This purpose of this study was to investigate whether prophylactic pinning of the contralateral hip in unilateral slipped upper femoral epiphysis affects subsequent femoral morphology.

To determine the effect of prophylactic pinning on growth we compared contralateral hip radiographs of 24 proximal femora prophylactically pinned with 26 cases observed, in a cohort of patients with unilateral SUFE. Validated measurements were used to determine hip morphology; the articulo-trochanteric distance (ATD) and the ratio of the trochanteric-trochanteric distance (TTD) to articulo-trochanteric distance (TTD:ATD) in addition to direct measurement of the femoral neck length. Post-operative radiographs were compared to radiographs taken at a 12–84 months follow-up.

Comparing pinned and unpinned hips the neck length was shorter (mean 5.1 mm vs 11.1 mm) and the ATD was lower (p=0.048). The difference between initial and final radiograph TTD:ATD ratio for each case was calculated. The average was 0.63 in the prophylactically pinned group and 0.25 in the unpinned group (p=0.07).

When hips of the same patient were compared on final radiographs, there was a smaller difference in TTD:ATD between the two sides when the patient had been prophylactically pinned (0.7) as opposed to observed (1.47). This was not statistically significant (p=0.14).

Universal prophylactic pinning of the contralateral hip in slipped upper femoral epiphysis is controversial and alteration of the proximal femoral morphology is one reason for this.

Our results show that prophylactic pinning does not stop growth but does alter subsequent proximal femoral morphology by causing a degree of coxa vara and breva. Some loss of growth in the prophylactically pinned hip contributes to reduction in leg length inequality at skeletal maturity which is advantageous.

No iatrogenic complications were observed with single cannulated screw fixation. Prophylactic pinning prevents the potential catastrophe of a subsequent slip, is safe and the effect on growth is, if anything, beneficial.

Level of evidence: III

Objectives

To evaluate the neck strength of school-aged rugby players, and to define the relationship with proxy physical measures with a view to predicting neck strength.

Between July 1994 and June 2004, 60 patients with 76 slipped upper femoral epiphyses were managed within the adult trauma service of three hospitals. Treatment was by a single cannulated screw.

Of these cases, 53 were unilateral, in 17 of which uncomplicated prophylactic fixation of the contralateral hip was performed. Of the other 36 cases, nine presented with a subsequent slip despite ongoing out-patient care. The subsequent slip was unpredictable in timing and unrelated to the age at the initial slip. It was more often unstable and in one case avascular necrosis developed. The overall rate of avascular necrosis, although in accordance with the literature, was 60% in acute unstable slips with a slip angle greater than 40°.

In our experience, prophylactic fixation was safer than continued observation of the contralateral hip.

The use of botulinum is established in the management of spasticity in cerebral palsy; most series concentrate on its injection into the Gastrocnemeii and hamstrings. During the swing phase, the rectus femoris acts concentrically at the hip, and eccentrically at the knee, to accelerate the thigh while controlling the rate of knee flexion. In spasticity there is prolonged activity with some of the rectus firing concentrically, resulting in a decreased rate of knee flexion, decreased peak flexion and a delay to its occurrence. These factors contribute to poor foot clearance.

Our aim was to establish whether the temporary paralysis of the rectus femoris by botulinum injection can improve knee kinematics.

Patients included were ambulant diplegics with clinical and kinematic evidence of rectus femoris spasticity. Independent clinical assessment was combined with 3D gait analysis pre and post injection. Kinematic Data for sagittal plane knee flexion/extension allowed us to calculate changes in the rate of flexion, the degree of peak flexion and time to its occurrence. Clinical evidence of spasticity was detected using the fast Duncan Ely test. There were 7 patients who underwent 15 injections into Rectus Femoris. Age range: 8–25 years (mean, 14–4 years). From the sagittal plane knee flexion graphs 10/15 had improvement in the rate of knee flexion, 9/15 had improvement in the peak flexion and 8/15 in the time to peak flexion. The mean increase in the fast Duncan Ely was 20. 5 degrees.

Using 3 Dimensional gait analysis we observed an improvement in the kinematic data following injection of the rectus femoris with botulinum.

This was accompanied by a clinical reduction of spasticity as measured by the Duncan Ely test. As with other muscle groups, botulinum injection of the rectus femoris has the potential to be both therapeutic and diagnostic.

The advantages and disadvantages of endoscopic compared with open carpal tunnelreleasearecontroversial. We have performed a prospective, randomised, blinded assessment in a district general hospital in order to determine if there was any demonstrable advantage in undertaking either technique. Twenty-five patients with confirmed bilateral idiopathic carpal tunnel syndrome were randomised to undergo endoscopic release by the single portal Agee technique to one hand and open release to the other.

Independent preoperative and postoperative assessment was undertaken by a hand therapist who was blinded to the type of treatment. Follow-up was for 12 months.

The operating time was two minutes shorter for the open technique (p < 0.005). At all stages of postoperative assessment, the endoscopic technique had no significant advantages in terms of return of muscle strength and assessment of hand function, grip strength, manual dexterity or sensation.

In comparison with open release, single-portal endoscopic carpal tunnel release has a similar incidence of complications and a similar return of hand function, but is a slightly slower technique to undertake.