To determine the normal values and usefulness of the C1/4 space
available for spinal cord (SAC) ratio and C1 inclination angle,
which are new radiological parameters for assessing atlantoaxial
instability in children with Down syndrome. We recruited 272 children with Down syndrome (including 14 who
underwent surgical treatment), and 141 children in the control group.
All were aged between two and 11 years. The C1/4 SAC ratio, C1 inclination
angle, atlas-dens interval (ADI), and SAC were measured in those
with Down syndrome, and the C1/4 SAC ratio and C1 inclination angle
were measured in the control group.Aims
Patients and Methods
Despite its intrinsic ability to regenerate form and function after injury, bone tissue can be challenged by a multitude of pathological conditions. While innovative approaches have helped to unravel the cascades of bone healing, this knowledge has so far not improved the clinical outcomes of bone defect treatment. Recent findings have allowed us to gain in-depth knowledge about the physiological conditions and biological principles of bone regeneration. Now it is time to transfer the lessons learned from bone healing to the challenging scenarios in defects and employ innovative technologies to enable biomaterial-based strategies for bone defect healing. This review aims to provide an overview on endogenous cascades of bone material formation and how these are transferred to new perspectives in biomaterial-driven approaches in bone regeneration. Cite this article: T. Winkler, F. A. Sass, G. N. Duda, K. Schmidt-Bleek. A review of biomaterials in bone defect healing, remaining shortcomings and future opportunities for bone tissue engineering: The unsolved challenge.
The recognition of hips at risk of displacement
in children with cerebral palsy (CP) is a difficult problem for
the orthopaedic surgeon. The Gross Motor Function Classification
System (GMFCS) and head–shaft angle (HSA) are prognostic factors
for hip displacement. However, reference values for HSA are lacking.
This study describes and compares the development of HSA in normal
hips and children with CP. We selected 33 children from a retrospective cohort with unilateral
developmental dysplasia of the hip (DDH) (five boys, 28 girls) and
50 children (35 boys, 15 girls) with CP with GMFCS levels II to
V. HSA of normal developing hips was measured at the contralateral
hip of unilateral DDH children (33 hips) and HSA of CP children
was measured in both hips (100 hips). Measurements were taken from
the radiographs of the children at age two, four and seven years.
The normal hip HSA decreased by 2° per year (p <
0.001). In children
with CP with GMFCS levels II and III HSA decreased by 0.6° (p =
0.046) and 0.9° (p = 0.049) per year, respectively. The HSA did
not alter significantly in GMFCS levels IV and V. Between the ages of two and eight years, the HSA decreases in
normal hips and CP children with GMFCS level, II to III but does
not change in GMFCS levels IV to V. As HSA has a prognostic value
for hip displacement, these reference values may help the orthopaedic
surgeon to predict future hip displacement in children with CP. Cite this article:
Paediatric fractures are common and can cause
significant morbidity. Socioeconomic deprivation is associated with an
increased incidence of fractures in both adults and children, but
little is known about the epidemiology of paediatric fractures.
In this study we investigated the effect of social deprivation on
the epidemiology of paediatric fractures. We compiled a prospective database of all fractures in children
aged <
16 years presenting to the study centre. Demographics,
type of fracture, mode of injury and postcode were recorded. Socioeconomic
status quintiles were assigned for each child using the Scottish
Index for Multiple Deprivation (SIMD). We found a correlation between increasing deprivation and the
incidence of fractures (r = 1.00, p <
0.001). In the most deprived
group the incidence was 2420/100 000/yr, which diminished to 1775/100
000/yr in the least deprived group. The most deprived children were more likely to suffer a fracture
as a result of a fall (odds ratio (OR) = 1.5, p <
0.0001), blunt
trauma (OR = 1.5, p = 0.026) or a road traffic accident (OR = 2.7,
p <
0.0001) than the least deprived. These findings have important implications for public health
and preventative measures. Cite this article:
Extendible endoprostheses have been available for more than 30
years and have become more sophisticated with time. The latest generation
is ‘non-invasive’ and can be lengthened with an external magnetic
force. Early results have shown a worryingly high rate of complications
such as infection. This study investigates the incidence of complications
and the need for further surgery in a cohort of patients with a
non-invasive growing endoprosthesis. Between 2003 and June 2014, 50 children (51 prostheses) had a
non-invasive growing prosthesis implanted for a primary bone sarcoma.
The minimum follow-up was 24 months for those who survived. Their
mean age was 10.4 years (6 to 14). The incidence of complications
and further surgery was documented.Aims
Patients and Methods
External fixation is widely used in orthopaedic
and trauma surgery. Infections around pin or wire sites, which are usually
localised, non-invasive, and are easily managed, are common. Occasionally,
more serious invasive complications such as necrotising fasciitis
(NF) and toxic shock syndrome (TSS) may occur. We retrospectively reviewed all patients who underwent external
fixation between 1997 and 2012 in our limb lengthening and reconstruction
programme. A total of eight patients (seven female and one male)
with a mean age of 20 years (5 to 45) in which pin/wire track infections
became limb- or life-threatening were identified. Of these, four
were due to TSS and four to NF. Their management is described. A
satisfactory outcome was obtained with early diagnosis and aggressive
medical and surgical treatment. Clinicians caring for patients who have external fixation and
in whom infection has developed should be aware of the possibility
of these more serious complications. Early diagnosis and aggressive
treatment are required in order to obtain a satisfactory outcome. Cite this article:
This study compared the long-term results following Salter osteotomy
and Pemberton acetabuloplasty in children with developmental dysplasia
of the hip (DDH). We assessed if there was a greater increase in
pelvic height following the Salter osteotomy, and if this had a
continued effect on pelvic tilt, lumbar curvature or functional outcomes. We reviewed 42 children at more than ten years post-operatively
following a unilateral Salter osteotomy or Pemberton acetabuloplasty.
We measured the increase in pelvic height and the iliac crest tilt
and sacral tilt at the most recent review and at an earlier review
point in the first decade of follow-up. We measured the lumbar Cobb angle
and the Short Form-36 (SF-36) and Harris hip scores were collected
at the most recent review.Aims
Patients and Methods
The aim of this study was to evaluate the correlation between
Salter’s criteria and Kalamchi’s classification of avascular necrosis
in patients treated for developmental dysphasia of the hip (DDH). The study involved a retrospective analysis of 123 patients (123
hips) with DDH treated by operative and non-operative reduction
before the age of two years, with a minimum follow-up of ten years.
Salter’s criteria (S1 to S4) were determined from radiographs obtained
at one to two years post-reduction, whilst the Kalamchi grade was determined
from radiographs obtained at ten or more years of age. Early post-reduction
radiographs were also used to evaluate the centre-head distance
discrepancy (CHDD) and the occurrence of a dome-shaped deformity
of the proximal femoral metaphysis (D-shaped metaphysis). The prognosis was described as good (Kalamchi grade K0 or KI),
fair (Kalamchi grade KII) or poor (Kalamchi grade KIII or KIV) for
analysis and correlation with the early Salter criteria, CHDD and
D-shaped metaphysis.Aims
Patients and Methods
Although atlantoaxial rotatory fixation (AARF) is a common cause
of torticollis in children, the diagnosis may be delayed. The condition
is characterised by a lack of rotation at the atlantoaxial joint
which becomes fixed in a rotated and subluxed position. The management of
children with a delayed presentation of this condition is controversial.
This is a retrospective study of a group of such children. Children who were admitted to two institutions between 1988 and
2014 with a diagnosis of AARF were included. We identified 12 children
(four boys, eight girls), with a mean age of 7.3 years (1.5 to 13.4),
in whom the duration of symptoms on presentation was at least four weeks
(four to 39). All were treated with halo traction followed by a
period of cervical immobilisation in a halo vest or a Minerva jacket.
We describe a simple modification to the halo traction that allows
the child to move their head whilst maintaining traction. The mean follow-up
was 59.6 weeks (24 to 156).Aims
Patients and Methods
After the initial correction of congenital talipes equinovarus
(CTEV) using the Ponseti method, a subsequent dynamic deformity
is often managed by transfer of the tendon of tibialis anterior
(TATT) to the lateral cuneiform. Many surgeons believe the lateral
cuneiform should be ossified before surgery is undertaken. This
study quantifies the ossification process of the lateral cuneiform
in children with CTEV between one and three years of age. The length, width and height of the lateral cuneiform were measured
in 43 consecutive patients with unilateral CTEV who had been treated
using the Ponseti method. Measurements were taken by two independent
observers on standardised anteroposterior and lateral radiographs
of both feet taken at one, two and three years of age.Aims
Patients and Methods
The mucopolysaccharidoses (MPS) are a group of
inherited lysosomal storage disorders with clinical manifestations relevant
to the orthopaedic surgeon. Our aim was to review the recent advances
in their management and the implications for surgical practice. The current literature about MPSs is summarised, emphasising
orthopaedic complications and their management. Recent advances in the diagnosis and management of MPSs include
the recognition of slowly progressive, late presenting subtypes,
developments in life-prolonging systemic treatment and potentially
new indications for surgical treatment. The outcomes of surgery
in these patients are not yet validated and some procedures have
a high rate of complications which differ from those in patients
who do not have a MPS. The diagnosis of a MPS should be considered in adolescents or
young adults with a previously unrecognised dysplasia of the hip.
Surgeons treating patients with a MPS should report their experience
and studies should include the assessment of function and quality
of life to guide treatment. Cite this article:
The aim of this prospective study was to investigate
prematurity as a risk factor for developmental dysplasia of the hip
(DDH). The hips of 221 infants (88 female, 133 male, mean age 31.11
weeks; standard deviation ( These results suggests that prematurity is not a predisposing
factor for DDH. Cite this article:
The aims of this study were to describe the course of non-operatively
managed, bilateral Perthes’ disease, and to determine specific prognostic
factors for the radiographic and clinical outcome. We identified 40 children with a mean age of 5.9 years (1.8 to
13.5), who were managed non-operatively for bilateral Perthes’ disease
from our prospective, multicentre study of this condition, which
included all children in Norway who were diagnosed with Perthes’
disease in the five-year period between 1996 and 2000. All children
were followed up for five years. The hips were classified according to the Catterall classification.
A modified three-group Stulberg classification was used as an outcome
measure, with a spherical femoral head being defined as a good outcome,
an oval head as fair, and a flat femoral head as a poor outcome. Aims
Patients and Methods
A total of 30 patients with thoracolumbar/lumbar adolescent idiopathic
scoliosis (AIS) treated between 1989 and 2000 with anterior correction
and fusion surgery using dual-rod instrumentation were reviewed. Radiographic parameters and clinical outcomes were compared among
patients with lowest instrumented vertebra (LIV) at the lower end
vertebra (LEV; EV group) (n = 13) and those treated by short fusion
(S group), with LIV one level proximal to EV (n = 17 patients). Aims
Patients and Methods
The traditional techniques involving an oblique
tunnel or triangular wedge resection to approach a central or mixed-type
physeal bar are hindered by poor visualisation of the bar. This
may be overcome by a complete transverse osteotomy at the metaphysis
near the growth plate or a direct vertical approach to the bar.
Ilizarov external fixation using small wires allows firm fixation
of the short physis-bearing fragment, and can also correct an associated angular
deformity and permit limb lengthening. We accurately approached and successfully excised ten central-
or mixed-type bars; six in the distal femur, two in the proximal
tibia and two in the distal tibia, without damaging the uninvolved
physis, and corrected the associated angular deformity and leg-length
discrepancy. Callus formation was slightly delayed because of periosteal
elevation and stretching during resection of the bar. The resultant
resection of the bar was satisfactory in seven patients and fair
in three as assessed using a by a modified Williamson–Staheli classification. Cite this article:
Our aim was to describe the mid-term appearances of the repair
process of the Achilles tendon after tenotomy in children with a
clubfoot treated using the Ponseti method. A total of 15 children (ten boys, five girls) with idiopathic
clubfoot were evaluated at a mean of 6.8 years (5.4 to 8.1) after
complete percutaneous division of the Achilles tendon. The contour
and subjective thickness of the tendon were recorded, and superficial
defects and its strength were assessed clinically. The echogenicity,
texture, thickness, peritendinous irregularities and potential for
deformation of the tendon were evaluated by ultrasonography.Aims
Patients and Methods
Children treated for osteosarcoma around the knee often have
a substantial leg-length discrepancy at skeletal maturity. The aim
of this study was to investigate the results of staged skeletal
reconstruction after a leg lengthening procedure using an external
fixator in these patients. We reviewed 11 patients who underwent staged reconstruction with
either an arthroplasty (n = 6) or an arthrodesis (n = 5). A control
group of 11 patients who had undergone wide excision and concurrent
reconstruction with an arthroplasty were matched for gender, location,
and size of tumour. We investigated the change in leg-length discrepancy,
function as assessed by the Musculoskeletal Tumor Society Scale
(MSTS) score and complications.Aims
Patients and Methods
The purpose of this retrospective study was to differentiate
between the MRI features of normal post-operative change and those
of residual or recurrent disease after intralesional treatment of
an atypical cartilage tumour (ACT)/grade I chondrosarcoma. We reviewed the case notes, radiology and histology of 75 patients,
who had been treated for an ACT/grade I chondrosarcoma by curettage,
phenolisation and bone allografting between 1994 and 2005. The first
post-operative Gd-enhanced MRI scan was carried out within one year
of surgery. Patients had a minimum of two scans and a mean follow-up
of 72 months (13 to 169). Further surgery was undertaken in cases
of suspected recurrence.Aims
Patients and Methods
Adolescent idiopathic scoliosis affects about
3% of children. Non-operative measures are aimed at altering the natural
history to maintain the size of the curve below 40° at skeletal
maturity. The application of braces to treat spinal deformity pre-dates
the era of evidence-based medicine, and there is a paucity of irrefutable
prospective evidence in the literature to support their use and
their effectiveness has been questioned. This review considers this evidence. The weight of the evidence
is in favour of bracing over observation. The most recent literature
has moved away from addressing this question, and instead focuses
on developments in the design of braces and ways to improve compliance. Cite this article:
