To determine the advantages and risks of plating after lengthening (PAL) of tibia in children and adolescents 35 consecutive tibial lengthenings were done for limb length discrepancy (LLD) in 26 patients. Gradual lengthening by an external fixator from a tibial (usually diaphyseal) osteotomy was followed by internal fixation with a lateral tibial submuscular plate. The mean age at the time of the lengthening was 10.3 years (4.8 – 16.8 years). The aetiology for LLD was congenital in 21, acquired in 3, and developmental in 2 patients. The mean follow-up was 4.3 years (8 months – 9.9 years).Introduction
Materials and Methods
Femoral shaft fractures in children is a serious injury that needs hospitalization, with a high prevalence in the age group 6–8 years old. Various treatment options are available and with a comparable weight of evidence. Submuscular plating provides a dependable solution, especially in length-unstable fractures and heavier kids. We present a novel technique to facilitate and control the reduction intraoperatively, which would allow for easier submuscular plate application. We have retrospectively reviewed four boys and three girls; all were operated in one centre. Polyaxial clamps and rods were applied to the sagittally-oriented bone screws, the reduction was done manually, and the clamps were tightened after achieving the proper alignment in the anteroposterior and lateral fluoroscopy views. The submuscular plate was applied as described, then clamps and bone screws were removed.Introduction
Materials and Methods
The optimal treatment of segmental tibial fractures (STF) is controversial. Intramedullary nailing (IMN) and external fixation (EF) have unique benefits and complications. To compare outcomes for AO/OTA 42C2 and 42C3 fractures treated using IMN with those treated using EF in a University Teaching Hospital.Background
Aim
Temporary hemiepiphysiodesis using 8 plate guided growth has gained widespread acceptance for the treatment of paediatric angular deformities. This study aims to look at outcomes of coronal lower limb deformities corrected using temporary hemiepiphysiodesis over an extended period of follow up. A retrospective analysis was undertaken of 56 children (92 legs) with coronal plane deformities around the knee which were treated with an extraperiosteal 2 holed titanium plate and screws between 2007 and 2015. Pre and post-op long leg radiographs and clinic letters were reviewed.Background
Methods
The aim of this double-blind prospective randomised controlled
trial was to assess whether low intensity pulsed ultrasound (LIPUS)
accelerated or enhanced the rate of bone healing in adult patients
undergoing distraction osteogenesis. A total of 62 adult patients undergoing limb lengthening or bone
transport by distraction osteogenesis were randomised to treatment
with either an active (n = 32) or a placebo (n = 30) ultrasound
device. A standardised corticotomy was performed in the proximal
tibial metaphysis and a circular Ilizarov frame was used in all
patients. The rate of distraction was also standardised. The primary
outcome measure was the time to removal of the frame after adjusting
for the length of distraction in days/cm for both the per protocol
(PP) and the intention-to-treat (ITT) groups. The assessor was blinded
to the form of treatment. A secondary outcome was to identify covariates affecting
the time to removal of the frame.Aims
Patients and Methods
The outcomes of open tibial fractures in a paediatric population are reported. A retrospective analysis of consecutive cases, classified by the Gustilo-Anderson system, over the last 8 years was undertaken. The outcomes recorded were time to union, non-union, infection rates and re-operation rates.Background:
Methods:
To assess efficacy of pulsed ultrasound for accelerating regenerate consolidation. A multicentre two arm patient and assessor double blind RCTObjective:
Design:
Calcium sulphate (CaSO4) is a recognised form of delivery of antibiotic for the treatment of bone infection. Complications inherent in the rapid reabsorption are well recognised (predominantly that of wound breakdown and leakage). There is little data on the frequency of these complications. The purpose of this study was to quantify the incidence of wound leakage from CaSO4 and the service impact in orthopaedic surgery. Infective limb reconstruction cases managed with gentamicin impregnated CaSO4 between 2004–2012 were identified. Co-morbidities and factors influencing wound leakage were recorded. Medical and wound care notes were analysed. Episodes of delayed discharge and unscheduled clinic attendance due to wound leakage were recorded. 80 patients (18 female, 62 male), with a mean age of 45 years (18–80 years, median 46 years) underwent 84 procedures utilising CaSO4. 47 were in the tibia, 14 in the femur, 10 in the humerus. A mean of 36 mL (4–150 mL, median 22 ml, unknown in 18 cases) was used. 31 cases (37%) had post-operative wound leakage, the majority from the tibia(55%) and femur(25%). 21 cases (25%) leaked within the first week. Each 10 ml rise in CaSO4 volume lead to a 50% rise in leakage incidence. Leak duration ranged from 4 days–10 months. The majority leaked between 1–4 months before ceasing spontaneously and without specific treatment. 14 cases (17%) required a cumulative 32 unscheduled clinic appointments for leakage. Further surgery was required for infection in 7 cases (8.3%). Delayed discharge was not clearly attributable to CaSO4. The mode of skin closure and cultured organism did not affect leakage. CaSO4 has unpredictable leakage, but is present in 1/3 of patients. Volume of CaSO4 impacts on leakage. Leakage usually self-resolves and does not clearly impact on final outcomes. The cost impact of ongoing wound care and additional clinic appointments may be substantial.
The purpose of this study is to report a unique overgrowth syndrome and discuss the insights into the complex orthopaedic management. Written consent to report this case was granted. The patient's condition, wrongly diagnosed as Proteus syndrome, is characterised by a genetic mutation in PIK3CA, a critical regulator of cell growth. This lead to unregulated cellular division of fibroblasts isolated to the lower limbs. The legs weighed 117 kg, with a circumference of >110 cm. In addition to lower limb overgrowth, numerous musculoskeletal and organ pathologies have been encountered since birth requiring treatment from a wide variety of healthcare specialists and basic scientists. At 32 years, the patient developed septicaemia secondary to an infected foot ulcer. Amputation had been discussed in the elective setting, however the presence of sepsis expedited surgery. The above knee amputation took 9 hours and four assistants including a plastic surgeon. A difficult dissection revealed a deep subcutaneous fatty layer that integrated with deep muscle, massive hypertrophy of cutaneous nerves and the sciatic nerve and ossification within the distal quarter of the quadriceps muscles requiring osteotomy. The lower limb osteology was grossly aberrant. The size of the amputated limb did not permit use of a tourniquet and cell salvage reintroduced 10.5 litres of blood with a further 6 units of red cells intra-operatively. The leg stump successfully took to a split-skin graft. A unique phenomenon was witnessed post-operatively whereby the stump continued to grow due to upregulation of fibroblasts secondary to trauma. Targeted genetic therapies have been successfully developed to suppress this stump growth. This unique and unclassified overgrowth syndrome was caused by a mutation in the PIK3CA gene. Orthopaedic management of the oversized limb was complex requiring multiple surgeons and prolonged general anesthetic. A multi-disciplinary approach to this condition is required for optimizing outcomes in these patients.
The purpose of this study was to investigate the usefulness of PET-CT in the diagnosis and treatment of long bone infections following trauma. All patients referred to the limb reconstruction service for management of non-unions were treated by the same protocol. PET-CT with FDG was performed in all patients to assess if the non-union site was infected and if so, the extent of the infection. Those requiring operative management were treated in a 2-stage manner. Initially with debridement based on PET-CT; sampling for microbiology and histology; and then Teicoplanin and Ciprofloxacin. If samples were positive then the patients were treated for a total of 6 weeks with antibiotics based on microbiology advice before undergoing definitive fixation. The sensitivity, specificity, PPV, and NPV were then calculated for PET-CTs ability to predict presence of infection using extended cultures and histology as the gold standard. 38 consecutive patients underwent surgery, 24 male and 14 female. 24 were deemed infected on extended culture or histology. PET-CT was anecdotally found to be extremely useful at determining the extent of infection to plan debridement. PPV 0.83 NPV 0.89 Sensitivity 0.96 Specificity 0.61 As well as providing unique ability to demarcate areas of bony infection in the presence of metalwork, the ability to detect or exclude infection was exceptional. This is a test, however, which is operator dependent and requires a skilled Nuclear Radiology Consultant to accurately interpret images. In our relatively small pilot study the accuracy improved noticeably over one year. PET-CT has potential to be a powerful tool in the diagnosis and treatment of long bone infection following trauma and certainly warrants further investigation.
We describe the technique and results of medial
submuscular plating of the femur in paediatric patients and discuss its
indications and limitations. Specifically, the technique is used
as part of a plate-after-lengthening strategy, where the period
of external fixation is reduced and the plate introduced by avoiding
direct contact with the lateral entry wounds of the external fixator
pins. The technique emphasises that vastus medialis is interposed
between the plate and the vascular structures. A total of 16 patients (11 male and five female, mean age 9.6
years (5 to 17)), had medial submuscular plating of the femur. All
underwent distraction osteogenesis of the femur with a mean lengthening
of 4.99 cm (3.2 to 12) prior to plating. All patients achieved consolidation
of the regenerate without deformity. The mean follow-up was 10.5 months
(7 to 15) after plating for those with plates still Placing the plate on the medial side is advantageous when the
external fixator is present on the lateral side, and is biomechanically
optimal in the presence of a femoral defect. We conclude that medial
femoral submuscular plating is a useful technique for specific indications
and can be performed safely with a prior understanding of the regional
anatomy. Cite this article:
To determine whether the amount of fibula resection in fibula osteotomy influences outcome in deformity correction surgery. Retrospective case note and imaging review was performed on a cohort of 45 patients from November 2005 to July 2009 treated with lengthening and/or correction for leg deformity in either an adult or paediatric limb reconstruction centre. Method, extent and level of original fibular resection was recorded, as well as type of fixator, distraction regime and total gap at osteotomy site after distraction. Outcome was measured as premature, expected or non-union and subsequent need for reintervention.Statement of purpose
Methods
To assess safety, lengths gained, frame time and perform cost analysis of the technique of submuscular plating to the femur and tibia following distraction osteogenesis. Since 2005 we have performed submuscular plating to the femur and tibia after distraction osteogenesis in order to shorten time in external fixator.Purposes of the study
Introduction
Tension band epiphysiodesis for lower limb length discrepancy in children Planned physeal growth arrest (epiphysiodesis) for the treatment of limb length discrepancy (LLD) in growing children is a well described treatment modality in the literature. We describe our experience of temporary epiphysiodesis using a tension band technique with the “8-plate” in the treatment of LLD in growing children. The main objective of this study was to confirm whether bilateral 8-plates achieve an epiphysiodesis or not?Background
Aim
Since 2005 we have performed submuscular plating to the femur and tibia after distraction osteogenesis in selected cases in order to shorten the time in external fixator. The aim was to assess safety, lengths gained, frame time and perform cost analysis Retrospective analysis using notes and digital radiographs, with cost codes for 2011 prices. 23 patients (14 male), mean age 11 (range 4 to 17) were analysed. 14 were diagnosed as congenital longitudinal deficiency. Total 37 bones lengthened (14 femur and tibia, 7 tibia only, 2 femur only). Ilizarov fixator most commonly used for tibia, LRS fixator for femur.Aims
Methods
The purpose of the study was to assess the outcomes of the surgical management of humeral shaft non-unions. Between 2002 and 2010, 23 patients with humeral shaft non-unions underwent revision surgery. Nine were initially treated non-operatively, 11 with a plate, 1 with screws and 2 with an intramedullary nail. In previously operated patients with aseptic non-unions single stage revision was performed, while septic non-unions underwent a two stage revision. Revision stabilisation was by single or double plate fixation +/− external fixator, depending on bone loss and bone quality. Augmentation of fixation was with iliac crest bone graft in all cases. Data collected from the case notes and radiographs included: smoking habits, type and site of non-union, bone loss, infected or not, organism isolated, definitive stabilisation, augmentation used, post operative complications, further surgical interventions and time to radiological union.Aim
Method
The treatment of chronic osteomyelitis involves a debridement of affected non-viable tissue and the use of antibiotics. Where surgery leaves a cavity, dead space management is practised with antibiotic impregnated cement. These depots of local antibiotics are variable in elution properties and need removal. We review the use of bioabsorbable synthetic calcium sulphate as a carrier of gentamicin and as an adjunct in treating intramedullary osteomyelitis. A retrospective review of cases treated consecutively from 2006 to 2010 was undertaken. Variables recorded included aetiology, previous interventions, diagnostic criteria, radiological features, serology and microbiology. The Cierney-Mader system was used to classify. Treatment involved removal of implants (if any), intramedullary debridement and local resection (if needed), lavage and instillation of the gentamicin carrier, supplemented with systemic antibiotics. Follow-up involved a survival analysis to time to recurrence, clinical and functional assessment (AOFAS-Ankle/IOWA knee/Oxford Hip) and general health outcome (SF36).Introduction
Methods
The treatment of chronic osteomyelitis involves a debridement of affected non-viable tissue and the use of antibiotics. Where surgery leaves a cavity, dead space management is practised with antibiotic impregnated cement. These depots of local antibiotics are variable in elution properties and need removal. We review the use of bioabsorbable synthetic calcium sulphate as a carrier of gentamicin and as an adjunct in treating intramedullary osteomyelitis. A retrospective review of cases treated consecutively from 2006 to 2010 in the Royal Liverpool University Hospital was undertaken. Variables recorded included aetiology, previous interventions, diagnostic criteria, radiological features, serology and microbiology. The Cierney-Mader system was used to classify. Treatment involved removal of implants (if any), intramedullary debridement and local resection (if needed), lavage and instillation of the gentamicin carrier, supplemented with systemic antibiotics. Follow-up involved a survival analysis to time to recurrence, clinical and functional assessment (AOFAS-Ankle/IOWA knee/Oxford Hip) and general health outcome (SF36). There were 31 patients (22 male, 9 female). The mean age was 47 years (20-67). Twenty-five cases were post-surgery (6 open fractures) and 6 were haematogenous in origin. The median duration of osteomyelitis was 1.6yrs. The bones affected were 42% femur, 45% tibia, 3% radius and 10% humerus. 11 cases had diffuse as well as intramedullary involvement. 9 cases underwent segment resection and bone transport. We identified Staphylococcus Aureus in 16 and Coagulase Negative Staphylococcus in 6 cases. The median follow-up was 1.7 years (0.5-5.6). The median scores attained were: AOFAS-78, DASH-32, IOWA-71, Oxford-32. There were two recurrences. Dead space management of intramedullary infections is difficult. We describe a method for delivery of local antibiotics and provide early evidence to its efficacy. The treatment success to date is 93%. Bioabsorbable carriers of antibiotics are efficacious adjuncts to surgical treatment of intramedullary osteomyelitis.
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.
The threshold for decompression in acute compartment syndrome is quoted as a pressure difference between the compartment and diastolic blood pressure of less than 30mmHg. This study reports the findings of continuous compartment pressure monitoring in children who underwent tibial osteotomies. In this prospective observational study, twenty seven children who underwent tibial osteotomies had anterior compartment pressures monitored using a transducer-tipped probe for a minimum of 72 hours following surgery. Pressure data were collected hourly together with evidence of clinical signs, symptoms and patterns of analgesic use. Patients were also reviewed for late sequelae of compartment syndrome. One case of compartment syndrome were encountered. Pressure differences (diastolic BP - compartment pressure) were found to vary widely, with many children exceeding the threshold for decompression but without manifesting other signs of compartment syndrome. Fasciotomies were not performed in view of the conflicting evidence and subsequent review confirmed the absence of late sequelae. In these children, low diastolic blood pressures were a common but normal feature. The prevalence of compartment syndrome was 3.7% (1/27). The positive predictive value of using the adult threshold was 7.1%; the negative predictive value was 100%. We conclude that the threshold for decompression as applied to adults is unsuitable for use in children inasmuch as a positive result would lead to a correct diagnosis in only 7.1% of children. A negative test is more useful in correctly excluding compartment syndrome in 100% of the children studied.
This study sought to determine if treatment of resistant clubfeet by the Ilizarov method influenced the pattern of recurrence. Forty-seven children were identified as having undergone treatment by the Ilizarov method. Inclusion criteria for treatment with the Ilizarov method were clubfeet belonging to diagnostic categories that had recognised tendencies for resistance to standard methods of clubfoot management or a previous history of soft tissue releases performed adequately but accompanied by rapid relapse. There were 60 feet with a mean follow-up of 133 months (46-224). Diagnoses included 34 idiopathic types, 7 arthrogryposis, 1 cerebral palsy, and 5 other. Summary statistics and survival analysis was used; failure was deemed as a recurrence of fixed deformity necessitating further correction. This definition parallels clinical practice where attainment of ‘normal’ feet in this group remains elusive, and mild to moderate relapses that remain passively correctable are kept under observation. Soft tissue releases were common primary or secondary procedures. The mean time to revision surgery, if a soft tissue release was undertaken as a primary procedure, was 36 months (SD 22), and 39 (SD 23) months if undertaken for the second time. This compares with 52 months (SD 32) if Ilizarov surgery was used. Using survival analysis, there is a 50% chance of a relapse sufficiently marked to need corrective surgery after 44 months following the first soft tissue release, 47 months if after the second soft tissue procedure and 120 months after the Ilizarov technique. We conclude that resistant club feet, defined as those belonging to diagnostic categories with known poor prognoses or those that succumb to an early relapse despite adequate soft tissue surgery, may have longer relapse-free intervals if treated by the Ilizarov method.
To assess outcomes following a radical approach to cases of compartment syndrome in which a significant degree of muscle necrosis is found, 4 paediatric and adolescent patients with a delayed diagnosis of compartment syndrome in which muscle necrosis in single or multiple compartments were treated by radical debridement of necrotic tissue and reconstruction of the anterior compartment through transfer of peroneus brevis to extensor digitorum and hallucis longus tendons. Where suitable, a free vascularised and innervated gracilis muscle transfer to the tibialis anterior tendon stump was carried out with anastomosis of the nerve to gracilis to the deep peroneal nerve. Free gracilis muscle transfer was functional in one of the two patients whilst peroneus brevis transfer to extensor digitorum and hallucis tendons was functional in all three patients. In one patient, radical debridement resulted in loss of the entire anterior compartment requiring permanent ankle foot orthosis. All others had recovery of protective foot sensation and at minimum follow-up of 12 months were walking unaided. Infection was not seen in any patient. Prompt fasciotomy, debridement and reconstruction for late diagnosis of compartment syndrome proved limb-saving in our patients.
Gradual correction of periarticular deformities has necessitated the application of external fixators to accomplish the task. By contrast, such deformities when treated by acute correction are most often stabilised using internal fixation. Hemi-epiphyseal arrest, by stapling or transphyseal screw is a disadvantage by being an irreversible process which has to be delayed until later childhood. This study describes the preliminary results of using an alternative internal device which corrects angular deformity by acting as a tension band on one side of the growth plate. Twenty nine consecutive patients with significant coronal plane deformities in the lower limb were treated using the guided growth technique. This was accomplished through the extra-periosteal application of a 2-hole plate and screws (the 8-plate, Orthofix SRL, Verona). The plate was left in-situ and the patient monitored at regular intervals until the desired correction of the mechanical axis was accomplished. Plate removal was undertaken if the child was not skeletally mature at completion of treatment. Eighteen males and 11 females completed treatment and had their plates removed. The age of patients ranged from 5 to 14 years (average 11.5 years). There were 23 patients with genu valgum deformity with an average deformity of 9.8 degrees, and 6 patients with genu varum deformity with an average deformity of 29.9 degrees. The follow up period averaged 12.5 months from plate removal. The average duration of correction was 15.8 months. The overall rate of correction was 0.87 degrees per month. Two complications were recorded: plate migration in one patient and deep infection in another patient. We had one case of rebound deformity. The guided growth technique using the 8-plate is a simple and safe procedure for the treatment of lower limb angular deformity which produces temporary physeal arrest.
Fibular hemimelia is associated with equinovalgus deformity of the ankle and hind foot and antero-medial bowing of tibia. A wedge shaped distal epiphysis of the tibia and tight posterolateral soft tissues play an important role in the pathogenesis of ankle valgus and lateral subluxation of foot. Tethering effect of fibular anlage may contribute to the deformities in the tibia and ankle. Lengthening procedures are associated with progression of these deformities. The purpose of this study is to determine whether Exner Osteotomy and Excision of Fibular anlage will correct the valgus deformity of the ankle and antero-medial bowing of tibia. A bending osteotomy through the distal tibial physis as described by Exner and excision of Fibular Anlage was performed in six limbs in five children (4 boys, 1 girl) with fibular hemimelia. Histology of Excised Fibular anlage was studied under light microscopy. The mean age at the time of surgery was twenty two months (range: 8 months to 5 years). The mean follow-up was two years and two months (13 months to 4 years and 8 months). Full Correction of ankle valgus and tibial bowing was achieved in three feet where, a cortical strut graft was used in the open wedge osteotomy. In two feet synthetic bone substitute was used. In these, tibial bowing corrected but slight ankle valgus remained. In one foot where synthetic bone substitute was used and the postoperative compliance with AFO was poor, bowing of tibia improved but ankle valgus recurred. Premature fusion of growth plate did not occur in any of the cases. Histology of fibular anlage showed replacement of bone tissue by mature collagen bundles surrounded by fibroconnective tissue. Exner Osteotomy and Excision of Fibular Anlage in Fibular Hemimelia corrects the ankle valgus and antero-medial bowing of tibia.
Sub-muscular plating is an established technique in the management of long-bone fractures and reconstruction. In the femur, the presence of the vascular structures medially favours the lateral approach and as such, the technique of medial femoral sub-muscular plating has not, to the authors knowledge, been previously described. We report a series of 5 patients employing the medial approach to femoral sub-muscular plating. The indications and limitations of the technique are discussed with particular reference to reducing external fixation times, avoidance of stress risers and areas of previously traumatised or infected tissues. The surgical technique for medial femoral sub-muscular plating with emphasis on the role of vastus medialis in the protection of the vascular structures, together with cross sectional anatomy is described. Medial femoral sub-muscular plating is a useful technique in specific indications and can be performed safely with an understanding of the relevant anatomy.
We present the results of a series of 9 consecutive patients with subtrochanteric non-unions treated by double plates.
One patient with liver cirrhosis died 5 days postoperatively. Two patients are currently 8 weeks post surgery. All the others healed in a mean of 5.1 months (range 4–6 months). Two patients underwent distal femoral lengthening to compensate for bone loss.
We believe that double plating neutralizes all the forces around the proximal femur, providing the best mechanical environment. Given the limits of the small numbers and the retrospective nature of the study, we believe that this method of treatment offers a sound surgical strategy, reflected by our success rate.
We have carried out a retrospective review of 20 patients with segmental fractures of the tibia who had been treated by circular external fixation. We describe the heterogeneity of these fractures, their association with multiple injuries and the need for multilevel stability with the least compromise of the biology of the fracture segments. The assessment of outcome included union, complications, the measurement of the functional IOWA knee and ankle scores and the general health status (Short-form 36). The mean time to union was 21.7 weeks (12.8 to 31), with no difference being observed between proximal and distal levels of fracture. Complications were encountered in four patients. Two had nonunion at the distal level, one a wire-related infection which required further surgery and another shortening of 15 mm with 8° of valgus which was clinically insignificant. The functional scores for the knee and ankle were good to excellent, but the physical component score of the short-form 36 was lower than the population norm. This may be explained by the presence of multiple injuries affecting the overall score.
A total of 25 children (37 legs and 51 segments) with coronal plane deformities around the knee were treated with the extraperiosteal application of a flexible two-hole plate and screws. The mean age was 11.6 years (5.5 to 14.9), the median angle of deformity treated was 8.3° and mean time for correction was 16.1 months (7 to 37.3). There was a mean rate of correction of 0.7° per month in the femur (0.3° to 1.5°), 0.5° per month in the tibia (0.1° to 0.9°) and 1.2° per month (0.1° to 2.2°) if femur and tibia were treated concurrently. Correction was faster if the child was under 10 years of age (p = 0.05). The patients were reviewed between six and 32 months after plate removal. One child had a rebound deformity but no permanent physeal tethers were encountered. The guided growth technique, as performed using a flexible titanium plate, is simple and safe for treating periarticular deformities of the leg.
Two protocols for the operative technique and care of the pin-site with external fixation were compared prospectively. There was a total of 120 patients with 46 in group A and 74 in group B. Infection was defined as an episode of pain or inflammation at a pin site, accompanied by a discharge which was either positive on bacterial culture or responded to a course of antibiotics. Patients in group B had a lower proportion of infected pin sites (p = 0.003) and the time to the first episode of infection was longer (p <
0.001). The risk of pin-site infection is lower if attention is paid to avoiding thermal injury and local formation of haematoma during surgery and if after-care includes the use of an alcoholic antiseptic and occlusive pressure dressings.
This study has evaluated the results of plantar fascia release through a plantar incision. Materials and Methods A 4cm curved incision on the plantar surface of the heel, was used to release the plantar fascia in children. The incision allowed complete visualisation of the entire origin of the plantar fascia. The procedure was performed as part of treatment for pes cavus or resistant clubfoot. There were 27 feet in 17 patients. The ages ranged from three to sixteen years. The minimum follow up was six months after surgery. The wound was assessed for pain, numbness, and problem scarring as well as heel pad symptoms. A modified functional score was used. (American Orthopaedic Foot and Ankle Society Ankle/ Hindfoot Scale)
All wounds healed within two weeks. The scar was clearly visible in seven patients, and visible only on close inspection in 10 patients. None had heel tenderness, hypersensitivity or numbness and there were no signs of pad atrophy. Fifteen patients had no pain, while two had minimal pain score of two on the visual analogue scale. The functional score was more than 90. All the patients were satisfied with the cosmetic appearance of the scar.
The plantar incision is safe, effective and provides excellent visualisation of the plantar fascia for complete release with minimal morbidity.