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Volume 94-B, Issue SUPP_XXIV May 2012 British Society for Children's Orthopaedic Surgery (BSCOS) and British Limb Reconstruction Society (BLRS)

G. El-Adl M.A. Khalil A. Enan M.F. Mostafa M.R. El-Lakkany

Aim

A retrospective study was undertaken to evaluate and compare the results of telescoping (group I) versus non-telescoping rods (group II) in the treatment of osteogenesis imperfecta.

Materials and Methods

Thirty-three lower limb segments in ten patients were studied (14 segments in group I and 19 segments in group II). The surgical techniques of Sofield and Miller (1959) and Lang-Stevenson and Sharrard (1984) for rod insertion were used. All cases were assessed clinically regarding mobility status, growth and limb-length, refracture, and infection. They were also assessed radiologically regarding rod migration, bone outgrowing the rod, incorrect T-piece placement, breakage and bending of rods.


A.P. Cooper M.J. Flowers

Aims

The purpose of this study was to calculate the dislocation rate following open or closed reduction for developmental dysplasia of the hip (DDH) in our unit. In addition we evaluated the posterior neck line as a method of determining hip relocation and assessed the morphology of the dysplastic acetabulum on single slice CT scan.

Method

We retrospectively assessed all patients operated on for either open or closed reduction for DDH between August 2007 and August 2009 and evaluated their notes, CT scans and radiographs. The immediate post-operative dislocation rate was calculated, as was the subsequent re-dislocation rate and late subluxation rate. The acetabular morphology was assessed to determine whether the acetabulae were “S” shaped or “C” shaped. A novel method for confirming hip reduction was also appraised.


A.M. Hefny A.A. Abdelsamie A.H. Amin

Introduction

Septic arthritis of the hip in the newborn baby can result in severe long term sequelae in the form of dislocation of the hip, loss of movement and growth disturbance with leg length discrepancy. Reconstructive procedures for this difficult problem have not been satisfactory.

Patient and methods

This series comprises eight patients with septic hip sequelae . All of them had old septic hip and leg length discrepancy ranging from 4 cm to 15 cm. all underwent hip stabilization by pelvic support osteotomy and simultaneous limb lengthening and angular deformities correction using the Ilizarov frame. The age at the operation range from 8 years to 19 years, with an average follow up 4 years.


A.G. de Gheldere A. Hashemi-Nejad P. Calder S. Tennant D.M. Eastwood

Purpose

To document the success rate of closed reduction and soft tissue release in the treatment of bilateral true dislocation in developmental dysplasia of the hip (DDH).

Methods

Case-note review of 22 children (44 hips) with idiopathic bilateral hip dislocation referred to a tertiary centre before walking age. The management protocol was as follows:

Examination under general anaesthesia, arthrogram, closed reduction and appropriate soft tissue release (adductors/psoas), application of a ‘frog’ cast.

CT scan at 2 weeks to confirm reduction.

Change of cast and arthrogram at 6 weeks to confirm improving position and stability.

Cast removal at 12 weeks, and application of an abduction brace for 6 weeks.

Treatment failure could occur on day 1 (failure of reduction), at week 2 (failure to maintain reduction), at week 6, or after cast removal.


N. Nicolaou M Padman M.J. Bell J.A. Fernandes

PURPOSE OF THE STUDY

To assess if prolonged use of Bisphosphonates in Osteogenesis Imperfecta alters the pattern of femoral fractures.

Osteogenesis Imperfecta (OI) has been treated with Bisphosphonates for many years with some clear clinical benefits. In adult cohorts there are reports of a new pattern of atraumatic subtrochanteric fractures seen with Bisphosphonate treatment.

SUMMARY OF METHODS

This study assesses the location of femoral fractures in a cohort of 176 OI patients treated with Bisphosphonates over a two year period and compares it to a historical control group of 45 managed prior to the advent of this specific treatment.


D.M. Wright J. Sampath S.N. Nayagam A. Bass

The aim of this retrospective study was to review the outcome of patients treated with Fassier-Duval (FD) rods and highlight some of the complications found during treatment.

Between April 2006 and August 2010 we inserted 24 FD rods in 13 patients. 17 rods for osteogenesis imperfecta (OI), 2 for fractures and deformity associated with cerebral palsy, 1 for fracture associated with muscular dystrophy, 1 for fibrous dysplasia and 3 for centralisation of single bone forearms.

In the upper limb one patient required revision for proximal migration of the male component and another patient is waiting for revision for the same problem.

In the lower limb, a tibial nail was revised because of proximal migration of the male component. A femoral nail was adjusted because of loss of the proximal fixation. One of the OI patients fell, fractured the femur and bent a femoral nail. This awaits revision at a later date. A second OI patient fell on 2 separate occasions bending both a tibial and a femoral nail respectively. These were both revised to trigen intramedullary nails.

In all the other cases there were no complications.

In summary the Fassier Duval system provides a versatile way of providing intramedullary stabilisation for growing bones through a single entry point. However in our experience we have a 33% complication rate most notably bending of the rods. We advocate careful patient selection and using as high a diameter nail as is feasible.


S. Gillani J.A. Humphrey M. Barry

Purpose

A review of the role of external fixators in paediatric trauma at The Royal London Hospital Trauma and Orthopaedic Department.

Methods

Retrospective study between 2004 and 2010 reviewing traumatic bone injuries that required initial management with an external fixator. Information was collected through the patients' medical documents and radiographs.


C.J. Edwards E.D. Gent R. Asp M.G. Uglow

Statement of Purpose

Our experience with Taylor Spatial Frame correction of complex foot deformities in children.

Persistent foot deformity in congenital talipes equinovarus is a challenge. Open surgery is associated with complications including difficulty in achieving acute corrections in stiff, scarred feet. Gradual correction using the Ilizarov circular frame has been described as an alternative and we present the experience using a computer assisted hexapod gradual frame correction with the Taylor Spatial Frame (TSF).

A retrospective audit of sequential patients treated by TSF was performed. Technique, outcome, complications and key learning points were recorded.

21 paediatric patients underwent 27 treatments with a Taylor Spatial frame for complex foot deformity correction. Average age 11 years with majority diagnosis of congenital talipes equinovarus. The deformities severity meant acute correction would result in either neurovascular or soft tissue compromise.

Plantigrade feet with good function was achieved in 22 feet. 3 feet were deemed as failures. 2 feet have residual deformity but acceptable function. According to Paley's classification, there were 4 complications, 7 obstacles and 35 difficulties (pin tract infection and pain management). Complications did contribute to poorer outcomes. The key learning points were: protection of the ankle joint and distal tibial physis; staged osteotomy reduces swelling and complication rates; and consideration of further procedures at frame removal is important. Finally a thorough preoperative counselling programme should be instituted and patients warned of the time commitment and high difficulty rates associated with treatment. Managing patient expectation with goals is as important as meticulous surgery.

Although complication rates were high, the majority of treatment goals were met, therefore the TSF is valid in the treatment of complex deformities in the foot. Most patients with severe deformity can achieve a plantigrade functional foot but residual stiffness and need for minor orthotics is almost universal.


A. Ghassemi N. Nicolaou R.A. Hill

PURPOSE

To report the experience and evolution of treatment of Congenital Pseudarthrosis of the Tibia in a single surgeon, consecutive series of 19 patients.

METHODS

A retrospective case series review, with radiological assessment and functional outcome scores including the Activity Scale for Kids (ASK) and the Oxford Ankle Foot Questionnaire (OAFQ) Child & Teenager version. Patients were classified as per Boyd & Andersen. Alteration in the Tibial mechanical axis was compared pre-treatment and at last review.


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C.C. Taylor N.M.P. Clarke

Purpose

We describe two recent cases of intraosseous (IO) access resulting in amputation in critically ill infants and make contemporary recommendations on the safe practice of this technique.

Methods/results

This is a retrospective case series of two children transferred from peripheral hospitals to our unit. One child (5 months) was resuscitated after cardiorespiratory decompensation due to diaphragmatic hernia. The other child (18 months) deteriorated during presentation with purpura fulminans two days after a scald injury. Both children underwent emergent bilateral tibial IO access using power driven needle systems. Initial resuscitation included large volumes of 0.9% normal saline. One child received doses of adrenaline and 8.4% sodium bicarbonate, whole blood and an initial dopamine infusion; the other received 8.4% sodium bicarbonate, 10% calcium gluconate and whole blood. Total infused volumes were 400mL and 730 ml respectively.

Progressive lower limb tension became evident in both children after 12 hours; bilateral posterior tibial fractures were noted in one child. Ultimately, both children underwent surgical fasciotomy, but extensive necrosis necessitated unilateral below knee amputation at days 12 and 13 respectively.


N. Siddiqui O. Malaga-Shaw D.M. Eastwood

Purpose

To define the orthopaedic problems associated with pseudoachondroplasia (PSACH) and their functional impact.

Methods

We reviewed the medical records of 12 consecutive patients presenting to our unit. Radiographic analysis of deformity included assessment of mechanical axis and dysplasia at hip, knee and ankle measured by acetabular index (AI), Reimer's migration percentage (MP), neck-shaft angle, distal lateral femoral (aDFLA) and proximal (mMPTA) and distal tibial angles.

The paediatric/adolescent PODCI questionnaires and the SF36 were used to assess quality of life issues.


A. Aarvold J.O. Smith C.J Edwards E.R Tayton E.D. Gent R.O C. Oreffo

Background

Unicameral bone cysts (UBCs) are difficult to treat and have a high recurrence rate. Their pathogenesis is unknown making targeted therapies difficult. Attributed causes include venous and interstitial fluid obstruction, oxygen free radicals, lysosomal enzymes, prostaglandins and genetic factors. Skeletal stem cells (SSCs) are osteoblast precursors critical to bone formation and cyst fluid may influence their growth, however the association between SSCs and cyst fluid has never been investigated.

Aim

To investigate the effect of UBC fluid on SSC growth.


A. Roposch L.K. Liu D. Kulaveerasingham

Purpose of the study

To determine the consistency with which specialist orthopaedic surgeons rate the importance of criteria for the diagnosis of DDH which had previously been generated in a BSCOS and EPOS multi national study.

Methods

163 members of BSCOS received a questionnaire containing 37 criteria that, in a previous study, had been found to be important for the diagnosis of DDH in infants under 8 weeks. A visual analogue scale was used to rate the importance of each criterion in the diagnosis of DDH. We determined the consistency using the intra-class correlation coefficient (values > .80 are anticipated). Analyses were preformed for all members of BSCOS and for geographic regions.


V. Goriainov C.G. Gibson N.M.P. Clarke

AIMS

We present a retrospective study of bilateral CDH. We analysed the correlation of complications to the confounding factors.

MATERIAL AND METHODS

We reviewed all bilateral CDH patients treated by the same surgeon at Southampton between 1988-2006. The patient recruitment was carried out as follows:

Group A – failed Pavlik harness;

Group B – late presentations not treated in Pavlik harness.


A.S. Allam

Background

CRUS is difficult to treat. Many techniques have been tried in an effort to restore forearm rotation; however, they have not been successful. It is inadvisable by many authors to perform any operation with the hope of obtaining pronation and supination.

Patients and Methods

Eleven children; 3 - 8 years old with CRUS, Wilkie type I, with fixed full pronation deformity were managed by the new ALLAM'S OPERATION which is a one stage intervention including separation of the bony fusion, special cementation technique of the ulnar (or radial) side of the osteotomy, double osteotomy of the radius and a single osteotomy of the ulna (all of the 3 osteotomies were done percutaneously) with intramedullary K. wire fixation of osteotomies at the mid-prone position and above elbow cast application for 6 weeks.


R.A. Rajan J. Chandrasenan J. Metcalfe C. Konstantoulakis

The purpose of our study was to independently assess the modified Herring lateral pillar classification.

Methods and results

35 standardised true antero-posterior radiographs of children in various stages of fragmentation were independently assessed by 6 senior observers on 2 separate occasions (6 weeks apart). Kappa analysis was used to assess the inter and intraobserver agreement between observations made. Intraobserver analysis revealed at best only moderate agreement for two observers. 3 observers showed fair consistency, whilst 1 remaining observer showed poor consistency between repeated observations (p<0.01). The highest scores for interobserver agreement varying between moderate to good could only be established between 2 observers. For the remaining observers results were just fair (p<0.01).

Conclusion

This stdy highlights the lack of agreement between senior clinicians when applying the modified LPC. This clearly has clinical implications. To our knowledge this is the first time the modified lateral pillar classification has been independently tested for its reproducibility by a specialist orthopaedic unit.


C.J. Geddis R. Ali J.A. Fernandes S.S. Madan

The purpose of this study was to determine the oblique plane deformity in slipped upper femoral epiphysis.

A retrospective radiographic review was undertaken in patients admitted with a slipped upper femoral epiphysis between March 2008 and October 2010. Patients in whom a CT scan had been performed in addition to plain radiographs were assessed further. Angular deformity in the coronal and sagittal planes were measured by the angle formed between the femoral neck and a line perpendicular to the physis on the AP pelvic radiograph and the axial CT scan respectively. The magnitude and direction of the resultant deformity was defined in the oblique plane. Additional demographic data (gender, age, side, procedure and complications) was collected.

Seven girls, average age of 12 (range 10 – 13) and 6 boys, average age of 13 (range 10 – 15) were identified. The slip was bilateral in 2, left sided in 6 and right sided in 5 cases. Two patients were pinned in situ, 8 had surgical dislocation performed to facilitate reduction prior to pinning and 3 patients had secondary procedures performed following in situ pinning. The average angulation in the oblique posteroinferior plane (25 degrees) was less than in the coronal (30 degrees) and the sagittal planes (62 degrees). The average magnitude was 67mm (range 31 – 88).

CT is useful adjunct particularly when a frog legged lateral view is not possible because of pain or the fear of further displacement. Determination of the deformity in the oblique plane may aid in positioning of the screw during in situ pinning and may be helpful in identifying patients in whom pinning maybe difficult.