), and in 12 skeletally immature
patients with achondroplasia who did not (Group 2). In Group 1,
23 patients underwent only tibial lengthening (Group 1a) and 12 patients
underwent tibial and femoral lengthening sequentially (Group 1b). The mean lengthening in the tibia was 9.2 cm (59.5%) in Group
1a, and 9.0 cm (58.2%) in the tibia and 10.2 cm (54.3%) in the femur
in Group 1b. The mean follow-up was 9.3 years (8.6 to 10.3). The
final mean total length of lower extremity in Group 1a was 526.6
mm (501.3 to 552.9) at the time of skeletal maturity and 610.1 mm
(577.6 to 638.6) in Group 1b, compared with 457.0 mm (411.7 to 502.3)
in Group 2. However, the mean actual length, representing the length
solely grown from the physis without the length of distraction,
showed that there was a significant disturbance of growth after
limb lengthening. In Group 1a, a mean decrease of 22.4 mm (21.3
to 23.1) (4.9%) was observed in the actual limb length when compared
with Group 2, and a greater mean decrease of 38.9 mm (37.2 to 40.8)
(8.5%) was observed in Group 1b when compared with Group 2 at skeletal
maturity. In Group 1, the mean actual limb length was 16.5 mm (15.8 to
17.2) (3.6%) shorter in Group 1b when compared with Group 1a at
the time of skeletal maturity. Premature physeal closure was seen
mostly in the proximal tibia and the distal femur with relative
preservation of proximal femur and distal tibia. We suggest that significant disturbance of growth can occur after
extensive limb lengthening in patients with achondroplasia, and
therefore, this should be included in pre-operative counselling
of these patients and their parents.
Early results of Ponseti treatment in 14 children (17 feet) aged between 2 and 10 years at the start of treatment are assessed. Method and Results 14 children aged between 2 and 10 years (mean 5.4) presented with relapsed or under- corrected club feet. All had previous treatment with strapping and bebax or pedro boots. 8 had subsequently undergone posterior release of the Achilles tendon, ankle and subtalar joint through a longitudinal posterior incision. All patients presented with absent heel strike, walking on the lateral border of the foot. 14 feet had a varus heel and 15 had an internal foot progression angle. Mean Pirani score was 2.14. Photographs and videos were taken. Ponseti casting was implemented. 15 feet required an Achilles tenotomy, and 15 feet had a tibialis anterior transfer to help maintain the correction. Pirani scores improved from a mean of 2.64 to 0.21 in the group that had had previous surgery, and 1.64 to 0.07 in those that had had previous conservative treatment. All patients achieved a heel strike and ceased to walk on the lateral border of the foot. Heel varus corrected in 11/14 and partially corrected in 3. Internal foot progression resolved in 12/15 and improved in 3. At latest follow up (16 months- 20 months), all transfers were working and all patients walked with heel strike and a plantargrade foot. 2 patients required further casting for relapse in forefoot adductus, and one for recurrent posterior tightness. Conclusions The Ponseti method has been successful in the under corrected or relapsed club foot in children aged between 2 and 10 years in this series, including those with previous surgical intervention.
Meningococcal septicaemia from meningococcal infection is a devastating illness affecting children. Advances in medical management have reduced the mortality rate to approximately 15 to 20% and children who survive can develop late orthopaedic sequelae from growth plate arrests with resultant complex deformities. Our aim in this study was to review and analyze the case histories of a series of patients with late orthopaedic sequelae, all treated by the senior author. We describe a treatment strategy to address the multiple deformities that may occur in these patients. Methods & Results Between 1990 and 2009, 12 patients were treated for late orthopaedic sequelae after meningococcal septicaemia by the senior author. There were 8 girls and 4 boys. All patients had lower limb involvement. 1 patient had involvement of the upper limb requiring treatment. Each patient had had a mean of 3 operations (range from 2 to 9). Methods of treatment included a combination of angular deformity correction, limb lengthening and epiphysiodesis. At final follow-up 9 of the 12 patients were skeletally mature. In 9 patients limb length discrepancy in the lower limb was corrected to within 1 cm, with normalization of the lower limb mechanical axis. Conclusion Meningococcal septicaemia can lead to late orthopaedic sequelae due to growth plate arrests. Central growth plate arrests leads to limb length discrepancy, and partial growth plate arrests leads to an angular deformity. In addition, limb amputations may occur and there may be altered growth of the stump requiring further surgery. In cases of central growth arrest with limb shortening alone, limb equalisation is performed with limb lengthening procedures. In cases of partial growth arrests, angular correction is performed together with ablation of the affected growth plate. We recommend ablation of the affected growth plates at the initial surgery to prevent recurrence of angular deformity. Angular correction can be performed acutely, with a dome or transphyseal osteotomy; or gradually, with application of Ilizarov or Taylor Spatial frames. Severe deformities of the tibial plateau are treated by plateau elevation with bone graft augmentation. With the appropriate strategy deformities can be corrected and further lengthening procedures can be undertaken if necessary. Long-term follow-up of these patients is essential to recognise and treat any recurrence of deformity.
