Aims

The aim of this study was to quantify the risk of developing cancer from the exposure to radiation associated with surgery to correct limb deformities in children.

This pilot study aims to investigate the utility and feasibility of a unique upright MR scan for imaging hips affected by Legg-Calve-Perthes Disease (LCPD) with patient standing up, in comparison to the standard supine scans.

Protocol development using this unique upright MRI included healthy adult and child volunteers. Optimum patient positioning in a comparable way between supine to standing was assessed. The balance between shorter scan time (to what a child can tolerate) and longer scan time (for better image acquisition). The study protocol has begun in 2 children with LCPD. Patient recruitment continues.

Early results indicate a dynamic deformity of the femoral head in early stage LCP disease. Femoral epiphysis height decreased on standing (7.8 to 6.8mm), width increased on standing (16.6 to 20.9mm) and lateral extrusion increased (3.5 to 4.1mm). Overall epiphyseal shape changed from trapezoidal (LCP femoral head when supine) to flattened triangular (LCP femoral head when standing). Differences were thus demonstrated in all parameters of bony epiphyseal height, width, extrusion and shape of a femoral head with LCP Disease when the child stood and loaded the affected hip.

Satisfactory image acquisition was possible with Coronal T1 GFE sequences, with both hips in the Field of View. 2.5min scans were performed with the child standing first, then supine. Hip position was comparable when standing and supine. Longer scans were not tolerated by younger children, more so those with LCP disease.

To our knowledge this is the first reported use of standing MRI in LCPD. A dynamic deformity has been demonstrated, with flattening, widening and worsened lateral extrusion when the child is standing compared to supine. This proof of concept investigation demonstrates the feasibility of upright MRI scanning and may demonstrate previously undetected deformity.

To evaluate effectiveness and safety of acute ulnar lengthening osteotomy in Madelung's deformity associated with Hereditary Multiple Exostoses (HME)

Seventeen ulnas in 13 patients had acute ulnar lengthening for HME associated forearm deformity. Defined radiographic parameters were compared pre- and post-operatively using student's t-test; ulnar variance, carpal slip, radial bowing, radial articular angle. All complications were noted.

Mean follow-up was 27 months (range 1.5 – 72months). An increase in ulna length by a mean of 15.4mm (range 4.5 – 29.3mm) was achieved acutely, corresponding to an increase of 9.3% of total ulnar length. Negative ulnar variance was improved from a pre-operative mean of 12.4mm (range 6.1–16.5mm) to a post-operative mean of 4.6mm (range 0–11.25mm) (p=<0.00001). Carpal slip was significantly improved by a mean of 2.2mm (p=0.02). No significant change in radial bowing (p=0.98) or radial articular angle (p=0.74) was observed. Inter-rater reliability was excellent (r=0.96, Pearson Correlation).

Three patients required second procedures for recurrence of deformity at 18 months – 6 years following their primary operation. There were no incidences of compartment syndrome, neurovascular injury nor infection. One ulna fractured intra-operatively requiring a longer plate. One patient had a non union which united on revision surgery.

Significant radiographic improvements in forearm and wrist alignment were seen with acute ulnar lengthening. The procedure is safe, with no compartment syndrome nor neurovascular injury and low complications rate. Recurrence rates in the skeletally immature patients are comparable to that reported with gradual lengthening. Acute ulnar lengthening for forearm deformity associated with HME has been demonstrated to be a safe, reproducible and effective surgical procedure.

Purpose of the Study

A cooled, side cutting burr designed for use in adult foot surgery has been used as a primary bone cutting device in children to facilitate a truly percutaneous method of performing osteotomies. Stabilisation of the femur was using a percutaneous locked nail and for the tibia percutaneous K-wires. The author describes the advantages and disadvantages of this method with results from the first cohort of patients treated.

Aim

To determine if the instigation of Magnetic Resonance Extremity (MRE) scanning in our unit as part of the management of suspected paediatric scaphoid fractures has prevented overuse of splints or casts reduced unnecessary clinic appointments and saved our department financially.

Statement of Purpose

Our experience with Taylor Spatial Frame correction of complex foot deformities in children.

Persistent foot deformity in congenital talipes equinovarus is a challenge. Open surgery is associated with complications including difficulty in achieving acute corrections in stiff, scarred feet. Gradual correction using the Ilizarov circular frame has been described as an alternative and we present the experience using a computer assisted hexapod gradual frame correction with the Taylor Spatial Frame (TSF).

A retrospective audit of sequential patients treated by TSF was performed. Technique, outcome, complications and key learning points were recorded.

21 paediatric patients underwent 27 treatments with a Taylor Spatial frame for complex foot deformity correction. Average age 11 years with majority diagnosis of congenital talipes equinovarus. The deformities severity meant acute correction would result in either neurovascular or soft tissue compromise.

Plantigrade feet with good function was achieved in 22 feet. 3 feet were deemed as failures. 2 feet have residual deformity but acceptable function. According to Paley's classification, there were 4 complications, 7 obstacles and 35 difficulties (pin tract infection and pain management). Complications did contribute to poorer outcomes. The key learning points were: protection of the ankle joint and distal tibial physis; staged osteotomy reduces swelling and complication rates; and consideration of further procedures at frame removal is important. Finally a thorough preoperative counselling programme should be instituted and patients warned of the time commitment and high difficulty rates associated with treatment. Managing patient expectation with goals is as important as meticulous surgery.

Although complication rates were high, the majority of treatment goals were met, therefore the TSF is valid in the treatment of complex deformities in the foot. Most patients with severe deformity can achieve a plantigrade functional foot but residual stiffness and need for minor orthotics is almost universal.

Introduction: Infection with Neisseria Meningitidis remains one of the most devastating illnesses in paediatrics. Affected patients can progress from a mild viral-like illness to septicaemia and death within a matter of hours. We present our clinical experience in identifying and managing the orthopaedic complications associated with meningococcal septicaemia and highlight the long-term problems of physeal growth arrest especially after limb amputation.

Methods: Between August 1997 and June 2005, 88 consecutive children aged from 1 month to 17 years were admitted to the paediatric intensive care unit with meningococcal septicaemia. These patients were retrospectively assessed for orthopaedic manifestations.

Results: During the acute phase of the disease, there were six deaths and 22 patients suffered tissue loss from amputations. Twenty digits were allowed to demarcate and were subsequently amputated. Ten Limb amputations were performed in 6 patients, all of which developed physeal growth arrests proximal to the level of amputation. Four patients had a substantial rise in lower leg compartmental pressures but only two patients underwent fasciotomies, one of which required bilateral below knee amputations.

Conclusions: Meningococcal septicaemia is a potentially lethal paediatric disease. In the acute phase, 22 patients needed orthopaedic input to address complications related to tissue loss, vascular and ischemic problems. Limb amputations due to meningococcal septicaemia will invariably result in physeal damage and our recommendation is that patients should always be screened for this late sequela after index admission. Additionally, early compartment decompression does not appear to improve limb survival.

Introduction: Infection with Neisseria Meningitidis remains one of the most devastating illnesses in paediatrics. Affected patients can progress from a mild viral-like illness to septicaemia and death within a matter of hours. We present our clinical experience in identifying and managing the orthopaedic complications associated with meningococcal septicaemia and highlight the long-term problems of physeal growth arrest especially after limb amputation.

Methods: Between August 1997 and June 2005, 88 consecutive children aged from 1 month to 17 years were admitted to the paediatric intensive care unit with meningococcal septicaemia. These patients were retrospectively assessed for orthopaedic manifestations.

Results: During the acute phase of the disease, there were six deaths and 22 patients suffered tissue loss from amputations. Twenty digits were allowed to demarcate and were subsequently amputated. Ten lower limb amputations were performed in 6 patients, all of which developed physeal growth arrests proximal to the level of amputation. Four patients had a substantial rise in lower leg compartmental pressures but only two patients underwent fasciotomies, one of which required bilateral below knee amputations.

Conclusions: Meningococcal septicaemia is a potentially lethal paediatric disease. In the acute phase, 22 patients needed orthopaedic input to address complications related to tissue loss, vascular and ischemic problems. Limb amputations due to meningococcal septicaemia will invariably result in physeal damage and our recommendation is that patients should always be screened for this late sequela after index admission. Additionally, early compartment decompression does not appear to improve limb survival.

Introduction: Previous studies on ankle arthroscopy have reported the results of treatment in adult patients. To our knowledge there are no studies reporting the out-come in children.

Aim: To analyse retrospectively the outcome of ankle arthroscopy in children.

Method: Between March 2005 and September 2007, twenty-two children (14 boys and 8 girls) underwent ankle arthroscopy for post-traumatic pathology. Their average age was 13.5 years (range 8.6 to 18). The symptoms were ankle pain (21 out of 22), instability (7) or clicking (6). Indications for arthroscopy were no response to conservative treatment, including physiotherapy, for at least 12 weeks or a grade 3 or 4 osteochondral defect (OCD) on imaging.

In five patients radiographs revealed an OCD. MR scans were obtained in eleven patients, which revealed OCDs in five, evidence of tarsal coalition in two, features suggesting posterior ankle impingement in 1 and normal scans in the remaining three.

At arthroscopy OCDs were visualised in nine cases, two of which were grade 4, four were grade 3 and three were grade 2. The grade 4 lesions were debrided and drilled, the grade 3 lesions had their edges debrided and the rest were stable. There were 3 false positive MRI scans where an OCD was reported but not seen on arthroscopy.

Impingement lesions were seen in twelve ankles (8 antero-lateral, 2 syndesmotic, 1 medial and 1 posterior), which were debrided. MRI scans had been performed in eight of these twelve cases but only one suggested an impingement lesion.

Results: Seventeen of our twenty- two patients had complete relief of symptoms at 3 months. They were back to their normal activity including sports. Three patients had persistent pain at 3 months. Two of these showed features of instability, one of which went on to have a Brostrom repair; the second had a repeat arthroscopy and debridement while the third improved with restricted activity. The average AOFAS score improved from 52 pre-operatively to 79 at 3 months following surgery.

Conclusions: Ankle arthroscopy has a successful outcome in paediatric patients with a painful ankle where conservative treatment has failed. MR imaging lacked sensitivity for diagnosing soft tissue impingement of the ankle.

Aim: To determine the value of the Pirani clubfoot-scoring system at initial presentation in predicting subsequent relapse.

Method: All clubfoot patients treated by one surgeon from 2002 to 2006 were included. Treatment followed the standard protocol, involving weekly stretching and casting until the foot was corrected, followed by Achilles tenotomy and plasters for 3 weeks. Thereafter, the child was placed in a foot abduction splint.

Relapses within 6 months of instigating the foot abduction splint were classed as early and subsequent relapses as late.

The severity of clubfoot was assessed using the Pirani scoring system which comprises two sub-scores – Midfoot Contracture Score (MFCS) and Hindfoot Contracture Score (HFCS). MFCS and HFCS can each be 0.0–3.0, giving rise to a Total Pirani Score (TPS) of 0.0–6.0.

Results: Sixty-one clubfoot patients were treated, with five lost to the follow-up. A total of 89 clubfeet were treated. There were 3 early and 19 late relapses. The average interval between initiating the foot abduction splint and late relapse was 23 months. TPS median was 4.5 in the no relapse group, 4.0 in the early relapse group, and 5.0 in the late relapse group. MFCS median was 2.0 in the no relapse group, 2.0 in the early relapse group, and 2.0 in late relapse group. HFCS median was 2.5 in the no relapse group, 2.5 in the early relapse group, and 3.0 in the late relapse group. Higher HFCS was statistically significant when comparing the late and no relapse groups (p< 0.05, 95% CI −0.5–0.0).

Conclusions: Higher Pirani scores were associated with late relapses, but HFCS is a stronger predictor of potential late relapse. Close follow-up is advised for patients at risk.

The majority of diaphyseal forearm fractures in children are treated by closed reduction and plaster immobilisation. There is a small subset of patients where operative treatment is indicated. Recent reports indicate that elastic intramedullary nailing (EIN) is gaining popularity over plate fixation. We report the results of EIN for diaphyseal fractures of the forearm in 44 children aged between 5 and 15 years during a three-year period. The indications were instability (26), redisplacement (14), and open fractures (4). Closed reduction and nailing was carried out in 18 cases. A single bone had to be opened in 16 cases and in 10 cases both bones were opened for achieving reduction. Out of the 39 both bone forearm fractures, 35 patients had stabilisation of both radius and ulna and in 4 cases only a single bone was nailed (Radius 3, Ulna 1).

Union was achieved in all the 44 cases at an average time of 7 weeks with one delayed union. All patients regained full flexion and extension of the elbow and wrist. Pronation was restricted by an average of 20° in 30% patients.

Complications were seen in 10 patients (20%). 4 patients had prominent metal work which required early removal. There was refracture in one case, which was treated by nail removal and re-fixation. Two patients developed post operative compartment syndrome requiring fasciotomy. EIN of the radius alone in a patient with fractures of both the bones of forearm, led to secondary displacement of the ulna. This resulted in ulnar malunion and a symptomatic distal radio-ulnar joint subluxation. This was successfully treated by ulnar osteotomy.

Compared to forearm plating EIN involves minimal scarring, easier removal and less risk of nerve damage. We therefore recommend EIN for the treatment of unstable middle and proximal third forearm fractures.

Introduction: To review the medium term outcome of staged surgery for treating recalcitrant idiopathic talipes equinovarus.

Methods: Between 1988 and 1995, we studied 91 club feet from a series of 120 recalcitrant feet in 86 patients requiring surgical treatment. The initial results have been reported previously and this cohort has been subsequently followed up for between 7 and 15years. The mean age at initial operation was 8.9 months. Surgery consisted of an initial plantar medial release followed two weeks later by a posterolateral release. This strategy was used specifically to address the problems of wound healing associated with single-stage surgery and to ascertain the rate of relapse after a two-stage procedure. The feet were classified preoperatively and prospectively into four grades according to the system suggested by Dimeglio et al. Reported relapse at last review was 0.0% in grade 2, 20.4% in grade 3 and 65.4% in grade 4 feet. The rate of overall relapse was 30.8%. At 7 to 15 year review an additional 9.1% in grade 2, 7.4% in grade 3, 11.5% in grade 4 had relapsed. Overall a further 8.8% had relapsed and were treated with further surgery. Functional outcome of the group remains good with 95.6% overall finding no restrictions to activities.

Conclusion: This review confirms that the strategy of staged surgery is supported in the medium term when considering rates of relapse and functional outcome.

Aim: To examine the effect of the low intensity ultrasound stimulation (SAFHS, Exogen) on new bone formation and stress shielding in a distraction osteogenesis model in New Zealand white rabbits.

Methods: Thirty male rabbits underwent a right tibial osteotomy at eight weeks of age. Distraction of the osteotomy by 0.75mm/day was performed for two weeks. Ultrasound stimulation commenced on the seventh day after wound healing. The ‘active’ group was stimulated for 20 minutes daily. The controls had identical dummy stimulators applied. Half of the animals were culled at four weeks and half at six weeks. Dual-energy x-ray absorptiometry scans evaluated BMC and BMD. Quantitative computerised tomography measured the cross-sectional areas. Four-point bend testing of distracted and non-operated tibiae was performed in a standardised fashion.

Results: No differences were identified between the active and control groups at four or six weeks with respect to BMD, BMC or cross-sectional area of the regenerated bone. Stress shielding osteopaenia was unaffected by ultrasound stimulation. No significant improvement in strength of the regenerate was identified in either group – there was a trend towards improved strength at four weeks.

Discussion: Low intensity pulsed ultrasound accelerates fracture healing in humans when immobilised by plaster of Paris. One published study purporting to show improvement in distraction osteogenesis is fatally flawed. We believe the intensity of the ultrasound may need to be increased to stimulate mechanically a bone rigidly fixed by an external fixator. Other interventions such as the use of growth factors or bisphosphonates provide much greater improvements in experimental animals and are much more convenient to apply.

From a cohort of 110 idiopathic clubfeet, 26 feet in 18 children requiring surgery for severe relapse have been studied. Surgery was comprised of a lateral column shortening procedure (Lichtblau) plus or minus a plantarmedial release. Surgery was staged to avoid wound complications.

Pre-operatively, feet were prospectively categorised into one of four grades according to a system reported by Dimeglio. Children were reviewed on two subsequent occasions. At review, feet were again graded. In addition, appearance and functional outcome was analysed and included an assessment of gait, activity and functional limitation.

Three children were lost to follow-up, leaving 22 feet in seven male and eight female patients available for review. The mean age at surgery was 43 months (23–82). The mean time from surgery to first and second reviews was 35 and 56 months, respectively.

There was a significant improvement in grading at first review compared to pre-operative grading (Wilcoxon signed ranks test). Although there remained a significant improvement in grading at second review compared to the preoperative grading, there was a significant reduction in the number of feet in which grading had improved when compared to first review.

There was no significant change in function between the two post-operative reviews (Chi-square tests), with the majority of children experiencing little functional limitation. There were no wound complications.

Relapse surgery, involving a lateral column shortening procedure for severe clubfoot, results in a significant initial improvement when assessed using a grading system. This improvement in grading subsequently decreases over time. However, the functional outcome in such cases remains favourable.