Aims. The aims of this study is to report the clinical and radiological outcomes after pre-, central-, and postaxial polydactyly
The traditional techniques involving an oblique
tunnel or triangular wedge
Proximal femoral
We describe the treatment of three boys with cavernous lymphangioma of the legs. The suggested guidelines for treatment are extensive surgical
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
Osteofibrous dysplasia (OFD) is a rare benign lesion predominantly affecting the tibia in children. Its potential link to adamantinoma has influenced management. This international case series reviews the presentation of OFD and management approaches to improve our understanding of OFD. A retrospective review at three paediatric tertiary centres identified 101 cases of tibial OFD in 99 patients. The clinical records, radiological images, and histology were analyzed.Aims
Methods
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
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
The Fassier Duval (FD) rod is a third-generation telescopic implant for children with osteogenesis imperfecta (OI). Threaded fixation enables proximal insertion without opening the knee or ankle joint. We have reviewed our combined two-centre experience with this implant. In total, 34 children with a mean age of five years (1 to 14) with severe OI have undergone rodding of 72 lower limb long bones (27 tibial, 45 femoral) for recurrent fractures with progressive deformity despite optimized bone health and bisphosphonate therapy. Data were collected prospectively, with 1.5 to 11 years follow-up.Aims
Methods
Proximal femoral varus osteotomy improves the
biomechanics of the hip and can stimulate normal acetabular development
in a dysplastic hip. Medial closing wedge osteotomy remains the
most popular technique, but is associated with shortening of the
ipsilateral femur. We produced a trigonometric formula which may be used pre-operatively
to predict the resultant leg length discrepancy (LLD). We retrospectively
examined the influence of the choice of angle in a closing wedge
femoral osteotomy on LLD in 120 patients (135 osteotomies, 53% male,
mean age six years, (3 to 21), 96% caucasian) over a 15-year period
(1998 to 2013). A total of 16 of these patients were excluded due
to under or over varus correction. The patients were divided into
three age groups: paediatric (<
10 years), adolescent (10 to
16 years) and adult (>
16 years). When using the same saw blades
as in this series, the results indicated that for each 10° of angle
of
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 aim of limb-salvage surgery in malignant bone tumours in children is to restore function and eradicate local disease with as little morbidity as possible. Allografts are associated with a high rate of complications, particularly malunion at the allograft-host junction. We describe a simple technique which enhances union of allograft to host bone taking advantage of the discrepancy in size between the adult allograft and the child’s bone. This involves lifting a flap of periosteum before
Delayed diagnosis is a well-known complication of a Monteggia
fracture-dislocation. If left untreated, the dislocated radial head
later becomes symptomatic. The purposes of this study were firstly,
to evaluate the clinical and radiological results of open reduction
of the radial head and secondly, to identify the factors that may
affect the outcome of this procedure. This retrospective study evaluated 30 children with a chronic
Monteggia lesion. There were 18 boys and 12 girls with a mean age
of 7.4 years (4 to 13) at the time of open reduction. The mean interval
to surgery, after the initial fracture, was 23.4 months (6 to 120).
Clinical grading used a Kim modified elbow score: radiological outcome
was recorded. The effect of the patient’s age, gender, duration
from initial injury, Bado classification, and annular ligament reconstruction
were analyzed. The mean follow-up was 42.2 months (15 to 20).Aims
Materials and Methods
Extendible endoprostheses have been available for more than 30
years and have become more sophisticated with time. The latest generation
is ‘non-invasive’ and can be lengthened with an external magnetic
force. Early results have shown a worryingly high rate of complications
such as infection. This study investigates the incidence of complications
and the need for further surgery in a cohort of patients with a
non-invasive growing endoprosthesis. Between 2003 and June 2014, 50 children (51 prostheses) had a
non-invasive growing prosthesis implanted for a primary bone sarcoma.
The minimum follow-up was 24 months for those who survived. Their
mean age was 10.4 years (6 to 14). The incidence of complications
and further surgery was documented.Aims
Patients and Methods
This study analysed the clinical and radiological outcome of
anatomical reduction of a moderate or severe stable slipped capital
femoral epiphysis (SCFE) treated by subcapital osteotomy (a modified
Dunn osteotomy) through the surgical approach described by Ganz. We prospectively studied 31 patients (32 hips; 16 females and
five males; mean age 14.3 years) with SCFE. On the Southwick classification,
ten were of moderate severity (head-shaft angle >
30° to 60°) and
22 were severe (head-shaft angle >
60°). Each underwent open reduction
and internal fixation using an intracapsular osteotomy through the
physeal growth plate after safe surgical hip dislocation. Unlike
the conventional procedure, 25 hips did not need an osteotomy of
the apophysis of the great trochanter and were managed using an
extended retinacular posterior flap. 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:
Of 48 consecutive children with Gartland III
supracondylar fractures, 11 (23%) had evidence of vascular injury,
with an absent radial pulse. The hand was pink and warm in eight
and white and cold in the other three patients. They underwent colour-coded
duplex scanning (CCDS) and ultrasound velocimetry (UV) to investigate
the patency of the brachial artery and arterial blood flow. In seven
patients with a pink pulseless hand, CCDS showed a displaced, kinked
and spastic brachial artery and a thrombosis was present in the
other. In all cases UV showed reduced blood flow in the hand. In
three patients with a white pulseless hand, scanning demonstrated
a laceration in the brachial artery and/or thrombosis. In all cases,
the fracture was reduced under general anaesthesia and fixed with
Kirschner wires. Of the seven patients with a pink pulseless hand
without thrombosis, the radial pulse returned after reduction in
four cases. The remaining three underwent exploration, along with
the patients with laceration in the brachial artery and/or thrombosis. We believe that the traditional strategy of watchful waiting
in children in whom the radial pulse remains absent in spite of
good peripheral perfusion should be revisited. Vascular investigation
using these non-invasive techniques that are quick and reliable
is recommended in the management of these patients. Cite this article:
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.
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.
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.
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:
Congenital pseudarthrosis of the tibia (CPT)
is a rare but well recognised condition. Obtaining union of the pseudarthrosis
in these children is often difficult and may require several surgical
procedures. The treatment has changed significantly since the review
by Hardinge in 1972, but controversies continue as to the best form
of surgical treatment. This paper reviews these controversies. Cite this article:
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.
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
Deformity of the forearm due to growth disturbance of the ulna occurs in a number of conditions such as ulnar deficiency, multiple exostoses, and neurofibromatosis. We report a previously unrecognised form, caused by focal cortical indentation. We have treated five children with this condition, three girls and two boys; the mean age at presentation was 5 years (2 to 8). The deformity was first recognised about the age of two years, and progressed gradually. The radiological findings were the same in all cases. The focal cortical indentation was seen at the distal end of the ulna with anteromedial bowing and dysplasia. The radial head was dislocated posterolaterally. In one patient the histological findings at the site of indentation were of a fold of tissue resembling periosteum, which interfered with enchondral ossification. Treatment by ulnar lengthening using an external fixator and osteotomy which corrected both the ulnar deformity and reduced the dislocated radial head in two cases gave the best results.
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 muscle imbalance is a causative or contributing factor.
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.
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.
Between June 2001 and November 2008 a modified Dunn osteotomy with a surgical hip dislocation was performed in 30 hips in 28 patients with slipped capital femoral epiphysis. Complications and clinical and radiological outcomes after a mean follow-up of 3.8 years (1.0 to 8.5) were documented. Subjective outcome was assessed using the Harris hip score and the Western Ontario and McMaster Universities osteoarthritis index questionnaire. Anatomical or near-anatomical reduction was achieved in all cases. The epiphysis in one hip showed no perfusion intra-operatively and developed avascular necrosis. There was an excellent outcome in 28 hips. Failure of the implants with a need for revision surgery occurred in four hips. Anatomical reduction can be achieved by this technique, with a low risk of avascular necrosis. Cautious follow-up is necessary in order to avoid implant failure.
We investigated patterns of refracture and their risk factors in patients with congenital pseudarthrosis of the tibia after Ilizarov osteosynthesis. We studied 43 cases in 23 patients. Temporal and spatial patterns of refracture and refracture-free survival were analysed in each case. The refracture-free rate of cumulative survival was 47% at five years and did not change thereafter. Refracture occurred at the previous pseudarthrosis in 16 of 19 cases of refracture. The risk of refracture was significantly higher when osteosynthesis was performed below the age of four years, when the tibial cross-sectional area was narrow, and when associated with persistent fibular pseudarthrosis. Refracture occurs frequently after successful osteosynthesis in these patients. Delaying osteosynthesis, maximising the tibial cross-sectional area and stabilising the fibula may reduce the risk of refracture.
Osteofibrous dysplasia is an unusual developmental condition of childhood, which almost exclusively affects the tibia. It is thought to follow a slowly progressive course and to stabilise after skeletal maturity. The possible link with adamantinoma is controversial and some authors believe that they are part of one histological process. We retrospectively reviewed 16 patients who were diagnosed as having osteofibrous dysplasia initially or on the final histological examination. Their management was diverse, depending on the severity of symptoms and the extent of the lesion. Definitive (extraperiosteal) surgery was localised ‘shark-bite’ excision for small lesions in five patients. Extensive lesions were treated by segmental excision and fibular autograft in six patients, external fixation and bone transport in four and proximal tibial replacement in one. One patient who had a fibular autograft required further excision and bone transport for recurrence. Six initially underwent curettage and all had recurrence. There were no recurrences after localised extraperiosteal excision or bone transport. There were three confirmed cases of adamantinoma. The relevant literature is reviewed. We recommend extraperiosteal excision in all cases of osteofibrous dysplasia, with segmental excision and reconstruction in more extensive lesions.
Congenital unilateral anterolateral tibial bowing in combination with a bifid ipsilateral great toe is a very rare deformity which resembles the anterolateral tibial bowing that occurs in association with congenital pseudarthrosis of the tibia. However, spontaneous resolution of the deformity without operative treatment and with a continuously straight fibula has been described in all previously reported cases. We report three additional cases and discuss the options for treatment. We suggest that this is a specific entity within the field of anterolateral bowing of the tibia and conclude that it has a much better prognosis than congenital pseudarthrosis of the tibia, although conservative treatment alone may not be sufficient.
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 muscle and bone complications, is a more effective approach. Nerve reconstruction should be reserved for those less common cases where the C5 and C6 nerve roots will not recover.
We analysed the operative technique, morbidity and functional outcome of osteotomy and plate fixation for malunited fractures of the forearm sustained in childhood. A total of 20 consecutive patients underwent corrective osteotomy of 21 malunited fractures at a mean age of 12 years (4 to 25). The mean time between the injury and the osteotomy was 30 months (2 to 140). After removal of the plate, one patient suffered transient dysaesthesia of the superficial radial nerve. The mean gain in the range of movement was 85° (20° to 140°). The interval between injury and osteotomy, and the age at osteotomy significantly influenced the functional outcome (p = 0.011 and p = 0.004, respectively). Malunited fractures of the forearm sustained in childhood can be adequately treated by osteotomy and plate fixation with excellent functional results and minimal complications. In the case of established malunion it is advisable to perform corrective osteotomy without delay.
Type BI rotationplasty is currently indicated for children with tumours of the proximal femur whereas type BIIIa rotationplasty is reserved for those in which the entire femur has to be removed. Our aim was to compare these two types of rotationplasty and determine whether the knee should be preserved in children with tumours of the proximal femur. We compared the post-operative complications, oncological outcome, range of movement, Enneking score and radiographs of six children, who had undergone type BI rotationplasty with those of 12 who had undergone type BIIIa rotationplasty. Patients with type BI rotationplasty had a mean Enneking score of 21.6 compared with 24.4 in those with type BIIIa rotationplasty, and worse mean results in all of the parameters investigated. We conclude that type BI rotationplasty has a worse functional outcome and more complications than type BIIIa rotationplasty in children under the age of ten years.
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.