Aim

The Pelvic Support Osteotomy (PSO) or Ilizarov Hip Reconstruction(IHR) is well described for the treatment of septic sequelae of infancy. The purpose of this study was to clinically, functionally and radiographically assess our short-term results of this procedure.

Aim: To evaluate the accuracy of ultrasound to locate the gastrocnemius musculotendinous junction (GMTJ) prior to surgery. There is no clear clinical method to precisely localise this junction, either in the paediatric or adult populations.

Method: Twenty calves in 12 paediatric patients with a diagnosis of spastic gastrocnemius muscle (GM) contracture underwent ultrasound examination prior to slide lengthening (Strayer). Surgeons did the ultrasound examination after only a short introduction to the method, using a portable ultrasound machine (Sonosite 180 PLUS) with a linear (5–10 MHz frequency range) transducer.

Only the GMTJ of medial head was located as it usually has a lower attachment and is thicker. The soleus muscle has short multipennate fibres running obliquely between aponeuroses overlying its anterior and posterior surfaces. GM has long parallel fibres and merges distally with the posterior aponeurosis of the soleus muscle. The GMTJ has a unique conical appearance on ultrasound. Pre operative skin markings were compared with the location of GMTJ during surgery.

Results: All ultrasound-guided locations of GMTJ were found to be accurate within 5mm at time of surgery.

Conclusions: This study indicates that ultrasound of the calf muscles by a surgeon prior to surgery is an accurate and reliable way of centering the incision over the GMTJ. The distinct morphological structure of the soleus muscle and overlying GM heads means that even surgeons with little ultrasound experience can perform the examination.

We present the long-term results of pectoralis major transfer to restore elbow flexion in seven patients (ten procedures). The early results in all the patients were encouraging but with longer follow-up a gradual and progressive flexion deformity was observed with a decrease in the arc of flexion in eight elbows, reaching ≥ 90° in all cases.

The results of pectoralis major transfer deteriorate with time due to the development of a recalcitrant flexion deformity of the elbow. With bilateral involvement we now recommend that the procedure be undertaken on one side only to allow the hand to reach the mouth for feeding, while the opposite side remains in extension for perineal toilet.

We performed limb lengthening and correction of deformity of nine long bones of the lower limb in six children (mean age, 14.7 years) with osteogenesis imperfecta (OI). All had femoral lengthening and three also had ipsilateral tibial lengthening. Angular deformities were corrected simultaneously. Five limb segments were treated using a monolateral external fixator and four with the Ilizarov frame. In three children, lengthening was done over previously inserted femoral intramedullary rods.

The mean lengthening achieved was 6.26 cm (mean healing index, 33.25 days/cm). Significant complications included one deep infection, one fracture of the femur and one anterior angulation deformity of the tibia. The abnormal bone of OI tolerated the external fixators throughout the period of lengthening without any episodes of migration of wires or pins through the soft bone. The regenerate bone formed within the time which is normally expected in limb-lengthening procedures performed for other conditions.

We conclude that despite the abnormal bone characteristics, distraction osteogenesis to correct limb-length discrepancy and angular deformity can be performed safely in children with OI.

Aim: The aim of the study was to evaluate the outcome of open surgery for DDH in a tertiary centre.

Method: Primary and tertiary referrals between 1983 and 1996 were followed up for 8.2 years (4.1 to 16.8 years). 60 hips in 47 patients had open reduction for DDH. 39 patients were females. 13 hips had bilateral involvement. Age at operation was 2.1 years (0.1 to 5.5 years). 32 patients were referred from elsewhere for surgery after closed or open primary treatment.

Results: Clinical and radiological assessment was done on all the patients. The outcome was evaluated using the McKay system and Severin grade for subluxation. 12 hips had Type II, III or IV or unclassifiable AVN according to the Kalamchi and MacEwen classification (20%). The other results are tabulated as follows:

Complications other than AVN were re-subluxation (3), redislocation(4), fractures (1), ankylosis, LLD(4), infection (2). There was only 1 (5.9%) complication in primary referral group and 13 (30.2%) in tertiary referral group (p=0.050). Tonnis grade of subluxation, presence of ossific nucleus, tear drop shape, Mose’s grading, CE angle of Wiberg were documented but were not found to significantly affect the outcome.

Conclusion: Multiple operation increases the risk of proximal femoral growth disturbance and affects the outcome. No statistical difference was noted in the AVN rate between the primary referral group and the tertiary referral group. However, there were significantly more complications in the tertiary referral group and there maybe a need for early tertiary referral.

Aim: To determine the ultra-structural morphology of bone in CLLLD.

Materials and Methods: Bone biopsies were taken from 8 patients with CLLLD undergoing surgery for limb reconstruction procedures. Specimens were fixed and processed for Electron microscopy using standard processing protocol. Ultra-thin araldite sections were stained with uranyl acetate and lead citrate and viewed in Philips CM12 electron microscope. Muscle biopsies were also undertaken.

Results: There were 5 boys and 3 girls of a mean age of 8.8 years (range 3 to 14 years). 6 had predominantly femoral deficiencies and 2 had combined femoral and fibular deficiencies. All specimens showed abnormal collagen fibril morphology. They showed variable diameter with irregular outlines in transversely section bundles and appeared unravelled in longitudinally sectioned bundles. The osteoid was disorganised in 4 of the 8 specimens and osteoblasts showed necrotic changes in 5 out of 8 specimens. Patchy mineralisation and increased proteoglycan distribution was observed in 3 out of 8 specimens.

Conclusion: Bone in CLLLD shows ultra-structural changes in collagen and osteoblasts that may account for the retarded bone growth and poor regenerate formation that occurs during limb lengthening in these patients.

We describe ten patients with Turner’s syndrome (karyotype 45, XO) who had leg lengthening for short stature. A high incidence of postoperative complications was encountered and many patients required intramedullary fixation as a salvage procedure. We discuss the reasons for this and highlight the differences between our findings and those of a similar series recently reported. In view of the considerable difficulties encountered, we do not recommend leg lengthening in Turner’s syndrome.

The Sheffield Expanding Intramedullary Rod System was developed after experiencing problems with existing rod systems in the management of osteogenesis imperfecta. Between 1986 and 1996 we treated 74 bones in the lower limb in 28 children at a median follow-up of 5.25 years. We have reviewed 24 children with a total of 60 rods.

Before surgery, all children had had multiple fractures of the lower limb. At review eight patients had experienced no further fractures, but three had suffered five or more subsequently.

Before initial stabilisation, 15 children had never walked, and only three (13%) used walking as their main means of mobility. After surgery, half of those who showed motor arrest were able to walk (p = 0.016). The number of patients able to walk, with or without aids, increased to 17 (p = 0.0001).

We have experienced no evidence of epiphyseal damage after the procedure, and complication rates requiring rod exchange have been low (7%).