Temporary epiphysiodesis (ED) is commonly applied in children and adolescents to treat leg length discrepancies (LLDs) and tall stature. Traditional Blount staples or modern two-hole plates are used in clinical practice. However, they require accurate planning, precise surgical techniques, and attentive follow-up to achieve the desired outcome without complications. This study reports the results of ED using a novel rigid staple (RigidTack) incorporating safety, as well as technical and procedural success according to the idea, development, evaluation, assessment, long-term (IDEAL) study framework. A cohort of 56 patients, including 45 unilateral EDs for LLD and 11 bilateral EDs for tall stature, were prospectively analyzed. ED was performed with 222 rigid staples with a mean follow-up of 24.4 months (8 to 49). Patients with a predicted LLD of ≥ 2 cm at skeletal maturity were included. Mean age at surgery was 12.1 years (8 to 14). Correction and complication rates including implant-associated problems, and secondary deformities as well as perioperative parameters, were recorded (IDEAL stage 2a). These results were compared to historical cohorts treated for correction of LLD with two-hole plates or Blount staples.Aims
Methods
Premature
Fractures through the physis account for 18–30% of all paediatric fractures, leading to
We report a case of spontaneous physeal
In Clinical practice damage to the growth plate is usually caused by trauma. In neonates and infants, sepsis involving the growth plate may lead to very severe deformities as well as limb length discrepancy. The management for the child with physeal
Introduction: Infection with Neisseria Meningitidis remains one of the most devastating illnesses in paediatrics. Affected patients can progress from a mild viral-like illness to septicaemia and death within a matter of hours. We present our clinical experience in identifying and managing the orthopaedic complications associated with meningococcal septicaemia and highlight the long-term problems of physeal
Introduction: Infection with Neisseria Meningitidis remains one of the most devastating illnesses in paediatrics. Affected patients can progress from a mild viral-like illness to septicaemia and death within a matter of hours. We present our clinical experience in identifying and managing the orthopaedic complications associated with meningococcal septicaemia and highlight the long-term problems of physeal
Purpose of Study. To assess the radiological outcomes of medial screw epiphyseodesis of the proximal femoral physis in the management of lateral
A Ring Fixator (Taylor Spatial Frame (TSF); Smith &
Nephew, Memphis, TN), was used in the treatment of 5 patients (ages 11 to 16 years) with proximal tibial
Methods: A Ring Fixator (Taylor Spatial Frame (TSF); Smith &
Nephew, Memphis, TN), was used in the treatment of 5 patients (ages 11 to 16 years) with proximal tibial
Physeal bar resection for partial
A review is presented of 13 young patients with congenital scoliosis who were treated by epiphysiodesis of part of the vertebral bodies combined with posterior fusion, both on the convex side; the plan was to
Aim: To review the outcome following
Survivors of infantile meningococcal septicaemia often develop progressive skeletal deformity as a consequence of physeal damage at multiple sites, particularly in the lower limb. Distal tibial physeal arrest typically occurs with sparing of the distal fibular physis leading to a rapidly progressive varus deformity. Isolated case reports include this deformity, but to our knowledge there is no previous literature that specifically reports the development of this deformity and potential treatment options. We report our experience of 6 patients (7ankles) with this deformity, managed with corrective osteotomy using a programmable circular fixator.
Survivors of meningococcal septicaemia often develop progressive skeletal deformity secondary to physeal damage at multiple sites, particularly in the lower limb. Distal tibial physeal arrest typically occurs with sparing of the distal fibular physis leading to a rapidly progressive varus ankle deformity. There is no previous literature reporting this ankle deformity following meningococcal septicaemia. We report the management of this deformity in 13 ankles in 10 consecutive patients 36 months after meningococcal septicaemia. Plain radiographs and MRI were used to define the deformity and the extent of growth plate involvement. The Taylor Spatial Frame (TSF) with a distal tibial metaphyseal osteotomy was used to restore the distal tibio-fibular joint. Distal fibular epiphysiodesis was performed in all ankles at the initial procedure. Distal tibial epiphysiodesis was performed at the time of fixator removal. The age at operation ranged from 3–14 years (mean 8). The preoperative ankle varus deformity ranged from 9–29 degrees (mean 19). The differential shortening of the tibia with respect to fibula was on average 1.2 cms. The mean time in frame was 136 days. After a mean follow-up of 1.7 years results were excellent in all patients with complete correction of deformity and shortening. Mechanincal axis was corrected in all patients. Complications included, 4 superficial pin site infections, 1 lateral peroneal nerve palsy which recovered completely. There were no major nerve or vascular complications. We consider that this approach provides a powerful method of correction for this difficult group of patients.
We reviewed 13 children with partial
Salter-Harris II fractures of the distal tibia affect children frequently, and when they are displaced present a treatment dilemma. Treatment primarily aims to restore alignment and prevent premature physeal closure, as this can lead to angular deformity, limb length difference, or both. Current literature is of poor methodological quality and is contradictory as to whether conservative or surgical management is superior in avoiding complications and adverse outcomes. A state of clinical equipoise exists regarding whether displaced distal tibial Salter-Harris II fractures in children should be treated with surgery to achieve anatomical reduction, or whether cast treatment alone will lead to a satisfactory outcome. Systematic review and meta-analysis has concluded that high-quality prospective multicentre research is needed to answer this question. The Outcomes of Displaced Distal tibial fractures: Surgery Or Casts in KidS (ODD SOCKS) trial, funded by the National Institute for Health and Care Research, aims to provide this high-quality research in order to answer this question, which has been identified as a top-five research priority by the British Society for Children’s Orthopaedic Surgery. Cite this article:
We report two cases of deformity of the ankle caused by physeal damage secondary to extravasation of an intravenous infusion in infancy. The possible mechanisms of injury to the physis are discussed.
The April 2024 Children’s orthopaedics Roundup. 360. looks at: Ultrasonography or radiography for suspected paediatric distal forearm fractures?; Implant density in scoliosis: an important variable?; Gait after paediatric femoral shaft fracture treated with intramedullary nail fixation: a longitudinal prospective study; The opioid dilemma: navigating pain management for children’s bone fractures; 12- to 20-year follow-up of Dega acetabuloplasty in patients with developmental dysplasia of the hip; Physeal fractures of the distal ulna: incidence and risk factors for premature
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
Summary Statement. The implantation of scaffold-free CTE from suspension culture into growth-plate defects resulted in a significant reduction in
Septicaemia resulting from meningococcal infection is a devastating illness affecting children. Those who survive can develop late orthopaedic sequelae from
Introduction. Genu valgum is a common presentation in paediatric patients with congenital limb deformities. The aim of this study is to assess the outcome of guided growth surgery in paediatric patients referred via our physiotherapy pathway with isolated genu valgum and associated patellar instability. Materials & Methods. Patients were identified from our prospective patellar instability database. Inclusion criteria was acquired or congenital genu valgum associated with patellar instability in skeletally immature patients. The mechanical lateral-distal femoral angle was assessed on long leg alignment radiographs (mLDFA <85 degrees). Surgical treatment was the placement of a guided growth plate (PediPlate, OrthoPediatrics, USA) on the medial distal femoral physis (hemi-epiphysiodesis). KOOS-child scores were collected pre-operatively and post-operatively (minimum at 6 months). Results. Eleven patients (seven female) with mean age of 12(range 5–15) were identified. Five patients had congenital talipes equinovarus(CTEV), one fibular hemimelia, one di-George syndrome, one septic
Paediatric bone and joint infections remain common in low- and middle-income countries (LMICs). We aimed to determine the complication rate and incidence of disseminated infection in paediatric bone and joint infections in an LMIC setting. Secondly, we aimed to elucidate factors associated with complications and disseminated disease. We retrospectively reviewed our database for children that presented with bone and joint infections between September 2015 and March 2019. Data were extracted to identify factors that were associated with development of complications and disseminated infection. We analysed 49 children. The median age at presentation was 6 years (range 1 month to 12 years). Locally advanced disease was present in 13 children (27%). The remaining 36 children were evenly divided (18/49 each, 37%) between isolated AHOM and SA, respectively. Disseminated disease was present in 16 children (33%) and was associated with locally advanced disease, an increase in number of surgeries and an increased length of stay. Twenty-six complications were documented in 22 (45%) children. Chronic osteomyelitis developed in 15/49 (31%) cases,
Open tibia fractures are common injuries in our paediatric population and are often associated with high-energy trauma such as pedestrian-vehicle accidents. At our institution, these injuries are routinely treated with debridement and mono-lateral external fixation. The purpose of this study was to determine the outcome of open tibia fractures treated according to this protocol, as well as the complication rate and factors contributing to the development of complications. We performed a retrospective folder review of all patients with open tibia fractures that were treated according to our protocol from 2015–2019. Patients treated by other means, who received primary treatment elsewhere, and with insufficient data, were excluded. Data was collected on presenting demographics, injury characteristics, management, and clinical course. Complications were defined as pin tract infections, delayed- or non-union, malunion,
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
Introduction and Aims: To determine the optimum management of
Forearm lengthening in children is controversial. Paley (1990) and Peterson (1994) advocate aggressive treatment of the deformity for cosmetic and functional reasons. Scoenecker (1997) has shown that mature patients are comfortable with their appearance and functional deficit. We reviewed 8 forearm lengthenings performed in 8 children in the 14 year period from 1991 to 2004. Five patients had ulnar shortening (osteochondromata = 4,
The use of retrograde femoral intramedullary nails in children for deformity correction is controversial. It is unknown if the injury to the central part of the growth plate results in premature bony union, leading to limb deformities or discrepancies. The aim of this study was to assess physeal healing and bone growth after insertion of a retrograde femoral nail thorough the centre of the physis in a skeletally immature experimental porcine model. Eleven immature pigs were included in the study. One leg was randomised for operation with a retrograde femoral nail (diameter 10.7 mm), whilst the non-operated contralateral remained as control. All nails were inserted centrally in coronal and sagittal plane under fluoroscopic guidance, and the nails spanned the physis. The nails were removed at 8 weeks. Both femora in all animals underwent MRI at baseline (pre-operatively), 8 weeks (after nail removal) and 16 weeks (before euthanasia). Femoral bone length was measured at 5 sites (anterior, posterior, central, lateral and medial) using 3d T1-weighted MRI. Growth was calculated after 8 weeks (growth with nail) and 16 weeks (growth without nail). Physeal cross-sectional area and percentage violated by the nail was determined on MRI. Operated side was compared to non-operated. Corresponding 95% confidence intervals were calculated. No differences in axial growth were observed between operated and non-operated sides. Mean growth difference was 0,61 mm [−0,78;2,01] whilst the nail was inserted into the bone and 0,72 mm [−1,04;1,65] after nail removal. No signs of angular bone deformities were found when comparing operated side to non-operated side. No premature bony healing at the physis occurred. Histology confirmed fibrous healing. Mean physeal violation was 5.72% [5.51; 5.93] by the femoral nail. The insertion of a retrograde femoral nail through the centre of an open physis might be a safe procedure with no subsequent
Distal femoral physeal fractures in children have a high incidence of physeal arrest, occurring in a mean of 40% of cases. The underlying nature of the distal femoral physis may be the primary cause, but other factors have been postulated to contribute to the formation of a physeal bar. The purpose of this study was to assess the significance of contributing factors to physeal bar formation, in particular the use of percutaneous pins across the physis. We reviewed 55 patients with a median age of ten years (3 to 13), who had sustained displaced distal femoral physeal fractures. Most (40 of 55) were treated with percutaneous pinning after reduction, four were treated with screws and 11 with plaster. A total of 40 patients were assessed clinically and radiologically after skeletal maturity or at the time of formation of a bar. The remaining 15 were followed up for a minimum of two years. Formation of a physeal bar occurred in 12 (21.8%) patients, with the rate rising to 30.6% in patients with high-energy injuries compared with 5.3% in those with low-energy injuries. There was a significant trend for physeal arrest according to increasing severity using the Salter-Harris classification. Percutaneous smooth pins across the physis were not statistically associated with
We would like to present this case series of 10 adolescent patients with displaced, closed diaphyseal tibial fractures managed using the Taylor Spatial Frame. Management options for these injuries include non-operative treatment, antegrade nailing, flexible nailing systems, plating and external circular fixation. External circular fixation allows anatomical reduction avoiding potential complications such as
Objectives. The aim of this experimental study on New Zealand’s white rabbits
was to investigate the transplantation of autogenous growth plate
cells in order to treat the injured growth plate. They were assessed
in terms of measurements of radiological tibial varus and histological
characteristics. . Methods. An experimental model of plate growth medial partial resection
of the tibia in 14 New Zealand white rabbits was created. During
this surgical procedure the plate growth cells were collected and
cultured. While the second surgery was being performed, the autologous
cultured growth plate cells were grafted at the right tibia, whereas
the left tibia was used as a control group. . Results. Histological examinations showed that the grafted right tibia
presented the regular shape of the plate growth with hypertrophic
maturation, chondrocyte columniation and endochondral calcification.
Radiological study shows that the mean tibial deformity at the left
angle was 20.29° (6.25 to 33) and 7.21° (5 to 10) in the right angle. . Conclusion. This study has demonstrated that grafting of autogenous cultured
growth plate cells into a defect of the medial aspect of the proximal
tibial physis can prevent bone bridge formation,
The management of spinal deformity in children
with univentricular cardiac pathology poses significant challenges to
the surgical and anaesthetic teams. To date, only posterior instrumented
fusion techniques have been used in these children and these are
associated with a high rate of complications. We reviewed our experience
of both growing rod instrumentation and posterior instrumented fusion
in children with a univentricular circulation. Six children underwent spinal corrective surgery, two with cavopulmonary
shunts and four following completion of a Fontan procedure. Three
underwent growing rod instrumentation, two had a posterior fusion
and one had spinal
Permanent
Between 1990 and 2001, 24 children aged between 15 months and 11 years presented with late orthopaedic sequelae after meningococcal septicaemia. The median time to presentation was 32 months (12 to 119) after the acute phase of the disease. The reasons for referral included angular deformity, limb-length discrepancy, joint contracture and problems with prosthetic fitting. Angular deformity with or without limb-length discrepancy was the most common presentation. Partial
Aims. Meningococcal septicaemia can result in
Introduction. Sparing of the spinal growth and scoliotic deformity control in patients with early-onset scoliosis is a challenge in spinal surgery. Loss of the surgical correction, implant breakage, and revision surgeries are the main disadvantages of present treatment methods. The purpose of this study is to investigate whether growing transpedicular instrumentation spares achieved surgical correction during patient's growth. Methods. This is a prospective study of 12 consecutive patients with early-onset scoliosis from one clinical centre. All patients underwent anterior convex
Patellar instability most frequently presents
during adolescence. Congenital and infantile dislocation of the
patella is a distinct entity from adolescent instability and measurable
abnormalities may be present at birth. In the normal patellofemoral
joint an increase in quadriceps angle and patellar height are matched
by an increase in trochlear depth as the joint matures. Adolescent
instability may herald a lifelong condition leading to chronic disability
and arthritis. Restoring normal anatomy by trochleoplasty, tibial tubercle transfer
or medial patellofemoral ligament (MPFL) reconstruction in the young
adult prevents further instability. Although these techniques are
proven in the young adult, they may cause
Introduction. A recent retrospective study of distal femoral physeal fractures (DFPFs) suggested closed manipulation alone has a high incidence of re-displacement, malunion or physeal bar formation. The paper concluded that all displaced DFPFs require internal fixation, and breaching the physis with k-wires is safe. We agree that hyper-extension/flexion injuries need stabilisation using k-wires but, in our experience, purely valgus/varus deformities can be successfully managed by manipulation under anaesthesia (MUA) and a moulded cylinder cast. Method. We prospectively observed DFPFs presenting over 12 months. Departmental policy is to treat varus/valgus deformities by MUA, with cylinder casting providing 3 point fixation. Hyper-extension/flexion injuries are reduced on a traction table. 2mm cross k-wiring is performed, leaving the wires under the skin, and a cylinder plaster applied. A post-operative CT scanogram accurately assesses limb alignment. Patients are mobilised immediately using crutches and weight-bearing as pain allows. Plaster and k-wires are removed after 4–5 weeks. Scanogram is then repeated, and again at 6 months and 1 year. Results. 17 cases presented over 1 year. 16 were male, with a median age of 15. 13 were injured playing soccer, 1 in a motor vehicle accident and 3 by other mechanisms. Internal fixation supplemented reduction in 13 cases. 1 patient required repeat MUA and k-wiring when post-operative scanogram identified significant varus mal-alignment. In all cases, cylinder casting was unproblematic and range of movement quickly recovered after plaster/wire removal. To date none have developed significant malunion or
Introduction: A review of the treatment of 33 open fractures in 29 children over the period 1997 to 2002. Method: Intravenous antibiotics, debridement and wound irrigation was performed prior to skeletal stabilisation incorporating plaster cast immobilisation (4%), K wire fixation (13%), screw fixation (13%), flexible intramedullary nail fixation (13%) and external fixation (57%). Secondary wound closure was undertaken if appropriate at 48 hours. The tibia was involved in 49% of cases with approximately equal distribution of other long bone extremities. Fractures were classified according to Gustilo et al (22% grade I, 26% grade II, 17% grade III and 35% grade IIIb). Results: The average age was 10 years in 22 boys and 7 girls. Tibial fracture union was an average of 9 weeks in gradeI and II compared with 20 weeks for grade III. The remaining fractures healed at an average of 10 weeks. Non union occurred in one patient (tibia). There was on case of
Purpose. The traditional management of pediatric aneurysmal bone cysts involves the application of intralesional resection principles that are used to treat benign aggressive tumors in general. Alternatively, some are treated by injections of sclerosing agents. The risks of these approaches include
The potential harm to the growth plate following reconstruction of the anterior cruciate ligament in skeletally-immature patients is well documented, but we are not aware of literature on the subject of the fate of the graft itself. We have reviewed five adolescent males who underwent reconstruction of the ligament with four-strand hamstring grafts using MR images taken at a mean of 34.6 months (18 to 58) from the time of operation. The changes in dimension of the graft were measured and compared with those taken at the original operation. No
Introduction: There is a paucity in the literature regarding the long term outcome of children with septic hips. Often, there is a delay in diagnosis which may lead to complications such as
Introduction and Aims: The aims of this study were to compare the over-the-top and four-strand techniques of paediatric anterior cruciate ligament reconstruction. An age and sex-matched control study of these two different ACL reconstructive techniques was done to determine if there are differences in instability, functional outcomes and growth plate-related problems. Method: Injuries, treatment and associated complications were collected from hospital charts. Pre-operative x-rays were used to determine growth plate status both at the distal femur and the proximal tibia. Pre-operative MRIs were studied to assess the position and nature of mid-substance ACL tear and any associated meniscal tear or pathology. Follow-up included examination as per International Knee Documentation Committee guidelines, including patient history and a clinical examination assessing the degree of anterior draw, presence and quality of a pivot shift test and pivot glide, and arthrometric measurements using the KT-1000 Arthrometer for anterior translational distance in millimetres. The Lysholm questionnaire was completed by all patients. Results: Thirty-nine paediatric patients were reviewed for anterior cruciate ligament injuries requiring reconstruction at the authors’ institution. Data collected included background information on the injury, including mechanism and age at injury and surgical information including age at surgery, surgical procedure, and technique. Surgical follow-up information was also collected including wound problems, re-ruptures, or
Although supracondylar fracture is a very common elbow injury in childhood, there is no consensus on the timing of surgery, approach for open reduction and positioning of fixation wires. We report our ten-year experience between 1993 and 2003 in 291 children. Most fractures (285; 98%) were extension injuries, mainly Gartland types II (73; 25%) and III (163; 56%). Six (2%) were open fractures and a neurovascular deficit was seen in 12 (4%) patients. Of the 236 children (81%) who required an operation, 181 (77%) were taken to theatre on the day of admission. Most (177; 75%) of the operations were performed by specialist registrars. Fixation was by crossed Kirschner wires in 158 of 186 (85%) patients and open reduction was necessary in 52 (22%). A post-operative neurological deficit was seen in nine patients (4%) and three (1%) required exploration of the ulnar nerve. Only 22 (4%) patients had a long-term deformity, nine (3%) from malreduction and three (1%) because of
Aim. Toxin-antitoxin (TA) systems are small genetics elements found in the majority of bacteria which encode a toxin causing bacterial
Background:. Acute deformity correction with the help of osteotomies and stabilisation with intramedullary (IM) nail is a recognised technique. We present our case series of long bong deformity correction using an innovative technique that aids accurate correction after osteotomy and insertion of IM nail. Technique:. On preoperative measurements the distance of the joint surface from the point of intersection of the joint orientation angle with the convex cortex and also its distance from apex of deformity were noted. These distances were reproduced intraoperatively and guide pin was inserted towards premeasured point in the convex cortex. Osteotomy was performed and appropriate sized locked IM nail inserted with the help of temporary blocking screws, resulting in the correction of deformities. Method:. Retrospective review of case notes and radiographs was performed of five patients who underwent long bone deformity correction using this technique. Average age of patients was 15.2yrs. Underlying diagnosis were hypophosphataemic rickets,
Meningococcal infection is the most common infective cause of death in children and causes significant morbidity in survivors. Patients admitted to the Paediatric Intensive Care Unit (PICU) of the Bristol Royal Hospital for Children from 01/01/2001 to 31/12/2012 with a primary diagnosis of meningococcal septicaemia were reviewed. A total of 10 (7.7%) of 130 patients developed orthopaedic complications. Those affected were significantly younger (p < 0.05), remained on PICU for longer (p < 0.001) and boys had a greater risk of developing orthopaedic complications (risk ratio: 3.1; 95% CI: 0.69–14.14). 9 patients required an amputation, 16/22 (72.7%) in the lower limb. Patient requiring amputation had multiple limb involvement. 48 growth plate abnormalities were identified in 8 patients, 39 (81.3%) in the lower limb, most commonly in the distal tibia. This study has identified a high incidence of musculoskeletal morbidity. Close surveillance of these patients is recommended to identify
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
Chondroblastomas arise in the epiphyseal area of bones. In the femoral head this can cause considerable difficulty in obtaining access as the epiphysis is entirely intra-articular. We have reviewed management and outcome of 10 patients with chondroblastoma of the femoral head to identify outcome and complications. The mean age was 14 years and all presented with pain (frequently in the knee) and a limp. All were diagnosed on plain Xray and MRI. Five younger children were treated by curettage by a lateral approach up the femoral neck (to try and minimise damage to the epiphysis) and five by a direct approach through the joint. Two of the five patients with a lateral approach developed local recurrence whilst none of the direct approaches did. Both local recurrences were cured with a direct curettage. One patient developed overlengthening of the leg by 1cm but there was no case of