Purpose of the study

We report on the clinical, radiographic and functional outcomes after salvage arthrodesis for complex ankle and hindfoot problems the Portsmouth experience with the Ilizarov ring fixator.

We report on the clinical, radiographic and functional outcomes after salvage arthrodesis for complex ankle and hind-foot problems - the Portsmouth experience with the Ilizarov ring fixator.

11 patients underwent ankle and hind-foot (tibio-calcaneal) arthrodeses using an Ilizarov ring fixator between 2006 and 2010. The indications included failed fusion after primary arthrodesis, sepsis complicating internal fixation of fractures, talar avascular necrosis and failed total ankle arthroplasty (TAR).

All patients had undergone multiple previous surgeries, which had failed. There were 8 males and 3 females in this group. Average age of the patients was 58 (43 years – 77 years) Mean follow up was 36 months (7 – 60 months). Mean frame time was 24 weeks (15 – 36 weeks). BMP 2 (Inductos) was used in three cases. The procedure was combined with a proximal corticotomy and lengthening in 2 patients who had undergone a talectomy and tibio-calcaneal fusion. There were no major complications apart from minor pin site infections requiring oral antibiotics. There were no deep infections, thromo-embolic issues, CRPS, or functional problems on account of limb shortening. Patients were assessed clinically, radiologically and using functional outcome scores - EQ50 and AOFAS. Solid arthrodesis was achieved in all but one patient who was subsequently revised with a hind-foot nail. All patients were satisfied with their overall improvement in pain and function.

We conclude that this is an effective salvage technique for complex ankle and hind-foot problems in patients with impaired healing potential, insufficient bone stock and progressive deformity.

Hallux rigidus is a common condition involving the first Metatarsophalyngeal (MTP) joint. Total joint arthroplasty is an acceptable modality of treatment. A number of different prosthesis have been used. Our study aims to evaluate the outcome of uncemented ceramic on ceramic (MOJE) prosthesis, in the treatment of painful hallux rigidus.

Between March 2000 and June 2005, 38 patients (53 feet) with painful hallux rigidus were treated with uncemented ceramic on ceramic (MOJE) prosthesis. There were 30 female and 8 male patients. The hallux meta-tarsophalangeal-interphalangeal scoring scale, by the American Orthopaedic Foot and Ankle Society, was used to assess these patients, pre-operatively and at follow up. A total score of 100 is possible in a patient with no pain, full range of MTP joint movement and good alignment.

The average follow up was for 34 months (range 12–68 months). Three revisions were carried out in three patients, 2 for deep infection, and 2 for persisting pain. Five patients showed radiological signs of osteolysis but had no symptoms. There was one late subluxation after 32 months. One patient developed a superficial infection, which was treated successfully.

The average AOFAS score pre-operatively was 45, compared to 91 post-operatively (p< 0.05). 23 patients (36 feet) classed the outcome as excellent to good. Ten of the patients subjectively described the out come of the procedure as excellent.

The preop range of movement (combined dorsiflex-ion and plantarflexion) was improved from a mean of 22 degrees to 68 degrees postoperatively.

The ceramic/ceramic (MOJE) total arthroplasty gave excellent results in 77% of patients. The early outcome is encouraging. We ewcommend continued use of this prosthesis for painful hallux rigidus.

Aim: Spinal stenosis is a known entity in achondroplasia and a need for screening for the symptomatic children was identified in a tertiary limb reconstruction service. The aim of this study was to evaluate whether clinical and radiological imaging would identify the at risk group.

Materials and methods: 205 achondroplastic children were treated at our service in the last 20 years. A prospective clinical screening programme for spinal stenosis which also included the MRI imaging of entire spine was however introduced only in 1996. 26 patients were available for this study. Case notes were reviewed for clinical symptoms and neurological signs. MR images were assessed for stenosis especially at Cervico medullary junction and lumbar level. Canal diameters were measured at all spinal levels from CMJ to lumbo-sacral junction. Neurosurgical interventions were recorded. An attempt was made to identify high risk factors that required surgical intervention.

Results: Delayed milestones were observed in 7 patients. Positive history of back pain or radicular pain was obtained in 10 whereas 10 patients had symptoms of neurogenic claudication. Brisk reflexes and clonus were consistent findings. Severe foramen magnum narrowing was observed in 23 patients and 13 showed ‘kinking’ or ‘pinching’, suggesting severe compression. Of the 17 patients seen by neurosurgeons 6 required single or multiple surgical decompressions. Ventriculo-peritoneal shunt was inserted in 4. 5 children required CMJ decompression and one required lumbar canal decompression. There was a 7 mm difference in AP diameter measured on MRI at CMJ between the two non operated and operated groups. Female patients with delayed milestones and CMJ narrowing to less than 25 mm were identified as high risk.

Conclusion: The cause of increased morbidity and mortality in young achondroplasts is attributable to severe CM compression. Sudden death can occur by acute or gradual progressive encroachment of respiratory centre at medulla oblongata. We were able to identify symptomatic patients early before developing myelomalacia and cord changes by screening all symptomatic children with achondroplasia. We propose that female gender, especially with delayed milestones as another high risk factor. We stress upon the importance of developing a nationalised selective screening programme with guidelines in specialist orthopaedic and joint multi-disciplinary Skeletal Dysplasia clinics.

Aim of the study: To evaluate the final outcome following joint distraction and reconstruction in patients with complex knee contractures in a select group with varied aetiology.

Materials and methods: Retrospective study of six patients (nine knees, 3 bilateral) with severe knee flexion contractures treated by gradual distraction using ring fixators. Most cases were syndromic or arthrogrypotic.. Case notes and radiographs were reviewed to assess the mobility and functional range of motion before and after the procedure.

Results: Staged procedures was carried out in 6 out of 9 knees accompanied by soft tissue releases, realignment of extensor mechanism and bony and joint realignment. The average age at operation was nine years and nine months and the mean follow up was 53 months. The average time spent in frame was 20 weeks. The correction was graded as good to excellent in 5 knees, fair in 1 and poor in 3 knees. The total arc of motion remained unchanged though the functional range of movement improved. The mobility improved significantly in most patients who were independent walkers with or without splints. Complications were of rebound phenomenon after frame removal in arthrogrypotic children, transient neuropraxia of common peroneal nerve in 2 epiphyseal separation in one and 3 sustained undisplaced fractures during mechanical distraction.

Conclusion: Syndromic and arthrogrypotic knee contractures are difficult to treat due to their severity and complexity. Planned staged procedures with joint distraction, patellar and bony realignment can produce satisfactory outcome in most making them functional independent ambulators.

Aim: To report our experience and early results with the Ilizarov pelvic support realignment lengthening osteotomy for complex hip pathology in children.

Material & Methods: Between 1997 & 2004, seven children were treated with this technique and five have completed treatment. The treatment was undertaken for sequelae of DDH in 4 patients and septic arthritis in 1 patient. The median age of the patients was 13(10–17). There were 3 boys and 2 girls. The outcome assessment was performed using the Harris hip score, clinical and radiological parameters.

Results: 4 patients presented with hip instability, shortening of the lower limb, pain and restricted motion. The remaining patient presented with a nonfunctional ankylosis with shortening. The median time between the onset of symptoms and the operation was 3 years (2–5). The median preoperative leg-length discrepancy was 3 cm (2–4.5). The median fixator time was 5 months (3–6). The median follow-up was 24 months (9–72).

Patients had improvement of pain, posture, hip instability, walking ability and limb length discrepancy. The median lengthening of the femur was 3 cm (2–5). The mechanical axis was realigned in all patients. All patients were satisfied with the outcome. Planned secondary contra lateral epiphyseodesis was required to equalise leg length in 2 patients. Complications included a stiff knee (1) that required a Judet quadricepsplasty, premature consolidation (1) that required reosteotomy and knee subluxation (1) that required cross knee stabilisation.

Conclusion: This is a safe and reliable alternative option to joint replacement, Colonna arthroplasty and arthrodesis for the reconstruction of multiply operated complex hip pathology in children.

Aim: To evaluate our results of articulated hip distraction in children with a painful, stiff hip.

Materials & Methods: Between 1988 & 2003, 10 children underwent hip distraction and 7 have completed treatment. The diagnoses were varied, though the presentations were those of pain & stiffness of the hip, poor posture and gait. The Orthofix articulated hip device was used in all patients. The outcome assessment was performed by clinical and radiological review.

Results: The mean age of the patients was 13.7 years (Range 12–17 years). The primary diagnosis was SUFE- 3, Perthes-4, trauma-1, septic arthritis -1, chemotherapy induced -1. The mean fixator time was 12 weeks (range 10–14 weeks). The follow-up period ranged from 4–183 months. Soft tissue releases and joint debridement were done in 6 and 2 patients respectively. Results were good in one, fair in five and poor in one patient. Patients with non-functional ankylosis gained functional position with some increase in range of motion. Grade 2 pin tract infections were noted in 4 patients.

Conclusion: Early results with hip distraction in this difficult, complicated group of patients are promising clinically and radiologically.