Aims

Multiple secondary surgical procedures of the shoulder, such as soft-tissue releases, tendon transfers, and osteotomies, are described in brachial plexus birth palsy (BPBP) patients. The long-term functional outcomes of these procedures described in the literature are inconclusive. We aimed to analyze the literature looking for a consensus on treatment options.

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Triplane ankle fractures are complex injuries typically occurring in children aged between 12 and 15 years. Classic teaching that closure of the physis dictates the overall fracture pattern, based on studies in the 1960s, has not been challenged. The aim of this paper is to analyze whether these injuries correlate with the advancing closure of the physis with age.

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Fixation techniques used in the treatment of slipped capital femoral epiphysis (SCFE) that allow continued growth of the femoral neck, rather than inducing epiphyseal fusion in situ, have the advantage of allowing remodelling of the deformity. The aims of this study were threefold: to assess whether the Free-Gliding (FG) SCFE screw prevents further slip; to establish whether, in practice, it enables lengthening and gliding; and to determine whether the age of the patient influences the extent of glide.

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Medial humeral epicondyle fractures (MHEFs) are common elbow fractures in children. Open reduction should be performed in patients with MHEF who have entrapped intra-articular fragments as well as displacement. However, following open reduction, transposition of the ulnar nerve is disputed. The aim of this study is to evaluate the need for ulnar nerve exploration and transposition.

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The paediatric trigger thumb is a distinct clinical entity with unique anatomical abnormalities. The aim of this study was to present the long-term outcomes of A1 pulley release in idiopathic paediatric trigger thumbs based on established patient-reported outcome measures.

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Radiological residual acetabular dysplasia (RAD) has been reported in up to 30% of children who had successful brace treatment of infant developmental dysplasia of the hip (DDH). Predicting those who will resolve and those who may need corrective surgery is important to optimize follow-up protocols. In this study we have aimed to identify the prevalence and predictors of RAD at two years and five years post-bracing.

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Children with spinal dysraphism can develop various musculoskeletal deformities, necessitating a range of orthopaedic interventions, causing significant morbidity, and making considerable demands on resources. This systematic review aimed to identify what outcome measures have been reported in the literature for children with spinal dysraphism who undergo orthopaedic interventions involving the lower limbs.

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Temporary hemiepiphysiodesis (HED) is applied to children and adolescents to correct angular deformities (ADs) in long bones through guided growth. Traditional Blount staples or two-hole plates are mainly used for this indication. Despite precise surgical techniques and attentive postoperative follow-up, implant-associated complications are frequently described. To address these pitfalls, a flexible staple was developed to combine the advantages of the established implants. This study provides the first results of guided growth using the new implant and compares these with the established two-hole plates and Blount staples.

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The gold standard for percutaneous Achilles tendon tenotomy during the Ponseti treatment for idiopathic clubfoot is a tenotomy with a No. 15 blade. This trial aims to establish the technique where the tenotomy is performed with a large-bore needle as noninferior to the gold standard.

Purpose. We describe a novel method to encourage children to weight-bear after frame surgery using a whoopee cushion; the objective of this study is to assess the amount of force taken though a limb using this method. Design/participants. The amount force is required to activate the whoopee cushion is measured when a subject takes weight though a whoopee cushion on a force plate. The speed of the foot in vertical and horizontal planes is assessed with motion analysis to correlate this to the activation of the cushion and is assessed under different conditions, and with different whoopee cushions. Results. The average force required to reach the activation point was between 28N and 32N when only one cushion was strapped to the plantar surface of the foot. This is independent of the vertical speed of the foot, and of the horizontal walking speed. The use of shoes does not significantly alter the force required to reach the activation point. This force is a useful value to differentiate touch weight-bearing from partial weight-bearing. A child's weight-bearing status can be progressed if more than one whoopee cushion is used as the force needed increases. Conclusions. The whoopee cushion has been used in the rehabilitation of children to encourage weight-bearing after frame surgery. It will allow the child to distinguish between different forces expected for touch-and partial weight bearing, and can also be used to progress weight-bearing if more than one cushion is used

Meningococcal septicaemia from meningococcal infection is a devastating illness affecting children. Advances in medical management have reduced the mortality rate to approximately 15 to 20% and children who survive can develop late orthopaedic sequelae from growth plate arrests with resultant complex deformities. Our aim in this study was to review and analyze the case histories of a series of patients with late orthopaedic sequelae, all treated by the senior author. We describe a treatment strategy to address the multiple deformities that may occur in these patients. Methods & Results Between 1990 and 2009, 12 patients were treated for late orthopaedic sequelae after meningococcal septicaemia by the senior author. There were 8 girls and 4 boys. All patients had lower limb involvement. 1 patient had involvement of the upper limb requiring treatment. Each patient had had a mean of 3 operations (range from 2 to 9). Methods of treatment included a combination of angular deformity correction, limb lengthening and epiphysiodesis. At final follow-up 9 of the 12 patients were skeletally mature. In 9 patients limb length discrepancy in the lower limb was corrected to within 1 cm, with normalization of the lower limb mechanical axis. Conclusion. Meningococcal septicaemia can lead to late orthopaedic sequelae due to growth plate arrests. Central growth plate arrests leads to limb length discrepancy, and partial growth plate arrests leads to an angular deformity. In addition, limb amputations may occur and there may be altered growth of the stump requiring further surgery. In cases of central growth arrest with limb shortening alone, limb equalisation is performed with limb lengthening procedures. In cases of partial growth arrests, angular correction is performed together with ablation of the affected growth plate. We recommend ablation of the affected growth plates at the initial surgery to prevent recurrence of angular deformity. Angular correction can be performed acutely, with a dome or transphyseal osteotomy; or gradually, with application of Ilizarov or Taylor Spatial frames. Severe deformities of the tibial plateau are treated by plateau elevation with bone graft augmentation. With the appropriate strategy deformities can be corrected and further lengthening procedures can be undertaken if necessary. Long-term follow-up of these patients is essential to recognise and treat any recurrence of deformity

Seven children who had partial arrest of the growth plate after neonatal arterial cannulation, developed obvious skeletal changes in adolescence. Cannulation of the femoral artery produced ischaemia which led to four cases of ipsilateral shortening of the lower limb and one of partial arrest of the proximal femoral physis with subsequent coxa valga. The two arrests in the upper limb affected the humerus, ulna and radius, and the radius alone, after cannulation of the brachial and radial arteries, respectively. These late effects of cannulation are not widely appreciated, and may occur as a result of thrombosis rather than extravasation

Recent reports have suggested an association between Perthes’ disease and an underlying thrombophilic or hypofibrinolytic tendency. In Northern Ireland there is a high incidence of Perthes’ disease (11.7 per 100 000 or 1 in 607 children) in a stable paediatric population. We reviewed 139 children with Perthes’ disease and compared them with a control group of 220 aged- and gender-matched healthy primary schoolchildren with similar racial and ethnic backgrounds. There were no significant deficiencies of antithrombotic factors protein C, protein S, antithrombin III or resistance to activated protein C. A total of 53 (38.1%) of the children with Perthes’ disease had a prolonged activated partial thromboplastin time (> 38) compared with 13 (5.9%) of the control group (p < 0.001). Our findings have shown that using standard assays, thrombophilia secondary to antithrombotic factor deficiency or resistance to activated protein does not appear to be an aetiological factor for Perthes’ disease. The cause of the prolonged activated partial thromboplastin time, usually associated with a clotting factor deficiency, is under further investigation

The aim of the study was to review the effectiveness of rigid IM nailing in stabilisation and deformity correction of lower limb long bones in adolescents with metabolic bone disease which to our knowledge has not been studied before. Medical records and radiographs were retrospectively reviewed looking at indications, deformity correction, number of osteotomies-if needed, bone healing, time to healing and incidence of complications. Between Aug 2010 and Mar 2015 fifteen patients (24 segments) had rigid IM nailing. Ten patients had Osteogenesis Imperfecta, four with McCune Albright syndrome and one with hypophosphatemic rickets. 22 femora and two tibiae were IM nailed. The mean age of the patients was 13.1 (9.6–16.75 years). Eleven out 24 segments were previously rodded. Eight segments were for acute fractures. 13 bones had significant deformities requiring corrective osteotomies. One patient had previous fracture non union. All patients were allowed to partial weight bear immediately postoperatively and were fully mobile six weeks following surgery. Mean follow up was 24 months (3–51 months) post-operatively. All deformities were corrected. All fractures and osteotomies radiologically united. Mean radiological union time was 5.5 months (6 weeks – 11 months). Patients with acute fractures had mean radiological union time of 4 months. Patients who had osteotomies had a mean radiological union time of 7.1 months. The patient with previous non union had BMP at the same time and radiologically healed in 10 months. Two patients had persistent bisphosphonate osteotomy lines but were asymptomatic. One patient had removal of a prominent distal locking screw and one had persistent Trendelenburg gait. Rigid intramedullary nailing is effective in stabilisation and deformity correction of long bones in adolescent patients with brittle bone disease. The technique has a low complication rate. We recommend the use of this technique in paediatric limb reconstruction in managing metabolic bone conditions

Between 1990 and 2001, 24 children aged between 15 months and 11 years presented with late orthopaedic sequelae after meningococcal septicaemia. The median time to presentation was 32 months (12 to 119) after the acute phase of the disease. The reasons for referral included angular deformity, limb-length discrepancy, joint contracture and problems with prosthetic fitting. Angular deformity with or without limb-length discrepancy was the most common presentation. Partial growth arrest was the cause of the angular deformity. Multiple growth-plate involvement occurred in 14 children. The lower limbs were affected much more often than the upper. Twenty-three children underwent operations for realignment of the mechanical axis and limb-length equalisation. In 15 patients with angular deformity around the knee the deformity recurred. As a result we recommend performing a realignment procedure with epiphysiodesis of the remaining growth plate when correcting angular deformities

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Guided growth has been used to treat coxa valga for cerebral palsy (CP) children. However, there has been no study on the optimal position of screw application. In this paper we have investigated the influence of screw position on the outcomes of guided growth.

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To compare changes in gait kinematics and walking speed 24 months after conventional (C-MLS) and minimally invasive (MI-MLS) multilevel surgery for children with diplegic cerebral palsy (CP).

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The treatment of tibial aplasia is controversial. Amputation represents the gold standard with good functional results, but is frequently refused by the families. In these patients, treatment with reconstructive limb salvage can be considered. Due to the complexity of the deformity, this remains challenging and should be staged. The present study evaluated the role of femoro-pedal distraction using a circular external fixator in reconstructive treatment of tibial aplasia. The purpose of femoro-pedal distraction is to realign the limb and achieve soft tissue lengthening to allow subsequent reconstructive surgery.

In order to treat painful subluxation or dislocation secondary to cerebral palsy, 11 patients (12 hips) underwent combined femoral and Chiari pelvic osteotomies with additional soft-tissue releases at a mean age of 14.1 years (9.1 to 17.8). Relief of pain, improvement in movement of the hip, and in sitting posture, and ease of perineal care were recorded in all, and were maintained at a mean follow-up of 13.1 years (8 to 17.5). The improvement in general mobility was marginal, but those who were able to walk benefited the most. The radiological measurements made before operation were modified afterwards to use the lateral margin of the neoacetabulum produced by the pelvic osteotomy. The radiological migration index improved from a mean of 80.6% (61% to 100%) to 13.7% (0% to 33%) (p < 0.0001). The mean changes in centre edge angle and Sharp’s angle were 72° (56° to 87°; p < 0.0001) and 12.3° (9° to 15.6°; p < 0.0001), respectively. Radiological evidence of progressive arthritic change was seen in one hip, in which only a partial reduction had been achieved, and there was early narrowing of the joint space in another. Painless heterotopic ossification was observed in one patient with athetoid quadriplegia. In seven hips the lateral Kawamura approach, elevating the greater trochanter, provided exposure for both osteotomies and allowed the construction of a dome-shaped iliac osteotomy, while protecting the sciatic nerve

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Though the pathogenesis of Legg-Calve-Perthes disease (LCPD) is unknown, repetitive microtrauma resulting in deformity has been postulated. The purpose of this study is to trial a novel upright MRI scanner, to determine whether any deformation occurs in femoral heads affected by LCPD with weightbearing.