Introduction

Management of deformity involving limb length discrepancy (LLD) using intramedullary devices offers significant benefits to both patients and clinicians over traditional external fixation. Following the withdrawal of the PRECICE nail, the Fitbone became the primary implant available for intramedullary lengthening and deformity correction within our service. This consecutive series illustrates the advantages and complications associated with the use of this device, and describes a novel technique modification for antegrade intramedullary lengthening nails.

Introduction

Amputation or disarticulation is a reliable option for management of severe foot deformities and limb-length discrepancies, the surgical restoration of which are unpredictable or unfavourable. Of the various surgeries involving foot ablation, Syme's amputation is preferred for congenital deformities as it provides a growing, weight bearing stump with proprioception and cushioning.

Introduction

Brachymetatarsia is a rare deformity affecting the toes and leading to functional and psychological impact. The main aim of the study is to assess the efficacy of the surgical callus distraction technique in terms of length achievement in the paediatric group. Secondary objectives are functional improvement, reported complications and overall duration of treatment.

BACKGROUND

Most closed tibial fractures in children can be treated conservatively. On the occasions that surgical intervention is required, there are various options available to stabilise the fracture. We would like to present our experience of using monolateral external fixators in the management of closed tibial fractures.

Background:

The outcomes of open tibial fractures in a paediatric population are reported.

We present our experience of using tension band plates to achieve guided growth in children for correction of calcaneus deformity of the ankle.

11 consecutive patients (13 ankles) fulfilled the inclusion criteria over a 4-year period. All underwent surgical treatment using a flexible two hole plate and screws on the posterior aspect of distal tibial physis. Measurements were done on preoperative, intraoperative screening and 1-year post operative plain AP and lateral ankle radiographs. The anterior distal tibia angle (ADTA), lateral distal tibial angle (LDTA) and screw divergence angle (angle subtended by lines passing through the long axis of the screws) were used to assess the deformity correction. A 2 tailed student t-test was carried out on the initial and 1-year post-op measurements to determine statistical significance with a p value <0.05 considered as significant

There were 10 residual clubfoot deformities, 2 post-traumatic deformities and 1 spinal tumor causing deformity. The average age of the patients was 10 years 5 months (range 4 to 13 years). There were 9 males and 2 females. The ADTA showed a statistically significant change with a p value of 0.0008 with a mean correction of 8.6 degrees (range of 2.3 to 15.6 degrees). The SDA demonstrated a mean correction of 15.4 degrees (range 0.3 to 41.8 degrees), p=0.002. The LDTA did not change significantly (p= 0.08), thus confirming no coincidental coronal plane deformity had occurred. 5 ankles required revision of fixation due to metalwork reaching its maximum limit of divergence at an average of 1 year. 2 ankles had screw pulled out due to osteolysis around the screw. There were no cases of infection.

We report satisfactory short-term results of correction of calcaneus deformity using a flexible tension band plate and screws system.

The purpose of this study is to assess the improvement in pain and function of the ankle when arthrodiastasis is used for end stage juvenile idiopathic arthritis [JIA] in the paediatric population.

All patients treated with ankle arthrodiastasis, 2009–2013 were studied. Clinical, radiological and survivorship data were examined. The Oxford Ankle Foot Questionnaire for Children (OxAFQ-C) and Parents (OxAFQ-P), along with the American Orthopaedic Foot and Ankle Society (AOFAS) Clinical rating system for Ankle-Hindfoot were recorded pre-operatively and at 6 months.

Eight patients (9 ankles) with severe tibiotalar JIA, refractory to medical management were treated. Average age at surgery was 14.5 years (range 8–19). Average length of arthrodiastasis was 3.5 months. Length of follow-up averaged 13 months (range 5–28 months).

All scores showed an improvement at 6 months. OxAFQ-C scores (out of 60) improved on average from 23 to 43. OxAFQ-P scores also improved from19 to 39. The largest improvement was found for the physical subsection. AOFAS Ankle-Hindfoot score (out of 100) averaged 34 pre-op and 74 at 6 months. Pain scored out of 10 decreased from an average of 7.4 to 4.3 at 6 months. All patients and parents were satisfied with the surgery and would have the procedure performed again.

Radiological studies demonstrated cartilage regeneration, joint restoration and deformity correction with arthrodiastasis. Survivorship was good (75%) at 36 months, but 2 patients (3 ankles) had subsequent surgery in the adult sector for progression of disease despite initial improvement following arthrodiastasis.

This case series demonstrates the efficacy of ankle arthrodiastasis as a surgical option in severe end-stage ankle inflammatory arthritis in paediatric patients in the short to midterm. It improved functional scores and pain scores which should delay the need for more radical joint fusion or replacement procedures in this challenging surgical condition.

We report our early experience with distracting external fixation used to offload the hip after avascular necrosis (AVN) of the femoral head secondary to severe slipped upper femoral epiphysis (SUFE).

A case series of five patients treated in a tertiary centre is reported. Electronic case records and radiographs were reviewed. Data recorded included demographics, initial presentation, timing of head collapse, timing and duration of distraction and outcome including referral to adult arthoplasty services.

Mean age at presentation was 12 years (range 12–15). 4 were females. Initial treatment in 4 cases was a delayed cuneiform osteotomy and pinning, one patient underwent serendipitous reduction and percutaneous pinning. Mean duration to initial surgery was 10 days (range 5–16). All patients had femoral head collapse at a mean of 148 days from time of presentation. 2 patients required backing out of screws due to intra-articular protrusion. All patients underwent distraction at a mean 193 days from presentation. Average distraction achieved was 10 mm and duration of application was 125 days (range 91–139)

All patients experienced improvement or resolution of pain but persistence of poor function, characterised by fixed adduction and limb length discrepancy. 3 patients were referred to adult arthroplasty services.

This may be an effective treatment option for pain associated with AVN post SUFE. However, in our experience normal anatomy and function of the hip is not restored if performed after collapse of the femoral head. Consideration should be given to application of the distractor either at the time of initial fixation or prior to femoral head collapse. Authors believe that timing of the application of the distractor is critical for a successful outcome and recommend a prospective study with large numbers.

Flexible flat foot is considered one of the commonest normal variants in children's orthopaedic practice. The weightbearing foot is usually regarded as flexible on the basis of results from clinical and radiographic examination as well as measured foot-ground pressure pattern.

Our aim was to compare the pedobarographic and radiographic findings of normal arched and symptomatic flexible flat feet and investigate if there were sensitive markers that could be used in selecting patients for surgical correction.

We retrospectively collected data from eighteen patients (ten to sixteen year old). Our control group consisted of ten patients (twenty feet) with normal arched feet and the study group of eight patients (fifteen feet) with symptomatic flat feet who were awaiting surgical correction.

The mean and standard deviations of three radiographic markers (Calcaneal pitch, Naviculocuboid overlap and lateral Talo-1st metatarsal angle) in addition to foot pressures measured at the hindfoot, medial/lateral/total midfoot (MMF, LMF, TMF), forefoot and the percentage of weight going through the MMF over the TMF (medial midfoot ratio (MMFR) during the mid-stance gait phase are reported. In addition, the sensitivity, specificity, positive predictive value and negative predictive value of the pedobarographic parameters were estimated.

There was a significant difference in the Naviculocuboid overlap (P<0.001 T test) and Calcaneal pitch (P<0.05 T test) between both groups. The flat feet group had significantly higher MMF, LMF, TMF and MMFR (P < 0.001 Mann-Whitney). LMF had the highest sensitivity and negative predictive value (94%) whereas MMF, TMF and MMFR had the highest specificity and positive predictive value (100%).

Compared to our control group, patients with symptomatic flexible flat feet had significantly higher pressures distributed in the midfoot, in particular in the medial midfoot. Pedobarography appears to be a sensitive and specific tool that can be used, in conjunction with clinical and radiographic findings, in diagnosing flat feet.

Our study suggests that pedobarography could be used to measure the degree of deformity before and after surgical intervention.

Background

Establishing the diagnosis in a child presenting with an atraumatic limp can be difficult. Clinical prediction algorithms have been devised to distinguish septic arthritis (SA) from transient synovitis (TS). Within Europe measurement of the Erythrocyte Sedimentation Rate (ESR) has largely been replaced with assessment of C-Reactive Protein (CRP) as an acute phase protein. We produce a prediction algorithm to determine the significance of CRP in distinguishing between TS and SA.

Background

Many scoring systems exist that assess ankle function, none of them are validated for use in a group of higher demand patients. This group of patients there have potential problems with ceiling effects, not being able to detect change or that a sports-subscale is not included. This study was to create a validated self-administered scoring system for ankle injuries in athletes by studying existing scoring systems and key-informant interviews.

Background

Establishing the diagnosis in a child presenting with an atraumatic limp can be challenging. There is particular difficulty distinguishing septic arthritis (SA) from transient synovitis (TS) and consequently clinical prediction algorithms have been devised to differentiate the conditions using the presence of fever, raised erythrocyte sedimentation rate (ESR), raised white cell count (WCC) and inability to weight bear. Within Europe measurement of the ESR has largely been replaced with assessment of C-reactive protein (CRP) as an acute phase protein. We have evaluated the utility of including CRP in a clinical prediction algorithm to distinguish TS from SA.

Treatment of acute Achilles tendon rupture is based on obtaining and maintaining apposition of the ruptured tendon ends. Surgical treatment utilises direct suture repair to produce this objective, while conservative or non-surgical management achieves the same effect of closing the tendon gap by immobilisation of the ankle joint in a plantar flexed position within a plaster cast or POP. There is still variability in the conservative treatment practices and protocols of acute Achilles tendon ruptures. The purpose of this study is to examine the current practice trends in the treatment of Achilles tendon ruptures amongst orthopaedic surgeons in the UK.

A postal questionnaire was sent to 221 orthopaedic consultants in 25 NHS hospitals in the Greater London area in June 2010. Type and duration of immobilisation were considered along with the specifics of the regime used.

Ninety questionnaires were returned giving a 41% response rate. Conservative treatment methods were used by 72% of respondents. A below knee plaster was the top choice of immobilisation (83%) within this group. The mean period of immobilisation was 9.2 weeks (Range 4-36). Weight bearing was allowed at a mean of 5.3 weeks (range 0-12)

The specific regime used by consultants was quite heterogeneous across the group, however the most used immobilisation regimen was a below knee plaster in equinus with 3 weekly serial plaster changes to a neutral position, for a total of nine weeks. A heel raise after plaster removal was favoured by 73% of respondents used for a mean period of 6.4 weeks (Range 2-36). In response to ultrasound use as a diagnostic tool, 42.4% of respondents would never use it, 7.6% would use it routinely, while 50% would use it only according to the clinical situation. Comparison of foot and ankle specialists with non-specialists did not reveal a significant difference in practice in duration of immobilisation or time to bearing weight.

Conservative management remains a widely practice option in the treatment of Achilles tendon ruptures. Although there are available a number of modern walking aids, the concept of functional brace immobilisation is not as widely used as below knee plaster cast immobilisation, which remains a popular choice amongst orthopaedic surgeons today. There is still no consensus on the ideal immobilisation regimen although a below knee plaster in equinus with serial changes for a total of nine weeks is the most frequently used choice. Further randomised controlled trials are required to establish the optimal treatment strategy for conservative management of Achilles tendon rupture.

Introduction: There is a paucity in the literature regarding the long term outcome of children with septic hips. Often, there is a delay in diagnosis which may lead to complications such as growth arrest, deformity and leg length discrepancy. We investigated the outcome of these patients and report the observed complications.

Methods: We performed a retrospective review of all children who underwent arthrotomy and washout for septic arthritis of the hip over a ten year period. Patients were identified from hospital databases and the coding department. Medical records were reviewed and data including demographics, method of presentation, laboratory investigations and outcome were recorded.

Results: We analysed the records of 70 patients who underwent formal arthrotomy and washout of their septic hip. Two patients had bilateral washouts (n = 72 hips). There were 36 (51%) female patients. 24 patients were under 1 year of age at presentation, with 11 of these in the neonatal period.

Temperature data was available for 48 patients, with a mean of 38.2 degrees Celsius at presentation. The mean ESR was 55.8. 28 patients (40%) grew an organism on culture of the hip fluid. The most common organism was Staphylococcus Aureus (64% of positive cultures).

66% (n=16) of patients in the < 1 year old group developed complications relating to growth arrest and leg length discrepancy. Seven of these patients (43%) underwent further surgery to correct deformity at a later date. In contrast, only 4.3% of patients in the > 1 year old group developed complications. The mean delay to surgery in patients who developed complications was 6.3 days with a mean delay to surgery of 3.1 days in patients who did not develop complications (p = 0.03, student’s T-Test).

Discussion: Paediatric Septic Arthritis remains a complex issue for both the patient and the surgeon. We have demonstrated that an increased delay in patients undergoing washout can lead to increased complications although this predominantly affects patients under 1 year of age. This can be explained by the lack of clinical signs in a < 1 year old child. Clinicians should have a high index of suspicion of septic arthritis in patients with features of sepsis with an unknown cause.

Purpose: In slipped capital femoral epiphysis (SCFE) with increasing slip angle and increasing impingement, pain, stiffness, limping and degenerative change may follow. Currently there are no accepted guidelines to guide management in patients with stable SCFE. The main purpose of this study was to evaluate the proximal femoral geometry in stable SCFE using a postero-anterior radiograph of the hip in the extended position and to determine its use in predicting subsequent surgical management.

Methods: Over a 7 year period, we evaluated the proximal femoral geometry in a consecutive series of 31 adolescents with stable SCFE using the prone extension hip radiograph and statistically analysed the relationship between lateral slip angle (LSA), the morphology of the metaphyseal-epiphyseal (ME) junction, pain and hip range of motion.

Results: The mean age was 13.5 years and statistical analysis shows that ME anatomy is strongly related to LSA and pain. Linear regression analysis shows a strong significant relationship between LSA and hip range of movements.

Conclusions: The prone extension hip x-ray, is capable of accurately predicting the response to a flexion valgus intertrochanteric osteotomy and will clearly demonstrate the degrees of flexion and valgus required to restore the proximal femoral anatomy to allow a more functional range of motion by reducing impingement. The prone extension hip x-ray will also indicate when an additional cheilectomy may be required or alternatively define degrees of proximal femoral deformity which are beyond the scope of intertrochanteric osteotomy and in which a more radical correction at the epiphyseal-metaphyseal junction is required.

Significance: We found the prone extension hip radiograph useful in selecting those hips amenable to management by flexion valgus intertrochanteric osteotomy and other surgical Methods:

Aim: To describe the epidemiology of paediatric bone infections in a single health district in England with particular reference to incidence and the changing pattern of the disease.

Method: Cases of chronic osteomyelitis and chronic regional multifocal osteomyelitis were excluded leaving 53 children diagnosed with acute haematological osteomyelitis (AHO) at a paediatric orthopaedic unit between January 2000 and December 2005. Patients were identified from the hospital coding system using the keywords ‘bone infection’ and ‘osteomyelitis’. The data were collected retrospectively from the patients’ hospital records and included demographic information, the delay between symptoms and presentation, clinical presentation, site of infection, organisms identified and laboratory results.

Results: The mean age of presentation was 40 months (range 0.5–179). The highest age incidence was between 0–3 yrs. There was no sex predilection with 27 girls and 26 boys. The mean duration of symptoms before presentation was 3.4 days (range 0–14 days). The presenting symptoms were pain at the affected site in 100% of cases, pyrexia (temperature > 38°C) in 47.1%, swelling of the affected site in 47.1%. The commonest bone affected was the femoral metaphysis. The commonest bacterium isolated was staphylococcus aureus. WBC, CRP and ESR were elevated in 44%, 84% and 92.1 % of the cases respectively. Plain radiographs and bone scan demonstrated signs of osteomyelitis in 32.1% and 78.8 % respectively. Surgical intervention was required in 21 patients.

Conclusions: The demographics and clinical presentation of AHO has not changed over the years. The commonest organism involved remains Staphylococcus aureus. ESR and bone scans were the most sensitive screening test for diagnosing the condition. Early initiation of third generation cephalosporin antibiotic therapy and surgical decompression, when necessary, was the mainstay of treatment.

Aim: To assess the effectiveness of a physiotherapist led normal variant clinic for children.

Method: The study comprised all children presenting to the physiotherapy clinic at the Royal Liverpool Children’s hospital between January 2000 and January 2006. The clinic is run by two specialist physiotherapists alongside a consultant led Orthopaedic clinic, providing support as required. Physiotherapy staff are able to request and interpret radiographs and order blood tests independently. The numbers of patients, the range of conditions seen in the clinic, and the outcome of the consultations recorded in the practitioner case-notes were examined for the purpose of this study.

Complete data was available for the full period under review except for the year 2003.

Results: During the five year study period 1594 children were seen, a mean of 318 patients annually (range 267–387). The age distribution of patients was 33.1% (527) under the age of 2, 38.9% (620) 2–5 years, 19.3% (307) 5–10 years and 8.8% (140) 10–16 years. The most common conditions seen were genu valgum 28.7% (458), genu varum 18.4% (293), in-toeing 14.7% (234) and toe walking 6.0% (96). Most patients (94.7% n=1509) were managed independent of consultant supervision by the physiotherapist. A minority of patients required consultant review in the clinic (4.2% n=67). Fewer still were referred to another medical clinic (1.1% n=18).

Conclusions: Children with a spectrum of orthopaedic conditions can be appropriately managed by a trained physiotherapist independent of consultant input.

Purpose of Study: To discuss on Clinical presentations, Investigations, Histopathology, Differential diagnosis and Treatment options based on a series of six Lipoblastomas that we encountered in our paediatric orthopaedic practice.

Materials and Methods: This series consists of six children with lipoblastoma who attended Alder Hey Hospital between 2000 and 2006. Mean age 17 months. Mean follow up was 26 months. The youngest was a six month old infant with a swelling on his right instep. The second patient was a three year old girl who presented with a limp and swelling in her foot, the third patient was an 18 month old boy with a swelling on the dorsum of his left forearm, fourth patient had a swelling of his left thigh and two patients had swellings in their back. They were investigated appropriately with MRI, CT or USG and surgical excision planned accordingly.

Results: Male to female ratio was 5:1. Age groups; 2 patients were of less than 12 months of age, another two of them was between 12 to 24 months and the last two were under 36 months at the time of diagnosis. Anatomically three patients had swellings in the lower limb, 2 had swellings over dorsum of their trunk one patient had a forearm swelling.

Investigations include MRI for one patient and CT for another USG was done for the remaining four. There was no post op complication for any of them. None of them have shown any recurrence during the follow-up.

Discussion: Lipoblastomas are uncommon, benign tumour of embryonal mesenchymal cells. It is a rare tumour but occurs mostly during infancy and early childhood. It most often presents on the extremities, back, head and neck.

Histology: cellular neoplasm composed of lipoblasts in different stages of maturation and fine vascular network, with well defined septa.

Cytogenetic evaluation often shows chromosomal anomalies of tumour cells like abnormalities of the long arm of chromosome 8, leading the rearrangement of the PLAG1 gene. Biopsy of the lesion is recommended, as clinical and radiological diagnoses can be misleading.

These tumours tend to spread locally and may recur in case of incomplete resection; metastatic potential has not been reported.

Differential diagnosis includes myxoid liposarcoma, welldiffrentiated liposarcoma, spindle cell lipoma, typical lipoma and soft tissue sarcoma.

Conclusion: All patients were originally thought to have simple lipomas or soft tissue swellings. This is primarily because lipoblastoma is a rare tumour and is rarely encountered in orthopaedic training. It is important that we orthopaedic surgeons be aware that lipoblastoma is in fact the most likely diagnosis of a fatty lump in a child of less than two years of age. Lipoblastomas needs through imaging and if possible cytogenetic evaluation for accurate diagnosis before surgery because complete surgical resection is mandatory to prevent a likely local recurrence.

The aetiology and pathophysiology of non-union is still unclear, but in this condition there is an abnormal bone metabolism. The paracrine matrix RAS has been implicated in the regulation of bone remodeling and injury responses, possibly via its effects on kinins. The influence of the local RAS or the genetic influence of the ACE/ BK2R genes to bone remodelling may thus be central to the disorder, or augmented in these conditions. We thus compared the distribution of the ACE I/D and BK2R “+9/-9” functional polymorphisms in patients with non-union and compared them to appropriate control.

Gene analysis was performed on buccal cells collected from all subjects and the data was analysed for 59 patients (46 males, 13 females; mean age 40.1±15.7 years) with non-union and 81 control subjects (49 males, 32 females; mean age 51.4±22.81 years. The overall genotype distribution was consistent with Hardy-Wein-berg equilibrium for the overall and individual groups for ACE (p0.16), B1BKR (p0.68) and B2BKR genotypes (p0.12)

As the -9 allele is associated with greater gene transcription and higher mRNA expression of the receptor we combined the -9/-9 homozygous and -9/+9 heterozygous groups and compared them with the homozygous +9/+9 groups. This showed a significant difference between the non-union and control groups, with the +9/+9 homozygous being less prominent in the former (p=0.03)

The B2BKR -9 allele is associated with the incidence of non-union in fracture healing, in this first study to address this question. We found no association with either the ACE I/D or B1BKR genotypes.

In conclusion, with previous findings that the absence of the -9 allele of the B2BKR +9/-9 polymorphism is associated with greater gene transcription and higher mRNA expression of the receptor our findings are suggestive that increased BK activity via the B2BKR may predispose to the development of non-union.

Aims: The purpose the study was to evaluate the radiographic progression of distal radial fractures treated with casting with or without percutaneous wires over a one-year period. Methods: One hundred consecutive patients with unilateral Collesñ fractures were enrolled (78 females, 22 males; mean age 72). These were treated with either a below elbow cast with or without manipulation, or by percutaneous wire þxation and a cast after adequate reduction. Two independent observers evaluated all the patients with serial X-rays at 1, 2, 6 weeks and 1 year. Radial length, shift and inclination and volar tilt were compared to the position immediately after injury. Results: Sixty seven patients showed loss of position beyond that seen at 6 weeks after injury. Only 15% of the 21 patients who did not require a manipulative reduction showed any progression of deformity. Only 19% of the 79 patients that had manipulation (± wire þxation) maintained this throughout. The rest showed either early (6 weeks) or late loss of position with a signiþcant proportion of these showing more than 2mm loss of radial length. Loss of position was more frequent in fractures that were only manipulated compared those manipulated and wired; the latter also tended to lose position late rather than early. Twelve of the 30 cases with early loss of position were re-manipulated but þnal position was almost uniformly equivalent to slip position. Conclusions: Radiological parameters are of prognostic importance. Our standard protocols do not hold fracture reduction at 1 year, with þnal deformity greater than appreciated. No beneþt of remanipulation was observed. There may be a need to modify traditional treatment to hold fractures for longer and be able to resist deforming forces.