Background. In poliomyelitis; hand to knee gait is the sum of quadriceps weakness and fixed knee flexion deformity. Limb shortening is another added problem. Usually, each problem is attacked separately; with variable end results and complication rates for each procedure. Patients and methods. 22 patients (16–46 y.); with poliomyelitis with hand to knee gait due to fixed knee flexion deformity of mild to moderate degree (10–400); and limb shortening of 4.5–9.5 cm., were managed simultaneously by a single operation. A distal femoral metaphyseal anterior closing wedge (recurvatum) corrective osteotomy was done to treat acutely the fixed knee flexion deformity(and subsequently hand to knee gait). A modified Wagner or Orthofix frame was applied as a mono-plane mono-axial lengthening device to stabilize the osteotomy and to lengthen the short limb. Lengthening was started in all cases two weeks post-operatively. Results. All cases showed full correction of the deformity with elimination of the hand to knee gait problem and all showed - the desired - limb length equalization. The femora were lengthened to an average of 6.4 cm.(= 21% of original femoral bone length), range of lengthening was: 4–9 cm. (= 11–26%). The average healing index was 37 days per centimeter (with a range of 31 to 53 days per centimeter.). Conclusion. Simultaneous management of hand to knee and limb shortening could be achieved by a single osteotomy which is used to extend the knee acutely and for distraction two weeks later using a mono-lateral frame. Results were good, complications were few and accepted and the procedure is well tolerated by the patients

Background. Extendable partial femoral replacements (EPFR) permit limb salvage in children with bone tumours in proximity to the physis. Older designs were extended through large incisions or minimally invasive surgery. Modern EPFR are lengthened non-invasively. Lengthening improves functional score (Futani, 2006) but has been associated with complications including infection (Jeys, 2005). This study is the first to look specifically at the relationship between EPFR lengthening and complications. Method. Retrospective review of 51 paediatric (<16 years) oncology patients undergoing primary (1 °) EPFR (minimally/noninvasive) between 06/1994 and 01/2006. Exclusions: 1 patient with 5cm extension without medical intervention and 5 patients with incomplete data. Results. There was a negative relationship between age at 1 ° operation and EPFR lengthening (p = 0.03). Mean lengthening for all (including revision) EPFR was 3cm (range 0–13.05). 28 (64%) patients were lengthened a mean 4.8cm at a mean 7 procedures each. 18 were not lengthened, of which 12 were deceased at last followup and 1 had undergone amputation. Lengthening of secondary prostheses contributed a mean 3.7cm to limb length. 2 tertiary implants were lengthened noninvasively by 1.2cm (3 lengthenings) and 1.275cm (5 lengthenings). 16 of 21 failed 1 ° femoral components had been lengthened. The 21 implants underwent a mean 4.2 lengthenings in comparison to mean 1.3 lengthenings in the 28 that did not fail. Number of 1 ° prosthetic lengthenings was positively related to risk of component failure (p = 0.035) and total number of complications (p = 0.049). Complication rate was also related to total lengthening of 1 ° prosthesis (in cm) (p = 0.004). There was a statistically insignificant (p = 0.059) trend towards increased infection rate with higher number of minimally invasive lengthening procedures. Complications were commoner in those undergoing lengthening (mean 3 vs 1.75 in non-lengthened prostheses). Number of lengthenings correlated with number of complications (p = 0.001). Total lengthening of distal EPFR correlated with incidence of knee fixed flexion deformity (FFD)(p = 0.034). Median lengthening was 3cm in those with FFD and 0cm in those without (p = 0.019). Open lengthening procedures caused 6 complications: 2 deep & 3 superficial infections and recurrent subluxation requiring acetabuloplasty in a proximal replacement. Summary/Conclusions. The inverse relationship between age at 1 ° operation and lengthening is expected if the aim of offsetting limb length discrepancy during growth is being achieved. Lengthening is associated with increased complications (particularly infection and FFD) and femoral component failure, suggesting that lengthening procedures are implicated in the cause of some complications. 5 infective complications after lengthening were theoretically avoidable if noninvasive growers were used

Coronal plane fractures of the posterior femoral condyle, also known as Hoffa fractures, are rare. Lateral fractures are three times more common than medial fractures, although the reason for this is not clear. The exact mechanism of injury is likely to be a vertical shear force on the posterior femoral condyle with varying degrees of knee flexion. These fractures are commonly associated with high-energy trauma and are a diagnostic and surgical challenge. Hoffa fractures are often associated with inter- or supracondylar distal femoral fractures and CT scans are useful in delineating the coronal shear component, which can easily be missed. There are few recommendations in the literature regarding the surgical approach and methods of fixation that may be used for this injury. Non-operative treatment has been associated with poor outcomes. The goals of treatment are anatomical reduction of the articular surface with rigid, stable fixation to allow early mobilisation in order to restore function. A surgical approach that allows access to the posterior aspect of the femoral condyle is described and the use of postero-anterior lag screws with or without an additional buttress plate for fixation of these difficult fractures.

Cite this article: Bone Joint J 2013;95-B:1165–71.