The aim of this prospective study was to investigate prematurity as a risk factor for developmental dysplasia of the hip (DDH). The hips of 221 infants (88 female, 133 male, mean age 31.11 weeks; standard deviation (. sd. ) 2.51) who were born in the 34th week of gestation or earlier, and those of 246 infants (118 female, 128 male, mean age 40.22 weeks; . sd. 0.36) who were born in the 40th week of gestation, none of whom had risk factors for DDH, were compared using physical examination and ultrasound according to the technique of Graf, within one week, after the correction of gestational age to the 40th week after birth or one week since birth, respectively. Both hips of all infants were included in the study. Ortolani’s and Barlow’s tests and restricted abduction were accepted as positive findings on examination. There was a statistically significant difference between pre- and full-term infants, according to the incidence of mature and immature hips (p < 0.001). The difference in the proportion of infants with an α angle < 60° between the two groups was statistically significant (p < 0.001). The incidence of pathological dysplasia (α angle < 50 º) was not significantly different in the two groups (p = 1.000). The Barlow sign was present in two (0.5%) pre-term infants and in 14 (2.8%) full-term infants. . These results suggests that prematurity is not a predisposing factor for DDH. Cite this article: Bone Joint J 2015; 97-B:716–20

McFarland fractures of the medial malleolus in children, also classified as Salter–Harris Type III and IV fractures, are associated with a high incidence of premature growth plate arrest. In order to identify prognostic factors for the development of complications we reviewed 20 children with a McFarland fracture that was treated surgically, at a mean follow-up of 8.9 years (3.5 to 17.4). Seven children (35%) developed premature growth arrest with angular deformity. The mean American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale for all patients was 98.3 (87 to 100) and the mean modified Weber protocol was 1.15 (0 to 5). There was a significant correlation between initial displacement (p = 0.004) and operative delay (p = 0.007) with premature growth arrest. Both risk factors act independently and additively, such that all children with both risk factors developed premature arrest whereas children with no risk factor did not. We recommend that fractures of the medial malleolus in children should be treated by anatomical reduction and screw fixation within one day of injury. Cite this article: Bone Joint J 2013;95-B:419–23

Introduction: Surgeons treating tibial fractures by the Ilizarov Method are faced with the diagnostic dilemma of determining whether a fracture has united to remove the frame safely. Methods: Considering frame removal we use three criteria:. Consideration of natural history of the injury – characteristics of the injury and existing knowledge of healing times. The appearance of remodelling bridging callus (often endosteal) on anteroposterior and lateral radiographs. Clinical behaviour of the injured limb within a dynamised frame – after 1 and 2 are met, rods connecting the rings stabilising the fracture are loosened. The frame is removed when the patient can stand on the affected limb and dynamised frame without pain, and after weightbearing without pain on the dynamised frame for 3–4 weeks. Results: Premature frame removal was identified in 2/106 tibial fractures treated with Ilizarov frames. In both cases subsequent CT scanning identified a healed fibula and stiff non-union of the tibia. In both, original fracture geometry was complex, with fracture lines outwith the planes of radiographic assessment. Timely frame removal in104/106 (98%). Discussion: In both cases of premature removal the frame was reapplied to achieve union. Premature removal must be balanced against the patient’s desire to have their cumbersome fixator removed at the earliest opportunity. It is said “It is better to leave a frame on one month too long than to remove it a day too soon”, but this merely emphasises that timing of frame removal remains an art rather than an exact science. Marsh and Montgomery have previously suggested use of CT scanning to assess union in peri-articular fractures. We recommend that in high energy tibial fractures whose fracture pattern geometry lies outwith the antero-posterior and lateral radiograph views, a CT scan should be considered to detect stiff non-union and avoid premature frame removal

1. In tuberculous disease of the hip, premature epiphysial fusion at the knee joint is due to rupture of the epiphysial cartilaginous plates consequent upon resorption of cancellous support and suppression of osteogenesis. 2. In the tibia, premature fusion is usually preceded by near-central "bulging" of the metaphysial and tibial marrow through the epiphysial plate. In the femur, epiphysial changes preceding fusion are of a fragmentary type. 3. Injury, in quiescent disease, plays little or no part in the causation of premature epiphysial fusion. 4. The factors which are responsible for these changes—local toxaemia and prolonged immobilisation—must exist for not less than two years. 5. In cases which are treated conservatively for long periods the incidence of premature fusion, with serious shortening of the limb, is so high that the wisdom of such treatment must be reconsidered

The purpose of this study was to determine the incidence of revision total knee replacement (TKR) within 5 years of the index procedure at a large multi-surgeon unit using a single prosthesis and to determine the cause of failure of those implants. This was a retrospective review of all primary Kine-max Plus TKR performed at the Avon Orthopaedic Center between 1.1.1990 and 1.1.2000. Cases were identified that required revision arthroplasty in any form within 5 years of the index procedure. Case notes and Xrays were reviewed to determine causes of failure. There were 2826 primary Kinemax Plus TKR performed during the study period. Of these 20 were known to have required revision surgery within 5 years. 8 were revised for deep infection of the prosthesis and 12 for aseptic causes. The overall incidence of premature failure of the Kinemax Plus TKR at 5 years was 0.71%. The incidence of aseptic premature failure at 5 years was 0.42%. Detailed examination of the clinical records indicated that some form of technical error at the time of the index arthroplasty was responsible for the early failure of 6 prostheses. This equates to 0.21% of the procedures performed. Aseptic loosening of the remaining 6 cases could not be attributed to a specific cause

Premature epiphysial fusion is a common complication of injury of the capitulum in childhood and sometimes results in valgus deformity. Premature fusion can either follow the normal pattern of fusion, perhaps being accelerated on the capitular side, or it can be confined to the capitulum and metaphysis. An optimistic prognosis with regard to valgus deformity and the possible onset of ulnar neuritis cannot be made in view of this complication, even in the undisplaced or perfectly reduced and immobilised cases

We performed a clinical and radiological study to determine the rate of failure of the Charnley Elite-Plus femoral component. Our aim was to confirm or refute the predictions of a previous roentgen stereophotogrammetric analysis study in which 20% of the Charnley Elite-Plus stems had shown rapid posterior head migration. It was predicted that this device would have a high early rate of failure. We examined 118 patients at a mean of nine years after hip replacement, including the 19 patients from the original roentgen stereophotogrammetric study. The number of revision procedures was recorded and clinical and radiological examinations were performed. The rate of survival of the femoral stems at ten years was 83% when revision alone was considered to be a failure. It decreased to 59% when a radiologically loose stem was also considered to be a failure. All the patients previously shown in the roentgen stereophotogrammetric study to have high posterior head migration went on to failure. There was a highly significant difference (p = 0.002) in posterior head migration measured at two years after operation between failed and non-failed femoral stems, but there was no significant difference in subsidence between these two groups. Our study has shown that the Charnley Elite-Plus femoral component has an unacceptably high rate of failure. It confirms that early evaluation of new components is important and that roentgen stereophotogrammetric is a good tool for this. Our findings have also shown that rapid posterior head migration is predictive of premature loosening and a better predictor than subsidence

We have determined the natural history of hip development in 42 patients with multiple epiphyseal dysplasia (MED). Premature osteoarthritis was a frequent outcome and was almost inevitable before the age of 30 years in those with incongruent hips. There were two types of immature hips: type I, the more severe form, had a fragmented and flattened ossific nucleus and acetabular dysplasia, was misshapen at skeletal maturity and osteoarthritic by 30 years of age; the milder type II hip had a small, rounded, uniformly ossified nucleus and a more normal acetabulum. Type II hips were well formed at maturity and were less prone to premature osteoarthritis. Considerable variations were noted in the manifestations of MED between families but not within families. The prognosis of a child's hip could be predicted; in sporadic cases from the type of immature hip, and in familial cases by also taking into account the outcome of affected relatives

Purpose of the study: Little work has been reported on the effects of BMP on bone healing after distraction and the data available in the literature are contradictory. The type of BMP as well as the optimal dose remain to be defined. We present the results and complications linked with the use of different doses of rhBMP-2 in a model of osteogenesis in distraction. Material and methods: Fifteen subadult New Zealand rabbits were selected at random and divided into three groups. On day 0, a mediodiaphyseal tibial osteotomy was cut and an M103 fixation implanted. In group I (5 rabbits), 750μg of rhBMP-2 with a type I collagen sponge (Inductos, Medtronic) were deposited on the osteotomy site. In group II (5 rabbits), 350 μg were deposited on the collagen sponge and in group III (controls, 5 rabbits), nothing was deposited. After the 7-day latency period, distraction was conducted for 21 days (0.5 mm(12hr). At the second week of distraction, the callus was analysed on the x-rays and ultrasounds and a weekly absorptiometry was obtained. The animals were sacrificed three weeks after healing was confirmed. Results: Quantitative radiographic assay showed significantly superior grading (Kirker-Head) in groups I and II (p< 0.05) compared with group III. The qualitative analysis showed premature healing of the regenerate preventing completion of the distraction (pin distortion) for 3/5 rabbits in group I and 1/5 in group II. Bone mineral content was superior in groups I and II in all times studied than in group III (p< 0.05). The difference was also significant between groups I and II (p=0.0087) demonstrating an expected dose effect. Discussion: Premature healing was achieved for the majority of animals in group I, underlining the importance of the dose of BMP used to stimulate bone healing after callotasis. The undesirable effect thus obtained should be taken into account in the clinical context. A dose of 100 μg/kg (350 μg, group III) appears to suffice in this model and defines the upper dose limit. Differed application of the compound (after distraction) should be useful and should be studied. Conclusion: The dose of rhBMP-2 used to stimulate bone healing is an essential parameter that should be defined for each experimental model. The dose effect of rhBMP-2 is demonstrated in this particular model

Premature epiphysial closure is an infrequent complication of Perthes' disease. Twenty-two patients with this condition are reviewed, three of whom were bilaterally affected. The aetiology, radiographic features and effect on function are discussed. The incidence of this complication can be reduced by an awareness of the clinical and radiographic signs which contra-indicate treatment by upper fermoral osteotomy

We found the ABG cementless hip has excessive acetabular wear and premature failure due to osteolysis. In 60 patients implanted at mean age 56 years, 66 hips (mean follow up 48 months), 7 were revised and 7 have severe acetabular osteolysis. In some this is entirely asymptomatic. There was significant association with osteolysis, length of follow up and wear but no correlation between wear and acetabular component position, age, liner thickness, and use of ceramic or CoCr heads. We recommend regular lifelong radiological review of these hips and suspension of use of this prosthesis until a wider review is undertaken

Premature closure of the growth plate of the femoral capital epiphysis associated with limitation of abduction and gluteal insufficiency is described. The indications for trochanteric advancement and the results obtained in the late treatment of Perthes' disease and of congenital dislocation are discussed. Nine hips treated after Perthes' disease had satisfactory results, in that all were improved; but in eight hips with deformity arising from congenital dislocation the outcome was less favourable

1. Three cases of premature epiphysial closure at the knee complicating prolonged immobilisation for congenital dislocation of the hip are described. 2. The etiology of this complication is briefly discussed, and it is suggested that relative ischaemia of the epiphysial plates is the most likely cause

Premature fusion of the triradiate cartilage was obtained surgically in 10 three-week-old rabbits, and compared with isolated fusion of the ilio-ischial and of the ilio-pubic limbs of the triradiate cartilage in two further groups of 10 rabbits. Complete fusion caused acetabular dysplasia five weeks after operation in all animals and hip dislocation at nine weeks in half of them; ilio-ischial fusion had a comparable effect. Ilio-pubic fusion had only a minimal effect on acetabular development. The posterior position of the ilio-ischial limb in the acetabulum and its predominance in the formation of the triradiate cartilage in quadrupeds may have contributed to its decisive effect on acetabular development

Freezing cold injuries (Frostnip and Frostbite) (FCI) have become uncommon in UK military personnel relative to non-freezing cold injuries (NFCI, ‘trench foot’). However if unidentified or inappropriately treated they may lead to avoidable medical downgrading or discharge. JSP 539 recommends delay or avoidance of surgical debridement where possible. An anonymised retrospective audit was performed of FMED7 medical reports of cases seen in the Institute of Naval Medicine Cold Injury Clinic (CIC) between July 2002 and January 2014 inclusive. In all 149 FCI cases were identified, 71 affected hands only of which 34 were bilateral, and 58 affected feet only, 34 of those being bilateral. A total of 17 patients had injured both hands and feet, with 10 bilateral. Royal Marines accounted for half of these cases, with the Army making up a further third, and the Royal Navy and RAF making up the remainder. Most FCI were found to have occurred in Norway, with Marine ranks being most commonly affected. Ten cases underwent surgery: aspiration of blisters, debridement of tissue, or amputation. Seven of these procedures took place prematurely, which appeared detrimental to recovery. No patients required fasciotomy. FCI are uncommon, but in arctic conditions their risk rises dramatically. The best treatment is conservative where possible following JSP 539 guidelines and consultation with CIC should occur at the earliest possibility. The Potential benefits of surgery must be weighed against problems of injured tissue healing and expert opinion should be obtained

We describe a cohort of patients with a high rate of mid-term failure following Kinemax Plus total knee replacement inserted between 1998 and 2001. This implant has been recorded as having a survival rate of 96% at ten years. However, in our series the survival rate was 75% at nine years. This was also significantly lower than that of subsequent consecutive series of PFC Sigma knee replacements performed by the same surgeon. No differences were found in the clinical and radiological parameters between the two groups. At revision the most striking finding was polyethylene wear. An independent analysis of the polyethylene components was therefore undertaken. Scanning electron microscopy revealed type 2 fusion defects in the ultra-high molecular weight polyethylene (UHMWPE), which indicated incomplete boundary fusion. Other abnormalities consistent with weak UHMWPE particle interface strength were present in both the explanted inserts and in unused inserts from the same period.

We consider that these type 2 fusion defects are the cause of the early failure of the Kinemax implants. This may represent a manufacturing defect resulting in a form of programmed polyethylene failure.

Purpose: To evaluate the real effectiveness of orthopaedic prenatal diagnosis. Introduction: Sonographic early detection of fetal club foot, spine abnormalities like “spina bifida” or spondylocostal ‘” dysostosis, limb discrepancy have been often reported in prenatal orthopaedic diagnosis. But in all these cases the role of the orthopaedic surgeon is secondary: In the case reported the joined evaluation of obstetrician and orthopaedic surgeon was able to anticipate delivery, avoid a severe and constrictive amniotic band on the lover limb which might cause an amputation of the ankle and foot. Material and methods: At 25th week of pregnancy a morphologic sonographic examination was carried out in a Caucasian healthy woman. It demonstrated an healthy male fetus presenting a constrictive amniotic band on the distal right leg causing a mild oedema of the foot. Four weeks later the oedema of ankle and feet was dramatically increased and on the distal tibia an initial notch on the cortex was observed. The risk of self-amputation in utero was high, so a decision to bring forward delivery was made by a obstetrician, and paediatrician orthopaedic surgeon. In the last two weeks of uterine life the fetus was treated to obtain a satisfactory lung maturity and at 32nd week a caesarean delivery was carried out. The baby, normal, (agar score 7–9, 2750 kg.) presented a tremendous oedema of the dorsal foot causing a complete disappearance of normal shape. The skin constriction was detected on the distal leg deeply extended to the bone. An X -ray early performed showed a lesion of the anterior margin of the tibia. A Sonographic Doppler of the distal leg was able to demonstrate vascular normality so at the age of two days the baby was admitted to the plastic and reconstructive surgery for the release of the amniotic band and for reductive surgery of foot’s redundant tissue. The follow-up was good with a temporary oedema post-surgery. In 60 days the appearance of the foot was satisfactory normal. Discussion: The ultrasonographic prenatal diagnosis of an amniotic band in the reported case probably has been able to avoid an amputation of the distal lower limb. The aim of this communication is to stress the role of the prenatal diagnosis in paediatric orthopaedic to emphasize the importance of early detection of congenital skeletal abnormalities. Severe and stiff club-foot, congenital “genu recurvatum” and amniotic band as. well, ought to be treated as soon as possible. Therefore, when diagnosed in selected pregnancies, if the fetus is healthy and the lung maturity is obtained with corticosteroIds and sulfactante factor sommmlstratlon, we advise a premature delivery never before 32nd week of intrauterine life. At this stage the deformities are less stiff and every treatment (manipulation, bandage, casting) offers better results and less risk