The aim of our survey was to study the current practice to manage DDH in UK by the members of the British Society for Children's Orthopaedic Surgery.

An online questionnaire link to ask about the management of DDH was emailed to 204 members of the British Society for Children's Orthopaedic Surgery. The response rate was 39%. 73% respondents have a local screening programme, 19% screen only high risk children and 8% had no screening programme. Pavlik harness was used by 87% respondents for Graf Type 2, 96% for Graf type 3 and 90% for Graf type 4. 14% respondents will only observe for Graf Type 2. 36% respondents will follow up children every week, 45% every 2 weeks, 3% every 3 weeks, 9% every 4 weeks, 4% every 6 weeks and 3% will decide the follow up according to severity of DDH and treatment.1.3% respondents will follow up these patients for 6 months, 13% for 12 months, 10.5% each for 24 months, 36 months, 48 months and 50% until skeletal maturity. After the failure of initial splintage, 7% respondents will consider surgery immediately, 13.5% at 3 months, 36.5% at 6 months, 4% at 9 months, 28% at 12 months, 5.4% according to HIP-OP Trial and 5.6% according to the situation.

There was no consensus about the treatment of DDH. 73% respondents have a local screening programme. The most common splintage method used was Pavlik harness. 45% respondents will follow up children every 2 weeks following the start of treatment. 50% respondents will follow up these patients until skeletal maturity. 36% respondents will consider surgery at 6 months following the failure of splintage. This survey highlights the fact that the management of DDH is an art based on the scientific evidence, parent's choice and personal expertise.

Purpose

To demonstrate experience of bone transport arthrodesis of the knee with simultaneous lengthening in the treatment of infected peri-articular fracture fixation associated with large condylar defects.

Introduction

We describe a minimally invasive technique that permits intra-focal bone graft of non-union sites with minimal disturbance of soft tissues and vascularity, and present the results of this technique.

Aim

(1) To determine whether any difference exists in AVN risk between surgical reduction [Fish] or pinning-in-situ [PIS] of severe slips. (2) To review the different classifications of SUFE in relation to AVN.

Aim

To analyse the results of the use of Recombinant Bone Morphogenic Protein (BMP-7) for treatment of fracture nonunions at our institution.

We reviewed 78 femoral and tibial non-unions treated between January 1992 and December 2003. Of these, we classified 41 as complex non-unions, because of infection (22), bone loss or prior failed surgery to produce union. These were treated with Ilizarov frames. 39 of the 41 nonunions healed successfully at a median time of 11 months.

Using the ASAMI scoring system, we had 17 excellent, 14 good, 4 fair and 6 poor bone results. The functional results were excellent in 14, good in 14, fair in 2 and poor in 2. All but 2 patients were extremely satisfied with the results. The average cost of treatment to the treating hospital was approximately £30,000 per patient. In comparison the cost for a patient with a below-knee amputation was £999 per year. This would amount to a cost of £36,000 per patient in their lifetime.

There is therefore not a great difference between the cost of limb salvage and amputation. The difference that exists favours limb salvage, if patient selection can accurately predict the salvage of a useful limb. Early referral to tertiary centres would reduce the morbidity and the prolonged time off work. The results justify the expense but the NHS needs to make financial provision for reconstruction of complex nonunions.

Purpose: To analyse the results of the use of Recombinant Bone Morphogenic Protein (BMP-7) for treatment of fracture nonunions at our institution.

Method: From 2001 to 2006, 23 patients with fracture non-union were treated with BMP-7 for bone healing. There were 14 male and nine females. The mean age of patients was 45 years (Range 21–76 yrs). There were 11 femoral, nine tibial and three humerus fractures. There were four open injuries. The average number of operations before BMP-7 insertion was 2.5 (Range 0–6). The mean time between the injury and BMP insertion was 52 months (Range 5–312). Nine (40%) patients had previous autologous bone graft inserted without union. 4 patients had BMP-7 insertion on its own. In another 4 patients it was mixed with allograft. In the rest of 15 patients BMP-7 was mixed with autologous bone graft. 2 patients needed BMP-7 insertion on 2 separate occasions. In all except 1 patient the original fixation of the fracture had to be revised using various appropriate methods.

Results: All the fracture went on to unite within an average of seven months (Range 4–16). There were no complications from the use of BMP-7.

Conclusion: Use of recombinant BMP-7, bone graft and stable fixation lead to fracture union in all our patients. We believe that the use of BMP-7 improved the chances of fracture healing in persistent non-unions and it is safe and easy to use.

A study to evaluate the efficacy of combined grafting (iliac crest autograft – ICAG, and human recombinant osteogenic protein 1 – rhOP1/BMP7) for long bone fracture non-unions (LBFNUs).

At both institutions prospective and retrospective data were collected. (Between Oct 2001 and Aug 2004 all LBFNUs that were grafted with a combination of BMP7 and ICAG). The records of the initial injury incident, treatment course, all operative interventions before and after the combined grafting and the follow up till final clinical & radiological union have been analysed. X2 test was used to analyse the results.

Forty-nine patients (31 males) with a mean age of 43 years (18–79) with LBFNUs were identified. The mean follow-up was 21.4 months (12–65). 7 were humeral, 13 femoral, and 29 tibial LBFNUs. Eleven were open (3 grade II, 8 grade IIIa–b). All non-unions were atrophic, and 8 had significant bone defects. The mean number of operations prior to the combined grafting was 2.5 (0–6). Clinical and Radiological union occurred within a mean time of 4.4 (3–12) months and 5.4 (4–16) months respectively. All of the fractures united. One patient, with an infected tibial non-union after an open fracture, ultimately underwent a below knee amputation. No complications or adverse effects from the use of BMP-7 were encountered.

BMP-7 was used as a bone-stimulating agent combined with conventional iliac crest bone grafting with a success rate of 98% in this series of patients with LBFNUs. This study supports the view that this combination of BMP-7 is safe and a power adjunct to be considered in the surgeon’s armamentarium for the management of such difficult cases.

Background: Aim of the study was to evaluate the clinical results of Montgomery Hip Screw for fixation of proximal femoral osteotomies. There are a number of devices for proximal femoral fixation, including sliding hip screws. Rotational instability of the proximal femoral segment can be a problem. To overcome this, a hip screw has been introduced with two screws in the proximal segment.

Methods and Results: A prospective cohort undergoing osteotomy was followed up. Inclusion criteria included consecutive patients < 16 years of age, with an indication for elective proximal femoral osteotomy. All operations were performed by senior author or under his supervision using a standard postero-lateral approach. Further incisions for adductor/psoas release and pelvic osteotomy were added as indicated. In 23 cases MHS was used with a mean follow up of 10 months (6 to 24). In 9 patients there was an underlying neurological problem, one case of LCPD, and the rest had DDH. Previous surgery with a hip screw on the contralateral side had been undertaken in 5 cases. The mean age was 5 years (range 1 to 12) and mean time to union was 6.3 weeks. There were no occurrences of rotational instability or failure of fixation. No wound complication was encountered in the cohort.

Conclusions: Early results indicate that Montgomery Hip Screw is a safe device for fixation of proximal femoral osteotomy with the added advantage of rotational stability.

Purpose: The purpose of this study was to evaluate the efficacy of a combined application of iliac crest autograft (ICAG) and human recombinant osteogenic protein 1 (BMP-7) for the treatment of non-unions of long bones fractures (LBF).

Patients and Methods: At both institutions we have prospectively and retrospectively collected and analysed data of patients admitted between October 2001 and August 2004 with a LBF nonunion (humerus, femur, tibia) and whose nonunion sites have been grafted with a combination of BMP7 and ICAG. All the records of the patients’ initial injury incident and treatment course, together with following operative interventions till and after the BMP7 application, and their follow up till final union have been analysed. Painless full weight bearing or use of the upper limp in the case of humerus (clinical union), and presence of bridging callous of two cortices visible on two x-ray views (radiological union). Chi square test was used to analyse the results.

Results: Forty-nine patients (31 males) with a mean age of 43 years (18–79) with LBF non-unions were identified. The mean follow-up was 21.4 months (range 12–65). 7 were humerus, 13 femurs, and 29 tibias. Eleven cases were open (3 grade II, and 8 grade IIIa-b). All non-unions were atrophic, and 8 were initially associated with bone loss. The mean number of operations performed prior to the combined ICAG and BMP7 application was 2.5 (0–6), including ICAG in 12 cases and bone marrow injection in 1 case. All but one of the fractures have united. Clinical and Radiological union occurred within a mean time of 4.4 (3–12) months and 5.4 (4–16) months respectively. One patient, with an infected tibial non-union following an open fracture, ultimately underwent a below knee amputation, secondary to recurrence of deep sepsis. The only patient whose (tibial) fracture has not still united is currently on an Ilizarov frame and slow progression has been reported following a recent CT. No complications or adverse effects from the use of BMP-7 were encountered.

Conclusion: BMP-7 was used as a bone stimulating agent combined with conventional iliac crest bone grafting with a success rate of 98% in this series of patients with LBF non-unions. This study supports the view that this combination of BMP-7 is safe and a power adjunct to be considered in the surgeon’s armamentarium for the management of such difficult cases.

Purpose: To compare the incidence of avascular necrosis, and radiological outcomes between groups treated by closed reduction, open reduction, and open reduction + femoral shortening, under the care of a single surgeon, with open reductions performed through an anterior approach, uninfluenced by the appearance of the ossific nucleus.

Methods: Between Sept 1991 and Dec 2003 we retrospectively studied 66 patients (3 bilateral; 10 males, 53 females) who had undergone reduction under anaesthesia. Of these 34 hips were reduced closed with adductor release (average 0.7 yrs, range 0.2–1.7), 11 reduced open (average age 1.0; 0.4–3.3) and 24 reduced open with femoral shortening (average age 2.4; 0.9–7.8).

Follow up radiographs were graded for the presence of AVN by the Bucholz and Ogden method. Radiological outcome was graded by the Severin score. Average follow up was up to the age of 6.6 years (SD 2.9) for the closed reduction group, open reduction group 8.0 (SD 3.6) and femoral shortening group 9.0 (SD 3.9)

Results:

AVN scores

Closed Reduction (n=34) : Grade 1 : 5.

Conclusions: The group with the highest incidence of AVN & worse Severin grades was the group (average age-1.0) who had open reduction without femoral shortening. The open reduction & shortening group had a higher proportion of good radiological results despite treatment being given at a older age. Concentric closed reduction, where possible, gave the best results.

Significance: Any child presenting with DDH at walking age (over 1) who requires open reduction should also have a femoral shortening. This gives the best chance of avoiding high grade AVN and achieving a good radiological result. Results might improve if open reductions without shortening were discontinued.

Introduction: We studied the radiological and functional outcome in patients treated for complex femoral and tibial non unions with the Ilizarov method, specifically analysing the data for factors that may predict return to work.

Methods and Results: 78 patients were treated for femoral and tibial non-union at our institute between January 1992 and December 2003. Of these 40 patients (41 non-union) satisfied the criteria for complex non-union. 18 patients who were working at the time of injury failed to return to work and 7 had returned to work. 16 were not employed at the time of injury and were excluded from the analysis. Functional and radiological outcome was assessed using the Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria. The minimum follow up was 18 months after removal of the frame.

Qualitative data for age, time to Ilizarov treatment, number of surgical procedures and time to union did not differ between the two groups (Student t-test). Those returning to work were more likely to have had a hypertrophic non union (p< .025) and were less likely to be using a walking aid (p< .05). No difference was seen between the groups with regards to segment involved, smoking, NSAID use, associated injuries, previous fixation, length of bone defect, free flap coverage, presence of infection, radiological and functional score.

Discussion: Our results suggest that return to work following Ilizarov treatment of a complex non-union does not correlate with either the biology of the fracture, the time course of treatment or the final result. We hypothesise that it is likely to be related to personality traits of the patients.

We reviewed 78 femoral and tibial nonunions treated between January 1992 and December 2003. Of these, we classified 41 in 40 patients as complex cases because of infection (22), bone loss (6) or failed previous surgery (13). The complex cases were all treated with Ilizarov frames. At a mean time of 14.1 months (4 to 38), 39 had healed successfully.

Using the Association for the Study and Application of the Methods of Ilizarov scoring system we obtained 17 excellent, 14 good, four fair and six poor bone results. The functional results were excellent in 14 patients, good in 14, fair in two and poor in two. A total of six patients were lost to follow-up and two had amputations so were not evaluated for final functional assessment. All but two patients were very satisfied with the results. The average cost of treatment to the treating hospital was approximately £30 000 per patient.

We suggest that early referral to a tertiary centre could reduce the morbidity and prolonged time off work for these patients. The results justify the expense, but the National Health Service needs to make financial provision for the reconstruction of this type of complex nonunion.

Aims: To compare two protocols of early mobilisation for minimally displaced radial head fractures through a single-blinded, prospective randomised trial. Methods: Sixty patients were randomly allocated to either immediate active mobilisation or 5-day delay before active mobilisation was commenced. Patients were reviewed at 7 days, 4 weeks and 3 months after injuries. A blinded observer assessed each patient. Results: All fractures united by the third month. At the end of 7days, the mobilisation group had less pain (VAS 6 vs 7.6, p=0.002); greater ßexion (mean 112û vs 98û, p=0.0004); greater strength in supination (p< 0.001) and better elbow function (Morrey Score 54 vs 43, p=0.005). By the fourth week, both groups were comparable in all parameters and improvement continued into the third month. Mean limit of extension at the third month were 2.3û in the immediate mobilisation group and 1.8û in the delayed group (NS). All had excellent function on the basis of the Morrey Score. Conclusions: Immediate mobilisation did not adversely affect the outcome; the patients had less pain and better elbow function at one week post-injury. Pain, ranges of movement and function were similar by the fourth week post-injury.

Aims: Nonunion in long bone fractures is rare in the skeletally immature. We report the outcome of a series of patients treated for tibial bone loss and non-union at average follow-up of 52 months. Methods: Nine children aged 18 months to 17 years were treated. Three patients had established non-union ranging from 7 months to 6 years, three had bone loss (1–6cm), and three had fractures in which non-union was anticipated (1 Gustilo IIIb and 2 Tcherne IIIñs). Treatment involved wound excision for open fractures, debridement of devascularised bone and stabilisation with monolateral þxators (2 patients) and circular þxators (7 patients). Five patients had unifocal treatment; four had multifocal treatment (3 bone transports). Treatment time ranged from 3 to 12 months, and was not related to the complexity of treatment. Functional outcome was measured using the Short Musculoskeletal Functional Assessment (SMFA). Results: At the latest follow-up (average 52 months), the mean range of knee motion was 3–125û and mean ankle range was 13û dorsißexion, 35û plantarßexion. Physeal arrest was present in three children (limb length discrepancy 2–4cm) but with no deformity. Functional outcome revealed a ÒDysfunction IndexÒ of 0–19% (ave. 7%) and a ÒBother IndexÒ of 0–16% (ave. 6%). Conclusions: Limb salvage of severe tibial fractures in which nonunion were established or anticipated were worthwhile. Good function can be obtained. The duration of treatment was not related to the complexity of treatment but was increased by leaving sterile but avascular bone unexcised

Hip dysplasia in cerebral palsy (CP) poses technical challenges because of the need to produce large corrections in the face of soft tissue contractures, and extreme distortion of the femur and acetabulum. In addition to adductor and flexor lengthenings, bony surgery may be required in the older child. We have developed an inter-trochanteric shortening osteotomy which allows a major varus realignment without resulting in an adducted leg. Medial displacement of the lower femoral shaft is carried out. The osteotomy is fixed using a Richards Intermediate Hip Screw, whose lag screw and barrel are inserted into the upper face of the osteotomy (not through the lateral cortex as in the standard technique). The plate is attached to the femur below in the normal way. The plate is not prominent laterally because of the medial displacement.

We have performed 37 such osteotomies in 29 patients.19 were male, 18 were female. Age range 3–12 years, mean 8 years. Mean time since operation 5.8 years. Additional procedures were carried out in 16 patients. The mean neck shaft angle pre-operatively was 159 degrees, post-operatively it was 118 degrees. The mean change was 41 degrees. The mean migration percentage pre-operatively was 56.8%, post-operatively it was 15.7%. The mean change was 41.1%. We found the technique to be easier, more stable, and obtained better correction screw did not seem to be a problem, we think because the osteotomy is above the than conventional femoral osteotomy. Rotation of the upper segment around the psoas attachment, and psoas is released.