Aim

The aim of the study was to characterise gait in patients with achondroplasia post lengthening.

Purpose

To examine the effect of limb lengthening on the quality of life of people who have disproportionate short stature (DSS).

Background: Information on embryological hip development has been obtained from post mortem examination

. There is less information on normal foetal hip

AIM: To assess the value of MRI of the foetus and neonate to provide information on normal and abnormal hip development.

To establish normal patterns of hip development.

To obtain charts that could be used to detect abnormality earlier.

There are three aspects to this study:

Validation – analysing MRI scans of babies hips prior to post mortem (the gold standard) would verify MRI as a valid tool for such studies.

PATIENT SELECTION: 30 patients for each aspect of this pilot study, 90 in total (3).

For the initial validation process, parents who had consented to post mortem were asked to consider additionally an MR scan of their neonate’s hips, a total of 30 cases.

Method: MR images in axial and coronal planes were obtained using a high resolution T2 weighted sequences (4).

Measurements were made, by two independent observers, of the width and depth of the acetabulum and the radius & diameter of the femoral head, volume and area were calculated. Inter-observer variation was assessed.

Results: The babies ranged in gestation from 17 – 42 weeks

With the exception of the acetabular width each dimension showed little development until week 20 when the line of growth rose exponentially. The acetabular width showed only a slow rate of growth despite the changes seen in the femoral head. Levels of observer agreement were high (ICCs = 0.98) for all but depth (ICCs = 0.86). The measurements for all dimensions were in line with previous post mortem studies.

CONCLUSION: MRI is a valid and acceptable alternative to post mortem in the assessment of hip development eventually allowing early detection of abnormal hip development.

Background The ossific nucleus of the femoral head is usually present ultrasonographically around 12 weeks of age. It has been considered that the presence of an ossific nucleus in the femoral head is an indication of hip stability. In the ultrasound scan clinic for the assessment of developmental dysplasia of the hip at Sheffield Children’s Hospital, we have identified unstable hips with ossific nuclei, as well as, the appearance of ossific nuclei at as early as 2 weeks of age. These observations suggested the need to clarify the initial considerations that the ossific nucleus appeared ultrasonographically around 12 weeks of age and was an indicator of hip stability.

Aim To determine the relationship, if any, between the presence of the ossific nucleus of the femoral head ultrasonographically and stability of the hip.

Patient selection We have included in our study all the children who have had an ultrasound scan of their hips from 1996 to 1999 at Sheffield Children’s Hospital for suspected developmental dysplasia.

Methodology We have retrospectively reviewed reports of ultrasound scans performed for developmental dysplasia of the hip between 1996 and 1999. We have looked at the report for both the hips of each child. We have collected and analyzed data with regard to the age of the child at the time of the scan, the depth of the acetabulum, the shape of the femoral head, the presence or absence of an ossific nucleus, the dynamic stability of the hips and the congruity of the joint as reported on the ultrasound report. We report the findings in the first 318 hips of the 627 available patients in the study period.

Results The ossific nucleus can appear as early as 2 weeks and yet may not be visible until 24 weeks. In the 318 hips examined the ossific nucleus was present in 46 (14.47%). The age range for these scans was 1–40 weeks after birth. Of the 318 hips 252 (79.24%) were stable on dynamic screening, 274 (86.16%) had a normal(spherical) appearance of the femoral head, 209 (65.72%) had normal acetabular development and 263 (82.7%) demonstrated congruence of the hip joint. These data have been analyzed using Microsoft excel at confidence intervals of 0.8, which suggest no relationship between the presence of the ossific nucleus and hip stability.

Conclusion The limited early results of this study have shown that the ossific nucleus of the femoral head can appear from a very early age, may not appear until well after 12 weeks of age and is not an indicator of hip stability. Its presence on ultrasound scan does not exclude developmental dysplasia of the hip.

Background Information on embryological hip development has been obtained from post mortem examination (1). There is less information on normal fetal hip (2). Magnetic resonance imaging (MRI) allows development to be followed in the healthy baby.

Aim To assess the value of MRI of the foetus and neonate to provide information on normal and abnormal hip development.

To establish normal patterns of hip development.

To obtain charts that could be used to detect abnormality earlier.

There are three aspects to this study:

Validation – analysing MRI scans of babies hips prior to post mortem (the gold standard) would verify MRI as a valid tool for such studies.

Patient selection 30 patients for each aspect of this pilot study, 90 in total (3).

For the initial validation process, parents who had consented to post mortem were asked to consider additionally an MR scan of their neonate’s hips, a total of 30 cases.

Method MR images in axail and coronal planes were obtained using a high resolution T2 weighted sequences (4).

Measurements were made, by two independent observers, of the width and depth of the acetabulum and the radius & diameter of the femoral head, volume and area were calculated. Inter-observer variation was assessed.

Results The babies ranged in gestation from 17 – 42 weeks

With the exception of the acetabular width each dimension showed little development until week 20 when the line of growth rose exponentially. The acetabular width showed only a slow rate of growth despite the changes seen in the femoral head. Levels of observer agreement were high (ICCs 95% = 0.98) for all but depth (ICCs 95% = 0.86). The measurements for all dimensions were in line with previous post mortem studies.

Conclusion MRI is a valid and acceptable alternative to post mortem in the assessment of hip development eventually allowing early detection of abnormal hip development.

Aims: To review the early results of Birmingham hip resurfacing (BHR). First 116 hips (98 patients). Materials: A cohort of consecutive patients prospectively underwent BHR in a single arthroplasty Surgeonñs practice in a University Hospital out side Birmingham. Inclusion criteria þt and active patients expected to out live conventional THR. 98 patients mean age 50 years (range 19–67). Pathology OA 85%, Perthes 7%, DDH 4.7% & SUFE 2%. Mean follow-up 30 months (range 12–45). Scoring systems used were Harris hip score (HHS), WOMAC & SF 36. Results: All patients under review, no radiological loosening.

HHS:Mean pre-arthroplasty score 47 (range 10–73), 1 yr score 99 (n=38), 2yr 97.3 (n=30) at 3yr 100 (n=26) & 4th yr 100 (n=4), this shows a statistically signiþcant improvement (P=0.001).

WOMAC: Pain: pre-op score 18.8, at 1 year 5.6 & 2nd year 5.7. Stiffness: pre-op 8.5, 1 year 2.7 & 2nd year 2.7. Physical: 49.3, 1 year 23.4 & 2nd year 22.6.

This shows a statistically signiþcant improvement in score (p=0.025) SF-36 Analysed against an age/sex match control group of normal values using a 2 tailed Ôtñ Test, seven of the eight domains showed no statistical signiþcant difference. Complications: One fracture following a fall, 2 AVN & early fractures (patients had deep cysts in proximal head now such patients are not offered BHR), one dislocation following RTA Conclusions: Birmingham hip resurfacing can provide excellent level of activity and patient satisfaction. Careful patient selection is needed. A long-term study is needed to evaluate the long-term beneþt and survivorship

Fine-wire accepted as a minimally external fixation is invasive technique, which can provide better outcomes than traditional open methods in the management of complex fractures of the tibial plateau. Available fixators vary in their biomechanical stability, and we believe that a stable beam-loading system is essential for consistently good outcomes. We assessed, prospectively, the clinical, radiological and general health status of 20 of 21 consecutive patients with complex fractures of the tibial plateau who had been treated using a standard protocol, with percutaneous screw fixation and a neutralisation concept with a fine wire beam-loading fixator allowing early weight-bearing.

Bony union was achieved in all patients, with 85% having good or excellent results. Full weight-bearing started during the first six weeks in 60% of patients. The general health status assessment correlated well with the knee scores and reflected a satisfactory outcome.

To review the early functional results of Birmingham hip resurfacing. First 116 hips (98 patients), a cohort of consecutive patients prospectively underwent BHR in a single arthroplasty Surgeon’s practice in a University Hospital outside Birmingham. Inclusion criteria fit and active patients. 98 patients mean age 50 years (range 19–67). Pathology OA 85%, Perthes 7%, DDH 4.7% & SUFE 2%. Mean follow-up 30 months (range 12–45). Scoring systems used were Harris hip score (HHS), WOMAC & SF36.

HHS: mean pre-arthroplasty 47 (range 10–73), one year 99 (n=57), at 2 years 97.3 (n=26) and at third year 100 (n=3), statistically significant improvement (P=0.001).

WOMAC: pain: pre-op score 18.8, at 1 year 5.6 and second year 5.7. Stiffness: pre-op 8.5, 1 year 2.7 & 2^nd year 2.7. Physical: 49.3, 1 year 23.4 & 2^nd year 22.6.

This shows a statistically significant improvement in pain score (p=0.025) and physical function score (p=0.025).

SF-36 one-year post op, when analysed against an age/sex match control group normal values using a 2 tailed ‘t’ Test, seven of the eight domains showed no statistical significance. Only the Social Functioning domain showed a statistically significant result (p=0.011).

One fracture following a fall (patient had deep cysts in proximal head now such patients are not offered BHR), one dislocation following RTA and one AVN in a 50 years old post menopausal lady.

Birmingham hip resurfacing can provide excellent level of activity and patient satisfaction. A long-term study is needed to evaluate the long-term benefit and survivorship.

To assess the outcome of bicondylar tibial fractures, treated prospectively with fine wire fixation in the Limb Reconstruction Service.

Twenty patients with mean age 56 years with bicondylar tibial plateau fractures, were treated at the author’s institution with fine wire fixation over a three-year period. Ten followed road traffic accidents and four followed high-energy falls; The remainder mainly in the elderly resulted from a simple fall. There were four Schatzeker type V, and sixteen type VI. Four were open fractures (Gustilo grade III); Seven patients sustained associated fractures at the same time. They were treated according to a prospective protocol and were followed up for an average of thirty months, (11 – 51). The protocol included CT Scan Guided planning, closed reduction if possible and percutaneous interfragmentary screw fixation to reconstruct the articular surface, under image intensifier control; The external fixator was applied in neutralization. Mobilization and full weight bearing was encouraged as early as possible

Ten patients started full weight bearing between four and six weeks post operatively, in nine cases with other injuries weight bearing was delayed. All patients healed with an average time in the fixator of eighteen weeks, (9–25).

Fifteen patients had a range of movement from Zero to at least 120 degrees flexion. Using Rasmussen’s functional and radiological scoring system, fifteen out of twenty scored good or excellent. Complications included deep vein thrombosis in one patient, loss of fracture reduction in three, superficial pin tract infection which resolved with local pin care and a short courses of antibiotic in five patients, there was no deep infection.

The Sheffield hybrid external fixator is strong, permits early fracture recovery and weight bearing and may have significantly contributed to the high rate of good results in this group, of which more than 50% were over sixty years old. This technique is recommended for treatment of this difficult fracture.