The risk of AVN is high in Unstable Slipped Capital Femoral Epiphysis (SCFE) and the optimal surgical treatment remains controversial. Our AVN rates in severe, unstable SCFE remained unchanged following the introduction of the Modified Dunn Procedure (MDP) and as a result, our practice evolved towards performing an Anterior Open Reduction and Decompression (AOR) in an attempt to potentially reduce the “second hit” phenomenon that may contribute. The aim of this study was to determine the early surgical outcomes in Unstable SCFE following AOR compared to the MDP.

All moderate to severe, Loder unstable SCFEs between 2008 and 2022 undergoing either an AOR or MDP were included. AVN was defined as a non-viable post-operative SPECT-CT scan.

Eighteen patients who underwent AOR and 100 who underwent MPD were included. There was no significant difference in severity (mean PSA 64 vs 66 degrees, p = 0.641), or delay to surgery (p = 0.973) between each group. There was no significant difference in the AVN rate at 27.8% compared to 24% in the AOR and MDP groups respectively (p = 0.732). The mean operative time in the AOR group was 24 minutes less, however this was not statistically significant (p = 0.084). The post-reduction PSA was 26 degrees (range, 13-39) in the AOR group and 9 degrees (range, −7 to 29) in the MDP group (p<0.001). Intra-operative femoral head monitoring had a lower positive predictive value in the AOR group (71% compared to 90%).

Preliminary results suggest the AVN rate is not significantly different following AOR. There is less of an associated learning curve with the AOR, but as anticipated, a less anatomical reduction was achieved in this group. We still feel that there is a role for the MDP in unstable slips with a larger remodelling component.

The treatment of joint-fractures is a common task in orthopaedic surgery causing considerable health costs and patient disabilities. Percutaneous techniques have been developed to mitigate the problems related to open surgery (e.g. soft tissue damage), although their application to joint-fractures is limited by the sub-optimal intra-operative imaging (2D- fluoroscopy) and by the high forces involved. Our earlier research toward improving percutaneous reduction of intra-articular fractures has resulted in the creation of a robotic system prototype, i.e. RAFS (Robot-Assisted Fracture Surgery) system.

We propose a robot-bone attachment device for percutaneous bone manipulation, which can be anchored to the bone fragment through one small incision, ensuring the required stability and reducing the “biological cost” of the procedure. It consists of a custom-designed orthopaedic pin, an anchoring system (AS secures the pin to the bone), and a gripping system (GS connects the pin and the robot). This configuration ensures that the force/torque applied by the robot is fully transferred to the bone fragment to achieve the desired anatomical reduction.

The device has been evaluated through the reduction of 9 distal femur fractures on human cadavers using the RAFS system. The devices allowed the reduction of 7 fractures with clinical acceptable accuracy. 2 fractures were not reduced: in one case the GS failed and was not able to keep the pin stationary inside the robot (pin rotates inside the GS). The other fracture was too dislocated (beyond the operational workspace capability of the robot). A more stable GS will be designed to avoid displacements between the pin and the robot.

Aim

Vascular compromise following supracondylar fractures is frequently described. Near Infra-red Spectrometry (NIRS) is a technique through which real-time data can be gathered non-invasively on the oxygenation status of tissues. The drive now is to gain knowledge on how NIRS data can be interpreted and to validate its use in the clinical setting.

Anatomic reduction (subcapital re-alignment osteotomy) via surgical hip dislocation – increasingly popular. While the reported AVN rates are very low, experiences seem to differ greatly between centres. We present our early experience with the first 29 primary cases and a modified fixation technique.

We modified the fixation from threaded Steinman pins to cannulated 6.5mm fully-threaded screws: retrograde guidewire placement before reduction of the head ensured an even spread in the femoral neck and head. The mean PSA (posterior slip angle) at presentation (between 12/2008 and 01/2011) was overall 68° (45–90°). 59% (17/29) were stable slips (mean PSA 68°), and 41% (12/29) were unstable slips unable to mobilise (mean PSA 67°). The vascularity of the femoral head was assessed postoperatively with a bone scan including tomography.

The slip angle was corrected to a mean PSA of 5.8° (7° anteversion to 25° PSA). We encountered no complications related to our modified fixation technique.

All cases with a well vascularised femoral head on the post-operative bone scan (15/17 stable slips and 8/12 unstable slips) healed with excellent short term results.

Both stable slips with decreased vascularity on bone scan (2/17, 12%) had been longstanding severe slips with retrospectively suspected partial closure of the physis, which has been described as a factor for increased risk of avascular necrosis (AVN). One of these cases was complicated by a posterior redislocation due to acetabular deficiency. In the unstable group, 4/12 cases (33%) had avascular heads intra-operatively and cold postoperative bone scans, 3 have progressed to AVN and collapse.

Anatomic reduction while sparing the blood supply of the femoral head is a promising concept with excellent short term results in most stable and many unstable SCFE cases. Extra vigilance for closed/closing physes in longstanding severe cases seems advisable. Regardless of treatment, some unstable cases inevitably go on to AVN.

Most minimal invasive surgical (MIS) systems use traditional implant systems combined with new instrumentation. In this study we analyzed a THR system that basically implies that all components are implanted through the femoral neck. The cemented femoral component consists of a highly polished tapered design. The acetabular component is made of Alumina and has an outside diameter of 20 mm. The purpose of this study was to investigate the range of motion, the wear characteristics, the fatigue characteristics of the femoral neck and the stability of the femoral component.

The range of motion of the MIS prosthetic system was calculated with a mathematical model that enabled calculation of prosthetic impingement angles. To assess the wear properties, four pairs of Zirconia heads on alumina acetabuli were tested in a hip simulato. To assess the probability of femoral neck fracture, 3 components were tested according to ISO7206. The stability of the femoral components were tested in five fresh cadaver using dynamic loading conditions. After this test, the load was increased until reconstructive failure occurred.

The ROM was in the order of 100 degrees of flexion and at least 30 degrees in other directions. The bearings showed remarkably low wear with a maximum of 0.02 mm3. All three stems survived the ISO-fatigue test. During the dynamic experiments the specimens did not fail, and no macroscopic damage was detected. Migration was only minor and stabilized during testing. The post-testing failure loads varied between 4.1 and 5.5 kN.

The ROM, stem-neck strength and wear properties of the system seem acceptable. The stability of the femoral component was satisfying; but the post-testing strength may be similar to loads that are applied on the hip at a falling accident. We conclude that these results are encouraging and warrant further studies to develop this system.

The aim of this study was to assess the usefulness of Cast index and an indigenously developed Gap index as measures of poor moulding of plaster. 20 cases of re-manipulation of distal third forearm fractures excluding growth plate injuries were compared with a control of 80 patients. 5 patients in the control group had an axial deviation of more than 10 degrees but were not remanipulated and therefore were included in the failure group. The gap index and the cast index of the two groups was compared as predictors of failure of conservative treatment. The groups were similar in terms of demography and post reduction alignment. There was a significant difference (< 0.001) in the Cast index and the Gap index of both the groups. The sensitivity of the Cast index (> 0.8) in predicting failure of plaster was 48% while that of the sum of Gap index (> 0.15) in AP & Lat view was 88%. Gap index was found to be more accurate (84%) than Cast index (78%) in predicting failure. The gap index is a better predictor of failure than the cast index. A quick assessment of these indices, especially by the less experienced surgeons, is a good practice before accepting any plaster following a manipulation of distal radial fractures. It would not only save the patient a second anaesthesia but also complications of a more extensive second procedure and of course hospital resources.

The increasing success rates of total hip replacements (THR) have led to a younger patient population with an increased probability for revision. The survival of revised components is improved by a good bone quality. This has led to an increased interest in bone preserving THR designs. A novel type of THR was developed of which the femoral component is cemented in the neck. The load carrying area of this prosthesis is reduced in comparison with conventional cemented implants. Whether an adequate stability can be achieved was biomechanically evaluated during simulated normal walking and chair rising. In addition, the failure behaviour was investigated.

Bone mineral density (BMD) was measured in 5 fresh frozen proximal human cadaver femora. The femoral heads were resected and a 20 mm diameter canal was created in the femoral necks. Bone cement was pressurised in this canal and the polished, taper-shaped prosthesis was subsequently introduced centrally. A servohydraulic testing machine was used to apply dynamic loads up to 1.8 kN to the prosthetic head. Radiostereophotogrammetric analysis was used to measure rotations and translations between prosthesis and bone. In addition, the constructions were loaded until failure in a displacement-controlled test.

During the dynamic experiments, the femoral necks did not fail, and no macroscopical damage was detected. The initial stability of the implant did not seem to be sensitive to bone quality. Maximal values were found for normal walking with a mean rotation of about 0.2 degrees and a mean translation of about 120 microns. These motions stabilised during testing. The failure loads in this study varied between 4.1 and 5.5 kN, higher failure loads were associated with higher BMD values. Most specimens showed subtrochanteric spiral fractures.

In conclusion, the stability of the prosthetic device may be adequate under dynamic, physiological loading conditions. The static failure loads were relatively low and require further optimisation of the prosthetic implant.

Introduction: Meningococcal septicemia is a devastating illness that primarily affects children. Late orthopaedic sequelae, though rare, are being seen more frequently as acute medical management has reduced the initial mortality rate.

Aims: To review the case histories and discuss the management of these children.

Methods: A retrospective review of medical notes and radiographs was undertaken at the participating hospitals. Outcomes assessed included clinical & radiologic outcome, limb length equalization and correction of the mechanical axis.

Results: Between 1990 and 2000, twenty patients aged 2 to7 years presented to the orthopaedic departments of the participating hospitals with late sequelae. On average presentation wasf 4 years (2 – 6) after the acute phase of the disease. The reasons for referral included angular deformity, limb length discrepancy, joint con-tracture or problems with prosthetic fitting. The lower limbs were involved more frequently than the upper limbs. In fourteen children multiple growth plates were affected. Partial growth arrest was the cause of the angular deformity and limb length discrepancy. All twenty children underwent operations for realignment of the mechanical axis and equalization of limb length. Recurrence of the angular deformity was almost universal.

Conclusion: Children who survive meningococcal septicaemia are at risk for developing late orthopaedic sequelae. Lower limbs are more commonly affected with deformities of limb length and axis. We recommend complete ablation of the affected growth plates at the initial surgery to prevent recurrence of the angular deformity. Further limb length equalization procedures can be anticipated. Early recognition and orthopaedic follow-up to skeletal maturity is essential for minimizing the effects of these sequelae.

Concomitant ipsilateral femoral and tibial fractures result from high velocity injuries and are often associated with other, life threatening, injuries. They are rare injuries in children with few published series, none of which comment on the use of flexible intramedullary nails in the treatment of such injuries.

We present our experience of concomitant ipsilateral femoral and tibial fractures in children and discuss the use of flexible intramedullary nails in their management.

Hospital records and radiographs of 19 such injuries in 18 patients were studied. These cases were divided into three groups based on the method of treatment. Group A: (8 cases) both the femoral and tibial fractures were internally fixed.

Group B: (4 cases) only one out of the two fractures had internal fixation while the other was externally immobilised.

Group C: (7 cases) both femoral and tibial fractures were treated with external immobilisation like external fixators, plaster cast or traction.

Six cases in group A were treated with flexible intra-medullary nailing The mean age was 8.5 years. The average follow up was 3.5 years. All patients were reviewed and assessed clinically following discharge from hospital.

Patients treated with internal fixation of both fractures had a shorter hospital stay and were able to weight bear earlier. Limb length discrepancy was common in conservatively treated patients. Mean limb length discrepancy was 3.8 cm of shortening. A better range of knee movement was observed in patients treated with flexible nail for femoral and tibial fracture. Over all a good result was achieved in 70% of the patients. Using our assessment criteria we found that Group A faired better than the other two groups on all accounts.

Only a few small series of such a rare injury has been mention in the literature. More complications have been reported in children under 10 years of age. In our study we found better results when both tibial and femoral fractures were treated with internal fixation. The out come results in our patients were not related to age.

We found that internal fixation with closed flexible intramedullary nailing of both femoral and tibial fractures was a safe and effective technique and has therefore been recommended.