A retrospective review of 80 patients with unilateral slipped capital femoral epiphysis from 1998–2012 was undertaken to determine the outcome of the unaffected hip. All patients were treated with either prophylactic single Richards screw fixation or observation of the uninvolved hip and were followed up for at least 12 months. The unaffected hip of 44 patients (mean age 12.6 years, range 9–17) had simultaneous prophylactic fixation and 36 patients (mean age 13.4 years, range 9–17.4) were managed with observation. Sequential slip of the unaffected hip was noted in 10 patients (28 per cent) in the observation group and only in 1 patient (2 per cent) in the group managed with prophylactic fixation. A Fisher's exact test showed significantly high incidence of sequential slip in unaffected hips when managed with regular observation (p-value 0.002). Only 3 cases had symptomatic hardware on the unaffected side after prophylactic fixation with one requiring revision of the metal work; one had superficial wound infection treated with antibiotics. No cases had AVN or chondrolysis.Methods
Results
The treatment of developmental dysplasia of the hip (DDH) in children remains controversial, we describe the clinical and radiological outcomes of 47 hips in 43 children treated with open surgery by one surgeon between 2004 and 2008 for DDH. The mean age at operation was 25 months (5 to 113) with a mean follow up of 89 months (22 to 169). 46 hips had an anterior open reduction, 1 had a medial approach performed and 16 had anterior open reductions only. 5 of the primary operations also had a pelvic osteotomy, 7 had a femoral osteotomy and 18 had a combined femoral and pelvic osteotomy. 7 (15%) of the hips required a second operation for dislocation, subluxation or dysplasia. At the latest follow up 40 of the 45 hips where Severin grades were recordable (89%) were graded as excellent or good, Severin class I or II. Clinically significant AVN (grade II to III according to the Kalamchi and MacEwen classification) was seen in 5 (11%) of the hips. We found a pelvic osteotomy to be a risk factor for AVN (p 0.02) and age at operation to be a risk factor for poor morphology at final follow up (p 0.03). We proceed to open surgery in patients over 12 months old or those with failed closed reduction. Over 18 months old a pelvic osteotomy should be performed in selective cases depending on intra-operative stability, but we will now consider doing this as a staged procedure and delaying the osteotomy for a period of time after open reduction to reduce the risk of AVN. We will also have a much lower threshold for performing a femoral shortening osteotomy in these patients as open reduction with Salters osteotomy alone tended to have a poorer outcome.
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:
Outcome studies of the Ponseti method from various centres have reported success rates ranging from 85–95%. The vast majority of patients can expect a supple, functional and pain free foot. The small percentage of feet that are resistant to Ponseti treatment often require open surgical correction, leading to scarring and stiffness. We present a method of correcting resistant equinus by a tenotomy and calcaneal pulldown technique. This method is complimentary to the Ponseti technique. Prospective study of 40 feet in 28 patients who underwent an Achilles tenotomy and calcaneal pulldown technique. The indications for this method were resistant equinus and problems with casting. Feet scored with the Pirani method. Under a general anaesthetic, a standard Achilles tenotomy was performed. The equinus deformity corrected by traction of the calcaneum with a “catspaw” retractor and dorsiflexion of the forefoot. Further treatment was performed according to the Ponseti method. The Ponseti clubfoot brace was used to maintain correction. 28 patients 40 feet. Mean preoperative Pirani score:3.0 (left 3.0, right 3.1 range 1.5–6). Mean preoperative Hindfoot Pirani score:2.5 (left 2.55, right 2.5 Range 1.5–3). Mean post operative Pirani score:2.0(left 2.0, right 2.0 Range 0.5–6). Mean postoperative Hindfoot pirani score:1.45. Three patients had severe arthrogryphosis, of whom 2 did not correct requiring open surgery. All idiopathic CTEV feet corrected with a range of 5–20 degrees of dorsiflexion at last follow up. The mean follow up was 43.64 months (range 7–96 months).Method
Results
The long term results of closed reduction of the hip for DDH were reviewed to determine if the presence of the ossific nucleus had an effect on outcome. The clinical and radiological outcome of a single-surgeon series of closed reduction for DDH was assessed in a strictly defined group of 48 hips in 42 patients with an average of 11.1 years follow up. In 50% of cases, the ossific nucleus was absent. 100% of patients had an excellent or good result (Severin classification) at final follow-up. 8.3% (4 hips) demonstrated evidence of avascular necrosis. Three were Kalamchi & MacEwen Type I and one was type II. Two of the AVN cases did not demonstrate an ossific nucleus at closed reduction, and both developed type I AVN. 6 hips underwent further surgery. The acetabular index and center-edge angle were not significantly different between the affected and unaffected hip at final follow-up. There was no relationship between the presence or absence of an ossific nucleus at the time of closed reduction and the final outcome. In this well defined group, closed reduction is safe and provides excellent results in the long-term. The absence of an ossific nucleus is not detrimental to the final outcome.
DDH incidence falls from 5–20 per 1000 at birth to 1–2 per 1000 by 3 weeks. Some patients present late and frequently require surgical intervention. If the hip cannot be contained without tension, these children undergo open reduction +/− a femoral shortening, varus and derotation osteotomy. Salter’s osteotomy, may be performed either at index surgery or later in the presence of persisting acetabular dysplasia. Our aim was to see if we could predict which cases of persistent DDH would require both femoral and pelvic surgery to contain the affected hip, using a single plain AP radiograph of the pelvis in the outpatient setting. We performed a retrospective study of all children older than 18 months with persistent DDH of one or both hips, over the last 5 years, who had undergone femoral and/or pelvic surgery to contain the hip. Plain AP pelvic radiographs were standardised according to the method described by Tonnis. From these radiographs the acetabular indices and child’s age in months, were recorded. Syndromic and children with non-standard x-rays were excluded. Thirty nine hips (34 female, 5 male), age range of 18–102 months, formed our study group. 53% of hips having femoral surgery later required pelvic surgery for persisting acetabular dysplasia. Examining the data in these cases, the difference between the acetabular index of the normal and affected hip was always greater than 20 degrees and the child’s age in months. Using this method we conclude that it is possible to predict which cases of persistent DDH will require pelvic surgery to fully contain the affected hip and that this can be done with one AP pelvic radiograph in the outpatient clinic. The benefit is avoidance of unnecessary pelvic osteotomies, and being able to determine the cases which should have a pelvic osteotomy at index procedure.
The results of the Ferguson medial approach for open reduction of developmental dysplasia of the hip (DDH) were reviewed for 49 hips with a follow-up of more than 48 months. The mean age at operation was 12.3 months (6 to 23). The mean length of clinical and radiological follow-up was 82 months (48 to 148). Three redislocations occurred. Group I avascular necrosis according to the classification of Kalamchi and MacEwen was seen in four hips, group II in two hips and group III in one hip; 92% of the hips were classified as Severin class I and II. The acetabular index and centre edge (CE) angles were within normal limits at final follow-up, but were still significantly different from the unaffected side. We conclude that the Ferguson procedure is safe and reliable for low dislocations in children aged six to 18 months.
The results of the Ferguson medial open reduction of the hip for DDH were reviewed to determine the complications, re-operation rate, clinical and radiological outcome. Notes were reviewed for 75 cases, of which 5 were bilateral. X-rays were available for 69 hips and were analysed for Acetabular index (AI) and Centre Edge (CE) angles of the operated and unaffected hips. The hips were assessed for avascular necrosis by the method of Kalamchi and MacEwan and were graded according to Severin. The mean age at operation was 11.8 months (range 3-23, SD 4.42, mode 11). The mean clinical follow up was 65.1 months (range 4-148, SD 33.4). The mean radiological follow up was 58.2 months (range 3 – 131, SD 31). No further surgical procedure was required for 60 hips (75%). Of the remainder, a Salter osteotomy was performed for 8 hips, of which 6 had additional procedures. 8 hips required a femoral osteotomy, 2 an Arthrogram and one a triple pelvic osteotomy. The AI improved following surgery, with a rate of increase double that for the unaffected side. The mean centre edge of the operated side was 6 degrees less than the unaffected side. Tables 2 and 3 show that the majority of hips had no avascular necrosis and a good radiological outcome. The results compare favourably with the literature. The conclusion is that the Ferguson medial open reduction has good long-term results with low rates of avascular necrosis.
We set out to determine whether delayed opening of drains following total knee replacement reduced blood loss and hence transfusion requirements without detriment to wound status and range of movement. We performed a prospective randomised controlled trial in two centres. Seventy six patients undergoing primary total knee replacement surgery were entered into the study. In one group (45 patients) the drains were opened immediately following surgery. In the other group (31 patients) the drains were left clamped for a period of two hours. Parameters measured following surgery were overall drainage, drop in haemoglobin, transfusion requirements, wound status and overall range of movement. All patients were followed up in a dedicated research clinic for a period of six months. No significant difference was found in the volume of drained blood between the two groups. In addition, there was no significant difference between the pre and post operative haemoglobin levels. Range of knee movement and wound status were satisfactory in both groups. The authors believe that although clamping drains has no adverse effects on knee wounds and range of movement, in this study it has no benefit in reducing blood loss or transfusion requirements
