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In cerebral palsy patients, while upper limb function is acknowledged as being important, it has traditionally taken a back seat to lower limb function. This is partly due to inexperience and partly due to difficulty deciding on the best way of improving upper limb function.
In Swansea since June 2008 we have been offering a multi-disciplinary service for the assessment and treatment of upper limb problems in cerebral palsy. The core team consists of a consultant orthopaedic surgeon, a consultant plastic surgeon with a special interest in CP upper limb problems, a consultant paediatric neurologist, a community paediatric physiotherapist and a community paediatric occupational therapist.
Upon referral, the physiotherapist and occupational therapist carry out initial functional assessment of the patient. This is followed by a joint assessment by the whole team in a special clinic held every 3 months. If required, the child is offered surgery, botox injections or both. Further follow-up is in the special clinic until the child is suitable for follow-up in a normal clinic.
We present our initial experience with this multi-disciplinary approach, the problems encountered in setting up the service and our plans for the future.
Purpose of study
To determine whether hemiplegia causes abnormal torsion of the radius of the affected compared with the unaffected limb as demonstrated by MRI measurements, and to assess whether this correlates with the passive range of movement as measured clinically.
Methods
27 patients who fit the inclusion criteria were recruited from an existing database of hemiplegic patients into our prospective cohort study.
A clinical assessment was made of each subject to determine the range of active and passive upper limb movements. A functional assessment of the children's upper limbs was made using the validated House score. Subsequent MRI scans of both upper limbs were then performed. A single radiologist (blinded as to the affected limb) then measured the torsional profiles of both radii using a method validated by Bindra et al.
Purpose We report the long term outcome of a minimally invasive technique avoiding the risks associated with open reduction and bone grafting in paediatric lateral condyle fracture non-unions.
Methods The Toronto Hospital for Sick Children's radiology database was searched to isolate all those who sustained a lateral condyle elbow fracture and had developed a non-union between the years 1998 and 2008. This identified 16 patients who had undergone percutaneous fixation for the treatment of their non union. Each individuals clinical notes and radiographs were reviewed from presentation to final follow-up.
Results Median age at injury was 5.1 (3.2, 7.2) in the successful and 2.8 (2.1, 4.7) in the unsuccessful groups (p=0.18). 11 patients (68.7%) had been initially managed non-operatively. Median time from injury to non-union diagnosis was 15.7 weeks in the successful, and 225.5 weeks in the unsuccessful group (p=0.039).
Mean time to union post fixation was 16.2 weeks (+/- 6.74) and mean time to surgery was 5.2 weeks (+/- 4.11). Surgery was successful, defined as radiological and clinical union, in 12 of 16 patients (75%). 43.8% had metalwork removal and no cases of avascular necrosis were reported.
Conclusion We have demonstrated this technique to be successful in those non-unions addressed within 16 weeks from initial injury to diagnosis. We had 4 failures, these occurred in patients whose non-unions were diagnosed more than 31 weeks from the time of injury (31; 68; 383; 427 weeks). Each of these failures had been managed non-operatively as part of their primary treatment plan.
Percutaneous fixation is feasible and safe. Patients not achieving union were diagnosed significantly later. There was a trend towards successfully treated patients being younger.
Meningococcal septicaemia from meningococcal infection is a devastating illness affecting children. Advances in medical management have reduced the mortality rate to approximately 15 to 20% and children who survive can develop late orthopaedic sequelae from growth plate arrests with resultant complex deformities. Our aim in this study was to review and analyze the case histories of a series of patients with late orthopaedic sequelae, all treated by the senior author. We describe a treatment strategy to address the multiple deformities that may occur in these patients.
Methods & Results Between 1990 and 2009, 12 patients were treated for late orthopaedic sequelae after meningococcal septicaemia by the senior author. There were 8 girls and 4 boys. All patients had lower limb involvement. 1 patient had involvement of the upper limb requiring treatment. Each patient had had a mean of 3 operations (range from 2 to 9). Methods of treatment included a combination of angular deformity correction, limb lengthening and epiphysiodesis. At final follow-up 9 of the 12 patients were skeletally mature. In 9 patients limb length discrepancy in the lower limb was corrected to within 1 cm, with normalization of the lower limb mechanical axis. Conclusion
Meningococcal septicaemia can lead to late orthopaedic sequelae due to growth plate arrests. Central growth plate arrests leads to limb length discrepancy, and partial growth plate arrests leads to an angular deformity. In addition, limb amputations may occur and there may be altered growth of the stump requiring further surgery. In cases of central growth arrest with limb shortening alone, limb equalisation is performed with limb lengthening procedures. In cases of partial growth arrests, angular correction is performed together with ablation of the affected growth plate. We recommend ablation of the affected growth plates at the initial surgery to prevent recurrence of angular deformity. Angular correction can be performed acutely, with a dome or transphyseal osteotomy; or gradually, with application of Ilizarov or Taylor Spatial frames. Severe deformities of the tibial plateau are treated by plateau elevation with bone graft augmentation. With the appropriate strategy deformities can be corrected and further lengthening procedures can be undertaken if necessary. Long-term follow-up of these patients is essential to recognise and treat any recurrence of deformity.
Purpose
Habitual hip subluxation and dislocation is a potentially disabling feature of Trisomy 21 and we describe long-term outcomes following the precise use of femoral varus derotation osteotomy.
Methods
16 consecutive hips, 9 children, with Trisomy 21 aged =10 years, were identified from hospital databases. Clinical notes and radiographs from presentation to final follow-up were reviewed.
Aims
We aimed to examine the true incidence of DDH in our area, and to investigate both known and unknown risk factors for the condition.
Methods
Data were prospectively recorded on all live births in the Exeter area from January 1998 to December 2008. The data included the baby's gestational age, sex, demographic details of parents, maternal age and parity, geographic and socioeconomic data, mode of presentation and delivery, and family history of DDH. Data were also collected prospectively on all treated cases of DDH (Graf 2c and above) for the same period. Using the population live birth data as controls, odds ratios (OR) and confidence intervals were calculated.
Purpose
To investigate the effect of soft tissue release (STR) and the length of postoperative immobilisation on the long term outcomes of closed reduction (CR) of the hip for developmental dysplasia of the hip.
Materials
77 hips (72 patients) who had undergone closed reduction (CR) between 1977-2005 were studied retrospectively to review their outcome (Severin grade), identify the reasons for failure and to assess factors associated with residual dysplasia. Particular attention was paid to the use of a STR at the time of CR (to improve initial hip stability) and the duration of postoperative immobilisation.
We have reviewed the complication rate over a ten year period for removal of screws placed for slipped capital femoral epiphysis (SCFE) and have surveyed the views of orthopaedic surgeons with an adult hip practice in Scotland on leaving the metalwork in situ. Whilst screw removal is favoured by many orthopaedic surgeons, a recent review of the literature reported that the complication rate for removal of implants placed for SCFE was 34%.
Between 1998 and 2007 84 patients had insertion of screws for SCFE. Of these 54 patients had screws removed, 51 of these records were available. The median duration between insertion and removal of screws was 2 yrs 7 months. Of the 51 children, overall five (9.8%) had complications - three (5.9%) major and two (3.9%) minor. Two screws could not be removed; one patient sustained a fracture after screw removal and two developed an infection.
We assessed the attitudes of adult hip surgeons on this topic using an electronic questionnaire which was completed by 29 out of 40 recipients. 78.6% of respondents support routine removal and 21.4% favour leaving the screw permanently in place. 82.2% had needed to remove metalwork from a hip requiring arthroplasty in a patient whose metalwork was inserted during childhood; and described their experience of this including the complications encountered.
We have identified a lower complication rate following screw removal inserted for SCFE than in published series. Most adult hip surgeons support routine removal once the physis is closed but studies regarding the long-term outcome of retained orthopaedic implants are needed since even with this lower complication rate the question of routine removal remains unclear.
Aim
To assess if Osteoset (CaSO4) improves graft incorporation after shelf procedure and whether spica immobilisation is necessary
Methods/results
49 patients with acetabular dysplasia treated by shelf procedure were reviewed retrospectively. Group 1 (19 children) and group 2 (12 adults) had shelf acetabuloplasty using autogenous bone graft and CaSO4. Group 3 (18 children) underwent shelf acetabuloplasty using autogenous bone graft alone. Group 2 was assessed separately to avoid age bias. Within group 3 we compared 10 patients managed in plaster for six weeks with 8 mobilized on crutches post operatively.
Total shelf and graft area, total shelf length, extra-osseous shelf length and speed of graft incorporation were measured radiologically.
There was no difference in shelf indices between patients treated in plaster and those mobilized on crutches.
Use of CaSO4 significantly enlarged shelf volume by 3 months post-operative with less resorption, which was maintained throughout follow-up. In contrast the non-CaSO4 group showed a steady decrease in shelf volume. The extra-osseous shelf length was initially similar in groups 1 & 3. By 6 weeks the group 1 extra-osseous shelf was significantly greater than for group 3 and was maintained throughout follow-up. Graft incorporation was faster in group 1.
Shelf area and extra-osseous shelf length improved significantly in group 2. However total shelf length decreased slightly by 6 months.
Purpose
To document the incidence and nature of complications associated with hemiepiphysiodesis using a screw and plate device (8-plate, Orthofix).
Methods
We reviewed case notes and radiographs of 71 children (130 segments) with lower limb deformities treated with temporary hemiepiphyseal arrest using the 8-plate. 96% of deformities were in the coronal plane, 4% sagittal. 72% of coronal deformities demonstrated valgus malalignment. We defined three types of complications: complications
Complications were related to variables of patient age, gender, diagnosis, location of deformity and associated surgery.
This study aimed to determine the major diagnoses and needs of children in Rwanda with musculoskeletal conditions to enable the Rwandan government to begin to plan orthopaedic and rehabilitation services.
BACKGROUND
When faced with developing orthopaedic services for children in Sub-Saharan Africa, there is little objective evidence-based data on the magnitude and type of services needed. Rwanda is a small country that is in the process of developing orthopaedic and rehabilitation services, and its Ministry of Health supported a survey that would provide information necessary for planning such services.
METHODS
A national survey of musculoskeletal impairment (MSI) prevalence was undertaken. Of a population of 8.4 million, 8368 people were enumerated. Four thousand one hundred thirty-four were aged 16 years or less. Cases who failed a screening test for MSI were examined, allocated a diagnostic category, and assessed as to treatment needed.
Statement of purpose of study: To determine how effective Flexible Intramedullary Nails are in treating tibial and femoral fractures in adolescents. Summary of Methods used: Retrospective review of consecutive adolescent patients treated over a seven year period with Flexible Intramedullary Nails for tibial and femoral fractures. Statement of Conclusion: We conclude that the higher than expected rates of malunion and delayed union suggest that other treatments should be considered when treating adolescents with unstable tibial or femoral fractures.
Introduction Flexible intramedullary nails (FIN) are increasingly used in the management of paediatric tibial and femoral fractures. Recently, concerns have been raised regarding the use of FIN in older children. The aim of this study was to determine how effective FIN's are in treating tibial and femoral fractures in adolescents.
Methods Hospital records were used to identify all patients aged 11 years or older under going FIN for tibial and femoral fractures between 2003 and 2009. Radiographs and case notes were reviewed to identify complications.
Results 35 consecutive adolescent patients underwent FIN for tibial (n=21) and femoral fractures (n=15) with a mean age of 12.9 years. 2 femoral and 9 tibial fractures were open. Eight patients sustained multiple injuries. Mean radiographic follow up was 29 weeks. 60% (n=9) and 38% (n=9) of femoral and tibial fractures respectively malunited. Fracture severity was associated with increased malunion for both tibial and femoral fractures (P=0.046 and P=0.044 respectively). There were no cases of non-union. 2 femoral fractures took longer than 20 weeks to unite and 7 tibial fractures took longer than 16 weeks to unite. One patient developed post operative compartment syndrome, one patient developed deep infection and two patients were treated with post operative traction for loss of fracture position.
Discussion Previous publications from multiple centres, including ours, have demonstrated excellent results of FIN for tibial and femoral fractures in the general paediatric population. However, concerns have recently been raised about the use of FIN in older, heavier children and with unstable fracture patterns. This is the first published series of adolescent patients undergoing FIN. We conclude that the higher than expected rates of malunion and delayed union suggest that other treatments should be considered when treating adolescents with unstable tibial or femoral fractures.
