We retrospectively studied the possibility that direct trauma to the biceps
Previous studies have identified clinical and
demographic risk factors for recurrence in the treatment of idiopathic clubfoot
(congenital talipes equinovarus). Evertor
Pyomyositis is rarely seen in temperate climates. Typically, it presents with the formation of an abscess requiring surgical drainage and it has been reported as a differential diagnosis for septic arthritis of the hip. We describe the occurrence of pyomyositis of the iliacus
We operated on 111 patients with 159 congenital club feet with the aim of correcting the deformity and achieving dynamic
We treated 20 children (40 limbs) with diplegic cerebral palsy who could walk by multilevel soft tissue operative procedures including conversion of the biarticular semitendinosus and gastrocnemius to monoarticular
Aims. There is a lack of high-quality research investigating outcomes of Ponseti-treated idiopathic clubfeet and correlation with relapse. This study assessed clinical and quality of life (QoL) outcomes using a standardized core outcome set (COS), comparing children with and without relapse. Methods. A total of 11 international centres participated in this institutional review board-approved observational study. Data including demographics, information regarding presentation, treatment, and details of subsequent relapse and management were collected between 1 June 2022 and 30 June 2023 from consecutive clinic patients who had a minimum five-year follow-up. The clubfoot COS incorporating 31 parameters was used. A regression model assessed relationships between baseline variables and outcomes (clinical/QoL). Results. Overall, 293 patients (432 feet) with a median age of 89 months (interquartile range 72 to 113) were included. The relapse rate was 37%, with repeated relapse in 14%. Treatment considered a standard part of the Ponseti journey (recasting, repeat tenotomy, and tibialis anterior tendon transfer) was performed in 35% of cases, with soft-tissue release and osteotomies in 5% and 2% of cases, respectively. Predictors of relapse included duration of follow-up, higher initial Pirani score, and poor Evertor
Aims. Perthes’ disease is a condition leading to necrosis of the femoral head. It is most common in children aged four to nine years, affecting around one per 1,200 children in the UK. Management typically includes non-surgical treatment options, such as physiotherapy with/without surgical intervention. However, there is significant variation in care with no consensus on the most effective treatment option. Methods. This systematic review aims to evaluate the effectiveness of non-surgical interventions for the treatment of Perthes’ disease. Comparative studies (experimental or observational) of any non-surgical intervention compared directly with any alternative intervention (surgical, non-surgical or no intervention) were identified from: Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMcare, Allied and Complementary Medicine Database (AMED), and the Physiotherapy Evidence Database (PEDro). Data were extracted on interventions compared and methodological quality. For post-intervention primary outcome of radiological scores (Stulberg and/or Mose), event rates for poor scores were calculated with significance values. Secondary outcomes included functional measures, such as range of movement, and patient-reported outcomes such as health-related quality of life. Results. In all, 15 studies (1,745 participants) were eligible for inclusion: eight prospective cohort studies, seven retrospective cohort studies, and no randomized controlled trials were identified. Non-surgical interventions largely focused on orthotic management (14/15 studies) and physical interventions such as
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. A PROSPERO-registered systematic literature review was performed following PRISMA guidelines. All relevant studies published until January 2023 were identified. Individual outcomes and outcome measurement tools were extracted verbatim. The measurement tools were assessed for reliability and validity, and all outcomes were grouped according to the Outcome Measures Recommended for use in Randomized Clinical Trials (OMERACT) filters.Aims
Methods
Multiple secondary surgical procedures of the shoulder, such as soft-tissue releases, tendon transfers, and osteotomies, are described in brachial plexus birth palsy (BPBP) patients. The long-term functional outcomes of these procedures described in the literature are inconclusive. We aimed to analyze the literature looking for a consensus on treatment options. A systematic literature search in healthcare databases (PubMed, Embase, the Cochrane library, CINAHL, and Web of Science) was performed from January 2000 to July 2020, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The quality of the included studies was assessed with the Cochrane ROBINS-I risk of bias tool. Relevant trials studying BPBP with at least five years of follow-up and describing functional outcome were included.Aims
Methods
Given the possible radiation damage and inaccuracy of radiological investigations, particularly in children, ultrasound and superb microvascular imaging (SMI) may offer alternative methods of evaluating new bone formation when limb lengthening is undertaken in paediatric patients. The aim of this study was to assess the use of ultrasound combined with SMI in monitoring new bone formation during limb lengthening in children. In this retrospective cohort study, ultrasound and radiograph examinations were performed every two weeks in 30 paediatric patients undergoing limb lengthening. Ultrasound was used to monitor new bone formation. The number of vertical vessels and the blood flow resistance index were compared with those from plain radiographs.Aims
Methods
To examine the long-term outcome of arthrodesis of the hip undertaken in a paediatric population in treating painful arthritis of the hip. In our patient population, most of whom live rurally in hilly terrain and have limited healthcare access and resources, hip arthrodesis has been an important surgical option for the monoarticular painful hip in a child. A follow-up investigation was undertaken on a cohort of 28 children previously reported at a mean of 4.8 years. The present study looked at 26 patients who had an arthrodesis of the hip as a child at a mean follow-up of 20 years (15 to 29).Aims
Methods
Reimers migration percentage (MP) is a key measure to inform decision-making around the management of hip displacement in cerebral palsy (CP). The aim of this study is to assess validity and inter- and intra-rater reliability of a novel method of measuring MP using a smart phone app (HipScreen (HS) app). A total of 20 pelvis radiographs (40 hips) were used to measure MP by using the HS app. Measurements were performed by five different members of the multidisciplinary team, with varying levels of expertise in MP measurement. The same measurements were repeated two weeks later. A senior orthopaedic surgeon measured the MP on picture archiving and communication system (PACS) as the gold standard and repeated the measurements using HS app. Pearson’s correlation coefficient (r) was used to compare PACS measurements and all HS app measurements and assess validity. Intraclass correlation coefficient (ICC) was used to assess intra- and inter-rater reliability.Aims
Methods
To identify the minimum set of outcomes that should be collected in clinical practice and reported in research related to the care of children with idiopathic congenital talipes equinovarus (CTEV). A list of outcome measurement tools (OMTs) was obtained from the literature through a systematic review. Further outcomes were collected from patients and families through a questionnaire and interview process. The combined list, as well as the appropriate follow-up timepoint, was rated for importance in a two-round Delphi process that included an international group of orthopaedic surgeons, physiotherapists, nurse practitioners, patients, and families. Outcomes that reached no consensus during the Delphi process were further discussed and scored for inclusion/exclusion in a final consensus meeting involving international stakeholder representatives of practitioners, families, and patient charities.Aims
Methods
This study compares the initial outcomes of minimally invasive techniques for single-event multi-level surgery with conventional single-event multi-level surgery. The minimally invasive techniques included derotation osteotomies using closed corticotomy and fixation with titanium elastic nails and percutaneous lengthening of
The aim of this study is to develop a core set of outcome domains that should be considered and reported in all future trials of childhood limb fractures. A four-phase study was conducted to agree a set of core outcome domains. Identification of candidate outcome domains were identified through systematic review of trials, and outcome domains relevant to families were identified through semi-structured interviews with 20 families (parent-child pairing or group). Outcome domains were prioritized using an international three-round Delphi survey with 205 panellists and then condensed into a core outcome set through a consensus workshop with 30 stakeholders.Aims
Methods
Although equinus gait is the most common abnormality
in children with spastic cerebral palsy (CP) there is no consistency
in recommendations for treatment, and evidence for best practice
is lacking. The Baumann procedure allows selective fractional lengthening
of the gastrocnemii and soleus
An internal rotation contracture is a common complication of obstetric brachial plexus palsy. We describe the operative treatment of seven children with a recurrent internal rotation contracture of the shoulder following earlier corrective surgery which included subscapularis slide and latissimus dorsi transfer. We performed z-lengthening of the tendon of the subscapularis
Open tibial fractures are limb-threatening injuries. While limb loss is rare in children, deep infection and nonunion rates of up to 15% and 8% are reported, respectively. We manage these injuries in a similar manner to those in adults, with a combined orthoplastic approach, often involving the use of vascularised free flaps. We report the orthopaedic and plastic surgical outcomes of a consecutive series of patients over a five-year period, which includes the largest cohort of free flaps for trauma in children to date. Data were extracted from medical records and databases for patients with an open tibial fracture aged < 16 years who presented between 1 May 2014 and 30 April 2019. Patients who were transferred from elsewhere were excluded, yielding 44 open fractures in 43 patients, with a minimum follow-up of one year. Management was reviewed from the time of injury to discharge. Primary outcome measures were the rate of deep infection, time to union, and the Modified Enneking score.Aims
Methods
We describe the long-term results in ten patients with obstetric brachial plexus palsy of anterior shoulder release combined with transfer of teres major and latissimus dorsi posteriorly and laterally to allow them to act as external rotators. Eight patients had a lesion of the superior trunk and two some involvement of the entire brachial plexus. The mean age at operation was six years, and the mean follow-up was 30 years. Before operation, the patients were unable actively to rotate the arm externally beyond neutral, although this movement was passively normal. All showed decreased strength of the external rotator, but had normal strength of the internal rotator
To compare changes in gait kinematics and walking speed 24 months after conventional (C-MLS) and minimally invasive (MI-MLS) multilevel surgery for children with diplegic cerebral palsy (CP). A retrospective analysis of 19 children following C-MLS, with mean age at surgery of 12 years five months (seven years ten months to 15 years 11 months), and 36 children following MI-MLS, with mean age at surgery of ten years seven months (seven years one month to 14 years ten months), was performed. The Gait Profile Score (GPS) and walking speed were collected preoperatively and six, 12 and 24 months postoperatively. Type and frequency of procedures as part of MLS, surgical adverse events, and subsequent surgery were recorded.Aims
Methods
We aimed to address the question on whether there is a place for shoulder stabilization surgery in patients who had voluntary posterior instability starting in childhood and adolescence, and later becoming involuntary and uncontrollable. Consecutive patients who had an operation for recurrent posterior instability before the age of 18 years were studied retrospectively. All patients had failed conservative treatment for at least six months prior to surgery; and no patients had psychiatric disorders. Two groups were identified and compared: voluntary posterior instability starting in childhood which became uncontrollable and involuntary (group VBI); and involuntary posterior instability (group I). Patients were reviewed and assessed at least two years after surgery by two examiners.Aims
Methods
We report the results of Vulpius transverse gastrocsoleus
recession for equinus gait in 26 children with cerebral palsy (CP),
using the Gait Profile Score (GPS), Gait Variable Scores (GVS) and
movement analysis profile. All children had an equinus deformity
on physical examination and equinus gait on three-dimensional gait
analysis prior to surgery. The pre-operative and post-operative
GPS and GVS were statistically analysed. There were 20 boys and
6 girls in the study cohort with a mean age at surgery of 9.2 years
(5.1 to 17.7) and 11.5 years (7.3 to 20.8) at follow-up. Of the
26 children, 14 had spastic diplegia and 12 spastic hemiplegia.
Gait function improved for the cohort, confirmed by a decrease in
mean GPS from 13.4° pre-operatively to 9.0° final review (p <
0.001). The change was 2.8 times the minimal clinically important
difference (MCID). Thus the improvements in gait were both clinically and
statistically significant. The transverse gastrocsoleus recession
described by Vulpius is an effective procedure for equinus gait
in selected children with CP, when there is a fixed contracture
of the gastrocnemius and soleus
Perthes’ disease is a condition which leads to necrosis of the femoral head. It is most commonly reported in children aged four to nine years, with recent statistics suggesting it affects around five per 100,000 children in the UK. Current treatment for the condition aims to maintain the best possible environment for the disease process to run its natural course. Management typically includes physiotherapy with or without surgical intervention. Physiotherapy intervention often will include strengthening/stretching programmes, exercise/activity advice, and, in some centres, will include intervention, such as hydrotherapy. There is significant variation in care with no consensus on which treatment option is best. The importance of work in this area has been demonstrated by the British Society for Children’s Orthopaedic Surgery through the James Lind Alliance’s prioritization of work to determine/identify surgical versus non-surgical management of Perthes’ disease. It was identified as the fourth-highest priority for paediatric lower limb surgery research in 2018. Five UK NHS centres, including those from the NEWS (North, East, West and South Yorkshire) orthopaedic group, contributed to this case review, with each entre providing clinical data from a minimum of five children. Information regarding both orthopaedic and physiotherapeutic management over a two-year post-diagnosis period was reviewed.Aims
Methods
Hip displacement, common in patients with cerebral palsy (CP), causes pain and hinders adequate care. Hip reconstructive surgery (HRS) is performed to treat hip displacement; however, only a few studies have quantitatively assessed femoral head sphericity after HRS. The aim of this study was to quantitatively assess improvement in hip sphericity after HRS in patients with CP. We retrospectively analyzed hip radiographs of patients who had undergone HRS because of CP-associated hip displacement. The pre- and postoperative migration percentage (MP), femoral neck-shaft angle (NSA), and sphericity, as determined by the Mose hip ratio (MHR), age at surgery, Gross Motor Function Classification System level, surgical history including Dega pelvic osteotomy, and triradiate cartilage status were studied. Regression analyses using linear mixed model were performed to identify factors affecting hip sphericity improvement.Aims
Methods
The treatment of tibial aplasia is controversial. Amputation represents the gold standard with good functional results, but is frequently refused by the families. In these patients, treatment with reconstructive limb salvage can be considered. Due to the complexity of the deformity, this remains challenging and should be staged. The present study evaluated the role of femoro-pedal distraction using a circular external fixator in reconstructive treatment of tibial aplasia. The purpose of femoro-pedal distraction is to realign the limb and achieve soft tissue lengthening to allow subsequent reconstructive surgery. This was a retrospective study involving ten patients (12 limbs) with tibial aplasia, who underwent staged reconstruction. During the first operation a circular hexapod external fixator was applied and femoro-pedal distraction was undertaken over several months. Subsequent surgery included reconstruction of the knee joint and alignment of the foot.Aims
Methods
To analyze outcomes reported in trials of childhood fractures. OVID MEDLINE, Embase, and Cochrane CENTRAL databases were searched on the eighth August 2019. A manual search of trial registries, bibliographic review and internet search was used to identify additional studies. 11,476 studies were screened following PRISMA guidelines. 100 trials were included in the analysis. Data extraction was completed by two researchers for each trial. Study quality was not evaluated. Outcomes reported by trials were mapped onto domains in the World Health Organization (WHO) International Classification of Function framework.Aims
Methods
To describe and analyze the mid-term functional outcomes of a large series of patients who underwent the Hoffer procedure for brachial plexus birth palsy (BPBP). All patients who underwent the Hoffer procedure with minimum two-year follow-up were retrospectively reviewed. Active shoulder range of movement (ROM), aggregate modified Mallet classification scores, Hospital for Sick Children Active Movement Scale (AMS) scores, and/or Toronto Test Scores were used to assess functional outcomes. Subgroup analysis based on age and level of injury was performed. Risk factors for subsequent humeral derotational osteotomy and other complications were also assessed. A total of 107 patients, average age 3.9 years (1.6 to 13) and 59% female, were included in the study with mean 68 months (24 to 194) follow-up.Aims
Methods
A total of 38 relapsed congenital clubfeet (16 stiff, 22 partially correctable) underwent revision of soft-tissue surgery, with or without a bony procedure, and transfer of the tendon of tibialis anterior at a mean age of 4.8 years (2.0 to 10.1). The tendon was transferred to the third cuneiform in five cases, to the base of the third metatarsal in ten and to the base of the fourth in 23. The patients were reviewed at a mean follow-up of 24.8 years (10.8 to 35.6). A total of 11 feet were regarded as failures (one a tendon failure, five with a subtalar fusion due to over-correction, and five with a triple arthrodesis due to under-correction or relapse). In the remaining feet the clinical outcome was excellent or good in 20 and fair or poor in seven. The mean Laaveg-Ponseti score was 81.6 of 100 points (52 to 92). Stiffness was mild in four feet and moderate or severe in 23. Comparison between the post-operative and follow-up radiographs showed statistically significant variations of the talo-first metatarsal angle towards abduction. Variations of the talocalcaneal angles and of the overlap ratio were not significant. Extensive surgery for relapsed clubfoot has a high rate of poor long-term results. The addition of transfer of the tendon of tibialis anterior can restore balance and may provide some improvement of forefoot adduction. However, it has a considerable complication rate, including failure of transfer, over-correction, and weakening of dorsiflexion. The procedure should be reserved for those limited cases in which
Whereas a general trend in the management of obstetric brachial plexus injuries has been nerve reconstruction in patients without spontaneous recovery of biceps function by three to six months of age, many recent studies suggest this may be unnecessary. In this study, the severity of glenohumeral dysplasia and shoulder function and strength in two groups of matched patients with a C5-6 lesion at a mean age of seven years (2.7 to 13.3) were investigated. One group (23 patients) underwent nerve reconstruction and secondary operations, and the other (52 patients) underwent only secondary operations for similar initial clinical presentations. In the patients with nerve reconstruction shoulder function did not improve and they developed more severe shoulder deformities (posterior subluxation, glenoid version and scapular elevation) and required a mean of 2.4 times as many operations as patients without nerve reconstruction. This study suggests that less invasive management, addressing the
The health-related quality of life (HRQoL) of paediatric patients with orthopaedic conditions and spinal deformity is important, but existing generic tools have their shortcomings. We aim to evaluate the use of Paediatric Quality of Life Inventory (PedsQL) 4.0 generic core scales in the paediatric population with specific comparisons between those with spinal and limb pathologies, and to explore the feasibility of using PedsQL for studying scoliosis patients’ HRQoL. Paediatric patients attending a speciality outpatient clinic were recruited through consecutive sampling. Two groups of patients were included: idiopathic scoliosis, and paediatric orthopaedic upper and lower limb condition without scoliosis. Patients were asked to complete PedsQL 4.0 generic core scales, Youth version of 5-level EuroQol-5-dimension questionnaire, and Refined Scoliosis Research Society 22-item (SRS-22r) questionnaire. Statistical analyses included scores comparison between scoliosis and limb pathology patients using independent-samples Aims
Methods
To identify a suite of the key physical, emotional, and social outcomes to be employed in clinical practice and research concerning Perthes' disease in children. The study follows the guidelines of the COMET-Initiative (Core Outcome Measures in Effectiveness Trials). A systematic review of the literature was performed to identify a list of outcomes reported in previous studies, which was supplemented by a qualitative study exploring the experiences of families affected by Perthes’ disease. Collectively, these outcomes formed the basis of a Delphi survey (two rounds), where 18 patients with Perthes’ disease, 46 parents, and 36 orthopaedic surgeons rated each outcome for importance. The International Perthes Study Group (IPSG) (Dallas, Texas, USA (October 2018)) discussed outcomes that failed to reach any consensus (either ‘in’ or ‘out’) before a final consensus meeting with representatives of surgeons, patients, and parents.Aims
Methods
The purpose of this study was to compare the prevalence of hip displacement and dislocation in a total population of children with cerebral palsy (CP) in Scotland before and after the initiation of a hip surveillance programme. A total of 2,155 children with CP are registered in the Cerebral Palsy Integrated Pathway Scotland (CPIPS) surveillance programme, which began in 2013. Physical examination and hip radiological data are collected according to nationally agreed protocols.Aims
Patients
At our institution surgical correction of symptomatic
flat foot deformities in children has been guided by a paradigm in
which radiographs and pedobarography are used in the assessment
of outcome following treatment. Retrospective review of children
with symptomatic flat feet who had undergone surgical correction
was performed to assess the outcome and establish the relationship
between the static alignment and the dynamic loading of the foot. A total of 17 children (21 feet) were assessed before and after
correction of soft-tissue contractures and lateral column lengthening,
using standardised radiological and pedobarographic techniques for
which normative data were available. We found significantly improved static segmental alignment of
the foot, significantly improved mediolateral dimension foot loading,
and worsened fore-aft foot loading, following surgical treatment.
Only four significant associations were found between radiological
measures of static segmental alignment and dynamic loading of the foot. Weakness of the plantar flexors of the ankle was a common post-operative
finding. Surgeons should be judicious in the magnitude of lengthening
of the plantar flexors that is undertaken and use techniques that
minimise subsequent weakening of this
The aims of this study were to evaluate the abductor function in moderate and severe slipped capital femoral epiphysis (SCFE), comparing the results of a corrective osteotomy at the base of the femoral neck and osteoplasty with 1) A total of 24 patients (mean age 14.9 years (Aims
Patients and Methods
The Ponseti method is the benchmark treatment for the correction of clubfoot. The primary rate of correction is very high, but outcome further down the treatment pathway is less predictable. Several methods of assessing severity at presentation have been reported. Classification later in the course of treatment is more challenging. This systematic review considers the outcome of the Ponseti method in terms of relapse and determines how clubfoot is assessed at presentation, correction, and relapse. A prospectively registered systematic review was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies that reported idiopathic clubfoot treated by the Ponseti method between 1 January 2012 and 31 May 2017 were included. The data extracted included demographics, Ponseti methodology, assessment methods, and rates of relapse and surgery.Aims
Patients and Methods
We reviewed a consecutive series of 33 infants who underwent surgery for obstetric brachial plexus palsy at a mean age of 4.7 months. Of these, 13 with an upper palsy and 20 with a total palsy were treated by nerve reconstruction. Ten were treated by
We present a method of manipulative reduction, immobilisation and fixation using a U-shaped plaster with the elbow in extension for extension-type supracondylar fractures of the humerus in children. When the elbow is in full extension, both the extensor and the flexor
We assessed the medium-term outcome of three methods of isolated calf lengthening in cerebral palsy by clinical examination, observational gait analysis and, where appropriate, instrumented gait analysis. The procedures used were percutaneous lengthening of tendo Achillis, open Z-lengthening of tendo Achillis and lengthening of the gastrosoleus aponeurosis (Baker’s procedure). We reviewed 195 procedures in 134 children; 45 had hemiplegia, 65 diplegia and 24 quadriplegia. We established the incidence of calcaneus and recurrent equinus and identified ‘at-risk’ groups for each. At follow-up, 42% had satisfactory calf length, 22% had recurrent equinus and 36% calcaneus. The incidence of calcaneus in girls at follow-up was significantly higher (p = 0.002) while boys had an increased rate of recurrent equinus (p = 0.012). Children with diplegia who had surgery when aged eight years or younger had a 44% risk of calcaneus, while those over eight years had a 19% risk (p = 0.046). Percutaneous lengthening of tendo Achillis in diplegia was the least predictable, only 38% having a satisfactory outcome compared with 50% in the other procedures. The incidence of recurrent equinus in hemiplegic patients was 38%. Only 4% developed calcaneus. The type of surgery did not influence the outcome in patients with hemiplegia or quadriplegia. Severity of involvement, female gender, age at operation of less than eight years and percutaneous lengthening of tendo Achillis were ‘risk factors’ for calcaneus. Hemiplegia, male gender, and an aponeurosis
Preserving growth following limb-salvage surgery of the upper
limb in children remains a challenge. Vascularized autografts may
provide rapid biological incorporation with the potential for growth
and longevity. In this study, we aimed to describe the outcomes
following proximal humeral reconstruction with a vascularized fibular
epiphyseal transfer in children with a primary sarcoma of bone.
We also aimed to quantify the hypertrophy of the graft and the annual
growth, and to determine the functional outcomes of the neoglenofibular
joint. We retrospectively analyzed 11 patients who underwent this procedure
for a primary bone tumour of the proximal humerus between 2004 and
2015. Six had Ewing’s sarcoma and five had osteosarcoma. Their mean
age at the time of surgery was five years (two to eight). The mean
follow-up was 5.2 years (1 to 12.2).Aims
Patients and Methods
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. A total of 59 young adults with spastic cerebral palsy, with
a mean age of 26 years (Aims
Patients and Methods
To assess the long-term effect of distal trochanteric transfer
(DTT) on the clinical and radiographic outcomes of patients with
Legg-Calvé-Perthes’ disease (LCPD) following a varus derotational
osteotomy (VDRO). For this single centre cross-sectional retrospective study we
analysed the data of 22 patients (24 hips) with LCPD who had greater
trochanteric overgrowth (GTO), following a VDRO performed in our
institution between 1959 and 1983. GTO was defined as an articular
trochanteric distance (ATD) of <
5 mm. We compared the radiographic
and clinical outcomes of patients who underwent DTT for GTO (ten
patients, ten hips) with those who did not (12 patients, 14 hips).
Age at presentation was 6.9 years (4 to 10) and 8.0 years (3.2 to
12) respectively. Symptoms associated with the hip and general quality
of life were assessed using the Harris hip score (HHS) and the Short Form
(SF)-36 questionnaires.Aims
Patients and Methods
Following the introduction of national standards in 2009, most
major paediatric trauma is now triaged to specialist units offering
combined orthopaedic and plastic surgical expertise. We investigated
the management of open tibia fractures at a paediatric trauma centre,
primarily reporting the risk of infection and rate of union. A retrospective review was performed on 61 children who between
2007 and 2015 presented with an open tibia fracture. Their mean
age was nine years (2 to 16) and the median follow-up was ten months
(interquartile range 5 to 18). Management involved IV antibiotics,
early debridement and combined treatment of the skeletal and soft-tissue injuries
in line with standards proposed by the British Orthopaedic Association.Aims
Patients and Methods
We wished to examine the effectiveness of tibial lengthening
using a two ring Ilizarov frame in skeletally immature patients.
This is a potentially biomechanically unstable construct which risks
the loss of axial control. We retrospectively reviewed a consecutive series of 24 boys and
26 girls, with a mean age of 8.6 years (4 to 14), who underwent
52 tibial lengthening procedures with a mean follow-up of 4.3 years
(4.0 to 16.9). Tibial alignment was measured before and after treatment
using joint orientation lines from the knee and a calculation of
the oblique plane axis.Aims
Patients and Methods
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:
Single event multilevel surgery (SEMLS) has been shown to improve
gait in children with cerebral palsy (CP). However, there is limited
evidence regarding long-term outcomes and factors influencing them. In total 39 children (17 females and 22 males; mean age at SEMLS
ten years four months, standard deviation 37 months) with bilateral
CP (20 Gross Motor Function Classification System (GMFCS) level
II and 19 GMFCS level III) treated with SEMLS were included. Children
were evaluated using gait analysis and the Gait Deviation Index
(GDI) before SEMLS and one, two to three, five and at least ten
years after SEMLS. A linear mixed model was used to estimate the
effect of age at the surgery, GMFCS and follow-up period on GDI. Aims
Methods
In 11 paediatric patients (seven girls and four
boys, from 12 to 15 years old) with unilateral obligatory patellar dislocation
and ligamentous laxity vastus medialis advancement, lateral release,
partial patellar ligament transposition and Galeazzi semitendinosus
tenodesis was undertaken to stabilise the patella. The diagnostic criterion
for ligamentous laxity was based on the Beighton scale. Outcomes
were evaluated radiologically and functionally by measurement of
the range of knee movement and isokinetic testing. The evaluation
also included the Lysholm knee scale. Follow-up studies took place
at a mean of 8.1 years (5 to 15) post-operatively. Normal patellar tracking without any recurrence of dislocation
was obtained in ten out of 11 patients. Pain related to vigorous
activity was reported by nine patients. Compared with the opposite
normal side, the isokinetic tests revealed a statistically significant
decrease in the maximal torque values for the affected quadriceps
muscle (p = 0.003 and p = 0.004), but no difference between the
knee flexors (for angular velocities of 60°/s and 180°/s) (p = 0.858
and p = 0.79). The applied surgical technique generally prevents the recurrence
of the disorder in children with habitual patellar dislocation and
ligamentous laxity. Quadriceps muscle weakness can be expected to
occur post-operatively, Cite this article:
We describe our experience in the reduction of
dislocation of the hip secondary to developmental dysplasia using ultrasound-guided
gradual reduction using flexion and abduction continuous traction
(FACT-R). During a period of 13 years we treated 208 Suzuki type
B or C complete dislocations of the hip in 202 children with a mean
age of four months (0 to 11). The mean follow-up was 9.1 years (five
to 16). The rate of reduction was 99.0%. There were no recurrent
dislocations, and the rate of avascular necrosis of the femoral
head was 1.0%. The rate of secondary surgery for residual acetabular
dysplasia was 19.2%, and this was significantly higher in those
children in whom the initial treatment was delayed or if other previous
treatments had failed (p = 0.00045). The duration of FACT-R was significantly
longer in severe dislocations (p = 0.001) or if previous treatments
had failed (p = 0.018). This new method of treatment is effective and safe in these difficult
cases and offers outcomes comparable to or better than those of
standard methods. Cite this article:
Slipped upper femoral epiphysis (SUFE) is the
most common hip disorder to affect adolescents. Controversy exists over
the optimal treatment of severe slips, with a continuing debate
between Between 2001 and 2011, 57 patients (35 male, 22 female) with
a mean age of 13.1 years (9.6 to 20.3, SD 2.3) were referred to
our tertiary referral institution with a severe slip. The affected
limb was rested in slings and springs before corrective surgery
which was performed via an anterior Smith-Petersen approach. Radiographic
analysis confirmed an improvement in mean head–shaft slip angle
from 53.8o (standard deviation ( This is a technically demanding operation with variable outcomes
reported in the literature. We have demonstrated good results in
our tertiary centre. 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
We investigated the incidence and risk factors
for the development of avascular necrosis (AVN) of the femoral head in
the course of treatment of children with cerebral palsy (CP) and
dislocation of the hip. All underwent open reduction, proximal femoral
and Dega pelvic osteotomy. The inclusion criteria were: a predominantly
spastic form of CP, dislocation of the hip (migration percentage,
MP >
80%), Gross Motor Function Classification System, (GMFCS) grade
IV to V, a primary surgical procedure and follow-up of >
one year. There were 81 consecutive children (40 girls and 41 boys) in
the study. Their mean age was nine years (3.5 to 13.8) and mean
follow-up was 5.5 years (1.6 to 15.1). Radiological evaluation included
measurement of the MP, the acetabular index (AI), the epiphyseal
shaft angle (ESA) and the pelvic femoral angle (PFA). The presence
and grade of AVN were assessed radiologically according to the Kruczynski
classification. Signs of AVN (grades I to V) were seen in 79 hips (68.7%). A
total of 23 hips (18%) were classified between grades III and V. Although open reduction of the hip combined with femoral and
Dega osteotomy is an effective form of treatment for children with
CP and dislocation of the hip, there were signs of avascular necrosis
in about two-thirds of the children. There was a strong correlation
between post-operative pain and the severity of the grade of AVN. Cite this article:
The aims of this study were to report functional
outcomes of salvage procedures for patients with cerebral palsy (CP)
who have chronic dislocation of the hip using validated scoring
systems, and to compare the results of three surgical techniques. We reviewed 37 patients retrospectively. The mean age at the
time of surgery was 12.2 years (8 to 22) and the mean follow-up
was 56 months (24 to 114). Patients were divided into three groups:
14 who underwent proximal femoral resection arthroplasty (PFRA group
1), ten who underwent subtrochanteric valgus osteotomy (SVO group 2),
and 13 who underwent subtrochanteric valgus osteotomy with resection
of the femoral head (SVO with FHR group 3). All patients were evaluated
using the Caregiver Priorities and Child Health Index of Life with
Disabilities (CPCHILD) and the Pediatric Quality of Life Inventory
(PedsQL). Significant improvements occurred in most CPCHILD and PedsQL
subsection scores following surgery in all patients, without significant
differences between the groups. There were 12 post-operative complications.
Less severe complications were seen in group 1 than in groups 2
and 3. Salvage surgery appears to provide pain relief in patients with
CP who have painful chronic dislocation of the hip. The three salvage
procedures produced similar results, however, we recommend the use
of PFRA as the complications are less severe. Take home message: Salvage surgery can be of benefit to patients
with CP with chronic painful hip dislocation, but should be limited
to selected patients considering complications. Cite this article:
A retrospective study was performed in 18 patients
with achondroplasia, who underwent bilateral humeral lengthening
between 2001 and 2013, using monorail external fixators. The mean
age was ten years (six to 15) and the mean follow-up was 40 months
(12 to 104). The mean disabilities of the arm, shoulder and hand (DASH) score
fell from 32.3 (20 to 40)
pre-operatively to 9.4 (6 to 14) post-operatively (p = 0.037). A
mean lengthening of 60% (40% to 95%) was required to reach the goal
of independent perineal hygiene. One patient developed early consolidation,
and fractures occurred in the regenerate bone of four humeri in
three patients. There were three transient radial nerve palsies. Humeral lengthening increases the independence of people with
achondroplasia and is not just a cosmetic procedure. Cite this article:
Pelvic obliquity is a common finding in adolescents
with cerebral palsy, however, there is little agreement on its measurement
or relationship with hip development at different gross motor function
classification system (GMFCS) levels. The purpose of this investigation was to study these issues in
a large, population-based cohort of adolescents with cerebral palsy
at transition into adult services. The cohort were a subset of a three year birth cohort (n = 98,
65M: 33F, with a mean age of 18.8 years (14.8 to 23.63) at their
last radiological review) with the common features of a migration
percentage greater than 30% and a history of adductor release surgery. Different radiological methods of measuring pelvic obliquity
were investigated in 40 patients and the angle between the acetabular
tear drops (ITDL) and the horizontal reference frame of the radiograph
was found to be reliable, with good face validity. This was selected
for further study in all 98 patients. The median pelvic obliquity was 4° (interquartile range 2° to
8°). There was a strong correlation between hip morphology and the
presence of pelvic obliquity (effect of ITDL on Sharpe’s angle in
the higher hip; rho 7.20 (5% confidence interval 5.59 to 8.81, p
<
0.001). This was particularly true in non-ambulant adolescents
(GMFCS IV and V) with severe pelvic obliquity, but was also easily
detectable and clinically relevant in ambulant adolescents with mild
pelvic obliquity. The identification of pelvic obliquity and its management deserves
closer scrutiny in children and adolescents with cerebral palsy. Cite this article:
We evaluated results at one year after surgical
correction of internal rotation deformities in the shoulders of
270 patients with obstetric brachial plexus palsy. The mean age
at surgery was 6.2 years (0.6 to 35). Two techniques were used:
open subscapularis elongation and latissimus dorsi to infraspinatus
transfer. In addition, open relocation was performed or attempted
in all patients with subluxed or dislocated joints. A mixed effects
model approach was used to evaluate the effects of surgery on internal
and external rotation, abduction, flexion and Mallet score. Independent
factors included operative status (pre- or post-operative), gender,
age, the condition of the joint, and whether or not transfer was
performed. The overall mean improvement in external rotation following
surgery was 84.6° (95% confidence interval (CI) 80.2 to 89.1) and
the mean Mallet score improved by 4.0 (95% CI 3.7 to 4.2). There was
a mean decrease in internal rotation of between 27.6° and 34.4°
in the relocated joint groups and 8.6° (95% CI 5.2 to 12.0) in the
normal joint group. Abduction and flexion were unchanged following
surgery. Adding a latissimus dorsi transfer did not result in greater
improvement in the mean external rotation compared with elongation
of the subscapularis alone. Cite this article:
In 1994 a cerebral palsy (CP) register and healthcare
programme was established in southern Sweden with the primary aim
of preventing dislocation of the hip in these children. The results from the first ten years were published in 2005 and
showed a decrease in the incidence of dislocation of the hip, from
8% in a historical control group of 103 children born between 1990
and 1991 to 0.5% in a group of 258 children born between 1992 and
1997. These two cohorts have now been re-evaluated and an additional
group of 431 children born between 1998 and 2007 has been added. By 1 January 2014, nine children in the control group, two in
the first study group and none in the second study group had developed
a dislocated hip (p <
0.001). The two children in the first study
group who developed a dislocated hip were too unwell to undergo
preventive surgery. Every child with a dislocated hip reported severe pain,
at least periodically, and four underwent salvage surgery. Of the
689 children in the study groups, 91 (13%) underwent preventive
surgery. A population-based hip surveillance programme enables the early
identification and preventive treatment, which can result in a significantly
lower incidence of dislocation of the hip in children with CP. Cite this article:
Proximal femoral resection (PFR) is a proven
pain-relieving procedure for the management of patients with severe cerebral
palsy and a painful displaced hip. Previous authors have recommended
post-operative traction or immobilisation to prevent a recurrence
of pain due to proximal migration of the femoral stump. We present
a series of 79 PFRs in 63 patients, age 14.7 years (10 to 26; 35
male, 28 female), none of whom had post-operative traction or immobilisation. A total of 71 hips (89.6%) were reported to be pain free or to
have mild pain following surgery. Four children underwent further
resection for persistent pain; of these, three had successful resolution
of pain and one had no benefit. A total of 16 hips (20.2%) showed
radiographic evidence of heterotopic ossification, all of which
had formed within one year of surgery. Four patients had a wound
infection, one of which needed debridement; all recovered fully.
A total of 59 patients (94%) reported improvements in seating and
hygiene. The results are as good as or better than the historical results
of using traction or immobilisation. We recommend that following
PFR, children can be managed without traction or immobilisation,
and can be discharged earlier and with fewer complications. However,
care should be taken with severely dystonic patients, in whom more
extensive femoral resection should be considered in combination
with management of the increased tone. Cite this article:
We present the long-term results of open surgery
for internal shoulder rotational deformity in brachial plexus birth palsy
(BPBP). From 1997 to 2005, 207 patients (107 females, 100 males, mean
age 6.2 (0.6 to 34)) were operated on with subscapularis elongation
and/or latissimus dorsi to infraspinatus transfer. Incongruent shoulder
joints were relocated. The early results of these patients has been
reported previously. We analysed 118 (64 females, 54 males, mean
age 15.1 (7.6 to 34)) of the original patient cohort at a mean of
10.4 years (7.0 to 15.1) post-operatively. A third of patients with
relocated joints had undergone secondary internal rotational osteotomy
of the humerus. A mixed effects models approach was used to evaluate the effects
of surgery on shoulder rotation, abduction, and the Mallet score.
Independent factors were time (pre-and post-surgery), gender, age,
joint category (congruent, relocated, relocated plus osteotomy)
and whether or not a transfer had been performed. Data from a previously published
short-term evaluation were reworked in order to obtain pre-operative
values. The mean improvement in external rotation from pre-surgery to
the long-term follow-up was 66.5° (95% confidence interval (CI)
61.5 to 71.6). The internal rotation had decreased by a mean of
22.6° (95% CI -18.7 to -26.5). The mean improvement in the three-grade
aggregate Mallet score was 3.1 (95% CI 2.7 to 3.4), from 8.7 (95%
CI 8.4 to 9.0) to 11.8 (11.5 to 12.1). Our results show that open subscapularis elongation achieves
good long-term results for patients with BPBP and an internal rotation
contracture, providing lasting joint congruency and resolution of
the trumpet sign, but with a moderate mean loss of internal rotation. Cite this article:
Supracondylar humeral fractures are common in
children, but there are no classification systems or radiological parameters
that predict the likelihood of having to perform an open reduction.
In a retrospective case–control study we evaluated the use of the
medial spike angle and fracture tip–skin distance to predict the
mode of reduction (closed or open) and the operating time in fractures
with posterolateral displacement. A total of 21 patients (4.35%) with
a small medial spike angle (<
45°) were identified from a total
of 494 patients, and 42 patients with a medial spike angle of >
45° were randomly selected as controls. The medial spike group had
significantly smaller fracture tip–skin distances (p <
0.001),
longer operating times (p = 0.004) and more complications (p = 0.033)
than the control group. There was no significant difference in the
mode of reduction and a composite outcome measure. After adjustments
for age and gender, only fracture tip–skin distance remained significantly
associated with the operating time (β = -0.724, p = 0.042) and composite
outcome (OR 0.863 (95% confidence interval 0.746 to 0.998); p = 0.048). Paediatric orthopaedic surgeons should have a lower threshold
for open reduction when treating patients with a small medial spike
angle and a small fracture tip–skin distance. Cite this article:
A total of 35 children with Erb’s palsy and shoulder
abduction of <
90° underwent transfer of teres major. In 18 cases (group
1) a trapezius transfer was added (combined procedure). In 17 cases
(group 2) teres major transfer was carried out in isolation (single
procedure). The mean gain in abduction was 67.2° (60° to 80°) in
group 1 and 37.6° (20° to 70°) in group 2, which reached statistical
significance (p <
0.001). Group 2 was further divided into those who had deltoid power
of <
M3 (group 2a) and those with deltoid power ≥ M3 (group 2b).
The difference in improvement of abduction between groups 2a and
group 2b was statistically significant (p <
0.001) but the difference
between group 2b and group 1 was not (p = 0.07). We recommend the following protocol of management: in children
with abduction ≥ 90° a single procedure is indicated. In children
with abduction <
90°: a combined procedure is indicated if deltoid
power is <
M3 and a single procedure is indicated if deltoid
power is ≥ M3. If no satisfactory improvement is achieved, the trapezius
can be transferred at a later stage.
We describe the technique and results of medial
submuscular plating of the femur in paediatric patients and discuss its
indications and limitations. Specifically, the technique is used
as part of a plate-after-lengthening strategy, where the period
of external fixation is reduced and the plate introduced by avoiding
direct contact with the lateral entry wounds of the external fixator
pins. The technique emphasises that vastus medialis is interposed
between the plate and the vascular structures. A total of 16 patients (11 male and five female, mean age 9.6
years (5 to 17)), had medial submuscular plating of the femur. All
underwent distraction osteogenesis of the femur with a mean lengthening
of 4.99 cm (3.2 to 12) prior to plating. All patients achieved consolidation
of the regenerate without deformity. The mean follow-up was 10.5 months
(7 to 15) after plating for those with plates still Placing the plate on the medial side is advantageous when the
external fixator is present on the lateral side, and is biomechanically
optimal in the presence of a femoral defect. We conclude that medial
femoral submuscular plating is a useful technique for specific indications
and can be performed safely with a prior understanding of the regional
anatomy. Cite this article:
Our goal was to evaluate the use of Ponseti’s
method, with minor adaptations, in the treatment of idiopathic clubfeet
presenting in children between five and ten years of age. A retrospective
review was performed in 36 children (55 feet) with a mean age of
7.4 years (5 to 10), supplemented by digital images and video recordings
of gait. There were 19 males and 17 females. The mean follow-up
was 31.5 months (24 to 40). The mean number of casts was 9.5 (6
to 11), and all children required surgery, including a percutaneous
tenotomy or open tendo Achillis lengthening (49%), posterior release
(34.5%), posterior medial soft-tissue release (14.5%), or soft-tissue
release combined with an osteotomy (2%). The mean dorsiflexion of
the ankle was 9° (0° to 15°). Forefoot alignment was neutral in
28 feet (51%) or adducted (<
10°) in 20 feet (36%), >
10° in
seven feet (13%). Hindfoot alignment was neutral or mild valgus
in 26 feet (47%), mild varus (<
10°) in 19 feet (35%), and varus
(>
10°) in ten feet (18%). Heel–toe gait was present in 38 feet
(86%), and 12 (28%) exhibited weight-bearing on the lateral border
(out of a total of 44 feet with gait videos available for analysis).
Overt relapse was identified in nine feet (16%, six children). The
parents of 27 children (75%) were completely satisfied. A plantigrade foot was achieved in 46 feet (84%) without an extensive
soft-tissue release or bony procedure, although under-correction
was common, and longer-term follow-up will be required to assess
the outcome. Cite this article:
We investigated the predictive value of intra-operative
neurophysiological investigations in obstetric brachial plexus injuries.
Between January 2005 and June 2011 a total of 32 infants of 206
referred to our unit underwent exploration of the plexus, including
neurolysis. The findings from intra-operative electromyography,
sensory evoked potentials across the lesion and gross muscular response
to stimulation were evaluated. A total of 22 infants underwent neurolysis
alone and ten had microsurgical reconstruction. Of the former, one
was lost to follow-up, one had glenoplasty and three had subsequent
nerve reconstructions. Of the remaining 17 infants with neurolysis,
13 (76%) achieved a modified Mallet score >
13 at a mean age of
3.5 years (0.75 to 6.25). Subluxation or dislocation of the shoulder
is a major confounding factor. The positive predictive value and
sensitivity of the intra-operative EMG for C5 were 100% and 85.7%,
respectively, in infants without concurrent shoulder pathology.
The positive and negative predictive values, sensitivity and specificity
of the three investigations combined were 77%, 100%, 100% and 57%, respectively. In all, 20 infants underwent neurolysis alone for C6 and three
had reconstruction. All of the former and one of the latter achieved
biceps function of Raimondi grade 5. The positive and negative predictive
values, sensitivity and specificity of electromyography for C6 were
65%, 71%, 87% and 42%, respectively. Our method is effective in evaluating the prognosis of C5 lesion.
Neurolysis is preferred for C6 lesions. Cite this article:
Our aim was to evaluate the effect of adding inhibitory casting to the treatment of young children with cerebral palsy who received injections of botulinum neurotoxin A (BoNT-A) to gastrocnemius for equinus gait. Of the 20 patients in the series, 11 in group A had inhibitory casts applied on the day of the first set of BoNT-A injections and nine in group B did not have casting. Both groups received another BoNT-A injection four months later. The patients were followed for eight months and examined at five intervals. Both groups showed significant improvement in gait parameters and function (p <
0.0001) and selective motor control (p = 0.041, − 0.036) throughout the study. Group A had significantly better passive dorsiflexion of the ankle (p = 0.029), observational gait score (p = 0.006) and selective motor control (p = 0.036). We conclude that the addition of inhibitory casting enhances and prolongs the results of treatment and mainly influences the passive range of movement, while BoNT-A mostly influences the dynamic motion. The second injection further improved the results of most parameters. The gross motor function measure, the selective motor control test and the modified Tardieu scale correlated well with the results of treatment. We recommend the use of inhibitory casting whenever augmentation of the effect of treatment with BoNT-A is needed.
We describe the early results of glenoplasty as part of the technique of operative reduction of posterior dislocation of the shoulder in 29 children with obstetric brachial plexus palsy. The mean age at operation was five years (1 to 18) and they were followed up for a mean of 34 months (12 to 67). The mean Mallet score increased from 8 (5 to 13) to 12 (8 to 15) at final follow-up (p <
0.001). The mean passive forward flexion was increased by 18° (p = 0.017) and the mean passive abduction by 24° (p = 0.001). The mean passive lateral rotation also increased by 54° (p <
0.001), but passive medial rotation was reduced by a mean of only 7°. One patient required two further operations. Glenohumeral stability was achieved in all cases.
Between 2005 and 2010 ten consecutive children
with high-energy open diaphyseal tibial fractures were treated by early
reduction and application of a programmable circular external fixator.
They were all male with a mean age of 11.5 years (5.2 to 15.4),
and they were followed for a mean of 34.5 months (6 to 77). Full
weight-bearing was allowed immediately post-operatively. The mean
time from application to removal of the frame was 16 weeks (12 to
21). The mean deformity following removal of the frame was 0.15°
(0° to 1.5°) of coronal angulation, 0.2° (0° to 2°) sagittal angulation,
1.1 mm (0 to 10) coronal translation, and 0.5 mm (0 to 2) sagittal
translation. All patients achieved consolidated bony union and satisfactory
wound healing. There were no cases of delayed or nonunion, compartment
syndrome or neurovascular injury. Four patients had a mild superficial
pin site infection; all settled with a single course of oral antibiotics.
No patient had a deep infection or re-fracture following removal
of the frame. The time to union was comparable with, or better than,
other published methods of stabilisation for these injuries. The
stable fixator configuration not only facilitates management of
the accompanying soft-tissue injury but enables anatomical post-injury
alignment, which is important in view of the limited remodelling
potential of the tibia in children aged >
ten years. Where appropriate
expertise exists, we recommend this technique for the management
of high-energy open tibial fractures in children.
The outcome of 56 children (61 shoulders) treated
surgically at the Rizzoli Institute between April 1975 and June 2010
for congenital elevation of the scapula is reported. There were
31 girls and 25 boys with a mean age at surgery of 6.4 years (2
to 15). The deformity involved the right shoulder in 20 cases, the
left in 31 and was bilateral in five. The degree of the deformity
was graded clinically and radiologically according to the classifications
of Cavendish and Rigault, respectively. All patients underwent a
modified Green procedure combined, in selected cases, with resection
of the superomedial portion of the scapula and excision of any omovertebral
connection. After a mean follow-up of 10.9 years (1 to 29.3), there
was cosmetic improvement by at least one Cavendish grade in 54 shoulders (88.5%).
The mean abduction of the shoulder improved from 92° (50° to 155°)
to 112° (90° to 170°) and the mean flexion improved from 121° (80°
to 160°) to 155° (120° to 175°). The unsatisfactory cosmetic result
in seven shoulders was due to coexistent scoliosis in two cases
and insufficient reduction of the scapular elevation in the other
five. An incomplete upper brachial plexus palsy occurred post-operatively
in three patients but resolved within seven months. We suggest that a modified Green procedure combined with resection
of the superomedial portion of the scapula provides good cosmetic
and functional results in patients with Sprengel’s shoulder.
Extensive limb lengthening may be indicated in achondroplastic patients who wish to achieve a height within the normal range for their population. However, increasing the magnitude of lengthening is associated with further complications particularly adjacent joint stiffness and fractures. We studied the relationship between the magnitude of femoral lengthening and callus pattern, adjacent joint stiffness and fracture of the regenerate bone in 40 femoral lengthenings in 20 achondroplastic patients. They were divided into two groups; group A had lengthening of less than 50% and group B of more than 50% of their initial femoral length. The patterns of radiological callus formation were classified according to shape, type and features. The incidence of callus features, knee stiffness and regenerate bone fracture were analysed in the two groups. Group B was associated with an increased incidence of concave, lateral and central callus shapes, adjacent joint and stiffness and fracture. Statistically, the incidence of stiffness in adjacent joints and regenerate bone fracture was significantly associated with the magnitude of lengthening. We suggest that careful radiological assessment of the patterns of callus formation is a useful method for the evaluation and monitoring of regenerate bone.
Forearm fractures in children have a tendency
to displace in a cast leading to malunion with reduced functional
and cosmetic results. In order to identify risk factors for displacement,
a total of 247 conservatively treated fractures of the forearm in
246 children with a mean age of 7.3 years ( Fractures of both forearm bones in children have a strong tendency
to displace even in an above-elbow cast. Severe fractures of the
non-dominant arm are at highest risk for displacement. Radiographs
at set times during treatment might identify early displacement,
which should be treated before malunion occurs, especially in older children
with less potential for remodelling. Cite this article:
The aim of this retrospective multicentre study was to report the continued occurrence of compartment syndrome secondary to paediatric supracondylar humeral fractures in the period 1995 to 2005. The inclusion criteria were children with a closed, low-energy supracondylar fracture with no associated fractures or vascular compromise, who subsequently developed compartment syndrome. There were 11 patients (seven girls and four boys) identified from eight hospitals in three countries. Ten patients with severe elbow swelling documented at presentation had a mean delay before surgery of 22 hours (6 to 64). One patient without severe swelling documented at presentation suffered arterial entrapment following reduction, with a subsequent compartment syndrome requiring fasciotomy 25 hours after the index procedure. This series is noteworthy, as all patients had low-energy injuries and presented with an intact radial pulse. Significant swelling at presentation and delay in fracture reduction may be important warning signs for the development of a compartment syndrome in children with supracondylar fractures of the humerus.
The medial rotation contracture caused by weak external rotation secondary to obstetric brachial plexus injury leads to deformation of the bones of the shoulder. Scapular hypoplasia, elevation and rotation deformity are accompanied by progressive dislocation of the humeral head. Between February and August 2005, 44 children underwent a new surgical procedure called the ‘triangle tilt’ operation to correct this bony shoulder deformity. Surgical levelling of the distal acromioclavicular triangle combined with tightening of the posterior glenohumeral capsule (capsulorrhaphy) improved shoulder function and corrected the glenohumeral axis in these patients. The posture of the arm at rest was improved and active external rotation increased by a mean of 53° (0° to 115°) in the 40 children who were followed up for more than one year. There was a mean improvement of 4.9 points (1.7 to 8.3) of the Mallet shoulder function score after surgical correction of the bony deformity.
We reviewed the long-term radiological outcome,
complications and revision operations in 19 children with quadriplegic
cerebral palsy and hip dysplasia who underwent combined peri-iliac
osteotomy and femoral varus derotation osteotomy. They had a mean
age of 7.5 years (1.6 to 10.9) and comprised 22 hip dislocations
and subluxations. We also studied the outcome for the contralateral
hip. At a mean follow-up of 11.7 years (10 to 15.1) the Melbourne
cerebral palsy (CP) hip classification was grade 2 in 16 hips, grade
3 in five, and grade 5 in one. There were five complications seen
in four hips (21%, four patients), including one dislocation, one
subluxation, one coxa vara with adduction deformity, one subtrochanteric
fracture and one infection. A recurrent soft-tissue contracture occurred
in five hips and ten required revision surgery. In pre-adolescent children with quadriplegic cerebral palsy good
long-term outcomes can be achieved after reconstruction of the hip;
regular follow-up is required.
Cite this article:
We reviewed the outcome in 24 children with bilateral spastic cerebral palsy aged seven years or younger for whom surgery was recommended between 1999 and 2005 following gait analysis. A total of 13 children (operative group) had surgery and the remaining 11 (control group) did not, for family or administrative reasons. The operative group had at least two post-operative gait analyses at yearly intervals, with eight children having a third and six children a fourth. The control group had a second analysis after a mean interval of 1.5 years (95% confidence interval 1.1 to 1.9). In the operative group, the Gillette gait index, the ranges of movement in the lower limb joint and knee extension in stance improved following surgery, and this was maintained overall at the second post-operative analysis. The minimum knee flexion in stance in the control group increased between analyses. These results suggest that surgical intervention in selected children can result in improvements in gait and function in the short to medium term compared with non-operative management.
Survivors of infantile meningococcal septicaemia often develop progressive skeletal deformity as a result of physeal damage at many sites, particularly in the lower limb. Distal tibial physeal arrest typically occurs with sparing of the distal fibular physis leading to a rapidly progressive varus deformity. There have been reports of isolated cases of this deformity, but to our knowledge there have been no papers which specifically describe the development of the deformity and the options for treatment. Surgery to correct this deformity is complex because of the patient’s age, previous scarring and the multiplanar nature of the deformity. The surgical goal is to restore leg-length equality and the mechanical axis at the end of growth. Surgery should be planned and staged throughout growth in order to achieve the best functional results. We report our experience in six patients (seven ankles) with this deformity, who were managed by corrective osteotomy using a programmable circular fixator.
Compartment pressures have not previously been studied in healthy children. We compared the pressures in the four lower leg compartments of healthy children with those of healthy adults. We included patients aged between two months and six years, and measured the pressures in 80 compartments of 20 healthy children using simple needle manometry. Measurements were repeated in a control group of 20 healthy adults. The mean compartment pressure in the lower leg in children was significantly higher than in adults (p <
0.001). On average, pressures in the four compartments varied between 13.3 mmHg and 16.6 mmHg in the children and between 5.2 mmHg and 9.7 mmHg in the adults. The latter is in accordance with those recorded in the literature. The mean arterial pressure did not relate to age or to pressure in the compartment. The findings of this study that the normal compartment pressure of the lower leg in healthy children is significantly higher than that in adults may be of considerable significance in clinical decision-making in children of this age.
We present our early experience of arthroscopic
reduction of the dislocated hip in very young infants with developmental
dysplasia of the hip (DDH). Eight dislocated hips, which had failed attempts at closed reduction,
were treated by arthroscopy of the hip in five children with a mean
age of 5.8 months (4 to 7). A two-portal technique was used, with
a medial sub-adductor portal for a 2.7 mm cannulated system with
a 70° arthroscope and an anterolateral portal for the instruments. Following
evaluation of the key intra-articular structures, the hypertrophic
ligamentum teres and acetabular pulvinar were resected, and a limited
release of the capsule was performed prior to reduction of the hip.
All hips were reduced by a single arthroscopic procedure, the reduction
being confirmed on MRI scan. None of the hips had an inverted labrum.
The greatest obstacle to reduction was a constriction of the capsule.
At a mean follow-up of 13.2 months (9 to 24), all eight hips remained
stable. Three developed avascular necrosis. The mean acetabular index
decreased from 35.5° (30° to 40°) pre-operatively to 23.3° (17°
to 28°). This study demonstrates that arthroscopic reduction is feasible
using two standardised portals. Longer follow-up studies are necessary
to evaluate the functional results.
We studied 24 children (40 feet) to demonstrate that a physiotherapist-delivered Ponseti service is as successful as a medically-led programme in obtaining correction of an idiopathic congenital talipes equinovarus deformity. The median Pirani score at the start of treatment was 5.5 (mean 4.75; 2 to 6). A Pirani score of ≥5 predicted the need for tenotomy (p <
0.01). Of the 40 feet studied, 39 (97.5%) achieved correction of deformity. The remaining foot required surgical correction. A total of 25 (62.5%) of the feet underwent an Achilles tenotomy, which was performed by a surgeon in the physiotherapy clinic. There was full compliance with the foot abduction orthoses in 36 (90%) feet. Continuity of care was assured, as one practitioner was responsible for all patient contact. This was rated highly by the patient satisfaction survey. We believe that the Ponseti technique is suitable for use by non-medical personnel, but a holistic approach and good continuity of care are essential to the success of the programme.
Elastic stable intramedullary nailing (ESIN)
is generally acknowledged to be the treatment of choice for displaced diaphyseal
femoral fractures in children over the age of three years, although
complication rates of up to 50% are described. Pre-bending the nails
is recommended, but there are no published data to support this.
Using synthetic bones and a standardised simulated fracture, we
performed biomechanical testing to determine the influence on the
stability of the fracture of pre-bending the nails before implantation.
Standard ESIN was performed on 24 synthetic femoral models with
a spiral fracture. In eight cases the nails were inserted without
any pre-bending, in a further eight cases they were pre-bent to
30° and in the last group of eight cases they were pre-bent to 60°. Mechanical
testing revealed that pre-bending to 60° produced a significant
increase in the stiffness or stability of the fracture. Pre-bending
to 60° showed a significant positive influence on the stiffness
compared with unbent nails. Pre-bending to 30° improved stiffness
only slightly. These findings validate the recommendations for pre-bending,
but the degree of pre-bend should exceed 30°. Adopting higher degrees
of pre-bending should improve stability in spiral fractures and
reduce the complications of varus deformity and shortening.
We present two children with massive defects of the tibia and an associated active infection who were treated by medial transport of the fibula using the Ilizarov device. The first child had chronic discharging osteomyelitis which affected the whole tibial shaft. The second had sustained bilateral grade-IIIB open tibial fractures in a motor-car accident. The first child was followed up for three years and the second for two years. Both achieved solid union between the proximal and distal stumps of the tibia and the fibula, with hypertrophy of the fibula. The first child had a normal range of movement at the knee, ankle and foot but there was shortening of 1.5 cm. The second had persistent anterior angulation at the proximal tibiofibular junction and the ankle was stiff in equinus.
We present the long-term results of pectoralis major transfer to restore elbow flexion in seven patients (ten procedures). The early results in all the patients were encouraging but with longer follow-up a gradual and progressive flexion deformity was observed with a decrease in the arc of flexion in eight elbows, reaching ≥ 90° in all cases. The results of pectoralis major transfer deteriorate with time due to the development of a recalcitrant flexion deformity of the elbow. With bilateral involvement we now recommend that the procedure be undertaken on one side only to allow the hand to reach the mouth for feeding, while the opposite side remains in extension for perineal toilet.
We report the outcome of 28 patients with spina bifida who between 1989 and 2006 underwent 43 lower extremity deformity corrections using the Ilizarov technique. The indications were a flexion deformity of the knee in 13 limbs, tibial rotational deformity in 11 and foot deformity in 19. The mean age at operation was 12.3 years (5.2 to 20.6). Patients had a mean of 1.6 previous operations (0 to 5) on the affected limb. The mean duration of treatment with a frame was 9.4 weeks (3 to 26) and the mean follow-up was 4.4 years (1 to 9). There were 12 problems (27.9%), five obstacles (11.6%) and 13 complications (30.2%) in the 43 procedures. Further operations were needed in seven patients. Three knees had significant recurrence of deformity. Two tibiae required further surgery for recurrence. All feet were plantigrade and braceable. We conclude that the Ilizarov technique offers a refreshing approach to the complex lower-limb deformity in spina bifida.
Percutaneous epiphysiodesis using transphyseal
screws (PETS) has been developed for the treatment of lower limb discrepancies
with the aim of replacing traditional open procedures. The goal
of this study was to evaluate its efficacy and safety at skeletal
maturity. A total of 45 consecutive patients with a mean skeletal
age of 12.7 years (8.5 to 15) were included and followed until maturity.
The mean efficacy of the femoral epiphysiodesis was 35% (14% to 87%)
at six months and 66% (21% to 100%) at maturity. The mean efficacy
of the tibial epiphysiodesis was 46% (18% to 73%) at six months
and 66% (25% to 100%) at maturity. In both groups of patients the
under-correction was significantly reduced between six months post-operatively
and skeletal maturity. The overall rate of revision was 18% (eight
patients), and seven of these revisions (87.5%) involved the tibia.
This series showed that use of the PETS technique in the femur was
safe, but that its use in the tibia was associated with a significant
rate of complications, including a valgus deformity in nine patients
(20%), leading us to abandon it in the tibia. The arrest of growth
was delayed and the final loss of growth at maturity was only 66%
of that predicted pre-operatively. This should be taken into account
in the pre-operative planning.
There were 47 patients with congenital muscular torticollis who underwent operative release. After a mean follow-up of 74 months (60 to 90), they were divided into two groups, one aged one to four years (group 1) and the other aged five to 16 years (group 2). The outcomes were assessed by evaluating the following parameters: deficits of lateral flexion and rotation, craniofacial asymmetry, surgical scarring, residual contracture, subjective evaluation and degree of head tilt. The craniofacial asymmetry, residual contracture, subjective evaluation and overall scores were similar in both groups. However, group 2 showed superior results to group 1 in terms of the deficits of movement, surgical scarring and degree of head tilt. It is recommended that operative treatment for congenital muscular torticollis is postponed until the patient can comply successfully with post-operative bracing and an exercise programme.
There is much debate about the nature and extent of deformities in the proximal femur in children with cerebral palsy. Most authorities accept that increased femoral anteversion is common, but its incidence, severity and clinical significance are less clear. Coxa valga is more controversial and many authorities state that it is a radiological artefact rather than a true deformity. We measured femoral anteversion clinically and the neck-shaft angle radiologically in 292 children with cerebral palsy. This represented 78% of a large, population-based cohort of children with cerebral palsy which included all motor types, topographical distributions and functional levels as determined by the gross motor function classification system. The mean femoral neck anteversion was 36.5° (11° to 67.5°) and the mean neck-shaft angle 147.5° (130° to 178°). These were both increased compared with values in normally developing children. The mean femoral neck anteversion was 30.4° (11° to 50°) at gross motor function classification system level I, 35.5° (8° to 65°) at level II and then plateaued at approximately 40.0° (25° to 67.5°) at levels III, IV and V. The mean neck-shaft angle increased in a step-wise manner from 135.9° (130° to 145°) at gross motor function classification system level I to 163.0° (151° to 178°) at level V. The migration percentage increased in a similar pattern and was closely related to femoral deformity. Based on these findings we believe that displacement of the hip in patients with cerebral palsy can be explained mainly by the abnormal shape of the proximal femur, as a result of delayed walking, limited walking or inability to walk. This has clinical implications for the management of hip displacement in children with cerebral palsy.
We describe a patient with cerebral palsy, of normal intelligence, who could not walk but who by the age of 16 had been successfully managed with a staged bilateral total hip arthroplasty using a constrained liner.
We evaluated radiological hip remodelling after shelf acetabuloplasty and sought to identify prognostic factors in 25 patients with a mean age of 8.9 years (7.0 to 12.3) who had unilateral Perthes’ disease with reducible subluxation of the hip in the fragmentation stage. At a mean follow-up of 6.7 years (3.2 to 9.0), satisfactory remodelling was observed in 18 hips (72%). The type of labrum in hip abduction, as determined by intra-operative dynamic arthrography, was found to be a statistically significant prognostic factor (p = 0.012). Shelf acetabuloplasty as containment surgery seems to be best indicated for hips in which there is not marked collapse of the epiphysis and in which the extruded epiphyseal segment slips easily underneath the labrum on abduction, without imposing undue pressure on the lateral edge of the acetabulum.
We describe our experience with the ‘four-in-one’ procedure for habitual dislocation of the patella in five children (six knees). All the patients presented with severe generalised ligamentous laxity and aplasia of the trochlear groove. All had a lateral release, proximal ‘tube’ realignment of the patella, semitendinosus tenodesis and transfer of the patellar tendon. The mean age at the time of the operation was 6.1 years (4.9 to 6.9), and the patients were followed up for a mean of 54.5 months (31 to 66). The clinical results were evaluated using the Kujala score. There has been no recurrence of dislocation. All the patients have returned to full activities and the parents and children were satisfied with the clinical results. The mean Kujala score was 95.3 (88 to 98). Two patients had marginal skin necrosis which healed after debridement and secondary closure. These early results in this small group have shown that the ‘four-in-one’ procedure is effective in the treatment of obligatory dislocation of the patella in children with severe ligamentous laxity and trochlear aplasia.
The results of a functional, clinical and radiological study of 30 children (60 hips) with whole-body cerebral palsy were reviewed at a mean follow-up of 10.2 years (9.5 to 11). Correction of windsweep deformity of the hips was performed by bilateral simultaneous combined soft-tissue and bony surgery at a mean age of 7.7 years (3.1 to 12.2). We were able to recall 22 patients; five had died of unrelated causes and three were lost to follow-up. Evaluation involved interviews with patients/carers and clinical and radiological examination. The gross motor functional classification system was used to assess overall motor function and showed improvement in seven patients. Of the 12 patients thought to have pain pre-operatively, only one had pain post-operatively. Improved handling was reported in 18 of 22 patients (82%). Those with handling problems were attributed by the carers to growth of the patients. All patients/carers considered the procedure worthwhile. The range of hip movements improved, and the mean windsweep index improved from 50 pre-operatively to 36 at follow-up. The migration percentage and centre-edge angle were assessed on plain radiographs. Radiological containment improved, the mean migration percentage improved from 50 pre-operatively to 20 at follow-up and the mean centre-edge angle improved from −5° to 29°. No statistical difference was noted between the three-year and ten-year follow-up results, indicating that the improvements in clinical and radiological outcome had been maintained.
The use of recombinant human bone morphogenetic protein-2 (rhBMP-2) for the treatment of congenital pseudarthrosis of the tibia has been investigated in only one previous study, with promising results. The aim of this study was to determine whether rhBMP-2 might improve the outcome of this disorder. We reviewed the medical records of five patients with a mean age of 7.4 years (2.3 to 21) with congenital pseudarthrosis of the tibia who had been treated with rhBMP-2 and intramedullary rodding. Ilizarov external fixation was also used in four of these patients. Radiological union of the pseudarthrosis was evident in all of them at a mean of 3.5 months (3.2 to 4) post-operatively. The Ilizarov device was removed after a mean of 4.2 months (3.0 to 5.3). These results indicate that treatment of congenital pseudarthrosis of the tibia using rhBMP-2 in combination with intramedullary stabilisation and Ilizarov external fixation may improve the initial rate of union and reduce the time to union. Further studies with more patients and longer follow-up are necessary to determine whether this surgial procedure may significantly enhance the outcome of congenital pseudarthrosis of the tibia, considering the refracture rate (two of five patients) in this small case series.
Achilles tenotomy is a recognised step in the Ponseti technique for the correction of idiopathic congenital talipes equinovarus in most percutaneous cases. Its use has been limited in part by concern that the subsequent natural history of the tendon is unknown. In a study of 11 tendons in eight infants, eight tendons were shown to be clinically intact and ten had ultrasonographic evidence of continuity three weeks after tenotomy. At six weeks after tenotomy all tendons had both clinical and ultrasonographic evidence of continuity.
Our aim in this retrospective study of 52 children with spastic hemiplegia was to determine the factors which affected the amount of residual pelvic rotation after single-event multilevel surgery. The patients were divided into two groups, those who had undergone femoral derotation osteotomy and those who had not. Pelvic rotation improved significantly after surgery in the femoral osteotomy group (p <
0.001) but not in the non-femoral osteotomy group. Multiple regressions identified the following three independent variables, which significantly affected residual pelvic rotation: the performance of femoral derotation osteotomy (p = 0.049), the pre-operative pelvic rotation (p = 0.003) and the post-operative internal rotation of the hip (p = 0.001). We concluded that there is a decrease in the amount of pelvic rotation after single-event multilevel surgery with femoral derotation osteotomy. However, some residual rotation may persist when patients have severe rotation before surgery.
In order to treat painful subluxation or dislocation secondary to cerebral palsy, 11 patients (12 hips) underwent combined femoral and Chiari pelvic osteotomies with additional soft-tissue releases at a mean age of 14.1 years (9.1 to 17.8). Relief of pain, improvement in movement of the hip, and in sitting posture, and ease of perineal care were recorded in all, and were maintained at a mean follow-up of 13.1 years (8 to 17.5). The improvement in general mobility was marginal, but those who were able to walk benefited the most. The radiological measurements made before operation were modified afterwards to use the lateral margin of the neoacetabulum produced by the pelvic osteotomy. The radiological migration index improved from a mean of 80.6% (61% to 100%) to 13.7% (0% to 33%) (p <
0.0001). The mean changes in centre edge angle and Sharp’s angle were 72° (56° to 87°; p <
0.0001) and 12.3° (9° to 15.6°; p <
0.0001), respectively. Radiological evidence of progressive arthritic change was seen in one hip, in which only a partial reduction had been achieved, and there was early narrowing of the joint space in another. Painless heterotopic ossification was observed in one patient with athetoid quadriplegia. In seven hips the lateral Kawamura approach, elevating the greater trochanter, provided exposure for both osteotomies and allowed the construction of a dome-shaped iliac osteotomy, while protecting the sciatic nerve.
In 1994, a register for cerebral palsy and a health-care programme were started in southern Sweden with the aim of preventing dislocation of the hip in children with cerebral palsy. It involved all children with cerebral palsy born in 1992 or later. None of the 206 affected children born between 1992 and 1997 has developed a dislocation following the introduction of the prevention programme. Another 48 children moved into the area and none developed any further dislocation. Of the 251 children with cerebral palsy, aged between five and 11 years, living in the area on January 1, 2003, only two had a dislocated hip. One boy had moved into the area at age of nine with a dislocation and a girl whose parents chose not to participate in the programme developed bilateral dislocation. One boy, whose condition was considered to be too poor for preventative surgery, developed a painful dislocation of the hip at the age of five years and died three years later. Eight of 103 children in a control group, consisting of all children with cerebral palsy living in the area between 1994 and 2002, and born between 1990 and 1991, developed a dislocation of the hip before the age of six years. The decreased incidence of dislocation after the introduction of the prevention programme was significant (p <
0.001). Dislocation of the hip in cerebral palsy remains a serious problem, and prevention is important. Our screening programme and early intervention when lateral displacement of the femoral head was detected appear to be successful.
In five children, six forearms with a fixed pronation deformity secondary to congenital radioulnar synostosis were treated by a derotation osteotomy of the distal radius and the midshaft of the ulna. There were three boys and two girls with a mean age of 4.9 years (3.5 to 8.25) who were followed up for a mean of 29 months (18 to 43). The position of the forearm was improved from a mean pronation deformity of 68° (40° to 80°) to a pre-planned position of 10° of supination in all cases. Bony union was achieved by 6.3 weeks with no loss of correction. There was one major complication involving a distal radial osteotomy which required exploration for a possible compartment syndrome.
We present a retrospective review of 167 patients aged 18 years and under who were treated for chronic haematogenous osteomyelitis at our elective orthopaedic hospital in Malawi over a period of four years. The median age at presentation was eight years (1 to 18). There were 239 hospital admissions for treatment during the period of the study. In 117 patients one admission was necessary, in 35 two, and in 15 more than two. A surgical strategy of infection control followed by reconstruction and stabilisation was employed, based on the Beit CURE radiological classification of chronic haematogenous osteomyelitis as a guide to treatment. At a minimum follow-up of one year after the end of the study none of the patients had returned to our hospital with recurrent infection. A total of 350 operations were performed on the 167 patients. This represented 6.7% of all children’s operations performed in our hospital during this period. One operation only was required in 110 patients and none required more than three. Below-knee amputation was performed in two patients with chronic calcaneal osteomyelitis as the best surgical option for function. The most common organism cultured from operative specimens was
Panton-Valentine leukocidin secreted by The Panton-Valentine leukocidin toxin not only destroys host neutrophils, immunocompromising the patient, but also increases the risk of intravascular coagulopathy. This combination leads to widespread involvement of bone with glutinous pus which is difficult to drain, and makes the delivery of antibiotics and eradication of infection very difficult without surgical intervention.
Continuous passive motion has been shown to be effective in the conservative treatment of idiopathic club foot. We wished to determine whether its use after operation could improve the results in resistant club feet which required an extensive soft-tissue release. There were 50 feet in the study. Posteromedial lateral release was performed in 39 feet but two were excluded due to early relapse. The mean age at surgery was eight months (5 to 12). Each foot was assigned a Dimeglio club foot score, which was used as a primary outcome measure, before operation and at 6, 12, 18 and 44 months after. Nineteen feet were randomly selected to receive continuous passive motion and 18 had standard immobilisation in a cast. After surgery and subsequent immobilisation in a cast the Dimeglio club foot score improved from 10.3 before to 4.17 by 12 months and to 3.89 at 48 months. After operation followed by continuous passive motion the score improved from 9.68 before to 3.11 after 12 months, but deteriorated to 4.47 at 48 months. Analysis of variance adjusted for baseline values indicated a significantly better score in those having continuous passive motion up to one year after surgery, but after 18 and 48 months the outcomes were the same in both groups.
We report 12 consecutive cases of vertical scapular osteotomy to correct Sprengel’s deformity, performed during a 16-year period, with a mean follow-up of 10.4 years. The mean increase in abduction of the shoulder was 53°. The cosmetic appearance improved by a mean of 1.5 levels on the Cavendish scale. Neither function nor cosmesis deteriorated with time. We recommend the procedure for correction of moderate deformities with a functional deficit.
We reviewed the results of a selective à la carte soft-tissue release operation for recurrent or residual deformity after initial conservative treatment for idiopathic clubfoot by the Ponseti method. Recurrent or residual deformity occurred in 13 (19 feet) of 33 patients (48 feet; 40%). The mean age at surgery was 2.3 years (1.3 to 4) and the mean follow-up was 3.6 years (2 to 5.3). The mean Pirani score had improved from 2.8 to 1.1 points, and the clinical and radiological results were satisfactory in all patients. However, six of the 13 patients (9 of 19 feet) had required further surgery in the form of tibial derotation osteotomy, split anterior tibialis tendon transfer, split posterior tibialis transfer or a combination of these for recurrent deformity. We concluded that selective soft-tissue release can provide satisfactory early results after failure of initial treatment of clubfoot by the Ponseti method, but long-term follow-up to skeletal maturity will be necessary.
The results of further soft-tissue release of 79 feet in 60 children with recurrent idiopathic congenital talipes equinovarus were evaluated. The mean age of the children at the time of re-operation was 5.8 years (15 months to 14.5 years). Soft-tissue release was performed in all 79 feet and combined with distal calcaneal excision in 52 feet. The mean follow-up was 12 years (4 to 32). At the latest follow-up the result was excellent or good in 61 feet (77%) according to the Ghanem and Seringe scoring system. The results was considered as fair in 14 feet (18%), all of whom had functional problems and eight had anatomical abnormalities. Four feet (5%) were graded as poor on both functional and anatomical grounds. The results were independent of the age at which revision was undertaken.
In a prospective study over 11 years we assessed the relationship between neonatal deformities of the foot and the presence of ultrasonographic developmental dysplasia of the hip (DDH). Between 1 January 1996 and 31 December 2006, 614 infants with deformities of the foot were referred for clinical and ultrasonographic evaluation. There were 436 cases of postural talipes equinovarus deformity (TEV), 60 of fixed congenital talipes equinovarus (CTEV), 93 of congenital talipes calcaneovalgus (CTCV) and 25 of metatarsus adductus. The overall risk of ultrasonographic dysplasia or instability was 1:27 in postural TEV, 1:8.6 in CTEV, 1:5.2 in CTCV and 1:25 in metatarsus adductus. The risk of type-IV instability of the hip or irreducible dislocation was 1:436 (0.2%) in postural TEV, 1:15.4 (6.5%) in CTCV and 1:25 (4%) in metatarsus adductus. There were no cases of hip instability (type IV) or of irreducible dislocation in the CTEV group. Routine screening for DDH in cases of postural TEV and CTEV is no longer advocated. The former is poorly defined, leading to the over-diagnosis of a possibly spurious condition. Ultrasonographic imaging and surveillance of hips in infants with CTCV and possibly those with metatarsus adductus should continue.
