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.

Introduction: Hip replacement patients are prone to dislocations during extreme hip movement in the early post operative period. An activity of daily living that puts them at risk of dislocation is picking an object off the floor. The aim of this study was to assess the movement of the hip using different techniques to pick an object of the floor.

Methods: An electromagnetic tracking system was used to assess hip movements for four different techniques in picking an object from the floor. These were -

Flexing forward to pick an object up between the feet.

Measurements were taken from 40 hips in 20 normal subjects aged 21 to 61. Sensors were attached over the iliac crest and the mid-shaft of the lateral thigh. Data was then collected from the magnetic tracker as each technique was repeated 3 times. The system recorded hip flexion and rotation data at 10 hertz, with an accuracy better than 1 degree. Data was then analysed and the mean readings for each technique were compared.

Results: For each of the four techniques listed above the respective mean (SD) results were:

Flexion: 81.4 (27.5), 83.3 (27.6), 93.3 (28.7) and 33.5 (17.6) degrees.

The most significant movements for each technique were flexion and external rotation.

The movements with the least and most flexion were kneeling (33.5 deg) and squatting (93.3 deg). They were significantly different with a paired t-test p< < 0.001.

The movement with the least and most external rotation were kneeling (7.5 deg) and side pick up (22.7 deg). They were significantly different with a paired t-test, p< < 0.001.

Conclusion: This study has found that the most effective technique to pick up an object from the floor is kneeling as this has the least amount of flexion and external rotation. We conclude that this is the safest technique in carrying out this activity in the early post operative stage for patients who have undergone a total hip replacement.

Introduction: Activities that require extreme hip movement can dislocate hip implants in the early post operative phase. The aim of this study was to assess the movement of the hip using four different techniques to retrieve an object from the floor.

Methods: An electromagnetic tracker was used to measure hip movement during these retrieval techniques:-

Flexing forward to pick up an object between the feet

Measurements were taken from 50 hips in 25 normal subjects aged 21 to 61. Sensors were attached over the iliac crest and the mid-shaft of the lateral thigh. Data was collected as each technique was repeated 3 times. The tracker recorded hip flexion and rotation data at 10 hertz, with an accuracy of 0.15 degree.

Results: For each of the four techniques the respective mean (SD) movements were:-

Flexion: 75.8(28.6), 79.2(27.2), 87.5(29.7) and 30.4(17.3).

Kneeling had significantly less flexion and external rotation than all the other techniques (paired t-test, P< < 0.001).

Discussion: Flexion and external rotation were the most significant movements for each technique. The movements with the least and most flexion were kneeling (30.40) and squatting (87.50). The movement with the least and most external rotation were kneeling (7.30) and side pick up (20.10).

Kneeling has the least amount of movement, therefore, it minimises the risk of dislocation when retrieving an object from the floor.

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.

Background: Osteoarthritic patients needing a TKA give pain as the major reason for being unable to exercise to lose weight. Weight gain in turn worsens the process of osteoarthritis, this feeds into the vicious cycle. Following a TKA, patients should ideally be able to exercise more and hence lose weight. We assessed this hypothesis in our prospective study by calculating BMI. BMI has been proven in previous studies to be a good reflection of body fat.

Materials and Methods: We prospectively followed up 94 patients in the knee arthroplasty clinic. Height, pre operative weight and post operative weight at 12 months were measured. All the peri-operative factors in all the patients were constant. We then calculated the pre and post operative BMI.

Results: Most of our patients at the 12 month follow up showed to have an increase in BMI. This difference was however not found to be statistically significant.

Conclusion: The result obtained in our study was contrary to previous studies which have shown significant change. We conclude that pre-operative pain alone is not a limiting factor in patient BMI changes peri-operatively.

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.

Background and Aim: It was observed by the senior author over 15 years that if the foot became dependant in the 1st 48 hours after foot surgery, the patient suffered marked swelling and pain. This effect seemed less after about 48 hours. The practice was adopted of keeping the foot elevated for at least 48 hours. Aware of the work of John Tooke and Gerry Rayman with postural effects on laser Doppler skin flow, we set out to see if there was a demonstrable scientific basis for this practice.

Materials and Method: Laser Doppler flow meter was used to assess blood flow in 14 patients, (16 feet), undergoing foot and ankle surgery. Flow was recorded in the big toe, at heart level and on dependency, preoperatively, and then sequentially at 24, 48, 72 and 96 hours post operatively. Postural vasoconstriction was calculated using the formula; Postural Vas.(%)=Blood flow at heart level – Blood flow on depend./ X 100 Blood flow at heart level The time taken for blood flow in the toe to get back to the pre-operative values was assessed. Room temperature, patient temperature and patient position were all kept constant.

Results: Postural vasoconstriction was recorded for all 14 patients at 48 hours, for 7 patients at 72 hours, and for 2 patients at 96 hours post operatively. All patients had an ankle block, except 2 patients who had a popliteal block. The mean postural vasoconstriction preoperatively was 51.31%; mean at 24 hours post op. was 23.05% mean at 48 hours post op. was 36.62% and mean at 72 hours post op. was 44.24%. The mean operative time was 87.25 minutes. There was a significant difference between the pre-op levels and the 24, 48 and 72 hours post-op levels (p< 0.05). At 96 hours post-op, the difference wasn’t significant. Greater operative time was associated with less postural vasoconstriction at the 72 hours postoperatively.

Conclusion: Results showed that it takes longer than 72 hours for microcirculation to get back to normal rather than 48 hours, but the return towards normality was evident by that time. The results emphasised the importance of post-operative foot elevation for at least 48 hours due of this phenomenon. With increasing operative time, it took longer for the microcirculation to get back to normal. The longer the surgery the longer the period of elevation required. We believe that this practice minimises post operative complications; such as oedema, wound breakdown, pain on dependency. No patients suffered DVT’s or PE’s. However, patients did start with active and passive foot and lower limb physiotherapy soon after surgery.

Aim The senior author observed over 15 years that if the foot became dependant during the first 48 hours following foot surgery, the patient suffered marked swelling and pain. This effect seemed less after about 48 hours. Aware of the work of Tooke and Rayman (1986) with postural effects on laser Doppler skin flow, we set out to see if there was a demonstrable scientific basis for this practice.

Method Laser Doppler flow meter was used to assess blood flow in 14 patients (16 feet), peri-operatively. Flow was recorded in the big toe, at heart level and on dependency, pre-operatively, and at 24, 48, 72 and 96 hours post-operatively. Postural vasoconstriction (PV) was calculated using the formula:

\batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \[PV\ (\%)\ =\ Blood\ flow\ at\ heart\ level\ {-}\ Blood\ flow\ on\ dependency\ {\times}\ 100\] \end{document}

Blood flow at heart level

Results PV was recorded for all 14 patients at 48 hours, for seven at 72 hours, and for two at 96 hours post-operatively. The mean PV pre-operatively was 51.31%; at 24 hours post-op. was 23.05%; at 48 hours post-op. was 36.62%; and at 72 hours post-op. was 44.24%. There was a significant difference between the pre-op. levels and the 24, 48 and 72 hours post-op. levels (p< 0.05).

Significance of work It takes longer than 72 hours for microcirculation to get back to normal rather than 48 hours, but the return towards normality was evident by that time. This emphasised the importance of postoperative foot elevation for at least 48 hours due of this phenomenon. We believe that this practice minimises post-operative complications, such as oedema, wound breakdown and pain on dependency.