The purpose of the study was to investigate the incidence of surgical site infection following elective paediatric orthopaedic surgery.

A pro forma adopted from a pilot study was filled out preoperatively for each elective operation performed during the study period. Each patient was then followed up for six weeks postoperatively to record any SSI that developed. Data collected included patient demographics, type of operation, grade of Surgeon, type of procedure, wound length, skin preparations, use of tourniquet, any antibiotic prophylaxis and length of operation.

This study collated data on 334 operations with 410 procedural sites over a six month period. Infection were recorded in 19 sites equivalent to a SSI rate of 4.63%. None of the patients developed long-term complications.

The mean age of the participants in the study was 11 years (range 0.5 to 17 years), 57% were males and 43% were females.

The infection were detected between 1 and 38 days after surgery. The outcome was not compromised in any of the patients as none of them required long-term treatment. Statistical analysis was undertaken.

The study proves that the surgical site infection after elective paediatric orthopaedic surgery is low and serve as a bases for consenting patients for surgery.

The aim of this study was to determine the effectiveness of intra-operative tranexamic acid in children with osteogenesis imperfecta, who have been shown to have increased bleeding tendency, in deformity correction surgery.

We retrospectively reviewed all cases of lower limb intramedullary rodding in patients with osteogenesis imperfecta treated in our unit from 2000–2013 in whom a pre and post- operative full blood count was available (n=69). Case notes were reviewed and patients were grouped according to the use of tranexamic acid. Peri-operative change in haemoglobin (Hb), haematocrit (HCT) and requirement for blood transfusion was assessed.

Of 69 operations performed, 62.3% were in female patients, 78.3% were femoral, and 43.5% were bilateral cases (19 femur, 11 tibia). In the non-tranexamic acid group there was a mean drop in Hb of 28.9 g/L (range 0–62), mean HCT drop of 8.8 (range 2.2–19.4) and 3 patients required red cell transfusion. In the tranexamic acid group there was a mean Hb drop of 22.5 g/L (range 1–49), mean HCT drop of 7.35 (range −0.8–16.7) and one patient required red cell transfusion. There was a significant decrease in Hb drop (p=0.0287) in the tranexamic acid group.

Tranexamic acid seems to decrease the drop in haemoglobin during lower limb intramedullary rodding in patients with osteogenesis imperfecta, with little associated risk. Protocols should be established for future use a further review undertaken.

Aim

To determine the rate of recurrence of coronal plane deformity in children treated with ‘guided growth’ using 8-plates, from the time of implant removal to skeletal maturity.

The Pelvic Support Osteotomy (PSO) or Ilizarov Hip Reconstruction(IHR) is well described for the treatment of septic sequelae of infancy. The purpose of this study was to clinically, functionally and radiographically assess our short-term results of this procedure.

25 patients (16 boys, 9 girls) who had undergone a IHR using the Ilizarov/TSF construct over a period of 10 years for a variety of pathologies were reviewed. The mean age at surgery was 15 years 4 months. The pre-operative diagnoses were SCFE(10), hip sepsis (6), DDH (6) and Perthes (3). All had significant leg length discrepancies, 16 had a painful stiff hip, 6 had a painful mobile hip and 3 had a painless unstable hip. At surgery, a mean measured proximal valgus angle of 51° and a mean extension angle of 15° was achieved. Distal femoral lengthening averaged 4.2 cm and distal varus correction was a mean of 8°. The mean fixator time was 173 days.

At a mean of 2 years and 7 months follow-up the lower-extremity length discrepancy had improved from a mean of 5.6 cm apparent shortening to 2.3 cm. Trendelenberg sign was eliminated in 18/25 cases. Improvements in range of hip movements and gait parameters were observed. Stance time asymmetry, step length asymmetry, pelvic dip and trunk lurch improved significantly. One patient had conversion to a total hip replacement after 7 years, 4 patients required re-do PSO due to remodelling of the proximal osteotomies, two had heterotopic ossification and two had significant knee stiffness due to lack of compliance.

The early results of IHR are encouraging to equalise limb lengths, negate trendelenburg gait, provide a mobile hip with a reasonable axis and the possibility of conversion to THR in the future if needed. Complications need to be anticipated and the effects of remodelling and maintaining adequate knee range of motion must be emphasised.

Aim

The use of intraoperative cell salvage as a tool for reducing allogenic transfusion has been demonstrated in pelvic osteotomies. The aims of this audit were to identify any problems or complications with cell salvage, reduction in allogenic transfusion and identify procedures that would benefit.

Aim

To evaluate the influence of arthrodiatasis in the natural history of the stages of the disease radiologically and also the timing of arthrodiatasis.

Aim

To study the results of using recombinant human bone morphogenic protein-2 (rhBMP-2) to achieve bone union in children with complex orthopaedic problems including skeletal dysplasia, congenital limb deficiencies and complex trauma.

Aim

To investigate the effectiveness of a decision-based protocol designed to minimise the use of medial incisions when performing crossed-wire fixation of supracondylar fractures of the distal humerus whilst minimising ulnar nerve injury.

Aim

The aim of the study was to characterise gait in patients with achondroplasia post lengthening.

Purpose

To examine the effect of limb lengthening on the quality of life of people who have disproportionate short stature (DSS).

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.

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.

Introduction: Percutaneous in situ pinning of severe SUFE can lead to problems. We describe our technique and results for surgical dislocation to reduce severe SUFE.

Method: Ganz’s approach of greater trochanteric flip, safe dissection and surgical dislocation to preserve the femoral head blood supply was followed to anatomically reduce the femoral head. We have treated 16 cases in this way, but describe nine with a minimum follow up of 2 years. Their mean age was 13.6 years (9 to 16 years). All had severe SUFE with four acute on chronic and two unstable slips. Two were previously pinned and another had a partially fused growth plate. The mean follow up was 3.1 years (2.1 to 4.6 years).

Results: All patients had a good to excellent outcome. Their pre-operative deformity was 84 degrees (65 to 110) measured by AP and cross table lateral x-rays, CT or MRI scans. The average hip external rotation deformity was 70 degrees. Post operatively internal and external rotation and all other movements were similar to the contra-lateral uninvolved hip. None developed avascular necrosis (AVN) or chondrolysis

Conclusions: This technique is demanding but can give good results for severe SUFE.

Introduction: Plastic deformation of the regenerate bone is a complication noted soon after limb lengthening. However, less is known about the factors responsible for the development of plastic deformation.

Materials and Methods: Retrospective analysis of 35 X-rays of achondroplast children who had limb lengthening were reviewed. The study compared Monofocal Vs Bifocal and Long lengthenings(> 10 cms) Vs modest lengthenings(≤ 10 cms) of tibial lengthening. Other parameters included in study were Bone healing Index, total length gained and sagittal and coronal axial deformities. There were 20 females and 15 males, 21 long lengthenings and 14 modest lengthenings in the study. The joint orientation and diaphyseal angles(antero-posterior and lateral X-ray views) was used for the measurement of plastic deformation of the regenerate bone.

Results: The mean age at operation was 10 years (range; 6–16 years). There were 29 cases of monolateral fixator and 6 of Ilizarov ring fixator, Of which 26 had monofocal lengthening and 9 had bifocal lengthening (34 callotasis and 1 chondrodiastasis). The total average length gained was 10 cms (range; 23–152). The mean bone healing index and external fixation index/time were 41 days and 352 days respectively. Plastic deformation of the regenerate bone was seen in 26 cases in total. 24 out of 29 cases of monolateral fixator (82%) developed plastic deformation. 44%(4/9) of bifocal group and 84%(22/26) of monofocal group showed evidence of plastic deformation. The long lengthenings showed plastic deformation in 85% (18/21) of the cases, whereas only 57%(8/14) of the cases were positive in modest lengthening group. Most of the axial deviation was in the coronal plane in 92% (24/26) and the sagittal plane accounted to only 23%(6/26) requiring surgical correction.

Conclusions: Long lengthenings and monofocal techniques showed more plastic deformation than bifocal and short lengthenings. However, Ilizarov ring fixator with bifocal corticotomy seemed to be promising with less association with the above entity in our recent experience.

Aim: To review our experience with epiphysiodesis using three different methods to correct LLD and to establish the efficacy of these procedures.

Method: A retrospective review of 42 patients from 1999 to 2008 with at least one year follow-up recorded type and location of the epiphysiodesis, average operating time and hospital stay, complications, method of prediction, timing and the final LLD. CT scanograms and mechanical axis view with grids were used to assess LLD.

Results: Epiphysiodesis was as per Canale for 26, by Metaizeau screw in 14 and by staples in 2. Average operation time was 42 minutes for Canale type, 45 minutes for the screws and 56 minutes for the staple cases. The pre operative LLD of 3.7 cms In the Canale group, improved to 1.2 cms over an average follow-up of 2.1 yrs. There were 4 minor and 2 major complications with a 92% success rate. For the screw group, the mean change was 1.8 cms over 2.2 yrs with 2 minor and 2 major complications giving a success rate of 85%. With staples the success rate was 100% and the mean change was 1.8 cms at an average of 2.3 yrs. In 14 cases where bone age reports were available, the multiplier method seemed better at predicting estimated LLD at skeletal maturity and timing of epiphysiodesis than the Moseley chart.

Conclusions: Percutaneous epiphysiodesis by any method is reliable, minimally invasive and with acceptable complication rate when compared to a corrective osteotomy or open Phemister-type epiphysiodesis. Our experience suggests that the Canale method has the least complications and best success rate. Paleys multiplier method was better at predicting LLD and timing of epiphysiodesis than the Moseley Chart.

Aim: To review our experience with hemi-epiphysiodesis using different methods for the correction of angular deformity about the knee.

Method: This was a retrospective review of 73 patients (101 knees) who underwent hemi-epiphysiodesis from 1999 to 2008. Assessment looked at the type and degree of deformity, implants used, average operating time and hospital stay, complications, degree of correction and the average time to correction.

Results: There were 50 boys and 23 girls with bilateral deformity in 28 cases. There were 88 valgus and 13 varus knees. Average follow-up was 17 months. Staples were used in 28 cases, “8” Plates in 24, Screws in 16 and Drilling in 5 cases. The distal femoral physis was involved in 46 knees, the proximal tibial physis in 21 and both physes in 34 knees (total 135 physes). Average operation time and hospital stay were similar for all methods. There were 6 minor and 3 major complications with staples with an average correction time of 14 months, 3 minor complications with an average correction time of 11 months with “8” plates, 3 minor and 1 major complication with an average correction time of 14 months with screws and 1 minor complication with drilling with an average correction time of 13 months. The outcome was considered as resolved in 47 and pending in 26 cases, with all showing progressive correction of deformity.

Conclusions: Hemi-epiphysiodesis by any method is an effective way to correct angular deformities about the knee in skeletally immature individuals within a reasonable time limit and with minimal morbidity when compared to a corrective osteotomy. Our experience suggests that “8” plates achieve faster correction with the least complications when compared to other methods. Valgus knee deformities corrected faster than varus ones.

Aim: To assess the ease of use and reliability of PICC lines for the delivery of intravenous antibiotics in children with septic joints.

Method: Over a twelve month period 22 children with septic joints were prospectively recruited. All received open arthrotomy and washout prior to commencing antibiotic treatment. At the time of surgery, a PICC line was inserted. All children were given intravenous antibiotics for two weeks then oral antibiotics for four weeks. Inflammatory blood markers were reviewed regularly. Upon removal of the PICC line the tip was sent for microbiological testing.

Results: All 22 children made a full recovery with a minimum of twelve months follow up (range 12–20 months). All PICC line tips were negative for microbiological culture after 48 hours.

Conclusion: Peripheral cannulation for intravenous access in children can be challenging. Younger children have chubby limbs and often fragile veins. Even with the use of topical analgesics the procedure can be traumatic for a young child. A PICC line inserted at the time of the surgical washout of the infected joint seems an ideal solution. PICC lines are safe, reliable and allow for at least two weeks of intravenous access, avoiding the need for regular re-cannulation of children.

Purpose: To alert the Orthopaedic fraternity that smoking needs to be considered in the Paediatric population and highlight it’s adverse effect on bone healing index.

Method: During assessment of Paediatric patients who had undergone limb reconstruction surgery, a sub-population was found to have a prolonged time to consolidation of the regenerate to norm. Screening for contributing factors, we were surprised to learn that this subgroup were active smokers. Revisiting their radiographs, it was felt that the quality of the regenerate appeared to differ from non-smokers.

Results: We identified 12 patients who were active smokers. 2 also had parents who smoked. They all exhibited a prolonged time to regenerate consolidation. We calculated their bone healing indices to compare with non smokers and found significant differences.

Conclusion: Smoking has adverse effects on bone healing in children as well as adults. We have drawn up an advise sheet to make patients and their parents aware of the adverse effects of active and passive smoking on bone healing.

AIM: The purpose of this prospective study was to asses the outcome of antegrade intramedullary wiring of displaced distal end of fifth metacarpal fracture in skeletally immature. Intramedullary wiring for fracture metacarpals have been well described in the literature. Retrograde wiring for neck of metacarpal fractures have been associated with limitation of extension at metacarpo-phalangeal joint due to involvement of gliding extensor mechanism. Foucher described ‘Bouguet’ osteosynthesis with multiple wires for metacarpal neck fracture which can be technically demanding in small bones of children. We describe an antegrade wiring using a single bent K-wire at the tip for reducing and stabilising displaced metacarpal neck fracture by rotating 180 degree after crossing fracture site, a method similar to Methaizeau technique for stabilisation of displaced radial neck fractures using nancy nail.

METHOD: Between 2000 to 2006 we treated 9 boys with displaced distal end of fifth metacarpal fracture +/− rotational deformity of little finger using above technique. All of them had closed injuries and the indication for surgery was rotatory mal-alignment or fracture angulation more than 40 degrees. The assessment involved a clinical and radiological examination. The mean age was 13 years. The mean follow-up was 15 months.

RESULTS: All fractures healed in anatomical alignment. There was no loss of active or passive movement of the little finger metacarpo-phalangeal joint or weakness of grip strength in any children. All children returned to pre-injury activity level within 4–6 weeks. There were no complications.

CONCLUSION: Early results of treating displaced little finger metacarpal neck fracture in children using antegrade intramedullary wire are encouraging.

Aim: Spinal stenosis is a known entity in achondroplasia and a need for screening for the symptomatic children was identified in a tertiary limb reconstruction service. The aim of this study was to evaluate whether clinical and radiological imaging would identify the at risk group.

Materials and methods: 205 achondroplastic children were treated at our service in the last 20 years. A prospective clinical screening programme for spinal stenosis which also included the MRI imaging of entire spine was however introduced only in 1996. 26 patients were available for this study. Case notes were reviewed for clinical symptoms and neurological signs. MR images were assessed for stenosis especially at Cervico medullary junction and lumbar level. Canal diameters were measured at all spinal levels from CMJ to lumbo-sacral junction. Neurosurgical interventions were recorded. An attempt was made to identify high risk factors that required surgical intervention.

Results: Delayed milestones were observed in 7 patients. Positive history of back pain or radicular pain was obtained in 10 whereas 10 patients had symptoms of neurogenic claudication. Brisk reflexes and clonus were consistent findings. Severe foramen magnum narrowing was observed in 23 patients and 13 showed ‘kinking’ or ‘pinching’, suggesting severe compression. Of the 17 patients seen by neurosurgeons 6 required single or multiple surgical decompressions. Ventriculo-peritoneal shunt was inserted in 4. 5 children required CMJ decompression and one required lumbar canal decompression. There was a 7 mm difference in AP diameter measured on MRI at CMJ between the two non operated and operated groups. Female patients with delayed milestones and CMJ narrowing to less than 25 mm were identified as high risk.

Conclusion: The cause of increased morbidity and mortality in young achondroplasts is attributable to severe CM compression. Sudden death can occur by acute or gradual progressive encroachment of respiratory centre at medulla oblongata. We were able to identify symptomatic patients early before developing myelomalacia and cord changes by screening all symptomatic children with achondroplasia. We propose that female gender, especially with delayed milestones as another high risk factor. We stress upon the importance of developing a nationalised selective screening programme with guidelines in specialist orthopaedic and joint multi-disciplinary Skeletal Dysplasia clinics.