Open tibial fractures are limb-threatening injuries. While limb loss is rare in children, deep infection and nonunion rates of up to 15% and 8% are reported, respectively. We manage these injuries in a similar manner to those in adults, with a combined orthoplastic approach, often involving the use of vascularised free flaps. We report the orthopaedic and plastic surgical outcomes of a consecutive series of patients over a five-year period, which includes the largest cohort of free flaps for trauma in children to date. Data were extracted from medical records and databases for patients with an open tibial fracture aged < 16 years who presented between 1 May 2014 and 30 April 2019. Patients who were transferred from elsewhere were excluded, yielding 44 open fractures in 43 patients, with a minimum follow-up of one year. Management was reviewed from the time of injury to discharge. Primary outcome measures were the rate of deep infection, time to union, and the Modified Enneking score.Aims
Methods
The aim of this study was to establish the incidence of developmental dysplasia of the hip (DDH) diagnosed after one-year of age in England, stratified by age, gender, year, and region of diagnosis. A descriptive observational study was performed by linking primary and secondary care information from two independent national databases of routinely collected data: the United Kingdom Clinical Practice Research Datalink and Hospital Episode Statistics. The study examined all children from 1 January 1990 to 1 January 2016 who had a new first diagnostic code for DDH aged between one and eight years old.Aims
Patients and Methods
We present the 2 year results for the first 54 patients after Selective Dorsal Rhizotomy (SDR) delivered in Bristol, concentrating on change in Reimers' migration index. Eligible patients are selected at the SDR multidisciplinary meeting. Physiotherapy assessment is performed pre-operatively and at 6, 12 and 24 months post-surgery. Data collected includes GMFCS, Gross Motor Function Measure (GMFM) 88 and Modified Ashworth score for spasticity for major lower limb muscle groups, amongst other data. Pelvic radiographs are taken pre-operatively and at 2 years post-operatively. Reimers' migration index was measured using the hospital picture archiving and communication system (PACS). The mean age was 7.2 (3.9–17.5) at the time of surgery. Pre- and post-operative pelvic radiographs were available for 30 patients (60 hips). 57% (n=34) hips showed an increase in migration percentage (mean 5.4%, range 0.1–17.5%) and 43% (n=26) hips showed a decrease (mean 4.0%, range 0–15.5%). Overall no significant difference was found in Reimers' migration index at 2 year follow up (mean increase 1.3% (95% CI −0.3–3.0), p=0.12). There was an improvement in GMFCS category (by 1 grade) for 9 patients and a worsening for 1 patient at 2 year follow up. The Modified Ashworth score for spasticity improved in all patients. There was a mean improvement of 1.7 in the hip adductors and 2.4 in the ankle plantar flexors. There was a statistically significant improvement in the GMFM 88 D and E domains of 14.7 (95% CI 11.3–18.1), p<0.0001 and 11.4 (95% CI 7.4–15.7), p<0.0001 respectively. We found no evidence that SDR leads to worsening hip subluxation at 2 year follow up. All patients had improvement in lower limb spasticity. Overall there was a statistically significant improvement in function, as shown by GMFM 88 domains for standing, walking, running and jumping.
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.
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
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
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
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
This study presents the early results of a novel procedure, both in timing and surgical technique, aimed to treat those cases of congenital hip dysplasia that present late or fail conservative treatment. 48 patients and 55 hips treated over the period from December 2004 to February 2011 were retrospectively reviewed. All were treated with adductor and psoas tenotomy, open reduction, capsulorrhaphy and acetabuloplasty by the senior author.Aim
Methods
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
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
Purpose This was an observational study to determine the prevalence of 25-hydroxyvitamin D (25[OH]D deficiency in our paediatric orthopaedic patient population. Methods We have measured serum 25(OH)D levels in 44 paediatric patients who presented with bone pain. None of these patients had a pre-existing diagnosis of 25(OH)D deficiency. The age of patients ranged from 11 months to 16.5 years. There were 23 female and 21 male patients. The range of diagnoses included hip pain/irritable hip (4), Blount's disease (4), developmental hip dysplasia (7), genu valgum (3), Legg Calve Perthes’ disease (6), slipped capital femoral epiphysis (11), knee pain (3), other (6). Those found to be 25(OH)D deficient underwent further biochemical investigation and were referred for paediatric endocrinology review with a view to vitamin D supplementation. Results We found 9 patients (20%) with serum 25(OH)D levels of <20ng/mL indicating 25(OH)D deficiency. 17 patients (39%) had serum 25(OH)D levels in the range 20-30ng/mL indicating possible deficiency. The remaining 18 patients (41%) had a normal level of 25(OH)D. There was no association between low serum 25(OH)D level and any specific diagnosis, nor with gender or age of patient. There was, however, a statistically significant difference between the serum 25(OH)D level in those patients with unexplained joint pain (mean 22.5ng/mL) and those with other diagnoses (mean 30.7ng/ml) (P<0.05). Conclusion Our results are consistent with other recent prevalence studies showing a concerning level of 25(OH)D deficiency among the paediatric population, and may suggest an increasing burden of disease in the coming years arising from the problem.
To assess the radiological outcomes of medial screw epiphyseodesis of the proximal femoral physis in the management of lateral growth arrest following treatment of developmental dysplasia of the hip. We identified 10 patients noted to have lateral growth disturbance of the proximal femoral physis, 9 of which were managed with medial screw epiphyseodesis. Serial radiographs were reviewed. A new technique was employed to monitor progression of lateral growth arrest and also to assess the role of screw epiphyseodesis in preventing further deterioration or indeed allowing for improvement. This method involved calculating the tilt angle (angle formed between a horizontal reference line and a line joining medial and lateral points of physis) and following its progression with increasing age.Purpose of Study
Methods
Clinical coding is used to record information from patient admissions in the form of coded data used for monitoring the provision of health services and trends, research, audit and NHS financial planning. A sample of 105 cases admitted to Southampton General paediatric orthopaedic department from 2006-9 was used. 31 admissions were grouped using HRG4 and the remaining 74 using HRG3.5. Accuracy of coding was calculated by establishing correct discharge coding and comparing them with coding records. The correct codes were run through HRG 3.5 and 4 payment groupers and their outcomes were compared financially to the HRG codes these admissions were actually grouped under.Purpose
Method
To determine whether hemiplegia causes abnormal torsion of the radius of the affected compared with the unaffected limb as demonstrated by MRI measurements, and to assess whether this correlates with the passive range of movement as measured clinically. 27 patients who fit the inclusion criteria were recruited from an existing database of hemiplegic patients into our prospective cohort study. A clinical assessment was made of each subject to determine the range of active and passive upper limb movements. A functional assessment of the children's upper limbs was made using the validated House score. Subsequent MRI scans of both upper limbs were then performed. A single radiologist (blinded as to the affected limb) then measured the torsional profiles of both radii using a method validated by Bindra et al.Purpose of study
Methods
Between June 1988 and December 1997, we treated 332 babies with 546 dysplastic hips in a Pavlik harness for primary developmental dysplasia of the hip as detected by the selective screening programme in Southampton. Each was managed by a strict protocol including ultrasonic monitoring of treatment in the harness. The group was prospectively studied during a mean period of 6.5 ± 2.7 years with follow-up of 89.9%. The acetabular index (AI) and centre-edge angle of Wiberg (CEA) were measured on annual radiographs to determine the development of the hip after treatment and were compared with published normal values. The harness failed to reduce 18 hips in 16 patients (15.2% of dislocations, 3.3% of DDH). These required surgical treatment. The development of those hips which were successfully treated in the harness showed no significant difference from the normal values of the AI for the left hips of girls after 18 months of age. Of those dysplastic hips which were successfully reduced in the harness, 2.4% showed persistent significant late dysplasia (CEA <
20°) and 0.2% persistent severe late dysplasia (CEA <
15°). All could be identified by an abnormal CEA (<
20°) at five years of age, and many from the progression of the AI by 18 months. Dysplasia was considered to be sufficient to require innominate osteotomy in five (0.9%). Avascular necrosis was noted in 1% of hips treated in the harness. We conclude that, using our protocol, successful initial treatment of DDH with the Pavlik harness appears to restore the natural development of the hip to normal. We suggest that regular radiological surveillance up to five years of age is a safe and effective practice.
Between 1988 and 1995, we studied 91 club feet from a series of 120 recalcitrant feet in 86 patients requiring surgical treatment. There were 48 boys and 20 girls. The mean age at operation was 8.9 months. Surgery consisted of an initial plantar medial release followed two weeks later by a posterolateral release. This strategy was adopted specifically to address the problems of wound healing associated with single-stage surgery and to ascertain the rate of relapse after a two-stage procedure. Immobilisation in plaster was used for three months followed by night splintage. The feet were classified preoperatively and prospectively into four grades according to the system suggested by Dimeglio et al. Grade-1 feet were postural and did not require surgery. All wounds were closed primarily. One superficial wound infection occurred in a grade-4 foot and there were no cases of wound breakdown. The rate of relapse was 20.4% in grade-3 and 65.4% in grade-4 feet. Two-stage surgery for the treatment of club foot seems to be effective in the reduction of wound problems but does not appear to give significantly better results in terms of relapse when performed for more severe deformities.
The Sheffield Expanding Intramedullary Rod System was developed after experiencing problems with existing rod systems in the management of osteogenesis imperfecta. Between 1986 and 1996 we treated 74 bones in the lower limb in 28 children at a median follow-up of 5.25 years. We have reviewed 24 children with a total of 60 rods. Before surgery, all children had had multiple fractures of the lower limb. At review eight patients had experienced no further fractures, but three had suffered five or more subsequently. Before initial stabilisation, 15 children had never walked, and only three (13%) used walking as their main means of mobility. After surgery, half of those who showed motor arrest were able to walk (p = 0.016). The number of patients able to walk, with or without aids, increased to 17 (p = 0.0001). We have experienced no evidence of epiphyseal damage after the procedure, and complication rates requiring rod exchange have been low (7%).
Only two cases have been reported of congenital dislocation of the hip in infants born after extrauterine pregnancies. We report a further two and discuss the management and the variable outcome. These cases seem to confirm that congenital dislocation of the hip is associated with moulding forces rather than being a teratological abnormality.
