Aims

Children with spinal dysraphism can develop various musculoskeletal deformities, necessitating a range of orthopaedic interventions, causing significant morbidity, and making considerable demands on resources. This systematic review aimed to identify what outcome measures have been reported in the literature for children with spinal dysraphism who undergo orthopaedic interventions involving the lower limbs.

Aims

Global literature suggests that female surgical trainees have lower rates of independent operating (operative autonomy) than their male counterparts. The objective of this study was to identify any association between gender and lead/independent operating in speciality orthopaedic trainees within the UK national training programme.

Van Nes rotationplasty may be used for patients with congenital proximal focal femoral deficiency (PFFD). The lower limb is rotated to use the ankle and foot as a functional knee joint within a prosthesis. A small series of cases was investigated to determine the long-term outcome. At a mean of 21.5 years (11 to 45) after their rotationplasty, a total of 12 prosthetic patients completed the Short-Form (SF)-36, Faces Pain Scale-Revised, Harris hip score, Oswestry back pain score and Prosthetic Evaluation Questionnaires, as did 12 age- and gender-matched normal control participants. A physical examination and gait analysis, computerised dynamic posturography (CDP), and timed ‘Up & Go’ testing was also completed. Wilcoxon Signed rank test was used to compare each PFFD patient with a matched control participant with false discovery rate of 5%.

There were no differences between the groups in overall health and well-being on the SF-36. Significant differences were seen in gait parameters in the PFFD group. Using CDP, the PFFD group had reduced symmetry in stance, and reduced end point and maximum excursions.

Patients who had undergone Van Nes rotationplasty had a high level of function and quality of life at long-term follow-up, but presented with significant differences in gait and posture compared with the control group.

Cite this article: Bone Joint J 2013;95-B:192–8.

Highly active anti-retroviral therapy has transformed HIV into a chronic disease with a long-term asymptomatic phase. As a result, emphasis is shifting to other effects of the virus, aside from immunosuppression and mortality. We have reviewed the current evidence for an association between HIV infection and poor fracture healing.

The increased prevalence of osteoporosis and fragility fractures in HIV patients is well recognised. The suggestion that this may be purely as a result of highly active anti-retroviral therapy has been largely rejected. Apart from directly impeding cellular function in bone remodelling, HIV infection is known to cause derangement in the levels of those cytokines involved in fracture healing (particularly tumour necrosis factor-α) and appears to impair the blood supply of bone.

Many other factors complicate this issue, including a reduced body mass index, suboptimal nutrition, the effects of anti-retroviral drugs and the avoidance of operative intervention because of high rates of wound infection. However, there are sound molecular and biochemical hypotheses for a direct relationship between HIV infection and impaired fracture healing, and the rewards for further knowledge in this area are extensive in terms of optimised fracture management, reduced patient morbidity and educated resource allocation. Further investigation in this area is overdue.

We have developed a clinical method for the graphic recording, analysis and planning of treatment of leg-length discrepancy during growth. Initially, the clinically determined discrepancy is plotted against the chronological age yearly, and then in late childhood at six-monthly intervals. CT and measurements of skeletal age are made in middle and late childhood to confirm the clinical findings. In a prospective study in 20 children, we observed that only eight had a linear increase in discrepancy. The observed pattern of increase was therefore used to estimate the mature discrepancy. Epiphyseodesis reference slopes were used to determine the most appropriate time and type of epiphyseodesis. In all children, the leg-length discrepancy at maturity was within 1 cm of the predicted amount. Changes in discrepancy due to leg lengthening or correction of deformity were also plotted graphically. We conclude that the clinical graphic method is simple to use, takes into account the varying patterns of discrepancy, and minimises radiation dosage.

We have studied the radiographic and CT features of 120 displaced intra-articular fractures of the calcaneum in order to define the pathological anatomy. In 96% of cases, the CT scans identified three main fragments: sustentacular, lateral joint and body. The sustentacular fragment was often rotated into varus, the lateral joint fragment into valgus and the body fragment impacted upwards, in varus and displaced laterally. The displacement of these fragments varied according to which of three fracture types was present, as defined by the composition of the fractured lateral wall of the calcaneum. In type 1 it was formed by the lateral joint fragment alone; in type 2 by both body and lateral joint fragments; and in type 3 by the body fragment alone. Fracture fragment displacement differs from that previously described, in that true uniform depression of the lateral joint fragment is rare.

The classification of intra-articular fractures of the calcaneum described in part I is related to an operative approach which allows accurate reduction and stable fixation of the fracture fragments. An extended lateral incision is used to avoid sural nerve damage and problems of soft-tissue healing. In type 3 fractures, access to the lateral joint fragment requires an osteotomy of the lateral wall, but after this the lateral joint fragment can be rotated out of the subtalar joint to allow transcalcaneal reduction of the medial wall. Reduction of the body fragment and lateral joint fragment on to the sustentacular fragment allows the three fragments to be stabilised by a 3.5 mm Y-shaped reconstruction plate. Our early results have been successful in terms of fracture reduction and the restoration of heel shape and joint congruity, but extended follow-up will be necessary to define the indications for this difficult procedure.

The results of treatment in 242 patients with intracapsular fractures of the neck of femur treated with Garden screws are presented with reference as to whether the screws were crossed or parallel. The incidence both of nonunion and of avascular necrosis was less in those fractures treated with parallel screws. The outcome was also superior if the reduction was good.

We reviewed 34 hindquarter amputations performed for malignant tumours around the hip from 1971 to 1988, classifying them as palliative or curative according to the resection margins or the presence of disseminated disease at the time of surgery. There were three peri-operative deaths, 12 palliative and 19 curative procedures. Ten patients died of disseminated disease within a year of surgery, eight of whom had had a palliative operation. Three patients died between one and five years after palliative surgery. One died of unrelated disease at nine years. Seventeen patients are disease free an average of 31 months from surgery, 16 after curative procedures. The median survival after palliative amputations was six months and the 5-year survival rate for curative cases was 83%.