Introduction

No published work exists regarding deep vein thrombosis (DVT) and pulmonary embolism (PE) incidence with the elective use of external fixators. The aim of this work was to establish the rate of DVT and PE in such cases to help inform whether thromboprophylaxis guided by risk factors is adequate or if a more aggressive approach is required.

Introduction

Patients undergoing limb reconstruction with the Taylor Spatial Frame (TSF) often perceive that their frame is loose due to the rattle they hear when mobilising. Our aim was to determine how much and where this movement is in the various frame/bone constructs currently on the market.

Aim

To evaluate the results and complications of bone transport in the treatment of massive tibial bone defects, using the Ilizarov method.

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).

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.

Purpose

To document the incidence and nature of complications associated with hemiepiphysiodesis using a screw and plate device (8-plate, Orthofix).

Introduction: Percutaneous epiphyseodesis is a simple method of achieving leg length equality in cases of minor leg length discrepancy, however few studies document its effectiveness. A retrospective study was undertaken to assess this.

Materials and methods: Patient notes and radiographs were reviewed. The growth remaining method was used to estimate timing. Percutaneous epiphyseodesis was performed with a drill and curette under radiological guidance.

Results: A total of 24 skeletally mature patients with a mean preoperative leg length discrepancy (LLD) of 2.8cm were identified. Skeletal age was significantly different from chronological age in 5 of 11 cases where it had been performed. In all patients, there was radiographic evidence of physeal closure soon after epiphyseodesis. At skeletal maturity, 14 patients have a LLD of 0–1cm and are considered to have a satisfactory outcome. 10 patients have a LLD> 2cms. In 6 of these, either presentation was too late or the amount of discrepancy too large for complete correction to be expected. In the other 4, skeletal age assessment may have been useful in 3, and in one additional case of overgrowth of the short limb prior to maturity. A successful outome was more likely when skeletal age assessment had been used (82% versus 57%). Of the 18 cases where there was sufficient time for a full correction to be achieved, the overall success rate was 72%. There were no significant clinical or radiological complications.

Conclusions:

Percutaneous drill epiphyseodesis is an effective method of achieving physeal ablation with no significant complications.

The stability of an external ring fixator using trans-osseous wires is determined by the number of wires per ring, their tension and their configuration. Ideally a crossing angle of 90° in the centre of the bone provides the greatest stability. This is however rarely possible due to the restrictions imposed by safe anatomical corridors. The Taylor Spatial Frame is a hexapod structure which relies on 6 connecting struts attached to fixed tabs on the ring; the Ilizarov system allows connecting rods to be placed in any available spaces.

The aim of this study was to identify differences in wire placement using the TSF compared with the standard Ilizarov ring.

Method: Cross-sectional anatomical diagrams of the tibia were taken from 3 levels. Lines representing wires were drawn crossing at the centre of the bone. The maximum crossing angles for an Ilizarov ring using safe anatomical corridors were calculated. A TSF ring was then superimposed on the image and angles recalculated taking into account impedance caused by the strut tabs. The angles were compared using a Students t-test taking p=0.05 as significant.

Results: The average maximum crossing angle of the Ilizarov wires was 61° compared with 36° for the TSF. At all 3 levels the angles were found to be significantly different (p=0.002).

Discussion: Limitations in the trans-osseous wire placement has implications for construct stability and therefore function. This may force the surgeon to make greater use of half pins, or more wires. We have shown significant differences in pin placement using the TSF which should be taken into consideration when using the system.

Normal acetabular development in developmental dysplasia of the hip (DDH) depends upon early and maintained congruent reduction. Computed tomography is an accepted method for evaluating this and attempts to quantify hip reduction, by various angular and linear measurements, have been reported.

The aim of this study was to assess initial CT scans, following open reduction in the older child with DDH, with comparison of outcome to evaluate prognostic value.

Method: Thirty consecutive patients underwent open reduction for DDH, with a mean age of 25.9 months at the time of operation. Acetabular morphology and the position of the femoral head were evaluated on the initial CT scan, taken on the first postoperative day, and AP pelvic radiograph taken at the latest follow-up.

Results: The acetabulae of the dislocated hips were found to be significantly more anteverted than the normal. The dislocated hips also had significantly increased lateral displacement both initially and at latest follow-up. Posterior displacement of the proximal femoral metaphysis should raise concern due to an association with the need for further surgical intervention. These results did not however correlate with outcome.

In conclusion, despite the significant differences noted between DDH and normal hips they did not predict acetabular development or persistent acetabular dysplasia.

Purpose: Congenital proximal radioulnar synostosis is a rare anomaly of failure of segmentation of the radius and ulna resulting in a fixed rotational position of the forearm from neutral to maximum pronation. Several surgical options have been proposed for the treatment of this condition. We have treated six forearms in five children with pronation deformity using derotational osteotomies of the radius and ulna with postoperative wire stabilisation of the ulna. The surgical technique and results of treatment with this method are presented.

Methods: With this technique, osteotomies were performed at the midshaft of the ulna and the distal diaph-yseal-metaphyseal junction of the radius. The insertion of intramedullary Ilizarov wires facilitated manual derotation of the radius and ulna to a functional position of 100 supination of the forearm. Postoperatively, the forearm was immobilised in a cast for an average of 6.3 weeks and the wire was removed when there was evidence of union. 3 boys and 2 girls with a mean age of 4.9 years underwent surgery with this method and were followed-up for an average of 29 months (range 12 to 43 months).

Results: Forearm position improved from an average pronation deformity of 68.3 degrees to the pre-planned position of 100 degrees supination in all cases. Bone union was achieved in all six forearms by 6.3 weeks. At their most recent follow-up, there was no loss of correction evident in any of the patients. There was one complication, namely haematoma formation at the radial osteotomy site mimicking compartment syndrome and requiring exploration, although no soft tissue compromise was evident.

Conclusion: The principal advantages of this technique include the ease of the surgical approach for the distal radial osteotomy, the longterm maintenance of rotational correction and the need for single wire stabilisation of the ulna only, which in theory reduces the potential risk of implant-related complications. We conclude that this modified forearm derotational osteotomy with wire stabilisation of the ulna alone is a safe and effective method for treating pronation deformity in children with congenital proximal radioulnar synostosis, although vigilance for early soft tissue complications is necessary.

Introduction: A review of the treatment of 33 open fractures in 29 children over the period 1997 to 2002.

Method: Intravenous antibiotics, debridement and wound irrigation was performed prior to skeletal stabilisation incorporating plaster cast immobilisation (4%), K wire fixation (13%), screw fixation (13%), flexible intramedullary nail fixation (13%) and external fixation (57%). Secondary wound closure was undertaken if appropriate at 48 hours. The tibia was involved in 49% of cases with approximately equal distribution of other long bone extremities. Fractures were classified according to Gustilo et al (22% grade I, 26% grade II, 17% grade III and 35% grade IIIb).

Results: The average age was 10 years in 22 boys and 7 girls. Tibial fracture union was an average of 9 weeks in gradeI and II compared with 20 weeks for grade III. The remaining fractures healed at an average of 10 weeks. Non union occurred in one patient (tibia). There was on case of growth arrest of the distal tibia. There were no cases of osteomyelitis.

Discussion: Open fractures in children most often result from high energy trauma. An increase in fracture and soft tissue severity is associated with a delayed union. Physeal injuries require close observation for potential growth arrest.

Aims: To compare the cost of intra-medullary implants used stabilising paediatric diaphyseal fractures with the clinical outcome. Methods: Between March 1994 and August 2001, at two centres, The Womenñs and Childrenñs Hospital, Adelaide, Australia and The Royal London Hospital, London UK 60 children were surgically treated for diaphyseal forearm fractures using Elastic Stable Intramedullary Nails (ESIN) or 2.5mm Kirschner wires. Having established no difference in the clinical outcome or subjective disability of either technique we compared the implant cost directly. Results: The two treatments both resulted in an excellent outcome with all fractures leading to union with no subjective disability. The Kirscner wires cost £3.00 per wire while the ESI Nails cost between £57.50 and £ 113.30 per wire, depending on the dimensions. Conclusions: We were not able to demonstrate any difference in outcome between ESIN and K-Wiring, although the nails do offer theoretical advantages. The cost implications of using the special implant are twenty fold or more, and as the pressures of cost cutting grow, we wonder if theoretical advantage is Òvalue for moneyÒ.

Introduction: The majority of forearm fractures in children can be managed with a plaster cast alone and manipulation under anaesthetic as required. A small number of cases however require surgical intervention. A variety of methods are available but the use of elastic intramedullary nails is becoming the technique of choice.

Method: We present a two-centre study assessing the outcome of either Elastic StabJe Intramedullary Nails (ESIN) or Kirschner wires as the method of fracture stabilisation in diaphyseal forearm fractures of the radius and ulna.

Results: ESIN group: 24 children underwent ESIN fixation. There were 22 boys and 2 girls, mean age 9.4 years (1.4–15.2 years, p=O.ll). Indications for stabilisation included 21 cases for fracture instability (immediate or delayed,) 2 irreducible fractures and 1 open fracture. 14 children underwent surgery on the day they sustained their fracture. The remainder were operated on an average 6.5 days following injury (1–14 days). In the K wire group: 36 children underwent K-wires fixation with 2.5mrn wires. There were 21 boys and 15 girls, mean age 10.6 years (2.2–15.5 years). Indication for stabilisation included 22 cases for fracture instability , 6 irreducible fractures and 8 open fractures. 32 children underwent surgery on the day they sustained their fracture. The remaining 4 patients were operated on the following day.

Conclusions: All fractures united with no resultant subjective disability. The complication rate following K-wires was 16% and that following nail fixation 9%. Loss of forearm rotation was documented in 4 children in the K-wire group and 3 children stabilised with nails. These results confirm an excellent outcome following intramedullary fixation. We have demonstrated no difference in outcome between K-wires and ESIN, although the elastic nails do offer some theoretical advantages.

The purpose of the study was to perform an independent assessment of the results of open reduction and internal fixation (ORIF) on a selected group of displaced intra-articular calcaneal fractures from two centres.

It still remains controversial whether to manage intraarticular calcaneal fractures conservatively or operatively with few long-term results. The identification of patients who may benefit from the procedure is still undecided.

Fifty fractures in 46 patients with a defined significant displacement of an intra-articular fracture of the calcaneum underwent ORIF by one of the two senior authors. Mean age at operation was 46 years and mean follow-up was 44 months. 88% of the injuries were due to a fall from a height. 30% of the patients had contralateral foot/ankle injuries, and 20% of the patients developed a superficial wound infection. The infection rate was significantly higher in patients whose surgery was delayed more than 14 days.

All patients were independently reviewed after a minimum two-year follow-up. A clinical, radiographic and subjective assessment of the outcome was made. The results were correlated to the original fracture type. The mean Atkins score was 88 (out of 100). Bilateral injuries fared worse. Heel pain at follow-up correlated with a poor score. Atkins scores over 90 occurred in 77% of Saunders Type II, 50% in Type III, and 43% in Type IV fractures. 94% returned to work at a mean of 10 months post-injury. Three patients have undergone a subtalar arthrodesis – two for persistent pain and one for a significant malunion. One patient required a flap but there have been no cases of chronic osteomyelitis.

In patients with significantly displaced fractures, ORIF is a worthwhile procedure with 90% of patients satisfied and 94% returning to work. Gross articular comminution does not preclude a good/excellent result if hindfoot alignment is restored. ORIF after fourteen days should be avoided due to the high risk of infection.

The purpose of the study was to perform an independent assessment of the results of open reduction and internal fixation (ORIF) on a selected group of displaced intra-articular calcaneal fractures from two centres.

It still remains controversial whether to manage intraarticular calcaneal fractures conservatively or operatively with few long-term results. The identification of patients who may benefit from the procedure is still undecided.

Fifty fractures in 46 patients with a defined significant displacement of an intra-articular fracture of the calcaneum underwent ORIF by one of the two senior authors. Mean age at operation was 46 years and mean follow-up was 44 months. 88% of the injuries were due to a fall from a height. 30% of the patients had contralateral foot/ankle injuries, and 20% of the patients developed a superficial wound infection. The infection rate was significantly higher in patients whose surgery was delayed more than 14 days.

All patients were independently reviewed after a minimum two-year follow-up. A clinical, radiographic and subjective assessment of the outcome was made. The results were correlated to the original fracture type. The mean Atkins score was 88 (out of 100). Bilateral injuries fared worse. Heel pain at follow-up correlated with a poor score. Atkins scores over 90 occurred in 77% of Saunders Type II, 50% in Type III, and 43% in Type IV fractures. 94% returned to work at a mean of 10 months post-injury. Three patients have undergone a subtalar arthrodesis – two for persistent pain and one for a significant malunion. One patient required a flap but there have been no cases of chronic osteomyelitis.

In patients with significantly displaced fractures, ORIF is a worthwhile procedure with 90% of patients satisfied and 94% returning to work. Gross articular comminution does not preclude a good/excellent result if hindfoot alignment is restored. ORIF after fourteen days should be avoided due to the high risk of infection.