Introduction

We present the first 12 consecutive patients, undergoing elective paediatric limb reconstruction with an external fixator, for the 12-month period October 2020-October 2021. This is a single surgeon series for a newly appointed Consultant with limited previous experience. Arrangements were made for mentoring by a senior surgeon recently retired from the NHS but still active in private practice.

Introduction

There is a drive to reduce length of stay in children undergoing limb reconstruction but a reduction in community physiotherapy input and a consequent pressure to ensure children are as independent as possible prior to discharge. This study aims to look at time taken and potential factors effecting the achievement of pre-set mobility goals and length of stay in this population

Previous studies have identified clinical and demographic risk factors for recurrence in the treatment of idiopathic clubfoot (congenital talipes equinovarus). Evertor muscle activity is not usually considered amongst them. This study aimed to evaluate whether recurrence could be predicted by demographic, clinical and gait parameters. From a series of 103 children with clubfeet, 67 had completed a follow-up of two years: 41 male and 26 female, 38 with idiopathic and 29 with non-idiopathic deformities. The mean age was 3.2 years (2.1 to 6.3). Primary correction was obtained in all 38 children (100%) with an idiopathic deformity, and in 26 of 29 patients (90%) with a non-idiopathic deformity. Overall, 60 children (90%) complied with the abduction brace regime. At a mean follow-up of 31.4 months (24 to 62), recurrence was noted in six children (15.8%) in the idiopathic and 14 children (48.3%) in the non-idiopathic group. Significant correlation was found between poor evertor activity and recurrence in both groups. No statistically significant relationship was found between the rate of recurrence and the severity of the initial deformity, the age at the time of treatment, the number of casts required or the compliance with the brace.

After correction of idiopathic and non-idiopathic clubfoot using the Ponseti method, only poor evertor muscle activity was statistically associated with recurrence. The identification of risk factors for recurrent deformity allows clinicians to anticipate problems and advocate early additional treatment to improve muscle balance around the ankle.

Cite this article: Bone Joint J 2014;96-B:1264–8.

Purpose: In neuromuscular conditions, ankle foot orthoses (AFO) prevent deformity and improve functional balance by increasing the base of support, stabilizing the ankle joint and influencing the kinematics of more proximal joints; this study was designed to evaluate the role of fixed AFOs on balance in spastic diplegic children.

Methods: 12 children (age 7–15yrs) with spastic diplegia were recruited. All were community ambulators (GMFCS II/III). All had used AFOs for 12 months. Each child walked along the GAITRite electronic walkway at their preferred speed: barefoot, in shoes, and in AFOs with shoes. The order of the walks was randomized limiting the effects of fatigue and confidence. Normalized velocity, cadence, stride length and percentage of gait cycle in single leg support were selected as surrogate measures of stability. The child’s balance during other functional activities was assessed with the paediatric balance scale (PBS).

A two-way analysis of variance (ANOVA) explored differences in gait between the various walks. Fried-man’s test tested for differences in PBS scores between subjects and conditions.

Results: Significant improvements were seen in mean values for normalized velocity (p=0.02), stride length (p< 0.01) and percentage of gait cycle in single leg support (p< 0.01) in footwear-AFO compared to barefoot. Whilst there were also improvements in mean values for these parameters in shoes alone compared to barefoot, only the difference in stride length reached statistical significance (p< 0.01). There were no significant differences in PBS scores in shoes alone or with AFOs compared with walking barefoot.

Conclusions: AFOs improved balance during gait but had no effect on balance during other activities. Whilst shoes alone had a positive impact on gait, the most significant effects were seen in the AFO-footwear combination.

Significance: Advice regarding AFO use and footwear choice should consider the effects on gait as well as prevention of deformity.

The healing index, external fixation time divided by length gain, is commonly used as an outcome measure in distraction osteogenesis. This can be imprecise, and experimentally, regenerate stiffness is the accepted measure, but this can be difficult to measure clinically. The aim of this study was to investigate whether radiostereometric analysis (RSA) may be used to determine stiffness of new bone.

Two Ilizarov frames of differing stiffness were constructed around Sawbones tibiae. Known loads were applied to the frames and RSA was used to analyse the movement that occurred at the distraction gap. The axial stiffness of the frames was calculated. The distraction gap was filled with materials with a range of stiffnesses, representative of regenerate at different stages of consolidation. Loads were applied and RSA was used to measure the stiffness of the construct. A simple load share model was then used to estimate stiffness of the materials, and these values compared with those obtained from a materials testing machine.

The measured stiffnesses of the frames were 94N/mm and 55N/mm. RSA tended to underestimate the material properties of the ‘regenerate’, and this effect became greater at higher stiffness. There was also a 30% difference in estimated stiffness of the ‘regenerate’ when comparing the two fixators.

RSA is a very precise non-invasive method for measuring regenerate displacement. However, simple models to estimate stiffness tend to underestimate the true value, and assumptions made in basic engineering models are not valid when the stiffness of the regenerate approaches that of surrounding bone.

Background: The main aim of this study was to compare the effectiveness of a brief intervention based on cognitive-behavioural principles (Solution Finding Approach – SFA) with the McKenzie approach (McK). A secondary aim was to determine if there were any clinical characteristics that distinguished patients who responded best to the McKenzie method.

Methods: Eligible patients who were referred by GPs to physiotherapy departments in the UK with neck or back pain were randomly allocated to McK (n= 161) or to SFA (n=154) and their outcome compared at 6 weeks, 6 and 12 months. In addition, putative predictors within the McKenzie group were compared using univariate analysis to examine the relationship between variables and outcomes. Significant variables were assessed using multiple logistic regression analyses.

Results: Both groups demonstrated modest improvements in outcomes. There were no statistically significant differences in outcomes, except 2 small but significant differences at 6 weeks. At 6 weeks, patient satisfaction was greater for McK (median 90% compared with 70% for SFA). The number of treatment successes in the McK group depended upon the definition used, but were limited. Less chronic back pain (rather than neck pain) in patients demonstrating centralisation responded best.

Conclusion: In the original RCT there were few differences between McK and SFA though modest improvements in both. In a secondary analysis of the results for the McK group there were few treatment successes according to our definition of success; these were most likely to occur in back pain patients with shorter duration symptom who demonstrated centralisation response.

Background: There is some evidence for the effectiveness of exercise therapy and clearer evidence for encouraging physical activity. The Back to Fitness programme was developed with this in mind. It is a simple and inexpensive treatment aimed at increasing normal use of the spine.

Objective: To compare the effects of a group exercise programme with individual physiotherapy for low back pain patients.

Method: Back Pain patients (n=237) referred to physiotherapy departments in a materially deprived part of the North East of England were randomised either to individual physiotherapy as usual or to the Back to Fitness programme. The primary outcome measure was the Roland Disability Questionnaire (RDQ). Secondary measures were the SF12, EQ5D and Pain Self-Efficacy questionnaire. Health care diaries were collected in order to compare the health care costs for the two treatment groups. Patients were followed up 3 months and 12 months after randomisation. Analysis was by intention to treat.

Results: In line with recent studies there were no statistically significant differences between the treatment groups on any outcome measure over time. An economic analysis highlighted the cost savings of the Back to Fitness programme. However, only small improvements in disability (RDQ) scores were observed in either treatment group. This contrasts with recent studies on the effects of individual physiotherapy and exercise therapy, and with previous reports on the effects of the Back to Fitness programme. One explanation may be socio-demographic related. An exploration of the deprivation sub-groups based on the Townsend Index of Material Deprivation suggested that poorer patients may have poorer outcomes.

Conclusions: There were no significant differences at outcome between treatment groups. The exercise programme tended to be slightly beneficial but neither therapy significantly reduced disability. Further research could explore the possible impact of material deprivation on outcome.