Aims

The aim of this study is to evaluate the surgical treatment with the best healing rate for patients with proximal femoral unicameral bone cysts (UBCs) after initial surgery, and to determine which procedure has the lowest adverse event burden during follow-up.

Purpose of the Study. A cooled, side cutting burr designed for use in adult foot surgery has been used as a primary bone cutting device in children to facilitate a truly percutaneous method of performing osteotomies. Stabilisation of the femur was using a percutaneous locked nail and for the tibia percutaneous K-wires. The author describes the advantages and disadvantages of this method with results from the first cohort of patients treated. Method. Patients under going osteotomy of the femur, tibia and fibula using a 2 mm × 20 mm side cutting burr were followed prospectively and assessed for scar size, bone healing time and complications. Results. Thirty six osteotomies were performed in the femur and tibia in 25 patients. A fibula osteotomy was always performed with a tibial osteotomy. Scar size for the femoral osteotomy was <15 mm and for the nail insertion <25 mm. For the tibia & fibula the scar size was <10 mm. Healing time was by 6 weeks in the tibia and in the femur was within 16 weeks in non-lengthening cases in all but 1 case of non-union (associated with Vitamin D insufficiency). Three burr bits broke during the learning curve including 2 in tibial osteotomies and 1 in the femur. Cortical thickness and slow burr speeds were associated with burr breakage. All wounds healed without infection. The optimum speed for the burr at 50 Nm of torque was established as 200 rpm in children under the age of 13 yrs. The initial recommended speed of 300 rpm increases healing time when performing osteotomies in children. Conclusion. Truly percutaneous surgery can be performed to osteotomise the femur and tibia using a cooled, side cutting burr with a locked femoral nail and crossed tibial wires with excellent cosmetic results and minimal complications. Level of Evidence IV

Between 1990 and 1998 we saw 21 children with primary subacute haematogenous osteomyelitis. Pain, swelling and a limp had been present for two to 12 weeks with little functional impairment. Laboratory tests were non-contributory. The lesions were classified radiologically into metaphyseal, diaphyseal, epiphyseal and vertebral. There were 24 sites involved, with most (20) being in the tibia; 17 lesions were in the diaphysis, five in the metaphysis and two in the epiphysis. The diagnosis was confirmed histologically in all cases. Staphylococcus aureus was cultured in six patients. Healing occurred in all patients after treatment with antibiotics for six weeks and radiological improvement was seen after three to six months. Subacute osteomyelitis develops as a result of increased host resistance and decreased bacterial virulence. The radiological features can mimic various benign or malignant bone tumours and non-pyogenic infections. Histological confirmation is necessary to avoid a delay in diagnosis

Two types of fracture, early and late, have been reported following limb lengthening in patients with achondroplasia (ACH) and hypochondroplasia (HCH).

We reviewed 25 patients with these conditions who underwent 72 segmental limb lengthening procedures involving the femur and/or tibia, between 2003 and 2011. Gender, age at surgery, lengthened segment, body mass index, the shape of the callus, the amount and percentage of lengthening and the healing index were evaluated to determine predictive factors for the occurrence of early (within three weeks after removal of the fixation pins) and late fracture (> three weeks after removal of the pins). The Mann‑Whitney U test and Pearson’s chi-squared test for univariate analysis and stepwise regression model for multivariate analysis were used to identify the predictive factor for each fracture. Only one patient (two tibiae) was excluded from the analysis due to excessively slow formation of the regenerate, which required supplementary measures. A total of 24 patients with 70 limbs were included in the study.

There were 11 early fractures in eight patients. The shape of the callus (lateral or central callus) was the only statistical variable related to the occurrence of early fracture in univariate and multivariate analyses. Late fracture was observed in six limbs and the mean time between removal of the fixation pins and fracture was 18.3 weeks (3.3 to 38.4). Lengthening of the tibia, larger healing index, and lateral or central callus were related to the occurrence of a late fracture in univariate analysis. A multivariate analysis demonstrated that the shape of the callus was the strongest predictor for late fracture (odds ratio: 19.3, 95% confidence interval: 2.91 to 128). Lateral or central callus had a significantly larger risk of fracture than fusiform, cylindrical, or concave callus.

Radiological monitoring of the shape of the callus during distraction is important to prevent early and late fracture of lengthened limbs in patients with ACH or HCH. In patients with thin callus formation, some measures to stimulate bone formation should be considered as early as possible.

Cite this article: Bone Joint J 2014;96-B:1269–73.

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.

We report our experience of the use of callus distraction with a monolateral fixator for the treatment of acquired radial club-hand deformity after osteomyelitis. Between 1994 and 2004, 13 patients with a mean age of eight years (4 to 15) were treated by callus distraction with a monolateral fixator after a preliminary period of at least four weeks in a corrective short-arm cast.

All patients achieved bony union and were satisfied with the functional and cosmetic outcome. There were no major complications, but three patients required cancellous bone grafting at the docking site for delayed union. Local treatment and oral antibiotics were required for pin-site infection in six patients. There were no deep infection or recurrence of osteomyelitis.

Achilles tenotomy is a recognised step in the Ponseti technique for the correction of idiopathic congenital talipes equinovarus in most percutaneous cases. Its use has been limited in part by concern that the subsequent natural history of the tendon is unknown. In a study of 11 tendons in eight infants, eight tendons were shown to be clinically intact and ten had ultrasonographic evidence of continuity three weeks after tenotomy. At six weeks after tenotomy all tendons had both clinical and ultrasonographic evidence of continuity.

Two protocols for the operative technique and care of the pin-site with external fixation were compared prospectively. There was a total of 120 patients with 46 in group A and 74 in group B. Infection was defined as an episode of pain or inflammation at a pin site, accompanied by a discharge which was either positive on bacterial culture or responded to a course of antibiotics.

Patients in group B had a lower proportion of infected pin sites (p = 0.003) and the time to the first episode of infection was longer (p < 0.001). The risk of pin-site infection is lower if attention is paid to avoiding thermal injury and local formation of haematoma during surgery and if after-care includes the use of an alcoholic antiseptic and occlusive pressure dressings.

Congenital unilateral anterolateral tibial bowing in combination with a bifid ipsilateral great toe is a very rare deformity which resembles the anterolateral tibial bowing that occurs in association with congenital pseudarthrosis of the tibia. However, spontaneous resolution of the deformity without operative treatment and with a continuously straight fibula has been described in all previously reported cases. We report three additional cases and discuss the options for treatment. We suggest that this is a specific entity within the field of anterolateral bowing of the tibia and conclude that it has a much better prognosis than congenital pseudarthrosis of the tibia, although conservative treatment alone may not be sufficient.