Aims

The aim of this study was to gain an agreement on the management of idiopathic congenital talipes equinovarus (CTEV) up to walking age in order to provide a benchmark for practitioners and guide consistent, high-quality care for children with CTEV.

Introduction

Leg length discrepancy (LLD) in patients with unilateral developmental dysplasia of the hip (DDH) can be problematic for both patients and surgeons. Patients can acquire gait asymmetry, back pain, and arthritis. Surgical considerations include timing of correction and arthroplasty planning. This study audits standing long leg films performed at skeletal maturity in our patients. The aim of this study is to identify if surgical procedure or AVN type could predict the odds of needing an LLD Intervention (LLDI) and influence our surveillance.

Purpose

To review the natural history of posteromedial bowing of the tibia and the outcome of limb reconstruction in this condition.

Purpose

This study compares outcomes in patients with complete congenital fibula absence, associated with severe lower limb deformity, treated with an amputation protocol to those using an extension prosthesis.

Purpose

This study aimed to objectively define gait derangements and changes before and after Tibialis Anterior Tendon Transfer surgery in a group of patients treated using the Ponseti method.

Purpose

This study compares outcomes in patients with complete congenital fibula absence treated with an amputation protocol to those using an extension prosthesis.

Aim

Differentiation between bone infarction and bone infection in sickle cell disease has traditionally been difficult, even with modern imaging techniques, and widespread antibiotic use is common. Early differentiation between the two conditions would enable more appropriate targeting of radiological investigations, antibiotics and surgery, and avoid un-necessary antibiotic usage.

Purpose of study

We hypothesised that Vitamin D deficiency could be related to SUFE in children without endocrinological abnormalities. We therefore sought to examine prevalence and severity of Vitamin D insufficiency in a cross-section of SUFE patients.

Purpose

To document the success rate of closed reduction and soft tissue release in the treatment of bilateral true dislocation in developmental dysplasia of the hip (DDH).

Purpose

To investigate the effect of soft tissue release (STR) and the length of postoperative immobilisation on the long term outcomes of closed reduction (CR) of the hip for developmental dysplasia of the hip.

Introduction: Shoulder relocation is commonly performed for the subluxating or dislocated shoulder secondary to Obstetric Brachial Plexus Palsy (OBPP). We have observed that even when relocation is performed at a young age, remodelling of the immature, dysplastic glenoid is often unreliable, resulting in recurrent incongruity and requiring treatment of the glenoid dysplasia.

Methods and results: In a series of 19 patients, we used a posterior bone block to buttress the deficient glenoid at the time of shoulder relocation. At a mean follow up of 28 months (6–73 months), we describe failure in at least 50% with erosion of the bone block, progressive subluxation and resultant pain.

A different technique of glenoplasty is now used. An osteotomy of the glenoid is performed postero-inferiorly, elevating the glenoid forward to decrease its volume. Bone graft, often taken from an enlarged and resected coracoid is then packed into the osteotomy and the whole assembly is held with a plate. In a series of 11 patients with a mean age of 6.7 years (1–18 years) we describe good results at short term followup, suggesting that this is a technique warranting further investigation.

Conclusion: We believe that where a deficient glenoid is found at surgery for relocation of the shoulder in OBPP, a glenoplasty should be performed at the same time whatever the age of the patient, as glenoid remodelling will not reliably occur. We no longer advocate posterior bone block in these cases as it has a significant failure rate.

Supracondylar humeral fractures are the most common elbow injury in children, usually sustained from a fall on the outstretched hand. Iatrogenic ulnarnerve injury is not uncommon following cross K wiring. NNH is the number of cases needed to treat in order to have one adverse outcome. A systemic review was undertaken to calculate relative risks, risk difference and number needed to harm following management of supracon-dylar fractures with cross or lateral K wires. It was found that there was one iatrogenic ulnar nerve injury for every twenty-seven cases that were managed with crossed K wires.

The aim of this study was to calculate the number of cross K wiring of supracondylar fractures of the humerus that would need to be performed for one iatrogenic ulnar nerve injury to occur.

Iatrogenic ulnarnerve injury is not uncommon following cross K wiring of supracondylar fractures of the humerus.

To date there are no clinical trials showing the benefit of cross K wiring over lateral K wiring in the management of supracondylar fractures of the humerus in children. If it can be confirmed that lateral K wiring is as effective as crossed K wiring, iatrogenic ulnar nerve injury can be avoided.

A systematic review of iatrogenic ulnar nerve injuries following management of supracondylar fractures was conducted. The databases MEDLINE 1966 – present, EMBASE 1980 – present, CINAHL 1982 – present, CDSR, and DARE were searched along with a meticulous search of the Journal of Paediatric Orthopaedics from 1998 to 2004. Of the two hundred and forty-eight papers identified, only thirty-six met the inclusion criteria. The papers where both lateral crossed K wires were used as treatment were identified for calculating relative rates, risk difference and number needed to harm.

NNH was 7.69. When a sensitivity analysis removing two studies that had five subjects or fewer and a 100% ulnar nerve injury rate was peformed, the NNH was 27.7. In other words, there was one iatrogenic ulnar nerve injury for every twenty-seven cases that were managed with crossed K wires.

Introduction: The Ilizarov external fixator has theoretical advantages over conventional revision surgery for the treatment of recurrent clubfoot deformity. The aim of this study was to assess the outcome of such treatment.

Materials & Methods: Patients were reviewed clinically and completed extensive questionnaires documenting pain, function and satisfaction before and after the frame at a mean follow-up of 44 months (range 14–131). All patient notes and radiographs were reviewed.

Results: There were 42 frames applied to 40 feet in 31 patients. Deformity was idiopathic in 29 cases. Pain and function scores after treatment improved in 67% and 72% of cases respectively. A subjective increase in stiffness was noted in 46%. Patient satisfaction with outcome was 61%. Pain and function scores were not significantly different in stiff versus non-stiff feet. The overall recurrence rate was 44%; these feet had been treated with the Ilizarov fixator at a younger mean age (7.8 years) than those feet which did not recur (12.6 years). Recurrence was highest in the idiopathic group (59%) compared with the constriction band group (17%) and the neuromuscular/syndromic group (0%), despite the fact that the idiopathic group were older overall. 71% of recurrences experienced significant pain post treatment, compared with only 36% of non-recurrent feet. Functional ability was, however, similar in the two groups. Further surgical treatment has currently been necessary in 6 patients, including 4 repeat Ilizarov frames. Complications included almost universal minor pin-site infections, flexion contractures of the toes in 5 feet and skin ulceration in 2 feet, 1 requiring a muscle flap.

Conclusions: Treatment of the relapsed clubfoot with the Ilizarov fixator can improve the appearance of the foot, correlating with improvement in pain and function. Risks include recurrence, particularly in young, idiopathic feet, an increase in stiffness of the ankle, which has implications for future surgery, and other complications.

Introduction: Percutaneous epiphyseodesis is a simple method of achieving leg length equality in cases of minor leg length discrepancy, however few studies document its effectiveness. A retrospective study was undertaken to assess this.

Materials and methods: Patient notes and radiographs were reviewed. The growth remaining method was used to estimate timing. Percutaneous epiphyseodesis was performed with a drill and curette under radiological guidance.

Results: A total of 24 skeletally mature patients with a mean preoperative leg length discrepancy (LLD) of 2.8cm were identified. Skeletal age was significantly different from chronological age in 5 of 11 cases where it had been performed. In all patients, there was radiographic evidence of physeal closure soon after epiphyseodesis. At skeletal maturity, 14 patients have a LLD of 0–1cm and are considered to have a satisfactory outcome. 10 patients have a LLD> 2cms. In 6 of these, either presentation was too late or the amount of discrepancy too large for complete correction to be expected. In the other 4, skeletal age assessment may have been useful in 3, and in one additional case of overgrowth of the short limb prior to maturity. A successful outome was more likely when skeletal age assessment had been used (82% versus 57%). Of the 18 cases where there was sufficient time for a full correction to be achieved, the overall success rate was 72%. There were no significant clinical or radiological complications.

Conclusions:

Percutaneous drill epiphyseodesis is an effective method of achieving physeal ablation with no significant complications.

Introduction and Aims: Recurrence of clubfoot deformity occurs in up to 25% of cases following surgery. The Ilizarov fixator has theoretical advantages over conventional revision surgery in feet with scarred tissue planes, abnormal anatomy and impairment of local blood supply. In addition, limb-length discrepancy can be addressed simultaneously.

The aim of the study was to assess the outcome of treatment of recurrent clubfoot deformity using the Ilizarov frame.

Method: There were 39 feet in 31 patients with at least 12 months follow-up. All patients completed questionnaires documenting pain, function and shoe-size before and after the frame. Twenty-six feet were reviewed clinically. Patient notes and radiographs of all patients were examined. The average period of follow-up was 48 months (14–131 months).

Results: Pain scores improved in 69%, with similar improvement in activity level, walking distance and walking surface. In 20 feet there was improvement in the type of shoes worn. Twenty patients felt their feet were stiffer after the frame. Patient satisfaction with outcome was 74%. A plantigrade foot was achieved initially in all, but deteriorated with time, so that at clinical review only 46% had plantigrade feet. A straight medial border was seen in 81%. The range of movement of ankle and sub-talar joints decreased after the frame. Recurrent deformity was present in 38%, being more likely in younger patients, but in only a few, has further surgery been necessary to date. Complications included minor pin-site infections, flexion contractures of the toes, revision of the frame and revision of one osteotomy.

Conclusion: Treatment of relapsed clubfoot with the Ilizarov frame improves the appearance of the foot, correlating with improvement in pain, function and shoewear. This must be balanced against an increase in stiffness of the ankle, which has implications for future surgery, and the risk of complications inherent in the technique.

The vertical configuration open MRI Scanner (Signa SPIO, General Electric) has been used to assess the place of interventional MR in the management of developmental dysplasia of the hip over the last four years. Twenty-six patients have been studied. In static mode, coronal and axial T1 – weighted spin echo images are initially obtained to assess the anatomy of the hip, followed by dynamic imaging in near-real time.

In all cases, dynamic imaging was very good for assessing and demonstrating stability. The best position for containment can be assessed and a hip spica applied. Scanning in two planes gives more information and allows more accurate positioning than an arthrogram. Confirmation of location of the hip after application of the spica can be easily demonstrated. Adductor tenotomies have been performed within the imaging volume, and in two cases, this enabled planning of femoral osteotomies. All patients have had a satisfactory outcome, but five have required open reduction and a Salter innominate osteotomy.

In ten cases, the opportunity has also arisen to alternative perform an arthrogram, either because of the complexity of the cases, or at a later date as an alternative to a repeat MRI, or because of difficulty with access to the machine.

The place of interventional MRI in DDH is not yet defined. As machines get better and the definition improves, the amount of information about the nature of dislocation, the relative size of the acetabulum to the femoral head, the state of the limbus, the best position for containment and stability, and the potential for growth of the acetabulum, particularly posteriorly will be increased.

It follows that the potential for more accurate definition of each hip and the outcome is better – and safer – than by arthrography, which remains the ‘gold standard’ but involves radiation and is only one-dimensional.

Conventional methods of imaging in the investigation of developmental dysplasia of the hip all have disadvantages, either in definition or in exposure to radiation. We describe a new open-configuration MR scanner which is unique in that it allows anaesthesia and access to the patient within the imaging volume for surgical procedures and application of casts. We performed 13 scans in eight anaesthetised infants. Dynamic imaging revealed two dislocated hips which were then visualised during reduction. Hip spicas were applied without removing the patient from the scanner. In one hip, an adductor tenotomy was carried out. In all patients, stressing the hips during dynamic imaging allowed an assessment of stability. This was particularly useful in two hips in which an analysis of stability in different positions facilitated the planning of femoral osteotomies. This method of imaging provides new and important information. It has great potential in the investigation of developmental dysplasia of the hip and, with ultrasound, may allow management without the need for radiography.