Introduction. Deformity influences the weight bearing stresses on the knee joint. Correction of mechanical alignment is performed to offload the knee and slow the rate of degenerative change. Fixator assisted
Intrathecal morphine (IM) is a common adjunct in paediatric spinal
Aims. The aims of this prospective study were to determine the effect of osteophyte excision on
Introduction. Lower limb mal-alignment as a result of fracture malunion can result in knee degenerative arthritis or predispose to early arthroplasty failure due to the altered mechanical axis. The choice of corrective osteotomy is often determined by potential complications. Opening wedge osteotomy is associated with poor bone healing especially in adult diaphyseal bone. Distraction osteogenesis enables gradual
We reported the outcomes of patients with Charcot neuropathy who underwent hind foot
Background:. Spinal
Introduction. Several hexapod external fixator devices are used in the treatment of bone fracture and
Background. Lateral column lengthening combining bony and soft tissue procedures has been described for symptom relief and
Coronal malalignment and leg length discrepancies (LLD) are frequently associated. Temporary hemiepiphysiodesis (tHED) is commonly employed for the correction of limb malalignment in skeletally immature patients. For treatment of LLD greater than 2 cm, lengthening with intramedullary legnthening nails is a safe and reliable technique. However, the combined application of these approaches in skeletally immature patients has not yet been investigated. Retrospective radiological and clinical analysis of 25 patients (14 females, 11 males) who underwent intramedullary femoral lengthening with an antegrade PRECICE® lengthening nail as well as tHED of the distal femur and / or proximal tibia between 2014 and 2019. tHED was conducted by implantation of flexible staples (FlexTack™) either prior (n = 11), simultaneously (n = 10), or subsequently (n = 4) to femoral lengthening. The mean follow-up period was 3.7 years (±1.4).Introduction
Materials & Methods
Osteogenesis imperfect (OI) is a geno- and phenotypically heterogeneous group of congenital collagen disorders characterized by fragility and microfractures resulting in long bone deformities. OI can lead to progressive femoral coxa vara from bone and muscular imbalance and continuous microfracture about the proximal femur. If left untreated, patients develop Trendelenburg gait, leg length discrepancy, further stress fracture and acute fracture at the apex of the deformity, impingement and hip joint degeneration. In the OI patient, femoral coxa vara cannot be treated in isolation and consideration must be given to protecting the whole bone with the primary goal of verticalization and improved biomechanical stability to allow early loading, safe standing, re-orientation of the physis and avoidance of untreated sequelae. Implant constructs should therefore be designed to accommodate and protect the whole bone. The normal paediatric femoral neck shaft angle (FNSA) ranges from 135 to 145 degrees. In OI the progressive pathomechanical changes result in FNSA of significantly less than 120 degrees and decreased Hilgenreiner epiphyseal angles (HEA). Proximal femoral valgus osteotomy is considered the standard surgical treatment for coxa vara and multiple surgical techniques have been described, each with their associated complications. In this paper we present the novel technique of controlling femoral version and coronal alignment using a tubular plate and long bone protection with the use of teleoscoping rods. After the decision to operate had been made, a CT scan of the femur was performed. A 1:1 scale 3D printed model (AXIAL3D, Belfast, UK) was made from the CT scan to allow for accurate implant templating and osteotomy planning. In all cases a subtrochanteric osteotomy was performed and fixed using a pre-bent 3.5 mm 1/3 tubular plate. The plate was bent to allow one end to be inserted into the proximal femur to act as a blade. A channel into the femoral neck was opened using a flat osteotome. The plate was then tapped into the femoral neck to the predetermined position. The final position needed to allow one of the plate holes to accommodate the growing rod. This had to be determined pre operatively using the 3D printed model and the implants. The femoral canal was reamed, and the growing rod was placed in the femur, passing through the hole in the plate to create a construct that could effectively protect both the femoral neck and the full length of the shaft. The distal part of the plate was then fixed to the shaft using eccentric screws around the nail to complete the construct.Introduction
Methodology
The extent of soft-tissue release and the exact structures that need to be released to correct deformity and balance the knee has been a controversial subject in primary total knee arthroplasty. Asian patients often present late and consequently may have profound deformities due to significant bone loss and contractures on the concave side, and stretching of the collateral ligament on the convex side. Extra-articular deformities may aggravate the situation further and make correction of these deformities and restoration of ‘balance’ more arduous. These considerations do not apply if a hinged prosthesis is used, as may be warranted in an elderly, low-demand patient. However, in active, younger patients, it may be best to avoid use of excess constraint by balancing the soft-tissues and using the least constrained implant. Releasing collateral ligaments during TKA has unintended consequences such as the creation of significant mediolateral instability and a flexion gap which exceeds the extension gap; both of these may require a constrained prosthesis to achieve stability. We will show that soft-tissue balance can be achieved even in cases of severe varus, valgus, flexion and hyperextension deformities without collateral ligament release. The steps are: 1) Determining pre-operatively whether deformity is predominantly intra-articular or extra-articular, 2) Individualizing the valgus resection angle and bony resection depth, 3) Meticulous removal of osteophytes, 4) Reduction osteotomy, posteromedial capsule resection, sliding medial or lateral condylar osteotomy, extra-articular corrective osteotomy, 5) Compensating for bone loss, 6)Only rarely deploying a more constrained device. Case examples will be presented to illustrate the entire spectrum of varus deformities.
Computer hexapod assisted orthopaedic surgery (CHAOS), is a method
to achieve the intra-operative correction of long bone deformities
using a hexapod external fixator before definitive internal fixation
with minimally invasive stabilisation techniques. The aims of this study were to determine the reliability of this
method in a consecutive case series of patients undergoing femoral
deformity correction, with a minimum six-month follow-up, to assess
the complications and to define the ideal group of patients for
whom this treatment is appropriate. The medical records and radiographs of all patients who underwent
CHAOS for femoral deformity at our institution between 2005 and
2011 were retrospectively reviewed. Records were available for all
55 consecutive procedures undertaken in 49 patients with a mean
age of 35.6 years (10.9 to 75.3) at the time of surgery.Aims
Patients and Methods
Introduction. Somatosensory evoked potential (SSEP) monitoring allows for assessment of the spinal cord and susceptible structures during complex spinal surgery. It is well validated for the detection of potential neurological injury but little is known of surgeon's responses to an abnormal trace and its effect on neurological outcome. We aimed to investigate this in spinal deformity patients who are particularly vulnerable during their corrective surgery. Methods. Our institutional neurophysiology database was analysed between 1. st. October 2005 and 31. st. March 2010. Monitoring was performed by a team of trained neurophysiology technicians who were separate from the surgical team. A significant trace was defined as a 50% reduction in trace amplitude or a 10% increase in signal latency. Patients suffering a significant trace event were examined post-operatively by a Consultant Neurologist who was separate from the surgical team. Results. 2386 consecutive operations (F:1719, M:667 median age 16 yrs) were performed in the time period and 72 operations reported a significant trace event (‘red alert’). From these cases 47 (65%) had a clearly documented intervention by the surgeon and 7 patients overall suffered a lasting neurological deficit (0.3%). The most common timing events were during instrumentation (50%) and during correction/distraction (16%). Most common responses were optimisation of patient/monitoring set-up (23%) and adjustment of metalwork (22%). There were 18 wake-up tests performed. We found SSEP monitoring to have a sensitivity of 100%, specificity 97.4%, positive predictive value 14% and negative predictive value 100%. A Chi-square test (p=0.016) was significant suggesting intervention had a beneficial effect on neurological outcome. Conclusion. We would advocate the use of SSEP monitoring in all patients undergoing spinal
The evolution of operative technology has allowed correction of complex spinal deformities. Neurological deficits following spinal instrumentation is a devastating complication and the risk is especially high in those with complex sagittal and coronal plane deformities. Prior to intraoperative evoked potential monitoring, spinal cord function was tested using the Stagnara Wake up test, typically performed after instrumentation once the desired correction has been achieved. This test is limited as it does not reflect the timeframe in which the problem occurred and it may be dangerous to some patients. Intraoperative neuromonitoring allows timely feedback of the effect of instrumentation and curve correction on the spinal cord. Pedicle screws that are malpositioned can result in poor fixation or neuronal injury. Evoked EMG monitoring can aid in accurate placement. A positive EMG response can alert the surgeon to a potential pedicle breech and allow them to reassess the placement of their hardware intraoperatively. The stimulation threshold is affected by the amount of surrounding bone acting as an insulator to electrical conduction and is variable in different regions of the spine. In the non-deformed, lumbar spine stimulation thresholds have been established. Such guidelines have not been well-developed for the thoracic spine, or for severely scoliotic spines. Thus our primary objective was to compare the stimulation threshold of the apical pedicle on the concave side to the stimulation threshold of the pedicles at the upper and lower instrumented levels. Intraoperative EMG stimulation thresholds were done at 192 apical pedicles on the concave side of the deformity and then compared to those thresholds found at 169 terminal level pedicles. Only pedicles for which a stimulation threshold was found were reported and excluded those where a breech was suspected. The lowest stimulation required for an EMG response was documented to a maximum stimulation of 20 mA. The mean threshold at the apex was 16.62 milliamps (mA) compared to 18.25mA at the terminal levels. This was compared with the t-test and showed a statistically significant difference (p<0.05). In this study we report only the thresholds for the concave side, the pedicle that is most likely to be reduced in size. The threshold for stimulation is reduced compared to those seen at the highest and lowest instrumented level. Most of the apexes are located in the mid-thoracic spine with the highest instrumented levels being in the high thoracic spine and the lowest levels being in the lumbar spine. This study provides preliminary evidence that the apical, concave pedicle has a lower threshold than the end pedicles and one cannot rely on established thresholds from different areas of the spine. The surgeon should be cognisant of these differences when instrumenting at the apical level. Ongoing work is examining the convex apex threshold as well as the relationship between the effect of age and a diagnosis other than adolescent idiopathic scoliosis.
This study addresses the evolution of the orthopaedic management of patients with hypophosphatemic rickets, with the aim of providing skeletal mature aligned lower limbs, with minimal surgical insult. We describe a case series of 8 patients with hypophosphatemic rickets that highlight an evolution in practice over the last 8 years. Our initial treatment involved external fixation with circular frames, addressing both axial deformity and length. Two contralateral long bones were addressed simultaneously and surgery was conducted in early adolescence. Problems encountered were poor quality regenerate, requiring prolonged periods in external fixation, and often recurrence of deformity following frame removal. Minor deformity recurrence made planning for the often inevitable knee replacement difficulty. Our current management is that patients only start surgical correction once skeletal maturity has been reached, two contralateral axial long bone corrections are performed using CHAOS (computer hexapod-assisted orthopaedic surgery) procedures with IM nails and multiple osteotomies (occasionally locking plates are required). Patients are able to fully weight bear immediately post operatively, after a suitable recovery period the remaining bones can be corrected. Then lengthening can be considered once the osteotomies have fully consolidated by exchange nailing of the femur, for an IM lengthening nail. At this stage the patient is able to fully consider the risks and benefits of this final and potentially unnecessary procedure. Hypophosphotaemic rickets is a rare condition, both the disease and its management can have severe effects on patients both physically and psychologically, at Bristol we have developed an treatment pathway that we feel helps to minimize the physical and psychological effects of treatment, with the end result of aligned lower limbs, that should provide a good basis for arthroplasty surgery if required in adulthood.Methods
Conclusions
Any intervention for limb with compromised bone and soft tissue in paediatric age group is often studded with complications of flare of infection, wound breakdown, delayed healing or failure of grafting. We report our experience with managing 8 such cases with periosteal sleeve taken from tibia along with fibular grafting. The lesion was gap non-union following bone sequestration in 7 cases (2 proximal humerus; 4 femur and one metacarpal) and one case tibia vara in post osteomyelitic tibia. The infective lesions were silent for minimum of 1 year before this procedure. The periosteal sleeve was taken from proximal tibia and fibular graft was also procured from same leg. Following freshening of bone ends, the fibular graft was applied at non-union/osteotomy site and enclosed in the freshly harvested periosteal sleeve. The limb was protected in plaster cast for 6 weeks and assessed clinicoradiologically at 3 and 6 weeks intervals. Uneventful union followed in 7 cases in 6 weeks time. In one case of proximal humerus, the osteosynthesis attempt failed. The periosteal and fibular graft site posed minimal morbidity for the child. Periosteal sleeve and fibular grafting offers a promising alternative for interventions in post osteomyelitic bone with compromised soft tissue.Conclusions
Double-level lengthening, bone transport, and bifocal compression-distraction are commonly undertaken using Ilizarov or other fixators. We performed double-level fixator-assisted nailing, mainly for the correction of deformity and lengthening in the same segment, using a straight intramedullary nail to reduce the time in a fixator. A total of 23 patients underwent this surgery, involving 27 segments (23 femora and four tibiae), over a period of ten years. The most common indication was polio in ten segments and rickets in eight; 20 nails were inserted retrograde and seven antegrade. A total of 15 lengthenings were performed in 11 femora and four tibiae, and 12 double-level corrections of deformity without lengthening were performed in the femur. The mean follow-up was 4.9 years (1.1 to 11.4). Four patients with polio had tibial lengthening with arthrodesis of the ankle. We compared the length of time in a fixator and the external fixation index (EFI) with a control group of 27 patients (27 segments) who had double-level procedures with external fixation. The groups were matched for the gain in length, age, and level of difficulty score.Aims
Patients and Methods
Introduction. Charcot neuroarthropathy is a limb threatening condition and the optimal surgical strategy for limb salvage in gross foot deformity remains unclear. We present our experience of using fine wire frames to correct severe midfoot deformity, followed by internal beaming to maintain the correction. Materials and Methods. Nine patients underwent this treatment between 2020–2023. Initial
Introduction. Management of deformity involving limb length discrepancy (LLD) using intramedullary devices offers significant benefits to both patients and clinicians over traditional external fixation. Following the withdrawal of the PRECICE nail, the Fitbone became the primary implant available for intramedullary lengthening and