Aims

The aim of this study was to develop and internally validate a prognostic nomogram to predict the probability of gaining a functional range of motion (ROM ≥ 120°) after open arthrolysis of the elbow in patients with post-traumatic stiffness of the elbow.

Aims

Despite advances in the treatment of paediatric hip disease, adolescent and young adult patients can develop early onset end-stage osteoarthritis. The aims of this study were to address the indications and medium-term outcomes for total hip arthroplasty (THA) with ceramic bearings for teenage patients.

Aims

The aim of this study was to investigate the changes in femoral trochlear morphology following surgical correction of recurrent patellar dislocation associated with trochlear dysplasia in children.

Aims

The purpose of this study was to evaluate the long-term outcome of adolescents with cerebral palsy who have undergone single-event multilevel surgery for a flexed-knee gait, followed into young adulthood using 3D motion analysis.

Aims

To assess complications and failure mechanisms of osteoarticular allograft reconstructions for primary bone tumours.

Aims

The aims of our study were to provide long-term information on the behaviour of the thoracolumbar/lumbar (TL/L) curve after thoracic anterior correction and fusion (ASF) and to determine the impact of ASF on pulmonary function.

Macrodactyly of the foot is a rare but disabling condition. We present the results of surgery on 18 feet of 16 patients, who underwent ray amputation and were followed-up for more than two years at a mean of 80 months (25 to 198).

We radiologically measured the intermetatarsal width and forefoot area pre-operatively and at six weeks and two years after surgery. We also evaluated the clinical results using the Oxford Ankle Foot Questionnaire for children (OxAFQ-C) and the Questionnaire for Foot Macrodactyly.

The intermetatarsal width and forefoot area ratios were significantly decreased after surgery. The mean OxAFQ-C score was 42 (16 to 57) pre-operatively, improving to 47 (5 to 60) at two years post-operatively (p = 0.021). The mean questionnaire for Foot Macrodactyly score two years after surgery was 8 (6 to 10).

Ray amputation gave a measurable reduction in foot size with excellent functional results. For patients with metatarsal involvement, a motionless toe, or involvement of multiple digits, ray amputation is a clinically effective option which is acceptable to patients.

Cite this article: Bone Joint J 2015;97-B:1364–9.

Slipped upper femoral epiphysis (SUFE) is one of the known causes of cam-type femoroacetabular impingement (FAI). The aim of this study was to determine the proportion of FAI cases considered to be secondary to SUFE-like deformities.

We performed a case–control study on 96 hips (75 patients: mean age 38 years (15.4 to 63.5)) that had been surgically treated for FAI between July 2005 and May 2011. Three independent observers measured the lateral view head–neck index (LVHNI) to detect any SUFE-like deformity on lateral hip radiographs taken in 45° flexion, 45° abduction and 30° external rotation. A control group of 108 healthy hips in 54 patients was included for comparison (mean age 36.5 years (24.3 to 53.9).

The impingement group had a mean LVHNI of 7.6% (16.7% to -2%) versus 3.2% in the control group (10.8% to -3%) (p < 0.001). A total of 42 hips (43.7%) had an index value > 9% in the impingement group versus only six hips (5.5%) in the control group (p < 0.001). The impingement group had a mean α angle of 73.9° (96.2° to 53.4°) versus 48.2° (65° to 37°) in the control group (p < 0.001).

Our results suggest that SUFE is one of the primary aetiological factors for cam-type FAI.

Cite this article: Bone Joint J 2014; 96-B:724–9.

We investigated the development of CT-based bony radiological parameters associated with femoroacetabular impingement (FAI) in a paediatric and adolescent population with no known orthopaedic hip complaints. We retrospectively reformatted and reoriented 225 abdominal CTs into standardised CT pelvic images with neutral pelvic tilt and inclination (244 female and 206 male hips) in patients ranging from two to 19 years of age (mean 10.4 years). The Tönnis angle, acetabular depth ratio, lateral centre–edge angle, acetabular version and α-angle were assessed.

Acetabular measurements demonstrated increased acetabular coverage with age and/or progressive ossification of the acetabulum. The α-angle decreased with age and/or progressive cortical bone development and resultant narrowing of the femoral neck. Cam and pincer morphology occurred as early as ten and 12 years of age, respectively, and their prevalence in the adolescent patient population is similar to that reported in the adult literature. Future aetiological studies of FAI will need to focus on the early adolescent population.

Cite this article: Bone Joint J 2013;95-B:598–604.

The reported prevalence of an asymptomatic slip of the contralateral hip in patients operated on for unilateral slipped capital femoral epiphysis (SCFE) is as high as 40%. Based on a population-based cohort of 2072 healthy adolescents (58% women) we report on radiological and clinical findings suggestive of a possible previous SCFE. Common threshold values for Southwick’s lateral head–shaft angle (≥ 13°) and Murray’s tilt index (≥ 1.35) were used. New reference intervals for these measurements at skeletal maturity are also presented.

At follow-up the mean age of the patients was 18.6 years (17.2 to 20.1). All answered two questionnaires, had a clinical examination and two hip radiographs.

There was an association between a high head–shaft angle and clinical findings associated with SCFE, such as reduced internal rotation and increased external rotation. Also, 6.6% of the cohort had Southwick’s lateral head–shaft angle ≥ 13°, suggestive of a possible slip. Murray’s tilt index ≥ 1.35 was demonstrated in 13.1% of the cohort, predominantly in men, in whom this finding was associated with other radiological findings such as pistol-grip deformity or focal prominence of the femoral neck, but no clinical findings suggestive of SCFE.

This study indicates that 6.6% of young adults have radiological findings consistent with a prior SCFE, which seems to be more common than previously reported.

Cite this article: Bone Joint J 2013;95-B:452–8.

A total of 157 hindquarter amputations were carried out in our institution during the last 30 years. We have investigated the reasons why this procedure is still required and the outcome. This operation was used as treatment for 13% of all pelvic bone sarcomas. It was curative in 140 and palliative in 17, usually to relieve pain. There were 90 primary procedures (57%) with the remaining 67 following the failure of previous operations to control the disease locally. The indication for amputation in primary disease was for large tumours for which limb-salvage surgery was no longer feasible. The peri-operative mortality was 1.3% (n = 2) and major complications of wound healing or infection arose in 71 (45%) patients. The survival at five years after hindquarter amputation with the intent to cure was 45%, and at ten years 38%. Local recurrence occurred in 23 patients (15%). Phantom pain was a significant problem, and only 20% used their prosthesis regularly. Functional scores were a mean of 57%. With careful patient selection the oncological results and functional outcomes of hindquarter amputation justify its continued use.

Cite this article: Bone Joint J 2013;95-B:127–31.

In the majority of patients with slipped upper femoral epiphysis only one hip is involved at primary diagnosis. However, the contralateral hip often becomes involved over time. There are no reliable factors predicting a contralateral slip. Whether or not the contralateral hip should undergo prophylactic fixation is a matter of controversy. We present a number of essential points that have to be considered both when choosing to fix the contralateral hip prophylactically as well as when refraining from surgery and instead following the patients with repeat radiographs.

In distal fibular resection without reconstruction, the stabilising effect of the lateral malleolus is lost. Thus, the ankle may collapse into valgus and may be unstable in varus. Here, we describe a child who underwent successful staged surgical correction of a severe neglected valgus deformity after excision of the distal fibula for a Ewing’s sarcoma.

Free vascularised fibular grafting has been reported to be successful for adult patients with osteonecrosis of the femoral head (ONFH). However, its benefit in teenage patients with post-traumatic ONFH has not been determined. We evaluated the effectiveness of free vascularised fibular grafting in the treatment of this condition in children and adolescents. We retrospectively analysed 28 hips in 28 patients in whom an osteonecrotic femoral head had been treated with free vascularised fibular grafting between 2002 and 2008. Their mean age was 16.3 years (13 to 19). The stage of the disease at time of surgery, and results of treatment including pre- and post-operative Harris hip scores, were studied. We defined clinical failure as conversion to total hip replacement. All patients were followed up for a mean of four years (2 to 7). The mean Harris hip score improved from 60.4 (37 to 84) pre-operatively to 94.2 (87 to 100) at final follow-up. At the latest follow-up we found improved or unchanged radiographs in all four initially stage II hips and in 23 of 24 stage III or IV hips. Only one hip (stage V) deteriorated. No patient underwent total hip replacement.

Free vascularised fibular grafting is indicated for the treatment of post-traumatic ONFH in teenage patients.

There is no published literature detailing the demographics of paediatric amputations in the United Kingdom. We performed this review of children and adolescents referred to a regional limb-fitting centre from the 1930s to the current decade who suffered amputation as a result of trauma, and compared our data with similar cohorts from other units. Of the 93 patients included, only 11 were injured in the last 20 years. Road traffic accidents accounted for 63% of traumatic amputations. Of all amputations, 81% were in the lower limb and 19% in the upper limb.

Our figures are similar to those from a United Kingdom national statistical database of amputees which showed on average four traumatic amputee referrals to each regional limb-fitting centre in the United Kingdom per ten-year period. Compared with the United States, the incidence of paediatric traumatic amputations in the United Kingdom is low.

We report the survival, radiological and functional outcomes of a single surgeon series of his first 144 consecutive Birmingham hip resurfacing procedures (130 patients) at a minimum of ten years. There were ten revisions during this time. Although no patients were lost to follow-up some did not complete the scoring assessment or undergo radiological assessment at ten years.

The ten-year survival for male patients was 98.0% (95% confidence interval 95.2 to 100). The ten-year survival for the total cohort with aseptic revision as the endpoint was 95.5% (95% confidence interval 91.8 to 99.0) and including revisions for sepsis was 93.5% (95% confidence interval 89.2 to 97.6). The median modified Oxford hip score at ten years was 4.2% (interquartile range 0 to 19) and the median University of California, Los Angeles score was 7.0 (interquartile range 5.0 to 8.0).

This study confirms the midterm reports that metal-on-metal hip resurfacing using the Birmingham Hip provides a durable alternative to total hip replacement, particularly in younger male patients wishing to maintain a high level of function, with low risk of revision for at least ten years.

Increasing follow-up identifies the outcome in younger patients who have undergone total hip replacement (THR) and reveals the true potential for survival of the prosthesis. We identified 28 patients (39 THRs) who had undergone cemented Charnley low friction arthroplasty between 1969 and 2001. Their mean age at operation was 17.9 years (12 to 19) and the maximum follow-up was 34 years. Two patients (4 THRs) were lost to follow-up, 13 (16 THRs) were revised at a mean period of 19.1 years (8 to 34) and 13 (19 THRs) continue to attend regular follow-up at a mean of 12.6 years (2.3 to 29). In this surviving group one acetabular component was radiologically loose and all femoral components were secure. In all the patients the diameter of the femoral head was 22.225 mm with Charnley femoral components used in 29 hips and C-stem femoral components in ten. In young patients who require THR the acetabular bone stock is generally a limiting factor for the size of the component. Excellent long-term results can be obtained with a cemented polyethylene acetabular component and a femoral head of small diameter.

The sternoclavicular joint is vulnerable to the same disease processes as other synovial joints, the most common of which are instability from injury, osteoarthritis, infection and rheumatoid disease. Patients may also present with other conditions, which are unique to the joint, or are manifestations of a systemic disease process. The surgeon should be aware of these possibilities when assessing a patient with a painful, swollen sternoclavicular joint.

We have studied the effects of bupivacaine on human and bovine articular chondrocytes in vitro. Time-lapse confocal microscopy of human articular chondrocytes showed > 95% cellular death after exposure to 0.5% bupivacaine for 30 minutes. Human and bovine chondrocytes exposed to 0.25% bupivacaine had a time-dependent reduction in viability, with longer exposure times resulting in higher cytotoxicity. Cellular death continued even after removal of 0.25% bupivacaine. After exposure to 0.25% bupivacaine for 15 minutes, flow cytometry showed bovine chondrocyte viability to be 41% of saline control after seven days. After exposure to 0.125% bupivacaine for up to 60 minutes, the viability of both bovine and human chondrocytes was similar to that of control groups.

These data show that prolonged exposure 0.5% and 0.25% bupivacaine solutions are potentially chondrotoxic.

Kienböck’s disease is a form of osteonecrosis affecting the lunate. Its aetiology remains unknown. Morphological variations, such as negative ulnar variance, high uncovering of the lunate, abnormal radial inclination and/or a trapezoidal shape of the lunate and the particular pattern of its vascularity may be predisposing factors. A history of trauma is common. The diagnosis is made on plain radiographs, but MRI can be helpful early in the disease. A CT scan is useful to demonstrate fracture or fragmentation of the lunate. Lichtman classified Kienböck disease into five stages. The natural history of the condition is not well known, and the symptoms do not correlate well with the changes in shape of the lunate and the degree of carpal collapse. There is no strong evidence to support any particular form of treatment. Many patients are improved by temporary immobilisation of the wrist, which does not stop the progression of carpal collapse. Radial shortening may be the treatment of choice in young symptomatic patients presenting with stages I to III-A of Kienböck’s disease and negative ulnar variance. Many other forms of surgical treatment have been described.