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

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

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.

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

Aim. To determine the rate of recurrence of coronal plane deformity in children treated with ‘guided growth’ using 8-plates, from the time of implant removal to skeletal maturity. Methods. Over a consecutive 5 year period between April 2008 and April 2013 we analysed our results of guided growth treatment using 8-plates to correct coronal plane lower limb deformity. Patients with neuromuscular disorders such as cerebral palsy were excluded. Deformity planning was performed using standardised techniques. Our standard practice is to remove the 8-plate and screws once deformity is corrected both clinically and radiologically. Patients were followed up until either skeletal maturity or recurrence, which necessitated reapplication of the 8-plate. We are aware of no study in which children treated with guided growth using 8-plates are followed up to skeletal maturity. Results. 267 patients were treated with 8-plates in our unit over this 5 year period. Of the patients in whom deformity was corrected and had subsequent plates removed, we identified 41 patients who have either reached skeletal maturity or had recurrence of deformity. Six patients required reapplication of the 8-plates implant. These were young and had skeletal dysplasia. Deformity parameters were analysed both clinically and radiologically in patients who have reached skeletal maturity and showed no recurrence, which necessitated further intervention. Conclusion. A higher proportion of younger patients, especially a sub-group with skeletal dysplasia had recurrence of deformity necessitating reapplication of the 8-plate device. In this group we recommend removal of only the metaphyseal screw once deformity is corrected. This would allow ease of reapplication if recurrence were to reoccur. Level of evidence: III

Purpose. A review of the role of external fixators in paediatric trauma at The Royal London Hospital Trauma and Orthopaedic Department. Methods. Retrospective study between 2004 and 2010 reviewing traumatic bone injuries that required initial management with an external fixator. Information was collected through the patients' medical documents and radiographs. Results. In total twenty-seven patients (15 male:12 female, mean age 11, age range 7-15) were initially treated with external fixators over the six year period. The injured bones included 18 tibias, 5 femurs, 2 humeri, 2 radius/ulna, 2 phalanges and 1 wrist. Three patients had two fractures requiring external fixators. Four patients had associated head injuries. Indications included twenty –one open fractures (3 Gustilo type 2, 6 Gustilo type 3A, 12 Gustilo type 3B), seven closed fractures in poly-trauma patients and two closed severely comminuted fractures. Ten fractures were treated with the external fixator as the definitive treatment, fourteen had application of cast following removal of the external fixator and six were converted to internal fixation. Twenty-eight Linear frames were applied (23 Hoffman IIs, 5 Compact Hoffmans) and two circular frames. Mean duration of frame stabilisation was 8 weeks (range 1-16 weeks). Complications included 2 pin site infections successfully treated with antibiotics, 2 patients with hypertrophic scars, 2 leg length discrepancies secondary to bone loss, 2 patients had delayed union and 2 patients had a lower limb deformity requiring intervention, one for adjustment of frame and the other for correction osteotomy with circular frame. Conclusion. The use of external fixators has an important role to play in the management of open fractures and poly-trauma paediatric patients

Purpose. To document the incidence and nature of complications associated with hemiepiphysiodesis using a screw and plate device (8-plate, Orthofix). Methods. We reviewed case notes and radiographs of 71 children (130 segments) with lower limb deformities treated with temporary hemiepiphyseal arrest using the 8-plate. 96% of deformities were in the coronal plane, 4% sagittal. 72% of coronal deformities demonstrated valgus malalignment. We defined three types of complications:. early (perioperative) complications eg infection and/or wound breakdown, bleeding, neurological impairment. implant related complications such as soft tissue irritation, plate breakage or migration,. complications involving the growth plate including rebound deformity, early physeal closure or iatrogenic deformity. Complications were related to variables of patient age, gender, diagnosis, location of deformity and associated surgery. Results. The average age at surgery was 10 years (range 3-16). There were 41 boys, 30 girls. 3/70 patients were treated for an idiopathic deformity: the remainder were affected by a wide range of pathologies (20% skeletal dysplasia, 20% metabolic bone disease). Full correction has occurred in 38% of patients. The remaining 45 children are all showing improvement in their deformity. 10 patients (14%) have had a complication: 3 patients had early complications (wound infection, wound breakdown and intra-operative hypotensive crisis) and 2 patients have had implant related complications (irritation and migration). In a further 5 patients there have been physis related problems: 1 over-correction, 1 recurrence and 3 cases in which the timing of the procedure or the ill-health of the physis did not allow correction to occur. Conclusion. The 8-plate is an effective device in the management of deformity secondary to pathological conditions. 10% of patients had complications: the majority were minor but care should be taken regarding the timing of the procedure related to the growth potential of the pathological physis

Conventional surgical treatment of relapsed or neglected club foot deformities is not always successful or easy to apply. The presence of shortened neurovascular structures and unhealthy skin may preclude the surgical interference. Bone resection in severe deformities results in short foot which is not satisfactory functionally and cosmetically. Objectives. In this study we evaluate the use of the bloodless technique for management of relapsed or neglected club foot deformities. Methods. From Jan 2000–2006, 64 cases older than 2 years with relapsed or neglected club foot deformities were referred to our center. Four cases were excluded because of inadequate follow up data. This thesis based on 60 consecutive cases (67 feet). The patients average age was 8 years and 4 months (range, 2–16 years). Seven cases were bilateral, 20 Left sides, and 34 Right sides. There were 57 relapsed club foot (5 bilateral), and 3 cases were neglected (2 bilateral). Patients with relapsed club foot had average 3 previous operations (range, 1–8 operations). There was no preoperative assembling of the apparatus. The construct was designed according to the condition of deformity: equinus, varus forefoot etc. Additional procedures, elongation of tendoachilis was done concomitantly with the original procedure in 10 cases. The patients were discharged from the hospital the same day of the operation. Results. The range of operative time was 1–3 hours with an average of 1.5 hours. Average time in the fixator was 19.6 weeks (range, 10 weeks–38 weeks). After fixator removal cast was applied for 2 months, followed by night splint and special shoes for their daily activities. The average follow-up period was 30.6 months (range, 12–84 months) after fixator removal. The results were good in 55 feet, fair in 9, bad in 3. Complications. All cases suffered from some sort of pin tract inflammation. For 8 cases: one of the wires had to be removed without anaesthesia due to persistent infection. For 3 cases: replacement of wires under general anaesthesia was performed. Oedema developed in the leg and dorsum of the foot or the ankle in 34cases. Frame adjustment under general anaesthesia in 3 cases. There are others such as: migration of the calcanean wire, 2 cases; over correction with valgus heel, two cases; flatfoot, 4 cases; talar subluxationin, 2 cases; talonavicular subluxation, one case; first metatarsophalangeal subluxation, 2 cases; flat topped talus, one case; broken wire, 2 cases and recurrence in 2 cases. Discussion. It seems logic that osteotomy of the tarsus must be carried out whenever skeletal growth of the foot is at such an advanced stage that correction can not be established by means of articular repositioning and remodeling. However, equinovarus deformity of the foot in 65 adults (38 feet) was treated by external fixator without open procedure (Oganesyan et al, 1996). After an average follow-up 10 years, satisfactory results were obtained in all feet except four. Conclusion. Ilizarov Treatment is lengthy, difficult, fraught with complications, and a technically demanding procedure. However, the complications did not affect the final outcome too much. Ilizarov method also offers the advantage of performing many additional procedures for other associated lower limb deformity. We believe that the bloodless technique using Ilizarov external fixator is an effective method in treating relapsed or neglected club foot deformities

We reviewed the outcome in 24 children with bilateral spastic cerebral palsy aged seven years or younger for whom surgery was recommended between 1999 and 2005 following gait analysis. A total of 13 children (operative group) had surgery and the remaining 11 (control group) did not, for family or administrative reasons. The operative group had at least two post-operative gait analyses at yearly intervals, with eight children having a third and six children a fourth. The control group had a second analysis after a mean interval of 1.5 years (95% confidence interval 1.1 to 1.9). In the operative group, the Gillette gait index, the ranges of movement in the lower limb joint and knee extension in stance improved following surgery, and this was maintained overall at the second post-operative analysis. The minimum knee flexion in stance in the control group increased between analyses.

These results suggest that surgical intervention in selected children can result in improvements in gait and function in the short to medium term compared with non-operative management.

A total of 25 children (37 legs and 51 segments) with coronal plane deformities around the knee were treated with the extraperiosteal application of a flexible two-hole plate and screws. The mean age was 11.6 years (5.5 to 14.9), the median angle of deformity treated was 8.3° and mean time for correction was 16.1 months (7 to 37.3). There was a mean rate of correction of 0.7° per month in the femur (0.3° to 1.5°), 0.5° per month in the tibia (0.1° to 0.9°) and 1.2° per month (0.1° to 2.2°) if femur and tibia were treated concurrently. Correction was faster if the child was under 10 years of age (p = 0.05). The patients were reviewed between six and 32 months after plate removal. One child had a rebound deformity but no permanent physeal tethers were encountered.

The guided growth technique, as performed using a flexible titanium plate, is simple and safe for treating periarticular deformities of the leg.

We present the results of treatment of developmental dysplasia of the hip in infancy with the Pavlik harness using a United Kingdom screening programme with ultrasound-guided supervision. Initially, 128 consecutive hips in 77 patients were reviewed over a 40-month period; 123 of these were finally included in the study. The mean age of the patients at the start of treatment was five weeks (1 to 12). All hips were examined clinically and monitored with ultrasound scanning. Failure of treatment was defined as an inability to maintain reduction with the harness. All hips diagnosed with dysplasia or subluxation but not dislocation were managed successfully in the harness. There were 43 dislocated hips, of which 39 were reducible, but six failed treatment in the harness. There were four dislocated but irreducible hips which all failed treatment in the harness. One hip appeared to be successfully treated in the harness but showed persistent radiological dysplasia at 12 and 24 months. Grade 1 avascular necrosis was identified radiologically in three patients at 12 months.