Aims

The aim of this study was to determine the consensus best practice approach for the investigation and management of children (aged 0 to 15 years) in the UK with musculoskeletal infection (including septic arthritis, osteomyelitis, pyomyositis, tenosynovitis, fasciitis, and discitis). This consensus can then be used to ensure consistent, safe care for children in UK hospitals and those elsewhere with similar healthcare systems.

Introduction

Derotation osteotomies are commonly performed in paediatric orthopaedic and limb reconstruction practice. The purpose of this study was to determine whether the use of a digital inclinometer significantly improves the accuracy in attaining the desired correction.

Background

Disruption of the normal relationship between the proximal tibia and fibula is seen in a number of different conditions such as skeletal dysplasias and post-infective deformity, as well as the consequence of lengthening procedures. Radiographic indices for the tibio-fibular relationship at the ankle have been described, but no similar measures have been reported for the proximal articulation.

We present the long term outcome from children with Legg-Calves-Perthes (LCPD) treated at our unit.

Patients treated for LCPD were identified retrospectively from an orthopaedic database between 1990 and 2005. Patient demographics, clinical examination, treatment and Herring classification were recorded at initial presentation and treatment. Long-term clinical and radiological follow-up was also recorded.

85 patients were identified and 4 excluded due to insufficient data giving a total of 81 patients. Of these, 58 were male and 23 female. Average age range at presentation was 6.5 years (range 1.5–14 yrs). The side affected was 34 right, 35 left, 24 bilateral giving 93 hips in total. Time between presentation and diagnosis averaged 4.7 months (range 0–48 months). In patients with recorded clinical examination 87% had reduced abduction and 88% reduced internal rotation. Treatment was largely conservative with 12 hips (13%) undergoing surgery within the first 4 years of diagnosis. Radiographs were available for 71 hips. Herring classification was A-12, B-22, C-37. Long term follow up averaged 16 years (range 10–25 yrs). Stulberg grading was available in 67 hips; Grade I 13, Grade II 21, Grade III 19, Grade IV 18 and Grade V 6. There were ongoing issues (mostly pain) in 18 hips, 5 of which required a subsequent operation.

No correlation was found between abduction and Stulberg grade (p-value = 0.7). A correlation was found between delay in diagnosis of ≥6 months and the need for a subsequent operation (p-value = 0.0408).

The overall trend as expected showed that a better Herring classification generally led to a more favourable Stulberg classification. Range of motion was not predictive for Stulberg grade.

The need for further surgical intervention for symptoms at long term follow up was 0.05%.

The purpose of this study was to investigate whether patient age of 16 years and under is a valid “red flag” for back pain, by determining how often magnetic resonance imaging (MRI) investigations in these patients demonstrated significant pathology.

This was a retrospective review of cases over a five-year period (2008–12). The radiology database was interrogated to identify all patients aged 16 and under who had undergone an MRI scan of their lumbar spine for a primary complaint of low back pain. All emergency and inpatient admissions were excluded from the study. Casenotes of each of these patients were analysed for demographics, clinical features, diagnosis and outcome.

After exclusions, 98 eligible cases were identified. The age range of these patients was 2–16 years (mean age 12.63 years). The MRI scan found no abnormalities in 71.4% of cases. In the scans with positive findings, there were 8 cases of spondylolysis, 3 spondylolistheses, 9 cases of disc degeneration and 5 cases of Scheuermann's. Tumour or infection were found in only 3% of cases, (2 cases sacroilitis, 1 sacral chondroblastoma); there had been sacral or sacroiliac tenderness in each of these cases.

In keeping with other recent studies, this study shows that the diagnostic yield of MRI in patients under the age of 16 with low back pain is relatively high (28.6%). However, scan findings did not significantly alter management in the vast majority of cases (97%). Serious pathology (infection or tumour) was found in only 3% of cases. We therefore suggest that an age of 16 years or less, in isolation, should not be a “red flag” indicator for low back pain. We do however advise a lower threshold for imaging in patients presenting with sacral region pain and tenderness.

The aim was to compare the efficacy of selective ultrasound-screening (SUSS) for developmental dysplasia of the hip (DDH) to clinical screening alone, by comparing outcomes in a contemporary group with those from a 40 year old cohort.

This was a retrospective cohort study. The department's DDH and surgical databases were used to identify all cases of DDH, and all cases of surgery for DDH during the study period (2009–13). Patients born outside our region, and teratologic cases were excluded from analysis. The Obstetric database provided the total number of live births over the five-year period. This data was used to calculate the incidence of late-diagnosis (age over 3 months) DDH and the rate of surgery for DDH in our region. These results were compared to those of a similar study from our institution published in 1977, after the introduction of universal clinical screening. Relative risk (RR) was calculated for the two groups, and analysed for statistical significance.

The incidence of late-diagnosis DDH over the recent 5-year study period was 0.66/1000 live births, compared to 0.6/1000 in the control group. The RR for late-diagnosis DDH was not significantly different between the two groups (RR 1.14, 95% CI 0.6 to 2.2). The rate of surgery for DDH was 0.86/1000, compared to 0.9/1000 live births in the control group. The RR for surgery for DDH in the current study population compared to the historic control was 0.97, but this difference was not statistically significant (95% C.I. 0.57 to 1.68; p=0.92).

Despite advances in screening for DDH over the last 40 years, neither the incidence of late diagnosis DDH, nor rates of surgery for DDH in our region have changed. Whilst previous studies have demonstrated that SUSS does not eliminate late-presenting DDH, this study suggests it confers no advantage over clinical screening alone.

Aim

Congenital Talipes Equinovarus (CTEV) has been excluded from the standards set by the NHS fetal anomaly screening programme (NHS FASP) for the 18⁺⁰–20⁺⁶ week fetal ultrasound scan (USS). Whilst adhering to NHS FASP guidelines, the antenatal ultrasound department at our centre performs “incidental screening” for CTEV; parents are informed if CTEV is noted incidentally during the scan and referral made to the fetal medicine department. Our aim was to investigate the effectiveness of incidental antenatal screening for structural CTEV.

Aim

Differing reports about the surgical management of the supracondylar humeral fracture make evidence-based practice very difficult, so knowledge of the contemporary practices and opinions of an expert body can provide a useful benchmark for appraisal; the aim of this study was to obtain this information.

Aim

Our aim was to compare the Wilkins'-modified Gartland classification and AO classifications of supracondylar humeral fracture with respect to: -Inter-observer reliability; Association of fracture-grade with radiological quality of reduction; Association of fracture-grade with complications.

Aim

To investigate the effectiveness of a decision-based protocol designed to minimise the use of medial incisions when performing crossed-wire fixation of supracondylar fractures of the distal humerus whilst minimising ulnar nerve injury.

Introduction

We report 3 cases from different centres of infantile tibia vara in which the deformity was due to slippage of the proximal tibial epiphysis on the metaphysis; the aim of this study was to define the features of this previously unreported condition, and their implications for management.

In order to eliminate the “conflict” that can occur with physiological roll back of the femur on the tibia, most modern knee arthroplasty prostheses are designed to have little conformity between the femoral and tibial surfaces. However, a consequence of this design is paradoxical anterior sliding of the femur on tibia, which can result in clinically significant gait abnormalities. Recent studies show that during movement of the knee, the medial side remains very nearly stable like a ball-in-socket joint, whilst the lateral side moves front to back, rotating around the centre of the medial side. A total knee joint prosthesis designed with these same kinematics may therefore be advantageous. The objective of this study was to investigate the hypothesis that the increased constraint of a medial pivot knee promotes earlier loosening of the prosthesis.

METHODS: This was a retrospective radiographic cohort study. Using our unit’s knee arthroplasty database, all patients with a Freeman-Samuelson 1000 knee arthroplasty (medial pivot design) or a Freeman-Samuelson Modular knee arthroplasty with a minimum follow-up of 2 years were identified, and matched as closely as possible for age, length of follow-up and pre-operative diagnosis (Osteoarthritis, Rheumatoid arthritis or Post-traumatic arthritis). This was a single surgeon series using a standard surgical approach with a posterior cruciate sacrificing technique. Standardised anteroposterior and lateral radiographs taken postoperatively, at 6 months, 1 year and then at yearly intervals, were examined systematically and independently of the senior surgeon (GS). Component migration and radiolucent line scores were allocated as recommended by the Knee Society.

RESULTS: Group 1 (n=55),–Freeman Samuelson Modular design, mean age–70.3 years, mean length of follow-up–4.5 years. Group 2 (n=48),–Freeman Samuelson 1000 design (Medial pivot), mean age–70.4 years, mean length of follow-up–4.3 years. There were no failures in group 1. There was one failure requiring revision of the femoral component in group 2. Radiolucent lines were more prominent and frequent in the tibia, particularly under the medial and lateral plateau’s (KSS zone 1 and 6). There was no significant difference in the overall radiolucent line scores between the two groups (p=0.39, Mann Whitney U test). Similarly we found no difference between radiolucent line progression in the specific tibial zones (1–6 KSS system). Radiolucent lines in the femur were infrequent and insignificant.

CONCLUSION: We found no statistically significant difference between the two designs of knee prosthesis in terms of either total radiolucent line score or rate of radiolucent line progression. The increased constraint of the medial pivot knee prosthesis does not appear to result in an increased incidence of radiographic loosening.

The purpose of this study was to determine whether the low rate of mechanical loosening of the SMILES rotating hinge distal femoral endoprosthesis relates to the hydroxyapatite (HA)-coated, grooved collar of the femoral component.

A database was used to identify two groups of cases of primary distal femoral replacement with a custom-designed and manufactured SMILES endoprosthesis at our unit; those with the collared femoral component (“collar group”), and those without a collar (“non-collargroup”). From these two groups, patients were pair-matched for age and length of bone resection. A retrospective review of serial biplanar pairs of radiographs of each patient, assessing radiolucent lines and extracortical bone pedicle.

11 matched pairs were identified, (14 females, 8 males), with a mean age of 36 years, (range 16–66). The pathology was primary bone tumour in 20 cases, (17 malignant, 3 benign), and metastatic disease in 2 cases. Mean length of follow-up was 85 months, (range 27–122). Radiolucent line score (RLS) progression over time was significantly lower in the collar group, (0.01 vs 0.73, p=0.001) (fig. 1 & 2), as was the mean final RLS, (2.72 vs 7.81, p=0.02). Mean RLS per radiographic quadrant was 0.56 in cases in which a bony pedicle was ingrown onto the prosthesis, (exclusively in the collared-group), 2.41 in cases in which the pedicle was not ingrown, (most prevalent in the non-collared group), and 1.02 in those cases without any pedicle formation, (ANOVA analysis, p=0.0002).

This study demonstrates that the HA-coated, grooved collar significantly reduces the progression of radiolucent lines, and consequently the overall RLS, explaining the reduced rate of mechanical loosening of the collared endoprosthesis. A bony pedicle that does not incorporate onto the prosthesis surface may be associated with an increase in radiographic loosening.

The purpose of this study was to evaluate the results of custom-made endoprosthetic reconstruction for both tumourous and non-tumourous conditions around the elbow joint.

28 consecutive cases of endoprosthetic elbow reconstruction, performed between 1989 and 2003, were identified using the unit database. There were 12 males and 16 females, with a mean age 48.9 years, (range 14–84). There were 16 cases of malignant tumour (10 primary, 6 secondary), 3 cases of benign tumour (one each of giant cell tumour, osteoblastoma and pigmented villonodular synovitis) and 10 non-oncological cases, (5 cases of fracture, 3 failed total elbow replacements and 1 infected synostosis). A distal humeral prosthesis was used in 16 patients, distal humeral and proximal ulna in 10 patients, proximal ulna with a humeral component in one patient and proximal radial replacement in one patient. Clinical and radiographic review of all available patients, including a functional assessment with The Toronto Extremity Salvage score (TESS) was undertaken.

28 consecutive cases of endoprosthetic elbow reconstruction, performed between 1989 and 2003, were identified using the unit database. There were 12 males and 16 females, with a mean age 48.9 years, (range 14–84). There were 16 cases of malignant tumour (10 primary, 6 secondary), 3 cases of benign tumour (one each of giant cell tumour, osteoblastoma and pigmented villonodular synovitis) and 10 non-oncological cases, (5 cases of fracture, 3 failed total elbow replacements and 1 infected synostosis). A distal humeral prosthesis was used in 16 patients, distal humeral and proximal ulna in 10 patients, proximal ulna with a humeral component in one patient and proximal radial replacement in one patient. Clinical and radiographic review of all available patients, including a functional assessment with The Toronto Extremity Salvage score (TESS) was undertaken.

Endoprosthetic reconstruction around the elbow joint is effective in a wide range of pathologies, allowing in most cases a reasonable level of function, even following two-stage revision for infection.

Introduction: Surgeons in the UK and Europe generally use a thinner cement mantle than their counterparts in the USA for the femoral component in total hip replacement (THR). The aim of this study was to compare the performance of different thicknesses of cement mantle using finite element analysis. The measures by which comparison might be made include cement cracking, subsidence, migration and stress shielding. In this study, we use a linear-elastic model of the implanted femur to give a prediction of the stresses in the cement mantle and in the femoral cortex. These measures give an indication of the relative rates of cement cracking and loss of bone stock due to stress shielding. To assess the reliability of our model in representing patients with different bone densities, we use a range of cancellous bone stiffnesses.

Method: Two cadaveric femora from the same donor were sized, reamed and implanted with identical plastic replica femoral components following standard surgical technique for the Stanmore Hip system. One was prepared using UK rasps, over-reaming by ~2mm, the other using US rasps, over-reaming by ~5mm. Serial CT-scans were used to create three-dimensional geometric models of the implanted femora. Two finite element meshes were hand-built in MSC. Marc finite element software, incorporating cortical and cancellous bone, bone cement and prosthesis. Each model consisted of 10,000 eight-noded brick elements, with a fully bonded stem-cement interface. The thick and thin cement mantles had thicknesses of 2.5mm and 1.0mm respectively, in regions where thickness is affected by rasp size. Models were identical in the distal medullary canal. Cortical bone was modelled as transversely isotropic, with longitudinal and transverse moduli of 17.0 and 11.5 GPa. Bone cement was given a modulus of 2.7 GPa. Loading conditions were chosen to represent the heel-strike phase of gait. In order to assess the impact of variability in patient bone density, cancellous bone modulus was varied between 0.06 and 2.90 GPa.

Results: Equivalent stress was examined on the external surface of the cortex and the internal surface of the cement mantle. The lowest cortical bone stresses were proximal and the highest cement stresses around the distal tip of the prosthesis. In the proximal cortex, higher equivalent stresses were observed medially and laterally with a thick cement mantle. Distally, lower cement stresses were observed in the thick cement mantle. With the highest cancellous modulus, there was little difference between the two models. As this modulus was reduced, stress differences between the models became more apparent. For all cancellous bone moduli, peak distal cement stresses were lower and minimum proximal calcar stresses higher in the thick cement mantle.

Discussion: Proximal stress shielding was greatest in the calcar, in agreement with clinical findings. The thicker cement mantle led to less stress shielding in this region. Cement stresses, highest around the distal tip of the prosthesis, were larger in the thin cement mantle. This suggests a higher rate of both cracking and bone resorption in thin cement mantles. Although observed over a range of cancellous bone stiffness, this finding applies particularly to patients with low bone density.

Introduction: Aseptic loosening remains the commonest causes of failure of total hip arthroplasty. Cement mantle defects are associated with aseptic loosening. This study aimed to determine a correlation between surgical approach and cement mantle defects in the Stanmore Hip. The Stanmore total hip replacement was chosen because it has greater than an eighty-five percent survivorship over 25 years and unlike other prostheses with comparable results such as the Charnley total hip, it remains essentially unchanged to date.

Method: This was a retrospective review of all Stanmore hips. AP and lateral radiographs were available for 62 patients operated via the posterior approach and 100 patients operated via the anterolateral approach. The mean cement thickness in all fourteen Gruen zones was estimated for each patient. Gruen zones IV and XI, representing the stem tip, were removed from data relating to mantle thickness. Mantles were graded as less than 2mm, 2–5mm, 5–10mm and more than 10mm. Alignment was also measured.

Results: Fifty-nine percent (32/54) of cement mantle defects are seen in Gruen zones VIII to XIV. The mean cement mantle thickness in A-L approach was 3.11mm compared to 4.23mm with the posterior approach. This corresponds with the frequency of cement mantle defects occurrence. No cement defects were seen in Gruen zones IV or XI. Using the anterolateral approach, defects were observed in 49 out of 1200 zones (4.08%) and using the posterior approach in 6 out of 744 zones (0.81%). With the anterolateral approach, 19 out of 100 cement mantles (19%) had defects, compared to only 3 out of 62 (4.84%) with the posterior approach. Defects were most commonly seen in zones I, V, VIII and XII, which corresponds to valgus and posterior orientation of the stem.

Discussion: The posterior approach does generate a more uniform cement mantle. Several studies suggest that a cement mantle smaller than 2mm or greater than 10mm can be detrimental to the survivorship of the arthroplasty. This study suggests that a deficient cement mantle is more likely using an anterolateral approach.

Introduction: Chondrosarcoma is the second most common malignant solid tumour of bone. The management of extra-axial low grade chondrosarcomas remains a controversial issue. Many groups advocate wide excision, necessitating substantial reconstructive surgery, often requiring massive endoprostheses or allografts. Our unit favours intralesional curettage, as it is less invasive and results in smaller defects affecting only the medulla, which can be reconstructed using simpler methods. The purpose of this study was to assess the oncological and functional outcomes of this treatment strategy.

Methods: Using our database, we identified patients with long bone chondrosarcoma that had undergone intralesional curettage between 1999 and 2001. The resultant defects had been filled with PMMA cement in 22 cases and bone graft in 2 cases. A review of all notes and radiographs was performed, with functional assessment of all available patients using the Musculoskeletal Tumour Society Scoring (MSTS).

Results: 24 consecutive cases were identified; 11 cases affecting the distal femur, 8 in the proximal humerus, 3 in the tibia and 1 each of the scapula and radius. Average age was 47 years, (range 22–75). Tumour grade was: grade 1 – 22 cases and grade 2 in 2 cases. Mean follow-up was 52 months, (range 38–73 months). There was a single case of local recurrence in a patient that had a grade 2 lesion; there were no incidences of metastases. Functional outcome was assessed in 20 of the 23 remaining cases, scoring a mean 93.7% (range 53–100) on the MSTS.

Conclusion: This study suggests intralesional curettage is an effective treatment strategy for extra-axial low grade chondrosarcoma with excellent oncological and functional results. Careful case selection, with stringent clinical and radiographic follow-up is recommended.

Introduction: Surgeons in the UK and Europe generally use a thinner cement mantle than their counterparts in the USA for the femoral component in total hip replacement. The aim of this study was to compare the performance of different thicknesses of cement mantle using finite element analysis. A linear-elastic model of the implanted femur is used to give a prediction of the stresses in the cement mantle and in the femoral cortex. These measures give an indication of cement cracking rates and stress shielding. To assess the reliability of our model in representing patients with different bone densities, we use a range of cancellous bone stiffnesses.

Method: Two cadaveric femora from the same donor were sized, reamed and implanted with identical Stanmore Hips. One was prepared using UK rasps, over-reaming by 2mm, the other using US rasps, over-reaming by 5mm. Serial CT-scans were used to create three-dimensional geometric models of the implanted femora. Two finite element meshes were hand-built in MSC.Marc finite element software, incorporating cortical and cancellous bone, bone cement and prosthesis, with a bonded stem-cement interface. Loading conditions were chosen to represent the heel-strike phase of gait. In order to assess the impact of variability in patient bone density, cancellous bone modulus was varied between 0.06 and 2.90 GPa.

Results: Equivalent stress was examined on the external surface of the cortex and the internal surface of the cement mantle. The lowest cortical bone stresses were proximal and the highest cement stresses around the distal tip of the prosthesis. In the proximal cortex, higher equivalent stresses were observed medially and laterally with a thick cement mantle. Distally, lower cement stresses were observed in the thick cement mantle. With the highest cancellous modulus, there was little difference between the two models. As this modulus was reduced, stress differences between the models became more apparent.

Discussion: Proximal stress shielding was greatest in the calcar, in agreement with clinical findings. The thicker cement mantle led to less stress shielding in this region. Cement stresses, highest around the distal tip of the prosthesis, were larger in the thin cement mantle. This suggests a higher rate of both cracking and bone resorption with thin cement mantles, particularly in patients with low bone density.

Introduction and Aims: We present a review of the long-term results of custom-made massive unicondylar femoral replacement for reconstruction following tumor excision, and compare the functional outcome of this procedure with prosthetic distal femoral replacement.

Method: Using our centre’s endoprosthetic database we identified and analysed all cases of massive unicondylar femoral replacement performed at our unit (group 1). Patients were evaluated for function, (Musculoskeletal Tumour Society System), and for stability (adapted from Oxford Knee Score). An age and sex-matched cohort of patients who had undergone distal femoral replacements for similar pathologies, and in who the follow-up was of a comparable time period (group 2) was evaluated in an identical manner. Statistical analysis was performed on the results.

Results: Twelve cases of massive unicondylar replacement have been performed between 1990 and 2001, for a variety of malignant and benign tumors. There have been no incidences of infection, aseptic loosening or tumor recurrence. One patient has died of metastatic disease and another has undergone revision to distal femoral replacement for osteoarthritis. Of the remaining 10 patients, nine were available for assessment

Each of the two groups consisted of five males and four females, with mean age 48 years in group 1 and 49 years in group 2. The average follow-up since surgery in both groups was 10 years. The mean MSTS and stability scores of group 1 were 83% and 3.9 respectively, and 71% and 3.2 for group 2; the difference in scores between groups was statistically significant (p< 0.02).

Conclusion: With stringent case selection criteria, the custom-made massive unicondylar femoral replacement produces a good outcome, with functional results significantly better than distal femoral replacement. This may be because a substantial proportion of the knee joint with at least one cruciate and one collateral ligament are kept intact, thus facilitating enhanced proprioception.

Purpose: The purpose of this study was to determine whether the low rate of mechanical loosening of the SMILES rotating hinge distal femoral endoprosthesis relates to the hydroxyapatite (HA)-coated, grooved collar of the femoral component.

Methods and results: A database was used to identify two groups of cases of primary distal femoral replacement with a custom-designed and manufactured SMILES endoprosthesis at our unit; those with the collared femoral component (“collar group”), and those without a collar (“non-collar group”). From these two groups, patients were pair-matched for age and length of bone resection. We performed a retrospective review of serial biplanar pairs of radiographs of each patient, assessing radiolucent lines and extracortical bone pedicle. 11 matched pairs were identified, (14 females, 8 males), with a mean age of 36 years, (range 16–66). The pathology was primary bone tumour in 20 cases, (17 malignant, 3 benign), and metastatic disease in 2 cases. Mean length of follow-up was 85 months, (range 27–122). Radiolucent line score (RLS) progression over time was significantly lower in the collar group, (0.01 vs 0.73, p=0.001) (fig. 1 & 2), as was the mean final RLS, (2.72 vs 7.81, p=0.02). Mean RLS per radiographic quadrant was 0.56 in cases in which a bony pedicle was ingrown onto the prosthesis, (exclusively in the collared-group), 2.41 in cases in which the pedicle was not ingrown, (most prevalent in the non-collared group), and 1.02 in those cases without any pedicle formation, (ANOVA analysis, p=0.0002).

Conclusion: This study demonstrates that the HA-coated, grooved collar significantly reduces the progression of radiolucent lines, and consequently the overall RLS, explaining the reduced rate of mechanical loosening of the SMILES prosthesis. A bony pedicle that does not incorporate onto the prosthesis surface may be associated with an increase in radiographic loosening.