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

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.

The aim of this retrospective study was to review the outcome of patients treated with Fassier-Duval (FD) rods and highlight some of the complications found during treatment.

Between April 2006 and August 2010 we inserted 24 FD rods in 13 patients. 17 rods for osteogenesis imperfecta (OI), 2 for fractures and deformity associated with cerebral palsy, 1 for fracture associated with muscular dystrophy, 1 for fibrous dysplasia and 3 for centralisation of single bone forearms.

In the upper limb one patient required revision for proximal migration of the male component and another patient is waiting for revision for the same problem.

In the lower limb, a tibial nail was revised because of proximal migration of the male component. A femoral nail was adjusted because of loss of the proximal fixation. One of the OI patients fell, fractured the femur and bent a femoral nail. This awaits revision at a later date. A second OI patient fell on 2 separate occasions bending both a tibial and a femoral nail respectively. These were both revised to trigen intramedullary nails.

In all the other cases there were no complications.

In summary the Fassier Duval system provides a versatile way of providing intramedullary stabilisation for growing bones through a single entry point. However in our experience we have a 33% complication rate most notably bending of the rods. We advocate careful patient selection and using as high a diameter nail as is feasible.

A significant proportion of children with cerebral palsy (CP) are malnourished. This is particularly the case for trace elements, vitamins and minerals. Children with CP undergoing major orthopaedic procedures lose blood intra operatively leading to post operative anaemia. The aim of our study was to estimate the prevalence of low levels of serum ferritin in children with CP awaiting major orthopaedic surgical intervention.

The ferritin levels and haemoglobin (Hb) were estimated pre-operatively in 35 children with CP (CP group) undergoing major orthopaedic surgery (Hip reconstruction or Single event multi-level surgery). During the same period, we randomly identified 1000 children (Control group) who underwent Ferritin estimation as part of routine investigations. A significant proportion of children in the study group had low levels of serum ferritin in spite of having normal haemoglobin.

It is well-recognised that commencement of iron either orally or intravenously in the post-operative period does not accelerate recovery from anaemia secondary to blood loss. It is important to note that many patients who have normal Hb levels preoperatively are iron deficient. Hb estimation alone is inadequate in this group. We therefore conclude that children with cerebral palsy undergoing major orthopaedic surgery must have their ferritin levels estimated and optimised well in advance of their surgery.

Introduction: Majority of children with cerebral palsy patients suffer from fixed flexion contractures of their knees. Procedures commonly used to correct knee flexion deformities include hamstring release, anterior femoral hemiepiphyseodesis and femoral extension osteotomies. The latter procedure can cause neurovascular complications. Femoral stapling procedures are not very popular because of a theoretical risk of permanent physeal closure. We present our initial experience in correction of knee flexion deformity by using the 8-plate technique. This uses guided growth in the distal femoral physis to achieve gradual correction of the knee flexion deformity.

Materials and Methods: We reviewed a consecutive series of 25 children with fixed flexion deformity of the knee who underwent anterior femoral hemiepiphysiodesis using a two-hole plate (8-plate) between April 2005 and April 2008. The pre-operative and postoperative knee flexion deformity (in degrees) and complication rates were also recorded. Paired t-Test was undertaken to assess the correction in the fixed flexion deformity post-operatively

Results: Total number of patients – 25, male:female = 19:6. Total number of limbs – 46

The mean age of the patients was 11.04 years (range between 4–16). Mean follow up time for the patients after they had undergone the procedure was 16.2 months (range 3 – 34). The Mean correction achieved − 21.52 degrees (range 5 – 40). Mean correction per month − 2.05 degrees. A paired ‘t’ test showed the correction was found to be highly statistically significant (p value < 0.001).

Conclusion: We conclude that this is a simple technique with few complications to date. The learning curve for this procedure is 1 case. All patients in our series have shown promising results, with sustained gradual correction to date.

The association between idiopathic congenital talipes equinovarus (CTEV) and developmental dysplasia of the hip is uncertain. We present an observational cohort study spanning 6.5 years of selective ultrasound screening of hips in clubfoot. From 119 babies with CTEV there were nine cases of hip dysplasia, in seven individuals. This suggests that 1 in 17 babies with CTEV will have underlying hip dysplasia.

This study supports selective ultrasound screening of hips in infants with CTEV.

Aim: To report the clinical and radiological outcome of intramedullary fixation following corrective femoral diaphyseal derotational osteotomy, particularly in children with cerebral palsy.

Methods: We conducted a retrospective study of all femoral diaphyseal derotational osteotomies with Trigen antegrade intramedullary fixation (TAN system, Smith & Nephew) from April 2005 to June 2006. There were 9 patients with 14 affected limbs. The diagnosis was spastic diplegia in 8 of the 9 children, of whom 5 underwent the osteotomy as part of multilevel surgery.

Results: The mean age at surgery was 13.7 years (Range 11.2 – 17.3 years). The mean preoperative femoral anteversion was 43.6 degrees (Range 30 – 50 degrees) with the mean internal & external rotation being 61.6 (Range 50 – 70) & 8.3 (Range 0 – 20) degrees respectively. The average follow-up period was 9.5 months (Range 1.5 – 15 months). All patients mobilised with crutches in an average of 5 days (Range 3 – 12 days) and full weight bearing was achieved by 65 days (Range 45 – 150 days). Marked improvement in gait was noted in all children with postoperative mean internal & external rotation being 42.9 & 52.6 degrees respectively. There have been no instances of avascular necrosis or postoperative complications to date. Correction was maintained at the final follow up in all children with good bony union by 8 – 12 weeks.

Conclusion: The key to the success of femoral derotational osteotomy for correction of excessive femoral anteversion in children lies in achieving correction and early mobilisation. Intramedullary fixation following diaphyseal derotational osteotomy in children is a safe, effective, cosmetic and reliable procedure with rapid bony union, attributable to biological fixation and early mobilisation. Good early results have been obtained in children with cerebral palsy undergoing this procedure as a part of multilevel corrective surgery.

Introduction: Majority of children with cerebral palsy patients suffer from fixed flexion contractures of their knees. Procedures commonly used to correct knee flexion deformities include hamstring release, anterior femoral hemiepiphyseodesis and femoral extension osteotomies. The latter procedure can cause neurovascular complications. Femoral stapling procedures are not very popular because of a theoretical risk of permanent physeal closure. We present our initial experience in correction of knee flexion deformity by using the 8-plate technique. This uses guided growth in the distal femoral physis to achieve gradual correction of the knee flexion deformity.

Materials and Methods: We analysed the case notes of patients who underwent an anterior distal femoral hemi-epiphyseodesis using the 8-plate techinique between April of 2005 and August 2006. A total of 18 limbs in 12 patients underwent this procedure. Preoperative and post operative flexion deformity was measured using a goniometer. All measurements were made by the senior surgeon.

Results: The mean age of the patients was 12.8 years (range between 9–16)

Mean follow up time for the patients after they had undergone the procedure was 8.5 months (range 3 – 15). The Mean correction achieved – 16.15 degrees (range 5 – 40)

Conclusion: We conclude that this is a simple technique with few complications to date. The learning curve for this procedure is 1 case. All patients in our series have shown promising results, with sustained gradual correction to date. We also present technical tips in the 8-plate anterior femoral hemi-epiphyseodesis procedure.

Purpose of study: The majority of children with cerebral palsy suffer from fixed flexion contractures of their knees. Procedures commonly used to correct these deformities include hamstring releases, anterior femoral hemi-epiphyseodesis and femoral extension osteotomies. The latter procedure can cause neurovascular complications. Femoral stapling procedures are unpopular because of the risk of permanent physeal closure. Soft tissue procedures are usually only partially effective, with a high recurrence rate. We present our initial experience of correcting of knee flexion deformities using the 8-plate technique which uses guided growth in the distal femoral physis to achieve gradual correction of the knee flexion deformity.

Method: The case notes of patients who underwent an anterior distal femoral hemi-epiphyseodesis using the 8-plate technique between April 2005 and August 2006 were analysed. A total of 18 limbs in 12 patients underwent this procedure. The pre- and post-operative flexion deformity was measured with a goniometer.

Results: The mean age of the patients was 12.8 years (range 9–16) and the mean follow up was 8.5 months (range 3–15). The mean correction achieved was 16.15 degrees (range 5–40)

Conclusions: This is a simple technique with a learning curve of 1 case and with few complications to date. All patients in our series have shown sustained gradual correction. We also present technical tips in the use of the 8-plate for anterior femoral hemi-epiphyseodesis.

Transepiphyseal separation of the neck of the femur following grand mal seizures is described in two children with cerebral palsy. Closed reduction and percutaneous fixation was followed by a period in a hip spica. Although the incidence of avascular necrosis of the femoral head is high following such injury, this has not occurred in these patients at a follow-up of 18 months.

Introduction: It is common practice to screen the hips of infant with a family history of DDH clinically and ultra-sonographically in selective screening programmes. The practice of regular radiographic follow-up of infants with a positive family history of Developmental Hip Dysplasia (DDH) is based on the widespread belief that Primary Acetabular Dysplasia is a genetic disorder that can occur in the absence of frank hip subluxation or dislocation¹. It has been our practice to obtain a 6 – 12 month screening radiograph in such patients but this practice is not conclusively supported in the literature.

Materials and Methods: We reviewed all such infants who had a normal clinical and ultrasound examination of the hips at the 6–8 week screening examination but who, because of the family history underwent further radiographic screening after a 6–12 month interval. The radiographs of all such infants (n=77) were analysed for any signs of late hip dysplasia.

Results and Discussion: Sixty six infant had normal X rays at the 6–8 month assessment and were discharged. The remaining eleven patients had acetabular angles at the upper end of the normal range for age and were reviewed again with further radiographs at 12 months. At this stage ten patients were normal and were discharged. The remaining patient was reviewed again at 18 months and 24 months and finally proved to be normal and was discharged. The result of a postal survey has suggested that majority of BSCOS members do not get follow up x-ray done if the clinical and ultrasound scan is normal at screening visit.

Conclusion: All of the seventy seven patients eventually developed normal radiographs and we question the need for radiographic follow up of infants with a family history of DDH but who have a normal clinical examination and ultrasound scan at 6–8 weeks.

We report our initial experience of using the Ponseti method for the treatment of congenital idiopathic club foot.

Between November 2002 and November 2004 we treated 100 feet in 66 children by this method. The standard protocol described by Ponseti was used except that, when necessary, percutaneous tenotomy of tendo Achillis were performed under general anaesthesia in the operating theatre and not under local anaesthesia in the out-patient department. The Pirani score was used for assessment and the mean follow-up time was 18 months (6 to 30).

The results were also assessed in terms of the number of casts applied, the need for tenotomy of tendo Achillis and recurrence of the deformity. Tenotomy was required in 85 of the 100 feet. There was a failure to respond to the initial regimen in four feet which then required extensive soft-tissue release. Of the 96 feet which responded to initial casting, 31 (32%) had a recurrence, 16 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior. The remaining 15 required extensive soft-tissue release. Poor compliance with the foot-abduction orthoses (Denis Browne splint) was thought to be the main cause of failure in these patients.

Aim : To evaluate our initial experience using the Ponseti method for the treatment of clubfoot .

Materials and Methods: 85 feet in 56 patients treated at Alder Hey Hospital, Liverpool between Nov 2002 – Dec 2004 were included in the study. The standard protocol described by Ponseti was used for treatment. Mean period of follow up was 12 months (6– 30 months). Evaluation was by the Pirani club foot score.

Results : Results were evaluated in terms of the number of casts applied, the need for tenotomy and the recurrence of deformity. Average nuber of casts required were 6. Tenotomy was required in 80% of feet. At the latest follow up approximately 15% of feet recurred following treatment and were managed surgically. Poor compliance was noted to be the main cause of failure in these patients. We have recently modified our splint and hope this will address some of the reasons for poor compliance. There was also a smaller subgroup of patients (approximately 5%) which failed to respond to the treatment regime and could not be brought to the point were tenotomy would be appropriate.

Conclusion: In our hands the ponseti technique has proved to be a very effective treatment method for the management of CTEV but like all treatment methods does have some limitations.

The practice of regular radiological follow-up of infants with a positive family history of developmental dysplasia of the hip is based on the widespread belief that primary acetabular dysplasia is a genetic disorder which can occur in the absence of frank subluxation or dislocation. We reviewed all infants who were involved in our screening programme for developmental dysplasia of the hip, between November 2002 and January 2004, and who had a normal clinical and ultrasound examination of the hip at six to eight weeks of age, but who, because of a family history of developmental dysplasia of the hip, had undergone further radiography after an interval of 6 to 12 months. The radiographs of 89 infants were analysed for signs of late dysplasia of the hip and assessed independently by three observers to allow for variability of measurement. There were 11 infants (11%) lost to follow-up.

All the patients had normal radiographs at the final follow-up and none required any intervention. We therefore question the need for routine radiological follow-up of infants with a positive family history of developmental dysplasia of the hip, but who are normal on clinical examination and assessment by ultrasound screening when six to eight weeks old.

Subluxation of the hip is common in patients with intermediate spinal muscular atrophy. This retrospective study aimed to investigate the influence of surgery on pain and function, as well as the natural history of subluxed hips which were treated conservatively. Thirty patients were assessed clinically and radiologically. Of the nine who underwent surgery only one reported satisfaction and four had recurrent subluxation. Of the 21 patients who had no surgery, 18 had subluxation at the latest follow-up, but only one reported pain in the hip. We conclude that surgery for subluxation of the hip in these patients is not justified.

Aim: Stainsby and Briggs described a procedure for the correction of þxed claw toes. We studied the results of the Stainsby procedure in non-rheumatoid þxed claw-toes performed between March 1995 and January 2000. Method: All procedures were reviewed independently by the junior authors. The outcome was measured using the American Orthopaedic Foot and Ankle Society lesser toe scale (Kitaoka 1994). Patients were asked about overall satisfaction and whether they would recommend the operation to a family member. Results: Thirty-seven patients were operated on, four of whom died and one moved away, leaving 32 patients (38 feet, 88 toes) for study. The median age of the study patients was 59.5years (16–80 years) and median follow-up was 37 months (12–60 months). Twenty-two patients had hallux valgus, 7 pes cavus and 6 underwent salvage surgery for previous failed forefoot surgery. The median AOFAS score at follow-up was 80 (37–95). Thirty-four feet (89%) were satisfactory and 25 patients (78%) would recommend the operation. Wound problems occurred in 11 feet (29%) and transient paraesthesiae in 9 (24%). Dissatisfaction was usually due to the ßoppiness of the toe. Conclusion: The Stainsby procedure is a good salvage procedure for severe claws toes with good patient perception and function.

Aim: Myerson and Sheriff described an anatomical basis for the correction of hammertoe deformity. Based on this model we performed a metatarsophalangeal soft tissue release and proximal interphalangeal arthroplasty. Method: Patients operated between March 1995 and January 2000 were retrospectively reviewed using the American Orthopaedic Foot and Ankle Society Scores (AOFAS) by independent assessors. Results: There were 84 patients with 99 feet and 179 hammertoes with a median follow-up of 28 months. The median AOFAS score was 83 and 87% of patients had a score of more than 60 points. Eighty-three percent of patients were satisþed while 17% were dissatisþed with the procedure. Pain at the metatarsophalangeal joint was the commonest cause of dissatisfaction with 14% having moderate or severe pain. Only 2.5% had metatarsophalangeal joint instability and 9% had callus formation. There was no statistical difference regarding the age and sex of the patient, number of toes operated on, associated hallux valgus surgery and follow-up of less than or greater than 2 years. Conclusions: This study is based on an anatomical model and shows a good result with no recurrence of hammertoe correction.

Myerson and Shereff described an anatomical basis for the correction of hammertoe deformity. Based on this model we added a metatarsophalangeal soft tissue release to a proximal interphalangeal arthroplasty as our routine method of correction of hammertoes with fixed PIP joint flexion and flexible MTP joint hyperextension.

Patients operated between March 1995 and January 2000 were retrospectively reviewed using the American Orthopaedic Foot and Ankle Society Scores (AOFAS) by independent assessors. There were 84 patients with 99 feet and 179 hammertoes with a median follow-up of 28 months. The median AOFAS score was 83. Eighty-three percent of patients were satisfied while 19% were dissatisfied with the procedure. Pain at the metatarsophalangeal joint was the commonest cause of dissatisfaction with 14% having moderate or severe pain. Nine percent had callus formation and 4% of toes were over-corrected.

There was no statistical difference in results related to the age and sex of the patient, number of toes operated on, associated hallux valgus surgery and follow-up of less than or greater than two years.

This study is based on an anatomical model and shows results comparable with other series with no recurrence of hammertoe deformity.

To determine whether reducing the splintage rate in DDH patients had any effect on the rate of surgical procedures for the treatment of DDH. .

Since 1991, in the Blackburn region, there has been a limited target ultrasound screening programme for developmental dysplasia of the hip.

The detailed records of the demographics, clinical and ultrasound findings, treatment and outcomes of all children screened by the senior author were reviewed.

In 1996 and 1997 only those with persistent major dysplasia at 8 weeks and those with dislocatable hips were placed into Pavlik harnesses.

In 1998 only those babies with persistent major dysplasia at 8 weeks of age, or persistent hip instability at 1–2 weeks were placed into Pavlik harnesses.

The splintage rates, late dislocation rates (diagnosed after 6 mnths of age) and surgery rates were determined.

During the study period 11164 babies were born in the region. 797 (7.1%) babies were seen by the senior author.

Surgery in early irreducible hips is unavoidable. Surgery in late dislocators is only avoidable by changing from a selective ultrasound screening policy to performing ultrasound screening on every baby born.

With a limited hip screening programme and clinical and ultrasound monitoring of patients, splintage rates can be minimised without increasing the rate of surgery for developmental dysplasia.

No child who would have been splinted by the criteria used by other centres, and who wasn’t splinted in this series, required surgery.

Between March 1995 and January 2000 we reviewed retrospectively 84 patients with hammer-toe deformity (99 feet; 179 toes) who had undergone metatarsophalangeal soft-tissue release and proximal interphalangeal arthroplasty. The median follow-up was 28 months. Patients were assessed by the American Orthopaedic Foot and Ankle Society Scores (AOFAS) and reviewed by independent assessors.

The median AOFAS score was 83, with 87% of patients having a score of more than 60 points; 83% were satisfied and 17% were dissatisfied with the procedure. Pain at the metatarsophalangeal joint was the commonest cause of dissatisfaction, with 14% having moderate or severe pain. Only 2.5% had instability and 9% had formation of callus.

There was no statistical difference for the age and gender of the patients, the number of toes operated on, associated surgery for hallux valgus or length of follow-up. Our study was based on an anatomical model and shows good results with no recurrence of deformity.