Aim. The current literature indicates that hip arthroscopy is safe in both adolescents and adults with good early outcomes but there are no available studies that directly compare the outcomes of this procedure for mixed indications between these two groups. Method. This was a prospective cohort study of 102 consecutive supine hip arthroscopies in 96 patients (48 adolescent (<18) hips, mean age 13.9 years and 54 adult (>18 hips), mean age 33.8 years) at a tertiary referral paediatric and adult university hospital followed-up for a minimum of two years. Patient demographics, indications for surgery, Modified Harris Hip (MHHS) and Non-Arthritic Hip (NAHS) scores, operative interventions and complications were recorded. Results. At two-year follow-up, the MHHS improved from a mean of 55.3 to 87.5 (p<0.05) in the adolescent group and from 58.7 to 86.9 (p<0.05) in the adult group while the NAHS improved from 57.1 to 86.7 (p<0.05) in the adolescent group and from 61.4 to 87.4 (p<0.05) in the adult group. There was no statistical significance difference in outcome between the two groups at 2 years. With respect to complications, there were 2 cases of transient lateral femoral cutaneous nerve palsy (1 adolescent and 1 adult) that resolved spontaneously. There were 3 transient pudendal nerve palsies that resolved spontaneously in the adolescent group by 4 weeks. There was no difference in mean operative traction time in both groups (47.6 minutes in adolescents versus 48.3 minutes in adults; p<0.05). No cases of proximal femoral physeal growth disturbance or osteonecrosis were seen at final follow-up. Conclusion. This study confirms that hip arthroscopy for mixed indications leads to good early outcomes with low complication rates in adolescent and adult patients. The incidence of pudendal nerve palsy in the adolescent group is however noted and is of concern

Aims

The management of fractures of the medial epicondyle is one of the greatest controversies in paediatric fracture care, with uncertainty concerning the need for surgery. The British Society of Children’s Orthopaedic Surgery prioritized this as their most important research question in paediatric trauma. This is the protocol for a randomized controlled, multicentre, prospective superiority trial of operative fixation versus nonoperative treatment for displaced medial epicondyle fractures: the Surgery or Cast of the EpicoNdyle in Children’s Elbows (SCIENCE) trial.

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

Aims

Osteonecrosis (ON) can cause considerable morbidity in young people who undergo treatment for acute lymphoblastic leukaemia (ALL). The aims of this study were to determine the operations undertaken for ON in this population in the UK, along with the timing of these operations and any sequential procedures that are used in different joints. We also explored the outcomes of those patients treated by core decompression (CD), and compared this with conservative management, in both the pre- or post-collapse stages of ON.

Aims

We aimed to address the question on whether there is a place for shoulder stabilization surgery in patients who had voluntary posterior instability starting in childhood and adolescence, and later becoming involuntary and uncontrollable.

Purpose. This report compares midterm results of open neck osteoplasty + neck osteotomy vs arthroscopic osteoplasty for severe Slipped Capital Femoral Epiphysis (SCFE). Method. Database from 2006 to 2013 identified 22 patients out of 187 operations for SCFE. 12 underwent Open Neck Osteotomy (ONO) and osteoplasty by Ganz surgical dislocation approach. 10 underwent Arthroscopic Osteoplasty (AO). The mean follow-up for the ONO and AO groups were 59 (46 – 70), 36.1 (33 – 46) months respectively. Results. The unpaired t-test showed that the post-operative corrections were significantly better in the ONO than the AO group. Slip angle (16.7° (1°–28.6°) Vs 47.1° (40.2° – 53.5°) p = .0003), head neck offset correction (5mm (2–13mm) Vs 0mm (0mm – 2mm) p = 0.0003), alpha angle (34.6° (23.2°–45.6°) Vs 61.88° (52.1° – 123°) p= 0.0003), Modified Harris Hip Score (MHHS) (90(86.2–99) Vs 75.5 (58.75 – 96.8) p= 0.003) and internal rotation p= 0.0002. Paired t-test showed significant improvement in corrections within the individual groups compared with their own preoperative values. The results of AO group were oblique plane slip angle (55° (47.7° – 63.2°) Vs 47.1° (40.2° – 53.5°) p= 0.001), alpha angle (90.7° (65° – 131°) Vs 61.88° (52.1° – 123°) p= 0.0001), head neck offset (0mm (−3 mm to 0mm) Vs 0mm (0mm – 2mm) p= 0.001) and MHHS (52.7 (28.7 – 89.1) Vs 75.5 (58.75 – 96.8) p= 0.0005). Complications in ONO group were varus malunion (1) and non-union(1) of the osteotomy. In the arthroscopic group persistent impingement in 3 patients and 5 were not able to return to sports. Conclusion. Our results showed improved hip function following arthroscopic osteoplasty in severe SCFE. Considering the risks of an open surgical dislocation we could find that arthroscopy contributed worthy improvement in hip function in low demand patients

Aims

To compare changes in gait kinematics and walking speed 24 months after conventional (C-MLS) and minimally invasive (MI-MLS) multilevel surgery for children with diplegic cerebral palsy (CP).

The traditional techniques involving an oblique tunnel or triangular wedge resection to approach a central or mixed-type physeal bar are hindered by poor visualisation of the bar. This may be overcome by a complete transverse osteotomy at the metaphysis near the growth plate or a direct vertical approach to the bar. Ilizarov external fixation using small wires allows firm fixation of the short physis-bearing fragment, and can also correct an associated angular deformity and permit limb lengthening.

We accurately approached and successfully excised ten central- or mixed-type bars; six in the distal femur, two in the proximal tibia and two in the distal tibia, without damaging the uninvolved physis, and corrected the associated angular deformity and leg-length discrepancy. Callus formation was slightly delayed because of periosteal elevation and stretching during resection of the bar. The resultant resection of the bar was satisfactory in seven patients and fair in three as assessed using a by a modified Williamson–Staheli classification.

Cite this article: Bone Joint J 2015;97-B:1726–31.

Controversy remains whether the contralateral hip should be fixed in patients presenting with unilateral slipped capital femoral epiphysis (SCFE). This retrospective study compares the outcomes and cost of those patients who had prophylactic fixation with those who did not.

Between January 2000 and December 2010 a total of 50 patients underwent unilateral fixation and 36 had prophylactic fixation of the contralateral hip. There were 54 males and 32 females with a mean age of 12.3 years (9 to 16). The rate of a subsequent slip without prophylactic fixation was 46%. The risk of complications was greater, the generic health measures (Short Form-12 physical (p < 0.001) and mental (p = 0.004) summary scores) were worse. Radiographic cam lesions in patients presenting with unilateral SCFE were only seen in patients who did not have prophylactic fixation. Furthermore, prophylactic fixation of the contralateral hip was found to be a cost-effective procedure, with a cost per quality adjusted life year gained of £1431 at the time of last follow-up.

Prophylactic fixation of the contralateral hip is a cost-effective operation that limits the morbidity from the complications of a further slip, and the diminished functional outcome associated with unilateral fixation.

Cite this article: Bone Joint J 2015;97-B:1428–34.

This study evaluated the results of a physeal-sparing technique of intra-articular anterior cruciate ligament (ACL) reconstruction in skeletally immature patients, with particular reference to growth disturbance. Between 1992 and 2007, 57 children with a mean age of 12.2 years (6.8 to 14.5) underwent ACL reconstruction using the same technique. At a mean of 5.5 years (2 to 14) after surgery, 56 patients underwent clinical and radiological evaluation. At that time, 49 patients (87.5%) had reached bony maturity and 53 (95%) achieved A or B according to the IKDC 2000 classification. Four patients had stopped participation in sports because of knee symptoms, and three patients (5.4%) had a subsequent recurrent ACL injury. There was no clinical or radiological evidence of growth disturbance after a mean growth in stature of 20.0 cm (3 to 38).

This study demonstrates that ACL reconstruction sparing the physes in children is a safe technique protecting against meniscal tears and giving better results than reconstruction in adults, without causing significant growth disturbance.

Panton-Valentine leukocidin secreted by Staphylococcus aureus is known to cause severe skin, soft tissue and lung infections. However, until recently it has not been described as causing life-threatening musculoskeletal infection. We present four patients suffering from osteomyelitis, septic arthritis, widespread intravascular thrombosis and overwhelming sepsis from proven Panton-Valentine leukocidin-secreting Staphylococcus aureus. Aggressive, early and repeated surgical intervention is required in the treatment of these patients.

The Panton-Valentine leukocidin toxin not only destroys host neutrophils, immunocompromising the patient, but also increases the risk of intravascular coagulopathy. This combination leads to widespread involvement of bone with glutinous pus which is difficult to drain, and makes the delivery of antibiotics and eradication of infection very difficult without surgical intervention.

We treated eight dysplastic acetabula in six skeletally mature patients with Down’s syndrome by a modified Bernese periacetabular osteotomy. The mean age at the time of surgery was 16.5 years (12.8 to 28.5). Mean length of follow-up was five years (2 to 10.4).

Pre-operatively the mean (Tönnis) acetabular angle was 28°, the centre-edge angle was −9°, and the extrusion index was 60%; post-operatively they were 3°, 37°, and 17%, respectively. Two patients with post-operative (Tönnis) acetabular angles > 10° developed subluxation post-operatively and required secondary varus derotation femoral osteotomies. Another patient developed a late labral tear which was treated arthroscopically. All eight hips remain clinically stable, and are either asymptomatic or symptomatically improved.

These results suggest that the modified Bernese periacetabular osteotomy can be used successfully in the treatment of acetabular dysplasia in patients with Down’s syndrome.