The Masquelet technique, also known as the ‘induced membrane technique’ has been utilised in adult reconstruction with varied success. However, there is limited literature on its use in children and this study aims to share our experience.

Introduction

Aim of this study was to review a single surgeon series and analyse the results of hip reconstruction and compare them to an historical cohort.

Background

Ilizarov hip reconstruction is a salvage option traditionally done with fixators, which often face limited compliance. We aimed at reviewing our early results of a novel technique with internal devices.

Purpose

Surgical correction of upper limb deformities in severe osteogenesis imperfecta (OI) is technically difficult and less absolving, hence we aimed to analyse the surgical complications of rodding the humeri in severe OI.

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.

Purposes of the Study

To study the incidence of delayed consolidation of regenerate in children undergoing correction or lengthening of lower limb deformities using an external fixator.

We present our experience of the modified Dunn procedure in combination with a Ganz surgical dislocation of the hip to treat patients with severe slipped capital femoral epiphysis (SCFE). The aim was to prospectively investigate whether this technique is safe and reproducible. We assessed the degree of reduction, functional outcome, rate of complications, radiological changes and range of movement in the hip. There were 28 patients with a mean follow-up of 38.6 months (24 to 84). The lateral slip angle was corrected by a mean of 50.9° (95% confidence interval 44.3 to 57.5). The mean modified Harris hip score at the final follow-up was 89.1 (sd 9.0) and the mean Non-Arthritic Hip score was 91.3 (sd 9.0). Two patients had proven pre-existing avascular necrosis and two developed the condition post-operatively. There were no cases of nonunion, implant failure, infection, deep-vein thrombosis or heterotopic ossification. The range of movement at final follow-up was nearly normal. This study adds to the evidence that the technique of surgical dislocation and anatomical reduction is safe and reliable in patients with SCFE.

Cite this article: Bone Joint J 2013;95-B:424–9.

Introduction: Obligatory external rotation during flexion is well recognised as a cardinal feature of Slipped Upper Femoral Epiphyses (SUFE). We have evaluated the significance of acetabular version in contributing to the external rotational deformity that is seen in otherwise normal hips. We present a small case series focussing on the characteristics of this pathology, highlighting its significance and outlining a treatment strategy.

Method: Five patients (eight hips) presented with disabling hip pain during non-sporting activities. All their hip radiographs had been reported as normal. The rotational profile of both acetabulum and femur in these patients was evaluated by MRI and CT scans.

Results: Clinical examination revealed otherwise normal hips but for an external rotation deformity which got worse on hip flexion. The average external rotation deformity with the hip in extension was 60 degrees, which worsened to 90 degrees during hip flexion. Three of these hips had been previously treated with in situ pinning for SUFE. Other hips were in patients who were either skeletally mature or close to skeletal maturity. We found that all were “profunda hips” with severe acetabular retroversion. The abnormality in acetabular version was best defined on axial imaging.

Conclusions: The femoral head is a spherical conchoid. The concept of version of the hip (both femoral and acetabular) as described by McKibbin, Tonnis and Ganz is reviewed. Femoral retroversion is common in patients with SUFE, but the addition of acetabular retroversion makes these hips disproportionately symptomatic. This deformity causes a combination of pincer and cam impingement, which is responsible for the marked disability. SUFE alone causes cam impingement, whilst a corresponding degree of slip without retroversion and profunda of the acetabulum is not that disabling.

Aim of the study: To evaluate the final outcome following joint distraction and reconstruction in patients with complex knee contractures in a select group with varied aetiology.

Materials and methods: Retrospective study of six patients (nine knees, 3 bilateral) with severe knee flexion contractures treated by gradual distraction using ring fixators. Most cases were syndromic or arthrogrypotic.. Case notes and radiographs were reviewed to assess the mobility and functional range of motion before and after the procedure.

Results: Staged procedures was carried out in 6 out of 9 knees accompanied by soft tissue releases, realignment of extensor mechanism and bony and joint realignment. The average age at operation was nine years and nine months and the mean follow up was 53 months. The average time spent in frame was 20 weeks. The correction was graded as good to excellent in 5 knees, fair in 1 and poor in 3 knees. The total arc of motion remained unchanged though the functional range of movement improved. The mobility improved significantly in most patients who were independent walkers with or without splints. Complications were of rebound phenomenon after frame removal in arthrogrypotic children, transient neuropraxia of common peroneal nerve in 2 epiphyseal separation in one and 3 sustained undisplaced fractures during mechanical distraction.

Conclusion: Syndromic and arthrogrypotic knee contractures are difficult to treat due to their severity and complexity. Planned staged procedures with joint distraction, patellar and bony realignment can produce satisfactory outcome in most making them functional independent ambulators.

Introduction: Prophylactic pinning of an asymptomatic hip in SCFE is controversial. Bone age has been used as evidence of future contralateral slip risk and used as an indication for such intervention. The efficacy of bone age assessment at predicting contralateral slip was tested in this study.

Patients and Methods: 18 Caucasian children prospectively had bone age assessment using wrist and hand x-rays when presenting with a unilateral SCFE. Patients and parents were informed about the chance of contralateral slip and risks of prophylactic fixation, and advised to attend hospital immediately on development of symptoms in contralateral hip. After in-situ fixation of the affected side prospective monitoring in outpatient department was performed. Surgical intervention was undertaken if the contralateral hip was symptomatic.

Results: Three children (2 boys) went on to develop to a contralateral slip at a mean of 20 months from initial presentation. 6 children (5 boys) were deemed at risk of contralateral slip due to a bone age below 12.5 years for boys and 10.5 for girls. Only one from this group developed a contralateral slip. The relative risk of proceeding to contralateral slip when the bone age is below the designated values was 1 (95% confidence interval of 0.1118 to 8.95).

Conclusion: Delayed bone age by itself is not a good predictor of future contralateral slip at initial presentation. Routine prophylactic pinning is not justified based on bone age alone, with the risks of surgical fixation it carries. Prospective long term longitudinal study is required.

Aim: The purpose of this study is to define the hip anatomy in cerebral palsy in a three dimensional geometrical manner and then perhaps plan a better surgical reconstruction for these affected hips.

Materials & Methods: The case notes and radiographs of 18 patients with cerebral palsy who underwent plain radiographs, axial CT and 3D CT scans from October 1993 to June 1995 were reviewed prospectively all being consecutive. The following indices were measured – acetabular anteversion (AA), anterior axial acetabular index (Anterior AAI), posterior axial acetabular index (Posterior AAI), Total axial acetabular index (Total AAI) and acetabular depth/femoral head diameter (AD/FHD) ratio.

Results: The acetabular index, and CEA angle clearly showed the hips to be dysplastic in frontal plane. FAV measurements done on CT scan in our study was 330 on the right and 420 on the left. This was significantly higher than normal in our group of patients. Acetabular anteversion was higher in our series, which contributed to hip instability. There were no patients with acetabular retroversion. The axial acetabular indices suggested predominant anterior than posterior acetabular dysplasia, and the total AAI was suggestive of a flatter and shallower acetabulum. A normal to minimally increased AAI in our study suggests an increase in the size rather than a true malrotation.

Conclusions: Our study shows that CT scan analysis is a useful tool in preoperative planning for hip reconstructions. This analysis gives a better idea of the distorted anatomy and a more accurate quantitative and qualitative assessment of the hips.

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.