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. A retrospective cohort review was performed of patient outcomes after treatment with the Fitbone nail at two tertiary referral limb reconstruction services (one adult, one paediatric) between January 2021 to December 2023. Aetiology, indications, initial and final LLD, use of concomitant rail assisted deformity correction (ORDER), removal time and healing index were assessed. Complications of treatment were evaluated and described in detail, alongside technique modifications to reduce the rate of these complications.Introduction
Materials & Methods
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. We reviewed data of all children who underwent Syme's amputation over the past 13 years at our institution. Surgical technique followed the same principles for Syme's but varied with surgeons.Introduction
Materials and Methods
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. For the series of cases involving all paediatric patients who had surgical correction at our unit from 2014 until the present, the electronic records were accessed to collect data. Pre-, peri- and post-operative assessments and investigations were used to evaluate patients' progress. The final plain films obtained were used to calculate the overall length achieved.Introduction
Materials and Methods
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.
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. All children with a presentation of ‘atraumatic limp’ and a proven effusion on hip ultrasound between 2004 and 2009 were included. Patient demographics, details of the clinical presentation and laboratory investigations were documented to identify a response to each of the four variables (Weight bearing status, WCC >12,000 cells/m3, CRP >20mg/L and Temperature >38.5°C). SA was defined based upon culture and microscopy of the operative findings.Background
Method
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. The Sports Athlete Foot and Ankle Score (SAFAS) was developed from interviews with athletes as well as expert-opinions. Initially 26 patients were interviewed before creating the scoring system, this was modified from the Foot and Ankle Outcome Score, this had been partially validated previously and the subjects regarded the content as relevant but incomplete. Secondly, SAFAS the content was validated in a group of 25 patients with a range of injuries and 14 athletes without ankle injury. It is a self-administered region specific sports foot and ankle score that containing four subscales assessing the levels of symptoms, pain, daily living and sports.Background
Methods
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.
