Purpose. This study compares outcomes in patients with complete congenital fibula absence, associated with severe lower limb deformity, treated with an amputation protocol to those using an extension prosthesis. Method. 32 patients were identified. 9 patients (2M: 7F, median age at presentation of 22 yrs) utilized an extension prosthesis. 23 patients (16M: 7F, median age at presentation of 10 months) underwent 25 amputations during childhood: only two underwent tibial kyphus correction to facilitate prosthetic wear. Mobility was assessed using the SIGAM and K scores. Quality of life was assessed using the PedsQL inventory questionnaire; pain by a verbal severity score. Patients undergoing amputation were further subdivided by age, below and above 2 yrs at the time of surgery. Results. 19 Syme and one Boyd amputation in 19 patients were performed early (mean age 15 months). 4 Syme and one trans-tibial amputation in 4 patients took place in older children (mean age 6.6 years). K Scores were significantly higher (mean 4 versus 2) and pain scores lower in the amputation group allowing high impact activity compared to community ambulation with an extension prosthesis. The SIGAM and PedsQL scores were all better in the amputation group, but not significantly so. There was no significant difference in the scores based on the time of amputation. Conclusion. Complete fibula absence can present with significant lower limb deformity. Parental counselling regarding management is paramount in achieving the optimum functional outcome. Childhood amputation for severe limb length inequality and foot deformity in congenital fibula absence offers excellent short term functional outcome with prosthetic support. The tibial kyphus deformity does not need routine correction and facilitates prosthetic suspension. Accommodative extension prosthesis does offer reasonable long term function but outcome scores are lower

Purposes of the Study. To study the incidence of delayed consolidation of regenerate in children undergoing correction or lengthening of lower limb deformities using an external fixator. Methods and Results. Between 2006 and 2011, 150 patients with lower limb deformities (excluding feet) were treated in our unit using external fixators. A retrospective review of our prospective database was carried out to identify patients with poor regenerate formation requiring bone grafting. Patients with acute fractures, pseudarthrosis of the tibia due to neurofibromatosis and those above the age of eighteen were excluded. An independent observer reviewed the medical records and radiographs. Eleven patients with ages ranging from 2 years 5 months to 17 years 5 months (mean average 9 years 9 months) formed the basis of our study – 3 males and 8 females. Factors that were associated with this complication include age greater than twelve years (10 patients), lack of weight bearing (6 patients), previous fixator (5 patients) and smoking (5 patients). The regenerate was deficient in nine tibial segments and two femoral segments. Six of the deficient tibial regenerates were at a proximal site whilst three were distal. There was no significant difference in length gained between these sites (p < 0.5). The mean time to regenerate bone grafting was 7 months. Time to healing following bone grafting was 2.5 months. Conclusion. Delayed consolidation of regenerate in children undergoing treatment of lower limb deformities, though recognised, is under reported. We believe this report will serve as a guide in the consenting process for children undergoing treatment using external fixators

Purpose. This study compares outcomes in patients with complete congenital fibula absence treated with an amputation protocol to those using an extension prosthesis. Introduction. Complete fibula absence presents with significant lower limb deformity. Parental counselling regarding management is paramount in achieving the optimum functional outcome. Amputation offers a single surgical event with minimal complications and potential excellent functional outcome. Method. 32 patients were identified. 9 patients (2M: 7F, median age at presentation of 22yrs) utilized an extension prosthesis. 23 patients (16M: 7F, median age at presentation of 10 months) underwent 25 amputations during childhood: only two underwent tibial kyphus correction. Mobility was assessed using SIGAM and K scores. Quality of life was assessed using the PedsQL inventory questionnaire; pain by a verbal severity score. Results. 19 Syme and one Boyd amputation in 19 patients were performed early (mean age 15 months). 4 Syme and one trans-tibial amputation in 4 patients took place in older children (mean age 6.6 years). K Scores were significantly higher (mean 4 versus 2) and pain scores lower in the amputation group allowing high impact activity compared to community ambulation with an extension prosthesis. The SIGAM and PedsQL scores were all better in the amputation group, but not significantly so. Conclusion. Childhood amputation for severe limb length inequality and foot deformity in congenital fibula absence offers excellent short term functional outcome with prosthetic support. The tibial kyphus does not need routine correction and facilitates prosthetic suspension. Accommodative extension prostheses offer reasonable long term function but outcome scores are lower

We have reviewed, retrospectively, all children with a lower limb deformity who underwent an acute correction and lengthening with a monolateral fixator between 1987 and 1996. The patients were all under the age of 19 years and had a minimum follow-up of eight months after removal of the fixator. A total of 41 children had 57 corrections and lengthening. Their mean age was 11.3 years (3.2 to 18.7) and there were 23 girls and 18 boys. The mean maximum correction in any one plane was 23° (7 to 45). In 41 bony segments (either femur or tibia) a uniplanar correction was made while various combinations were carried out in 16. The site of the osteotomy was predominantly diaphyseal, at a mean of 47% (17% to 73%) of the total bone length and the mean length gained was 6.4 cm (1.0 to 17.0). Univariate analysis identified a moderately strong relationship between the bone healing index (BHI), length gained, maximum correction and grade-II to grade-III complications. For logistic regression analysis the patients were binary coded into two groups; those with a good outcome (BHI ≤ 45 days/cm) and those with a poor outcome (BHI > 45 days/cm). Various factors which may influence the outcome were then analysed by calculating odds ratios with 95% confidence intervals. This analysis suggested a dose response between increasing angular correction and poor BHI which only reached statistical significance for corrections of larger magnitude. Longer lengthenings were associated with a better BHI while age and the actual bone lengthened had little effect. Those patients with a maximum angulatory correction of less than 30° in any one plane had an acceptable consolidation time with few major complications. The technique is suitable for femoral deformity and shortening, but should be used with care in the tibia since the risk of a compartment syndrome or neurapraxia is much greater

Introduction

Severe, multiplanar, fixed, pantalar deformities present a challenge to orthopaedic surgeons. Surgical options include limb salvage or amputation. This study compares outcomes of patients with such deformities undergoing limb preservation with either pantalar fusion (PTF) or talectomy and tibiocalcaneal fusion (TCF), versus below knee amputation (BKA).

Introduction

Patient-specific instruments (PSI) and surgical-guiding templates are gaining popularity as a tool for enhancing surgical accuracy in the correction of oblique bone deformities Three-dimensional virtual surgical planning technology has advanced applications in the correction of deformities of long bones and enables the production of 3D stereolithographic models and PSI based upon a patient's specific deformity. We describe the implementation of this technology in young patients who required a corrective osteotomy for a complex three-plane (oblique plane) lower-limb deformity.

This study aims to evaluate the development of deformity in patients with hypophosphataemic rickets and the evolution of the orthopaedic management thereof.

Fifty-four patients had undergone treatment for hypophosphataemic rickets at our institution since 1995. Clinical records for all patients were obtained. Forty-one patients had long leg radiographs available that were analysed using Traumacad™ software. Statistical analysis was performed using SPSS 23 (SPSS Inc., Chicago, Illinois, USA).

Of the 41 patients, 18 (43%) had no radiographic deformity. 20 have undergone bilateral lower limb surgery for persistent deformity (Mechanical Axis ≥ Zone 2). A further 3 patients are awaiting surgery. Six patients (12 limbs, 14 segments) had osteotomies and internal fixation as primary intervention: only one limb developed recurrent deformity. There were no major complications.

Fourteen patients (28 limbs) had 8-plates (Orthofix, Verona) applied. In 5 limbs correction is on-going. Neutral alignment (central Zone 1) was achieved in 14/20 (70%) patients. Two patients required osteotomy and external fixation for resistant deformity. The mean rate of angular correction following 8-plate application was 0.3 and 0.7 degrees/month for the tibia and femur respectively. The mean age at 8-plate insertion was 10.25y (5–15y). Patients with more than 3 years of growth remaining responded significantly better than older patients (Fisher Exact Test, p=0.024). Guided growth was more successful in correcting valgus deformity than varus deformity (Fisher Exact Test, p=0.04). In the younger patients, diaphyseal deformity corrected as the mechanical axis improved at the rate of 0.2 and 0.7 degrees /month for the tibial and femoral shafts. Serum phosphate and alkaline phosphatase levels did not affect response to surgery or complication rate.

Guided growth by means of 8-plates is a successful in addressing deformity in hypophosphataemic rickets. Surgery is best performed in patients with more than 3 years of growth remaining.

Purpose: To modify the technique of Sofield to minimize avascularity and to maximize stability.

Introduction: Sofield and Millar described a technique for the correction of severe long bone deformity in osteogenesis imperfecta which involved removing the diaphysis from the limb and cutting it into several segments. These segments were then threaded on a rod without regard to their original position in the bone, their end to end orientation, or their rotation. The patient was then immobilized in a plaster cast. In order to avoid the extreme bone atrophy seen in some patients, sometimes called ‘disappearing bone disease’, and to provide sufficient stability to obviate cast immobilization we have modified Sofield’s technique.

Surgical principles: Our technique follows the following guidelines: 1. Make as few osteotomies as possible; 2. Avoid, if possible, completely stripping any segment of bone; 3. In severely angulated bones which cannot be made straight without shortening, the part of the bone excised should include the area of maximum deformity; 4. In order to maximize angular stability make the cuts as far from the ends of the bone as possible; and 5. In order to achieve rotational stability make the cuts 45 degrees oblique.

Material and methods: We reviewed 46 bones of 23 patients aged 1 to 20 years at the time of the study. There were 23 tibiae and 23 femora. We measured the angular deformity of the mechanical axis of the distal femur and the proximal and distal tibia. Six patients had only one bone corrected, 9 had two, 4 had 3, and 2 patients had corrections of both tibiae and both femora. We counted the number of cuts on the post-operative x-ray. Achieving shortening by removal of a piece was counted as one cut since it did not produce an additional segment. We noted whether or not a post-operative cast was used.

Results: In no case, not even in the most severe deformities, were more than two cuts required. There was no difference in the tendency of the femur and tibia to require more than one cut. We observed no instances of ‘disappearing bone disease’. A few bones were so fragile that they tended to crumble during surgery and in these patients cast immobilization was employed.

Conclusions: Viability of bone is enhanced by minimizing the number of osteotomies and periosteal stripping. Oblique osteotomies provide sufficient rotational stability that post-operative immobilization is unnecessary.

Introduction. The aim of the study is to evaluate the results of using Ilizarov technique for correcting the post traumatic lower limb deformities. Materials and Methods. This prospective study included 25 femurs (Group A) and 65 tibias (Group B) underwent correction with Ilizarov technique and frame. Both groups had moderate and complex deformed segments. Outcomes were Ilizarov correction time, distraction index (DI), consolidation index (CI), Ilizarov index (II) and complications. Results. Within group A, mean correction of frontal plane deformity was 15°, sagittal plane was 10° rotational deformity was 20°. In group B, mean correction of frontal plane deformity was 19°, sagittal plane was 12° and rotational deformity was 10°. Conclusions. Ilizarov provided easy, accurate and excellent lower limb deformity correction and lengthening

Background: Feet and lower limb deformities compromise function of children to meet there growing abilities and peer demands. Ilizarov is a known tool in the correction of lower limb deformities. Purpose: to evaluate the functional outcome of Ilizarov correction of lower limb deformities, and to compare the functional outcome of correction of feet deformity versus other lower limb segments deformity. Subjects and Methods: 94 Ilizarov corrections of lower limb deformed segments (in 63 children) were performed, of them 43 were feet, 33 were tibial and 18 were femoral deformities. Etiology of deformity was congenital in 72, acquired in 18, and developmental in 4. Functional ability of walking distance, cope with peers, single leg stance, hopping on affected leg, and climbing stairs before and after deformity correction were assessed. Results: Mean follow was 55.1 ± 30.9 months, mean age at time of operation was 11.1 ± 5.3. At last follow up the corrected deformities of lower limb had a significant increase to full walking distance from 37, to 76 lower extremities (p=0.000). Coping with peers increased from 40, to 68 (p=0.000) extremities. The single stance on the affected extremity increased from 30, to 78(p=0.000). The hopping on affected limb increased from 18, to 41(p= 0.000), climbing stairs increased from 79 and 94(p=0.000) extremities. Although disability before correction was significantly more pronounced among feet deformities as regards single stance (p=0.001), and hopping on one leg (p=0.023). The improvement to full walking distance, coping with peers, single stance, hoping and climbing stairs was significantly higher among corrected feet (p=0.000), (p=0.000), (p=0.000), (p=0.000), (p=0.000) compared to other corrected lower limb deformities. Conclusion: Deformity of feet is significantly more disabling functionally than other lower limb deformities. Ilizarov foot correction is significantly more functionally rewarding than Ilizarov correction of other lower limb deformities

Our clinical experience in treating lower limb deformities by external fixation started in 1982 by applying an Ilizarov external fixation frame. Correcting lower limb deformity by gaining the proper length and the optimal mechanical performance is of the outmost importance and essential for valid restoration of the articular function. We treated 145 patients: 25 patients affected by post-traumatic deformities; 12 patients affected by axial deviation of the knee; 82 patients affected by limb shortening and associated limb deformities; eight patients with lower limb deformities and shortening following pathological hip alterations; and 18 patients affected by severe foot deformities. It is important to stress that in congenital lower limb deformities both axial deviation and limb shortening contribute to the final picture of the deformity. Combined (hybrid) external fixation provides an adequate correction of the mechanical axis and a proper lengthening of the shorter limb by a corticotomy followed by a gradual distraction

Introduction. Computer hexapod assisted orthopaedic surgery (CHAOS) has previously been shown to provide a predictable and safe method for correcting multiplanar femoral deformity. We report the outcomes of tibial deformity correction using CHAOS, as well as a new cohort of femoral CHAOS procedures. Materials and Methods. Retrospective review of medical records and radiographs for patients who underwent CHAOS for lower limb deformity at our tertiary centre between 2012–2020. Results. There were 70 consecutive cases from 56 patients with no loss to follow-up. Mean age was 40 years (17 to 77); 59% male. There were 48 femoral and 22 tibial procedures. Method of fixation was intramedullary nailing in 47 cases and locking plates in 23. Multiplanar correction was required in 43 cases. The largest correction of rotation was 40 degrees, and angulation was 28 degrees. Mean mechanical axis deviation reduction per procedure was 17.2 mm, maximum 89 mm. Deformity correction was mechanically satisfactory in all patients bar one who was under-corrected, requiring revision. Complications from femoral surgery included one under-correction, two cases of non-union, and one pulmonary embolism. Complications from tibial surgery were one locking plate fatigue failure, one compartment syndrome, one pseudoaneurysm of the anterior tibial artery requiring stenting, and one transient neurapraxia of the common peroneal nerve. There were no deaths. Conclusions. CHAOS can be used for reliable correction of complex deformities of both the femur and tibia. The risk profile appears to differ between femoral and tibial surgeries

Introduction: The management of deformities of the lower extremity in children with spina bifida is challenging. Surgery is fraught with high complication and recurrence rates. The Ilizarov technique has shown to be a successful tool in the management of complex lower limb deformity. There are few published series in the literature dealing specifically with Ilizarov correction of complex lower limb deformities in spina bifida. In this paper we present our experience of the Ilizarov technique for complex deformities in children with spina bifida. Methods: From 1989 to 2006, 33 patients with spina bifida underwent 48 corrections of their lower extremity deformity using the Ilizarov technique at one of three tertiary care centres (Royal Children’s Hospital, Melbourne, Australia, Musgrave Park Hospital, Belfast, Northern Ireland and Birmingham Children’s Hospital, Birmingham, UK). Notes were reviewed retrospectively. Patient demographics, indications for surgery, deformity analysis and the extent of surgery were recorded. Complications of the surgery and outcomes were noted. Results: Group I comprised of 12 fixed knee flexion deformities and one unstable neuropathic joint. Group II comprised 15 external tibial rotational deformities. Group III comprised 20 complex foot deformities. The mean age of the patients was 12.1 years (5.2–20.6 years). Prior to their treatment using the Ilizarov technique patients had undergone a mean of 1.6 previous surgeries (range: 0–5) on the affected limb. The mean duration of treatment in the frame was 9.3 weeks (range: 2–26 weeks). The mean follow-up is 4.0 years (range 0.3–9.0 years). Thirteen problems occurred in the 48 procedures (27.1%). Five obstacles occurred in the 48 procedures (10.4%). Thirteen complications occurred in the 48 procedures (27.1%). Further surgical procedures are either planned, or have been performed, in 8 of the 33 patients (24.2%). Following treatment, all feet were recorded to be plantigrade. All were comfortable in their respective orthoses where appropriate. Conclusion: Through the pitfalls in treating the complex lower limb deformity in spina bifida, the Ilizarov technique offers a refreshing approach. It offers distinct advantages throughout the treatment period. It modifies both the intraoperative and postoperative environment to address the morbidity of the significant complications associated with the traditional approach to the correction of the limb deformity in the child with spina bifida. Significance: This is a large series of complex limb reconstruction cases in spina bifida showing excellent results, an acceptable complication rate and recommendations for further use of this technique

Many studies describe the use of the Ilizarov ring fixator for lower limb lengthening and for the management of the 3-dimensional lower limb deformities in achondroplasia, and most confirm the efficacy of this technique. However, long term follow up of these achondroplastic patients is lacking. Most studies have focused on magnitude of lengthening, treatment time required and complications, but no study has analyzed the long term postoperative condition of these patients using an objective, functional method such as gait analysis. Nineteen (19) achondroplastic patients, 12 males and 7 females, aged 19–38 years (mean 27.3 y) who have undergone tibia and femur lengthening, using the Ilizarov method, at the age of 9–19 years (mean 12.6 y), were evaluated 5–19 years (mean 10.1 y) after their last surgery, using 3-dimensional gait analysis. Nineteen (19) normal, height-matched subjects were used as controls. The VICON Nexus 8 Camera System was used to accurately measure spatiotemporal characteristics (walking velocity, stride length, step length, cadence) and kinematics (range of motion) of lower limb joints. Statistical comparison of deformity parameters between achondroplastic patients and normal population was done using the student t- test. A level of p<0.05 was considered statistically significant. Walking velocity, step length and stride length were statistically significantly decreased (p<0.05) in achondroplastic patients compared to normal population values. The achondroplastic group presented with excessive anterior pelvic tilt (mean 21.9. o. ± 7.3), excessive pelvic rotation (range 28.7. o. ±7.8), decreased hip extension (mean 1.8. o. ±10.1) and decreased plantar flexion (mean 17.1. o. ±5.1) when compared to normal controls. There was no statistically significant difference in the knee kinematics between the operated achondroplastic patients and normal controls. The achondroplastic patients present decreased values in their spatiotemporal characteristics compared to the normal subjects because, despite the height gain, their lower limbs remain shorter. Their excessive anterior pelvic tilt is attributed to their lordosis. Their excessive forward pelvic rotation is an attempt to increase stride and step length. The decreased hip extension is due to their anterior pelvic tilt. The correction of these patients genu varum restored knee kinematics to normal. In order to address the hip and pelvis deformities a proximal femoral osteotomy should be considered. The Ilizarov method provides functional height gain and substantially corrects the three-dimensional lower limb deformities of achondroplastic patients especially around the knee joint but more planning needs to be implemented when the system is applied to correct the disease specific deformities of the hip and pelvis. Gait analysis is an objective tool that can be used to address these design issues

Aims. Meningococcal septicaemia can result in growth arrest and angular deformities. The aim of this case series was to review the pattern of involvement in the lower leg. Patients and Methods. The notes and radiographs of all patients presenting with a growth arrest or deformity affecting the lower leg following meningococcal septicaemia between 1995 and 2010 were reviewed. There were fourteen patients, eight girls and six boys. The mean age of the patients at the time of presentation was 9.6 years. Results. There was a variety of deformities with some patients exhibiting several deformities in the same limb and/or bilateral deformities. Some of the deformities were complex. Nine patients had a lower limb length discrepancy (mean 4.8cms, range: 1 to 13cms). There were a total of 27 lower limb deformities; three patients had bilateral lower limb deformities. In 14 the proximal tibia was involved causing genu varum in 12 cases and genu valgum in two cases. Seven distal tibia deformities all resulted in varus deformity. In all cases, the fibula was spared. Discussion. In this series involvement of the tibial physeal growth plates was frequently asymmetric and with two exceptions resulted in a varus deformity. The medial and anterior proximal tibial physis seems particularly susceptible to the sequelae of meningococcal septicaemia whereas the fibula physeal plates were always spared. These observations confirm the work of other authors and this characteristic pattern of involvement is likely to reflect the vascular anatomy of the physeal plates. The fibula may be protected from damage because of the nature of its blood supply. Modern limb reconstruction techniques, particularly the Spatial frame now permit correction of these complex and difficult deformities

We report the outcome of 28 patients with spina bifida who between 1989 and 2006 underwent 43 lower extremity deformity corrections using the Ilizarov technique. The indications were a flexion deformity of the knee in 13 limbs, tibial rotational deformity in 11 and foot deformity in 19. The mean age at operation was 12.3 years (5.2 to 20.6). Patients had a mean of 1.6 previous operations (0 to 5) on the affected limb. The mean duration of treatment with a frame was 9.4 weeks (3 to 26) and the mean follow-up was 4.4 years (1 to 9). There were 12 problems (27.9%), five obstacles (11.6%) and 13 complications (30.2%) in the 43 procedures. Further operations were needed in seven patients. Three knees had significant recurrence of deformity. Two tibiae required further surgery for recurrence. All feet were plantigrade and braceable. We conclude that the Ilizarov technique offers a refreshing approach to the complex lower-limb deformity in spina bifida

Background. Temporary hemiepiphysiodesis using 8 plate guided growth has gained widespread acceptance for the treatment of paediatric angular deformities. This study aims to look at outcomes of coronal lower limb deformities corrected using temporary hemiepiphysiodesis over an extended period of follow up. Methods. A retrospective analysis was undertaken of 56 children (92 legs) with coronal plane deformities around the knee which were treated with an extraperiosteal 2 holed titanium plate and screws between 2007 and 2015. Pre and post-op long leg radiographs and clinic letters were reviewed. Results. The mean age was 11.9 years (range 3 to 16) with a mean angular deformity of 12.3 degrees (5.1 to 33.5). The mean rate of correction was 0.8 degrees per month. Isolated distal femur correction occurred at a mean rate of 0.6 degrees per month (0.2 to 1.4) and isolated tibia at a rate of 0.5 degrees per month (0.0 to 1.7). Children treated with concurrent treatment of both femur and tibia corrected at a rate of 1.4 degrees per month (0.1 to 2.7). Similar rates of correction occur in children aged 10 and over compared to those younger than 10 (0.8 degrees per month compared to 0.7). We also saw similar rates of correction with extended follow up. The average rate of correction over the first 9 months post op was 0.8 degrees compared to 0.6 degrees over the following 10 months. Conclusion. This study is the largest long term follow up of 8 plate hemiepiphysiodesis which highlights the rate of correction in all age groups. Implications. With this knowledge surgeons can make a more informed decision regarding placement of hemiepiphysiodesis plates and length of time required for correction of angular deformities. It may also lead to consideration of alternative, more powerful techniques if the rate of correction is insufficient. Conflict of Interest: None declared

The August 2024 Children’s orthopaedics Roundup³⁶⁰ looks at: Antibiotic prophylaxis and infection rates in paediatric supracondylar humerus fractures; Clinical consensus recommendations for the non-surgical treatment of children with Perthes’ disease in the UK; Health-related quality of life in idiopathic toe walkers: a multicentre prospective cross-sectional study; Children with spinal dysraphism: a systematic review of reported outcomes; No delay in age of crawling, standing, or walking with Pavlik harness treatment: a prospective cohort study; No value found with routine early postoperative radiographs after implant removal in paediatric patients; What do we know about the natural history of spastic hip dysplasia and pain in total-involvement cerebral palsy?; Evaluating the efficacy and safety of preoperative gallows traction for hip open reduction in infants