Introduction

Metabolic bone disease encompasses disorders of bone mineralization, abnormal matrix formation or deposition and alteration in osteoblastic and osteoclastic activity. In the paediatric cohort, patients with metabolic bone disease present with pain, fractures and deformities. The aim was to evaluate the use of lateral entry rigid intramedullary nailing in lower limbs in children and adolescents.

The aim of the study was to review the effectiveness of rigid IM nailing in stabilisation and deformity correction of lower limb long bones in adolescents with metabolic bone disease which to our knowledge has not been studied before.

Medical records and radiographs were retrospectively reviewed looking at indications, deformity correction, number of osteotomies-if needed, bone healing, time to healing and incidence of complications.

Between Aug 2010 and Mar 2015 fifteen patients (24 segments) had rigid IM nailing. Ten patients had Osteogenesis Imperfecta, four with McCune Albright syndrome and one with hypophosphatemic rickets. 22 femora and two tibiae were IM nailed. The mean age of the patients was 13.1 (9.6–16.75 years). Eleven out 24 segments were previously rodded. Eight segments were for acute fractures. 13 bones had significant deformities requiring corrective osteotomies. One patient had previous fracture non union.

All patients were allowed to partial weight bear immediately postoperatively and were fully mobile six weeks following surgery. Mean follow up was 24 months (3–51 months) post-operatively. All deformities were corrected. All fractures and osteotomies radiologically united.

Mean radiological union time was 5.5 months (6 weeks – 11 months). Patients with acute fractures had mean radiological union time of 4 months. Patients who had osteotomies had a mean radiological union time of 7.1 months. The patient with previous non union had BMP at the same time and radiologically healed in 10 months. Two patients had persistent bisphosphonate osteotomy lines but were asymptomatic. One patient had removal of a prominent distal locking screw and one had persistent Trendelenburg gait.

Rigid intramedullary nailing is effective in stabilisation and deformity correction of long bones in adolescent patients with brittle bone disease. The technique has a low complication rate. We recommend the use of this technique in paediatric limb reconstruction in managing metabolic bone conditions.

Femoral head deformity can be a devastating outcome in a small percentage of patients with Perthes' disease. Deformities usually start during the fragmentation stage. In this study, we aimed to determine the effects of Vitamin D deficiency on the natural history of Perthes' disease.

Patients with Perthes' disease and Vitamin D deficiency presenting to our unit in the last 3 years were identified. All X-rays were reviewed retrospectively to determine the duration of the fragmentation and ossification stages. Treatment methods were obtained from the notes. Late presenters (i.e. after fragmentation stage) were excluded.

In our unit, Vitamin D deficiency is diagnosed if levels <72 nmol/L. Fifteen patients (17 hips) with Perthes' disease were found to be Vitamin D deficient. Levels ranged from (18–71 nmol/L). The mean length of the fragmentation stage was 15.7 months which is significantly higher than quoted literature figures (8 months). Ossification stage duration was 18.8 months which was comparable to quoted figures. However, patients with severe Vitamin D deficiency (< 52 nmol/L) were found to have longer ossification stage (20.6 months) compared with patients with mild deficiency (52–72 nmol/L) (16.4 months). Seven out of 16 patients (44%) required surgical containment which is significantly higher than the usually low rates of surgical intervention.

The critical fragmentation stage in Vitamin D deficiency is significantly longer putting the femoral head at higher risk of deformity and extrusion. This leads to higher rates of surgical containment. Also the severity of Vitamin D deficiency might be an important determinant of the period of time required for ossification and healing.

Vitamin D level is an important prognostic factor and must be measured in all patients with Perthes' disease. Prescribing Vitamin D supplements is advisable in this group of patients. However, the effects of these supplements on the course of the disease requires further research.

Level of evidence: III

Unicompartmental knee arthroplasty remains controversial in some quarters and has been subject to recent negative press. The aim of the present study was to determine the differences in pre-operative status and early post-operative improvement between patients having unicompartmental knee Replacement (UKR) and Total Knee Replacement (TKR).

Methods: A Prospective study. Ethical approval was obtained prior to the study. Patients undergoing knee arthroplasty by two orthopaedic surgeons were included. Decision to proceed to unicompartmental or total knee replacement was at the surgeons’ discretion and was not randomised. The Oxford and the Ameri-can Knee Society scores were used to assess outcome. (Oxford score was used as a 0–48 scale; 0 being better and 48 worse). Scores were documented pre-operatively and at six weeks post-operatively.

Results: 104 patients were included in the study. 84 patients had TKR and 20 patients had UKR. Patients under going TKR had significantly worse Oxford, knee and function scores pre-operatively (32.2, 29.2 and 39.6) as compared with the UKR patients (28.5, 40.5 and 46.7) (P= 0.03, 0.001 and 0.026 respectively). TKR was associated with greater improvements in Oxford (P= 0.025), knee (P=0.0.027) and function (p=0.06) scores. However, the post operative scores were comparable; 20.4, 78.9 and 58.7 for TKR and 20.7, 80.9 and 57.9 for UKR.

Conclusions: It could perhaps be expected that patients with unicompartmental disease would have better pre-operative knee status than patients with more advanced multicompartmental disease. It is therefore understandable that patients receiving total knee replacements are able to improve more post-operatively than those receiving unicompartmental devices. Unicompartmental knees achieve only marginal initial superiority in terms of knee scores at 6 weeks follow-up. This is important and if clinical superiority and prosthesis longevity are not proven at longer term follow-up it would question the use of unicompartmental arthroplasty.

Aims: To establish whether pre-existing anxiety and depression negatively impacts symptomatic and functional outcome of knee arthroplasty.

Methodology: A prospective study. Ethical approval was obtained prior to the study. Psychological status was assessed using the Hospital Anxiety and Depression Scale; a validated self-assessment tool for detecting anxiety and depression. The Oxford and the American Knee society scores were used to assess the knee status. All scores were documented pre-operatively and at six weeks post-operatively. Results were submitted for independent statistical analysis.

Results: 105 consecutive primary knee replacements were included in the study. 39% (41 patients) had abnormal pre-operative anxiety states. This percentage dropped to 28.2% (29 patients) post-operatively (P=0.034). 25.7% (27 patients) had abnormal pre-operative depression states which improved to 15.5% (16 patients) post-operatively (P=0.011). There were high degrees of correlation between abnormal anxiety and depression states both pre-operatively (P< 0.001) and post-operatively (P< 0.001). Patients with abnormal anxiety pre-operatively had worse knee scores both pre-operatively (P=0.17) and post-operatively (P=0.009) than those who did not. Patients with abnormal depression pre-operatively had worse pre-operative Oxford scores (P=0.036), and worse Oxford (p=0.006) and AKSS knee scores post-operatively (0.043).

Conclusions: Abnormal anxiety and depression states are common in patients with knee arthritis presenting for knee arthroplasty. These conditions can improve post-operatively. Patients with abnormal pre-operative anxiety and depression do less well following knee arthroplasty than those who do not. Pre-operative psychological assessment is easy to perform and does act as a predictor of early outcome. Further research is needed to assess whether treating these psychological conditions prior to knee arthroplasty improves the outcome or not.

The study aims to determine the effects of obesity on the patients’ symptoms and their knee function before knee arthroplasty, as well as their states of anxiety and depression.

Ethical approval was obtained before the start of the study. Weights and heights of all patients were measured and BMI calculated on admission. Anxiety and depression states were recorded using the Hospital Anxiety and Depression Scale (HADS). The severity of pain and loss of function of the knees undergoing arthroplasty was measured using the Oxford Knee Score and the American Knee Society Score. All scores were measured per-op and again at 6 weeks post-op.

To date, 28 patients were included. The mean body mass index was 28.9. Only six patients had a BMI of < 25. Patients with normal BMI (< 25) had mean anxiety and depression scores of 6.8 and 5.67 respectively. Overweight patients (BMI > 25) had scores of 5.59 and 4.9 respectively. Patients with BMI > 30 had scores of 6.71 (p= 0.22) and 7.0 (p= 0.04) respectively.

Patients with BMI > 30 had an improvement in anxiety scores of 1.33 points compared with 0.55 for patients with BMI < 30 (p= 0.3). Depression scores improved by 4 points in the BMI > 30 group compared with 0.67 in the BMI < 30 group (p= 0.03).

Improvements in the knee scores were comparable in both groups.

Obese patients with BMI of > 30 have higher rates of anxiety and depression pre-operatively. At 6 weeks follow up, there is an improvement in both measures of psychological distress but this is more pronounced for depressive symptoms.