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, growth arrests and juvenile osteoporosis. Results:. Length of follow up was from 6 to 24 months. All osteotomies had healed at an average of 46 days. Of the eleven bone segments, nine had normal alignment (within 2.5° of normal or contralateral side). In the other two bone segments the alignment was between 2.5° and 5°. Blocking screws were not used in both these cases. Conclusions:. This is a simple technique of deformity correction. Keys to improve accuracy of correction are preoperative planning, intraoperative blocking screws and oblique osteotomies to accommodate translation

Purpose. To review the natural history of posteromedial bowing of the tibia and the outcome of limb reconstruction in this condition. Patients and Methods. 38 patients with posteromedial bowing of the tibia presenting between 2000–2016 were identified. Mean follow up from presentation was 78 months. Seventeen patients underwent lengthening and deformity correction surgery, whilst 3 further patients are awaiting lengthening and deformity correction procedures. Results. The greatest correction of deformity occurred in the first year of life, but after the age of 4 years, remodelling was limited. The absolute leg length discrepancy (LLD) increased throughout growth with a mean 14.3% discrepancy in tibial length. In the lengthening group, mean length gained per episode was 45mm (35–60). Mean duration in frame was 192 days, with a healing index of 42.4 days/cm. Significantly higher rates of recurrence in LLD were seen in those undergoing lengthening under the age of 10 years (p=0.046). Four contralateral epiphysiodeses were also performed. Conclusions. Posteromedial bowing of the tibia improves spontaneously during the first years of life, but in 20/38 (53%) patients, limb reconstruction was indicated for significant residual deformity and/or worsening length discrepancy. For larger discrepancies and persistent deformity, limb reconstruction with a hexapod external fixator is an effective technique and should be considered as part of the treatment options. Level of evidence. Level 4 (Case series)

The Fassier-Duval (FD) rod, which offers a single-entry design and allows elongation for growth, has been widely adopted in paediatric deformity correction over the past decade, although evidence is limited in literature regarding the associated complications from its use. All FD roddings carried out in a Scottish tertiary referral centre were identified. The electronic records and radiographs of each procedure were reviewed. The follow-up duration, indications for surgery, complications arisen and further operations were recorded. 21 procedures in 11 patients were identified between 2009–2016. The mean age at operation was 6 years and 2 months. The median follow-up period was 3 years and 9 months. The main underlying pathology was osteogenesis imperfecta (71.4%, n=15). The main indication of surgery was deformity correction (61.9%, n=13). 11 (52.4%) FD roddings were for femur and the remainder were for tibia. The commonest complication was proximal migration (n=6, 28.6%). In our cohort we did not have negative telescoping or non-union. Two procedures (9.5%) were complicated by deep infections which were successfully treated. There were 3 further operations (14.3%), including one revision to a locked intramedullary nail for fracture and one below knee amputation for recurrent pseudarthrosis. We compared our results with those from Birke and co (J Paediatr Orthop 2011) from Australia. Our results are comparable and with a longer follow-up period. Although FD rodding allows children to maintain their mobility and prevent fractures, there are significant complications associated with its use. We hope in the future other centres can publish their results to allow improvements in surgical practice and implant design

Background:. Charcot arthropathy is a condition related to the loss of protective sensation of a joint. It normally presents in its early inflammatory phase, followed by bone destruction. Recognised treatment for this is total contact casting (TCC). However, in a small group this may be unsuccessful in preventing deformity progression. TCC can also be difficult in the presence of recalcitrant ulceration and deformed feet. Method:. 40 patients, with a diagnosis of Charcot foot, were followed from presentation in our unit over 3 years. An Ilizarov frame was used for two groups: those in the early phase who showed progressive deformity despite TCC (5 patients) and those with chronic ulceration (4 patients). Frames were modified to allow weight-bearing on the frame (with no foot contact). All other patents were treated with TCC. Results:. There were no amputations or cases of osteomyelitis. The Ilizarov frame successfully prevented further deformity when applied in the inflammatory phase. In patients with ulceration, deformity correction with a modified frame maintained correction and allowed the ulcers to heal rapidly whilst weight bearing. Conclusion:. Our series shows the Ilizarov frame can be used in the management of Charcot to prevent deformity progression and allow recalcitrant ulcers to heal following deformity correction

Tibial nonunion represents a spectrum of conditions which are challenging to treat, and optimal management remains unclear despite its high rate of incidence. We present 44 consecutive patients with 46 stiff tibial nonunions, treated with hexapod external fixators and distraction to achieve union and gradual deformity correction. There were 31 men and 13 women with a mean age of 35 years (18 to 68) and a mean follow-up of 12 months (6 to 40). No tibial osteotomies or bone graft procedures were performed. Bony union was achieved after the initial surgery in 41 (89.1%) tibias. Four persistent nonunions united after repeat treatment with closed hexapod distraction, resulting in bony union in 45 (97.8%) patients. The mean time to union was 23 weeks (11 to 49). Leg-length was restored to within 1 cm of the contralateral side in all tibias. Mechanical alignment was restored to within 5° of normal in 42 (91.3%) tibias. Closed distraction of stiff tibial nonunions can predictably lead to union without further surgery or bone graft. In addition to generating the required distraction to achieve union, hexapod circular external fixators can accurately correct concurrent deformities and limb-length discrepancies. Cite this article: Bone Joint J 2015;97-B:1417–22

Introduction. Fracture and deformity after frame removal is a known risk in 9–14.5% of patients after circular frame treatment. The aims of this study were to assess the effectiveness of our staged protocol for frame removal and risk factors for the protocol failure. Methods and materials. We identified 299 consecutive patients who underwent circular frame fixation for fracture or deformity correction in our unit from our prospective database. All 247 patients who followed the staged frame removal protocol were included in this study. We reviewed the electronic clinical record and radiographs of each patient to record demographics, risk factors for treatment failure and outcome following frame removal. We defined failure of the protocol as a re-fracture or change in bony alignment within 12 weeks of frame removal. Results underwent statistical analysis using Chi square analysis. Results. Of the 247 patients, 196 were trauma patients, of which 56 were open fractures and 48 were elective cases. There were 92 Ilizarov frames and 155 hexapods. 93 patients were smokers. The protocol failed to prevent mechanical failure after frame removal in 10 patients, of which four had refracture and six had an increase in deformity. The average increase in deformity was 7.7 in the frontal plane and 3.8 in the lateral plane. We identified risk factors for mechanical failure in eight of the ten; four were smokers, two were on steroids and two had hypophosphataemic rickets. Of the ten patients, four were for elective indications, six for trauma. Two of the six trauma patients had been treated for open fractures. ‘The type of frame and smoking history showed no statistical association with mechanical failure. Four patients went to have another frame, five were managed with plaster and one patient refused further treatment. Conclusion. Our staged reloading protocol may delay frame removal however it is a simple and effective way to confirm the timing of frame removal

Scheuermann's kyphosis is a structural deformity of the thoracic or thoracolumbar spine, which can result in severe pain, neurological compromise and cosmetic dissatisfaction. Modern surgical techniques have improved correction through a posterior-only or antero-posterior approach but can result in significant morbidity. We present our results of the surgical management of severe Scheuermann's kyphosis by a single surgeon with respect to deformity correction, global balance parameters, functional outcomes and complications at latest follow-up. We included 49 patients, of which 46 had thoracic and 3 had thoracolumbar kyphosis. Surgical indications included persistent back pain, progressive deformity, neurological compromise and poor self-image. Fourty-seven patients underwent posterior-only and 2 antero-posterior spinal arthrodesis utilising Chevron-type osteotomies and hybrid instrumentation. Mean age at surgery was 16.0 years with mean postoperative follow-up of 4.5 years. Mean kyphosis corrected from 92.1o to 46.9o (p<0.001). Concomitant scoliosis was eliminated in all of the 28 affected patients. Coronal and sagittal balance was corrected in all patients. Mean blood loss was 24% total blood volume. Mean operation time was 4.3 hours with mean inpatient stay of 9 days. SRS-22 questionnaire improved from a mean preoperative score of 3.4 to 4.6 at 2 years, with high treatment satisfaction rates. Complications included one toxic septicaemia episode but otherwise no wound infections, no junctional deformity, no loss of correction and no requirement for re-operation. Posterior spinal arthrodesis with the use of hybrid instrumentation can safely achieve excellent correction of severe Scheuermann's kyphosis helping to relieve back pain, improve functional outcomes and enhance self-image

Objectives. To determine the limits of spinal displacement before the onset of neurophysiological changes during spinal surgery. Assessing if the type of force applied or the section of the adjacent nerve roots increases the tolerance to displacement. Methods. Experimental study in 21 domestic pigs. Three groups were established according to the displacing force applied to the cord: separation (group 1, n=7), root stump pull (group2, n=7) and torque (group3, n=7). Successive records of cord-to-cord motor evoked potential were obtained. The displacing force was removed immediately when neurophysiological changes observed. The experiment was repeated after sectioning the adjacent nerve roots. Results. The diameter of the dura in the study area was 7.2 ± 1 mm. Group 1: evoked potential changes appeared with displacement of 10.1 ± 1.6 mm with roots unharmed and 15.3 ± 4.7 mm (p <0.01) with section of four adjacent roots. Group 2: evoked potential disturbance at 17.5 ± 4.7 mm, which increased to 23.5 ± 2.1 mm (p <0.05) after cutting the two contralateral roots. Group 3: cord allowed torque of 95.3° ± 9.2 increasing to 112.4 ° ± 7.1 ° if the contralateral roots were cut. Except in two cases in group 3 (torsion), the potentials were normalized immediately after releasing the deforming force. Discussion. This experimental study shows that it is possible to surgically displace the medulla a distance superior to the diameter of the dura without detecting neurophysiological changes. The limits of cord displacement may be increased by the section of the adjacent nerve roots and if the tensile force is applied by traction of the root stumps. These findings support the neurological safety of spine deformity correction by isolated posterior approach, obviating the morbidity related to an additional anterior procedure

Introduction. Medial column insufficiency in patients with painful acquired flatfoot can be difficult to appreciate. The reverse Coleman block test is used in this study to predict medial column instability. Methods. Patients who underwent a procedure for medial column insufficiency with use of the reverse Coleman block test pre-operatively were investigated. Weight bearing radiographs were used to determine the joints in the medial column contributing to the deformity and also to estimate the angle which the first ray must be depressed to re-establish hindfoot neutrality. The reverse Coleman block test corrects a mobile valgus heel to a neutral position by placing a block, of appropriate height, under the first metatarsal head. With the heel in neutral and the relative forefoot supination compensated the foot returns to a neutral anatomic position. Gender, age, complications and radiological outcomes were investigated. Results. Over the last three years 25 medial column procedures were performed for painful insufficiency on 17 females and five males by the senior author. Three patients underwent staged bilateral procedures. The average age was 62 years old. Three feet had been on operated on the medial column previously. The pre-operative weight bearing lateral radiographs showed instability in the medial column greater than 5° in 12 cases. With the reverse Coleman block test instability was seen in 25 cases and the deformity increased from an average of 7° (range 0° to 25°) to 14° (range 5° to 30°). Post-operative weight bearing radiographs, with fusion of the unstable joint, the average medial column alignment was 1° (range −10° to 10°). Three patients developed superficial infections requiring oral antibiotics for treatment. One patient had a non-union requiring revision surgery. Discussion. The reverse Coleman block test revealed instability in 13 out of 27 cases not seen with simple weight bearing lateral radiographs. The test also on average doubled the size of any deformity seen. This aided pre-operative planning to predict the scale of deformity correction required. Conclusion. The reverse Coleman block test is a useful test to determine medial column insufficiency and assist with pre-operative planning

Introduction. The aim of the treatment of children with early onset scoliosis is controlling growth of the spine. Whatever the etiology, early progressive deformations require multiple stages of surgery usually performed every 6–12 months. One have to be reckoned with complications requiring additional surgical intervention. Objective. The aim of the study is to present a new method of surgical treatment of early onset scoliosis involving the implantation of specially constructed implants to allow three dimensional correction of spinal deformity with a preserved capacity to continue the growth of spine without distraction staged operations followed by final spondylodesis in mature spine. Material. The clinical material consists of homogeneous group of patients: 8 girls and a one boy aged 6 to 14 years (mean age = 9 years). The estimated group four children had a single-curve, four children had a double-curve, while one child was affected by congenital kyphosis. The follow up ranged from 2 to 17 months (mean = 13.5 months). Method. Efficacy of spinal deformity correction using a “growing implants” was estimated by Cobb andgle measurement of the curvature 1/before the operation, 2/after surgery and 3/follow up. Results. During surgery, all patients obtained a large correction of curvature ranging from 50% to 100% (on average −70%). The degree of correction was directly dependent on the size of the initial deformation of 62 to 120 ° (average 77 °). During the entire period of observation in four children we have not identified the loss of correction or fits within the limits of measurement error. In one child thirty degree-loss correction stemmed from too selective implantation of the implants. During additional surgery the stabilization was extended to the extra two motor segments witch resulting in full correction. In one patient, due to rapid growth, rods were needed to be replaced for longer, because of the risk of pulling out from the lower screws. In one case we observed further correction during follow up. Conclusions. Using the method we obtained a very good correction in the first stage of treatment. Maintenance of correction does not require any intermediate staged operating procedures. Patients do not require corrective brace. Using “growing implants” in the early onset scoliosis one avoid complications peculiar to current growth-sparing procedures. These patients would have had 15 lengthening procedures after their initial correction if treated by conventional growing rod methods

Aims

We aimed to identify the pattern of nerve injury associated with paediatric supracondylar fractures of the humerus.