The management of chronic osteomyelitis requires the excision of necrotic and infected material followed by the prolonged administration of antibiotics. Sequestrectomy may be required before an involucrum has formed, resulting in a longitudinal bone defect. This can be difficult to fill. Vascularised grafts are complicated by a high rate of recurrent infection and thrombosis. We have managed defects of long bones in children after sequestrectomy by the use of non-vascularised fibular grafts harvested subperiosteally and held by an intramedullary Kirschner wire. Eight children underwent this procedure. In six the tibia was involved and in one each the humerus and radius. One patient was lost to follow-up. Six grafts united at both ends within 12 weeks. The seventh developed an infected nonunion distally which united after further debridement. One patient required a further sequestrectomy which did not compromise union. We have found this to be a straightforward technique with reliable results and were able to salvage the limb in all the seven patients who were reviewed

We present two children with massive defects of the tibia and an associated active infection who were treated by medial transport of the fibula using the Ilizarov device. The first child had chronic discharging osteomyelitis which affected the whole tibial shaft. The second had sustained bilateral grade-IIIB open tibial fractures in a motor-car accident. The first child was followed up for three years and the second for two years. Both achieved solid union between the proximal and distal stumps of the tibia and the fibula, with hypertrophy of the fibula. The first child had a normal range of movement at the knee, ankle and foot but there was shortening of 1.5 cm. The second had persistent anterior angulation at the proximal tibiofibular junction and the ankle was stiff in equinus

In our practice sequestration of the shafts of long bones in children because of acute osteomyelitis continues to be a problem. Conventional procedures for bone grafting are likely to fail. Vascularised grafts with microvascular anastomosis are technically demanding with a high rate of failure. Transfer of the rib on its vascular pedicle to achieve anterior fusion in the thoracic spine is now well established and the length of the pedicle available is adequate to allow grafting of a diaphyseal defect in the humerus. We describe the successful use of this procedure in two patients

Aims

Congenital pseudarthrosis of the tibia (CPT) has traditionally been a difficult condition to treat, with high complication rates, including nonunion, refractures, malalignment, and leg length discrepancy. Surgical approaches to treatment of CPT include intramedullary rodding, external fixation, combined intramedullary rodding and external fixation, vascularized fibular graft, and most recently cross-union. The current study aims to compare the outcomes and complication rates of cross-union versus other surgical approaches as an index surgery for the management of CPT. Our hypothesis was that a good index surgery for CPT achieves union and minimizes complications such as refractures and limb length discrepancy.

Aims

Children with spinal dysraphism can develop various musculoskeletal deformities, necessitating a range of orthopaedic interventions, causing significant morbidity, and making considerable demands on resources. This systematic review aimed to identify what outcome measures have been reported in the literature for children with spinal dysraphism who undergo orthopaedic interventions involving the lower limbs.

Aims

Osteofibrous dysplasia (OFD) is a rare benign lesion predominantly affecting the tibia in children. Its potential link to adamantinoma has influenced management. This international case series reviews the presentation of OFD and management approaches to improve our understanding of OFD.

Purpose. 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. Methods. 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. Results. mean follow up was 3.02±0.74 years with mean union time of 38.76±12.02 weeks. Delayed union (n=4) was seen at sites with large discrepancy between diameter of native bone and graft (like proximal tibial metaphysis). These cases united with plate fixation and bone grafting. There was weak positive correlation between union time and preoperative bone defect (+0.699). Subgroup analysis showed that there no significant difference between union times of patients with defect <4cms (mean of 31.7±11.5 weeks) and defect >4<6cms (mean 36.6±9 weeks), however the union time of patients with defect >6cms was significantly more (51±6.7 weeks). Conclusion. Non-vascularised fibula graft gives predictable results in children with post-osteomyelitic bone defects. Delayed unions are expected if the size of bone defect is >6cms or there is large discrepancy between the diameters of native and grafted bone

We carried out a morphometric analysis of acetabular dysplasia in patients with cerebral palsy requiring hip surgery using three-dimensional CT. We evaluated 54 hips in 27 patients. The contralateral normal hips of ten patients with unilateral Perthes’ disease were used as a control group. The acetabular defects were assessed qualitatively as anterior, posterior or global. Quantitative assessments were made using three-directional acetabular indices (anterosuperior, superolateral and posterosuperior) and measured by multiplanar reformation, from which we calculated the acetabular volume. In the qualitative study, posterior defects were most common in the subluxation group whereas global defects predominated in the dislocation group. In the quantitative study, all acetabular indices in both the subluxation and dislocation groups were higher than those in the control group and the superolateral indices showed a tendency to elevation in the dislocation group. The acetabular volume was largest in the control group, smallest in the dislocation group, and intermediate between the two in the subluxation group

Aim. Case Report presentation of traumatic cartilage loss in a child. Method. We present a case report of a 3-year-old girl who sustained a severe open fracture dislocation of her talus with complete loss of full thickness articular cartilage and subchondral bone over 80% of the talar dome. At presentation there was also a Salter Harris I fracture of the fibular, and an extensive soft tissue defect including absent anterior joint capsule. She required a free anterolateral thigh (ALT) flap to reconstruct this defect. The talar dome defect was treated with a cell-free chondro-inductive implant. This was the first use of this implant in the UK and the first use of such an implant in a child anywhere in the world. Result. At 3 years post-operative, the patient underwent thinning of the ALT flap and trimming of an anterior tibial overgrowth, which was causing impingement. At surgery the talar dome cartilage was looked pristine, with a line representing the tidemark between the original cartilage and the new formed. Biopsies were taken and histopathology performed. This was a rare and difficult case that has achieved a satisfactory outcome at this follow up stage. Conclusion. Cell-free chondro-inductive implants may hold promise for the treatment full thickness articular cartilage defects in children

Aims

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.

Aims

The treatment of tibial aplasia is controversial. Amputation represents the gold standard with good functional results, but is frequently refused by the families. In these patients, treatment with reconstructive limb salvage can be considered. Due to the complexity of the deformity, this remains challenging and should be staged. The present study evaluated the role of femoro-pedal distraction using a circular external fixator in reconstructive treatment of tibial aplasia. The purpose of femoro-pedal distraction is to realign the limb and achieve soft tissue lengthening to allow subsequent reconstructive surgery.

We describe the reconstruction of a defect of the medial malleolus which was the result of an accident in a ten-year-old child. A graft from the iliac crest, with the apophyseal cartilage and perichondrium, was used for reconstruction of the medial malleolus, the growth plate and the adjacent metaphyseal defect, respectively. The soft-tissue defect was covered with a free scapular flap with microvascular anastomosis. Three years after the injury stability of the ankle is excellent with adequate growth of the reconstructed epiphyseal plate

Aims

Hip displacement, common in patients with cerebral palsy (CP), causes pain and hinders adequate care. Hip reconstructive surgery (HRS) is performed to treat hip displacement; however, only a few studies have quantitatively assessed femoral head sphericity after HRS. The aim of this study was to quantitatively assess improvement in hip sphericity after HRS in patients with CP.

Aim. A prospective study to report the results of using gentamycin-collagen in the surgical treatment of osteomyelitis. Materials and Methods. After complete radiological and laboratory studies, empirical systemic Imipenem antibiotic was started pre-operatively followed by radical operation and implantation of Collatamp-EG®. Bone defects were treated with iliac or composite ceramic bone graft. Primary or secondary soft tissue reconstructive procedures were used. Closed gravitational suction drainage was used. Parental systemic antibiotics were continued for 2–3 weeks according to culture sensitivity results followed by oral therapy for another 4 weeks. Cattaneo et al scoring system was used to evaluate the final bony and functional results. Results. The mean number of Collatamp-EG® sponges implanted per patient were 3.6 and the mean follow-up period was 3.8 years. 85.7% of patients had showed positive cultures and staphylococcus aureus was the commonest cultured organism. The following complications were reported; pathological fracture (1), malnuion (2), nonunion (1). According to Cattaneo et al scoring system, bone healing was achieved in 94.4% of patients; bone infection control without relapse was achieved in 100% of patients. 89.2% of patients had complete functional recovery. Conclusions. Local antibiotic delivery system seems to be a useful and safe component in the armamentarium of the orthopedic surgeon dealing with bone infection by maximizing the local concentration while minimizing their systemic toxicity. Collatamp-EG® help bone and soft tissue repair without the need to remove it

Abstract. 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. Aim of the work. We evaluate the use of fibula in association of Ilizarov external fixator in management of massive post traumatic bone loss of tibial shaft. Materials and methods. Between December 1999 and 2004, we treated 8 adult patients with bone loss 10 cm and more. The indication was massive bone loss, extensive soft tissue scar, vascular compromise, and short tibial remnants. Whole fibula was used in 6 conditions and partial fibula in 2. The average age was 30.5 years (range: 25:51). The fibulas were prepared for transfer either as a whole or partially transfer. Ilizarov device was applied with a special construct for each condition accordingly. Free latismus dorsi was applied in 1 patient, and fasciocutanious flaps in 2. Four patients with whole fibula transfer continued to wear orthosis for outdoor activities. Results. The mean follow-up period was 40 months (range: 24:96) after healing. All fractures heeled between 8 and 24 months. Conclusion. We concluded that the Ilizarov external fixator is effective in management of management of massive post traumatic bone loss of tibial shaft. It provides advantages of compensation of bone defects, length, and early rehabilitation. It has the disadvantages of long healing time, long orthotic support. Its advantages are clear in case of massive bone loss, extensive soft tissue scar, vascular compromise, and short tibial remnants

Purpose. To define the orthopaedic problems associated with pseudoachondroplasia (PSACH) and their functional impact. Methods. 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. Results. 12 patients (9 female) were reviewed at median age 18yrs (range 12-43yrs). Most symptoms related to walking tolerance, joint discomfort and deformity: 9 patients had genu varum, 7 tibial torsion, 2 patella instability and 3 significant low back pain. All patients had hip dysplasia. 10 had medial displacement of the mechanical axis, with a mean mDFLA 105 deg (88 -128) and mMPTA 75deg (51-90). 2 patients have been treated only with growth hormone; 10 patients have undergone a total of 9 distal femoral, 19 proximal tibial and 2 supramalleolar osteotomies. 6 procedures were performed using an external fixator. 7 limb segments have been treated by guided growth and in all these cases alignment has improved. One patient has had bilateral hip arthroplasties (age 29), a second patient has had bilateral patellectomies. These 10 patients have undergone a mean 3.8 operative procedures on a mean 2.4 occasions. Patients scored less well than their peer groups in all domains of the PODCI assessment. All have maintained some independent mobility. Conclusions. PSACH is a severe skeletal dysplasia with deformity at all levels of the lower limb affecting patient satisfaction and quality of life. Knee deformities are those which most frequently require surgical intervention. Significance. The genetic defect in PSACH differs from that in achondroplasia, joint degeneration is more common and maintenance of limb alignment is essential

Purpose. To determine whether radiographically demonstrated femoral neck irregularities (pistolgrip-deformity, focal prominences or lytic defects) are associated with positive clinical impingement tests. Methods. The 1989 Bergen birth cohort (n=4004) was invited to a population-based follow-up including clinical examination and two pelvic radiographs. 2081 (52%) were enrolled. Associations between clinical and radiographic findings were examined using chi-squared or Fischer's exact test. Results. Radiographs from 1193, 18-19 year olds, (42% males) have been analysed. For males, irregularities were seen in 128/501 (15.5%) right and 149/501 (19.7%) left hips, of which 13 (10.2%) and 12 (8.1%) had a positive impingement-test respectively (p-values 0.06 and 0.04). The pistolgrip-deformity was seen in 15.8% of right and 19.4% of left hips, of which 6.3% and 7.2% had a positive impingement-test, respectively (p-values 0.6 and 0.3); the focal prominence in 9.2% right and 10% left hips, of which 15.2% and 4% had a positive impingement-test (p-values 0.008 and 0.74) and the lytic defect in 7% right and 8.8% left hips, of which 14.3% and 9.1% had a positive impingement-test (p-values 0.053 and 0.19). For females, irregularities were seen in 34/692 (4.9%) right hips and 46/692 (6.6%) left hips, of which 0 and 2 (4.3%) had a positive impingement-test (p-values 1 and 0.65). Each irregularity was seen in 2-3% of both right and left hips, with no positive impingement tests on the right side and one positive test for each left side, yielding p-values from 0.45 to 1. Conclusion. Femoral neck irregularities are common and symmetrical findings in young males, and are associated with a positive impingement-test. A focal right-sided prominence is associated with a positive test. These radiological findings seem to be less common, but symmetrical, in young females, but without any association with a positive impingement-test

A technique for epiphysiodesis using a cannulated tubesaw has been developed to combine the precision of the original Phemister method with newer percutaneous methods. The approach is unilateral, and requires minimal access. Reinsertion of the removed core of bone reduces haemorrhage from the defect and augments arrest of the growth plate. In 35 patients treated by this method predicted discrepancies of 2 to 4.5 cm were reliably reduced to 0.7 ± 0.6 cm, with no serious complications. The timing of surgery is critical, and relies upon careful monitoring of the pattern of discrepancy over several years, using clinical and radiographic measurements. Undercorrection of the disparity in three patients was the direct result of late referral

Aims

Preserving growth following limb-salvage surgery of the upper limb in children remains a challenge. Vascularized autografts may provide rapid biological incorporation with the potential for growth and longevity. In this study, we aimed to describe the outcomes following proximal humeral reconstruction with a vascularized fibular epiphyseal transfer in children with a primary sarcoma of bone. We also aimed to quantify the hypertrophy of the graft and the annual growth, and to determine the functional outcomes of the neoglenofibular joint.

Aims

The aim of this study was to report the clinical, functional and radiological outcomes of children and adolescents with tibial fractures treated using the Ilizarov method.