Legg-Calve-Perthes (Perthes Disease) was first recognised by three physicians, Arthur Legg (1874–1939), Jacqui Calve (1875–1954) and George Perthes (1869 – 1927) in 1910. Perthes disease is a rare childhood condition that affects the hip. It occurs when the blood supply to the femoral head is disrupted. Without this blood supply, the bone cells die and avascular necrosis can occur. The Herring classification is used to diagnose the stages of Perthes Disease. It is an important prognostic factor. There are three classifications, Herring A, B and C. Herring A has no involvement of the lateral pillar with no density changes noted on x-ray. Herring B has at least 50% of the lateral pillar height maintained on x-ray. Herring C has less than 50% of the lateral pillar height on x-ray (Herring et al, 1992). Children with Perthes disease require specialist Limb Reconstruction team throughout their treatment journey, this includes Orthopaedic surgery and therapy (Physiotherapy and Occupational Therapy). The National Limb Reconstruction Therapy Team is based at the National Orthopaedic Hospital, Cappagh. The therapy team consists of 1 Clinical Specialist Physiotherapist, 1 Senior Physiotherapist and 1 Senior Occupational Therapist who provide input to this cohort. This study aims to analyse the importance of a comprehensive pre-operative assessment by the therapy team (Physiotherapist and Occupational Therapist) to maximise patient outcomes post operatively. This is a quantitative research study conducted by the National Limb Reconstructive Therapy Service of the National Orthopaedic Hospital in Cappagh, Dublin. The inclusion criteria for this study consisted of:
Age – Patient must be part of the Paediatric Service, i.e., under the age of 16. Diagnosis – Patient must have a diagnosis of Perthes Disease with a Herring Classification documented. Application of a Hip Distractor Frame formed part of the patient's surgical management. Surgery was completed by Mr Connor Green. Surgery was completed between January 2021 and December 2022. Patient were required to have their external hip distractor frame removed by December 2022. Exclusion Criteria: Those not meeting the above inclusion criteria. Following the inclusion criteria, a number of cases were identified of which 10 cases were selected at random. A retrospective analysis of these samples was completed. The medical charts were reviewed as well as patient electronic healthcare records. Microsoft Excel was utilised to analyse the data and capture results.Introduction
Methodology
There is no doubt that the future of limb lengthening lies with internal lengthening. Complication rates are reduced and patient satisfaction is increased. The evolution of internal lengthening peaked with the dual direction, easily inserted and externally controlled PRECICE Nail. It has excelled in performance in accuracy and satisfaction. Its versatility increased with smaller sizes and increased excursion. A field safety notice was issued was issued in October 2021 by the parent company NuVasive. The advice was monitoring of current cases and a hold on implantation until after a review of process. At the National Orthopaedic Hospital Cappagh we elected to remove all implanted nails and assess the nail integrity and physiological changes associated with implantation. All patients in who a retained Precice nail at the time of the field safety notice were identified. Patients and families were contacted to explain the issued safety notice from the company and explain that we would be scheduling them for nail removal. This was part of our standard care but we prioritised this group on our waiting list. Consent was obtained for nail removal but also for histological assessment of canal scrapings, blood ion level analysis and independent assessment of the retrieved nail by our academic collaborators at University College Dublin. Ion levels were then repeated at an interval post removal with consent.Introduction
Materials & Methods
Aneurysmal bone cysts commonly found in lower limbs are locally aggressive masses that can lead to bony erosion, instability and fractures. This has major implications in the lower limbs especially in paediatric patients, with potential growth disturbance and deformity. In this case series we describe radical aneurysmal bone cyst resection and lower limb reconstruction using cable transport and syndesmosis preservation. Case 1 - A 12-year-old boy presented with a two-week history of atraumatic right ankle pain. An X-ray demonstrated a distal tibia metaphyseal cyst confirmed on biopsy as an aneurysmal bone cyst. The cyst expanded on interval X-rays from 5.5cm to 8.5cm in 9 weeks. A wide-margin en-bloc resection was performed leaving a 13.8cm tibial defect. A cable transport hexapod frame and a proximal tibial osteotomy was performed, with syndesmosis screw fixation. The transport phase lasted 11 months. While in frame, the boy sustained a distal femur fracture from a fall. The femur and the docking site were plated at the same sitting and frame removed. At one-year post-frame removal he is pain-free, with full ankle dorsiflexion but plantarflexion limited to 25 degrees. He has begun graduated return to sport.Introduction
Materials & Methods
Hip arthrodiastasis for paediatric hip conditions such as Perthes disease is growing in popularity. Intended merits include halting the collapse of the femoral head and maintaining sphericity by minimising the joint reaction force. This can also be applied to protecting hip reconstruction following treatment of hip dysplasia. Our aim was to assess functional outcomes and complications in a cohort of paediatric patients. A retrospective single-surgeon cohort study was performed in a University teaching hospital from 2018–2021. Follow-up was performed via telephone interview and review of patient records. Complications, time in frame and functional scores using the WOMAC hip score were recorded.Introduction
Materials and Methods
Patients undergoing complex limb reconstruction are often under immense physical, psychological and financial stress. We already provide psychological support within our unit. We have identified that patients struggle to obtain proper advice on the financial support to which they are entitled. In September 2019, In total 19 patients (68% male) have been seen. There have been 58 clinic appointments which have been a combination of face to face and virtual. The majority (80%) of issues dealt with relate to benefits – including claiming tax credits, universal credits and Personal Independence Payments. Other issues include housing problems, employment and claiming for travel and transport.Introduction
Materials and Methods
Hypoalbuminemia has previously been identified as an independent predictor of postoperative complications following total knee arthroplasty (TKA). Given the morbidity and financial burden associated with TKA complications, significant effort has gone into identifying patients at increased risk for perioperative complications. The American Society of Anesthesiologists (ASA) physical status score has been utilized for risk stratification of surgical patients for many years and is a measure of overall health. However, it is unclear how measures like albumin compare to the prognostic ability of this type of global health measure. This study aims to elucidate the utility of preoperative albumin compared with that of the ASA score in predicting complications following TKA. Patients undergoing TKA between 2005 and 2015 were identified using the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients were stratified based on preoperative hypoalbuminemia (<3.5 g/dL) and ASA score (≤ 2 vs. > 2). Multivariable regression analysis adjusted for age, sex, BMI, and smoking status was utilized to determine predictive potential of hypoalbuminemia and ASA score on each postoperative complication.Introduction
Methods
Acetabular cup malpositioning during total hip arthroplasty (THA) is known to lead to impingement, instability, wear-induced osteolysis, and increased rates of revision surgery. The purpose of this study was to independently evaluate the accuracy of acetabular cup orientation using a novel mechanical navigation device. Postoperative acetabular cup orientation was reviewed in 47 primary THAs using the HipSextant mechanical navigation device. Angles were measured with a validated two-dimensional/three-dimensional matching application. An outlier was defined as +/− 10 degrees outside of the preoperative plan for inclination and anteversion.Background
Methods
Optimising post-operative joint function is challenging when treating periarticular soft tissue sarcoma (STS). Radiotherapy reduces local recurrence rates but periarticular fibrosis may adversely affect joint function. Neo-adjuvant radiotherapy requires lower doses and smaller treatment volumes and therefore has potential benefits for the management of periarticular STS, but may lead to an increased risk of post-operative wound complications. This study assesses initial outcome and complications after treatment with neo-adjuvant radiotherapy and surgery for patients with periarticular STS. 17 patients treated with neo-adjuvant radiotherapy and surgery were identified. 3D conformal radiotherapy was delivered at a single centre with a dose of 50Gy in 25 fractions over 5 weeks. Patients were assessed weekly for adverse effects. Resection was planned 4–6 weeks after radiotherapy. Median follow-up was 13 months (range 5–44 months). No patients had significant adverse effects during radiotherapy. One patient had surgery delayed due to local skin reaction. Minor complications in five patients (three superficial infections, one seroma, one neuropraxia). One patient required further surgery due to incomplete margins. TESS scores for upper and lower limb patients were 86.1 and 78.1 respectively. No cases of local recurrence have occurred to date. Two patients have developed distant metastatic disease. The early results for periarticular STS managed with neo-adjuvant radiotherapy and surgery are excellent. There does not appear to be a significant increase in post-operative complication rates. With neo-adjuvant radiotherapy. Long term follow-up is required to demonstrate final functional outcome and local control rates.
Although soft tissue sarcoma (STS) is a rare malignancy, myxofibrosarcoma is a common form diagnosed. Myxofibrosarcoma is complicated by a high local recurrence rate (18–54%) and significant morbidity following treatment, hence management can be challenging. Patients treated between 2003–2012 were identified via a database within the histopathology department and case notes were retrospectively assessed. All histology samples were reviewed by a senior histopathologist to ensure a correct diagnosis.Background
Patients and Methods
The management of the dysplastic hip represents a clinical and a technical challenge to the paediatric orthopaedic surgeon. There is a great deal of variation in the degree and direction of acetabular dysplasia. Preoperative planning in the dysplastic hip is still largely based on plain radiographs. However, these plain films are a 2D projection of a 3D structure and measurement is prone to inaccuracy as a result. Hip arthrography is used in an attempt to analyse the 3D morphology of the hip. However, this still employs a 2D projection of a 3D structure and in addition has the risk of general anaesthesia and infection. Geometrical analysis based on multiplanar imaging with CT scans has been shown to reduce analysis variability. We present a system for morphological analysis and preoperative of the paediatric hip using this model. Our system can be used to determine the most appropriate osteotomy based on morphology. This system should increase the accuracy of preoperative planning and reduce the need for arthrography.
Complex foot and ankle surgery and reconstruction require accurate preoperative planning. In the foot procedures are challenging and can be associated with a range of complications. The aim of planning is to correct only the deformity and prevent extensive surgery. Knowledge of foot and ankle morphometry is vital. For comparison between different subjects the coordinate system must be constant. To the authors knowledge there has been no previous description of a coordinate system for the foot and ankle. CT images of ten anatomically normal feet were segmented in a general purpose segmentation program for grey value images and imported to a shape analysis program for biomechanics. A coordinate frame was defined in a 3 × 3 identity matrix using the inter-malleolar axis and a fibular diaphyseal centroidal axis in the construction. Centroidal vectors were defined in the metatarsals. Correlation of metatarsal length, inter-metatarsal angles, inter-malleolar distance and height was carried out. The forefoot was examined in relation to the medial and lateral columns. Metatarsal length had a significant correlation within each column and between the two columns notably in the 3rd (0.525 – 0.965) metatarsal at the columns junction. The 3rd metatarsals also correlated significantly (−0.583) with the inter-metatarsal angles. There was a weak correlation between the 1st 3rd and the 3rd 5th inter-metatarsal angles directly however, each had a large correlation with the 1st 5th inter-metatarsal angle (0.734 – 0.950). There was also a large correlation between the individual’s stature and the metatarsal length and the inter-malleolar distance. We have presented a means defining a coordinate system for three dimensional analyses in the foot and ankle. This coordinate system can be used for meaningful comparison of data between multiple subjects. We have shown that this coordinate system to be effective in practice in the morphometrical analysis of the normal forefoot.
Graft choices for revision anterior cruciate ligament (ACL) reconstruction and complex ligament reconstructions of the knee are controversial. The aim of our study was to analyze the biomechanical effect of harvesting bone plugs from both the distal and proximal poles of the patella, to simulate a simultaneous harvesting of a Bone – Patellar Tendon – Bone and Quadriceps Tendon – Bone grafts, in a transverse stress environment. Sixty Bovine Patellae were analysed. They were divided into 4 groups – based on the residual bone bridge (percentage of total length of patella) remaining after bone plug resection. 0 – 10%, 11 – 20%, 21 – 30% and >
30%. All patellae were tested in a modified 4 – point bending environment, to a maximum load of 10,000N, in a customized designed jig. This method simulates the axial bending stress on the patella during knee flexion. All dimensions of the patellae were recorded including Depth of patella at bone resection and wall thickness adjacent to plug resection site. All patellae with a 0% bone bridge fractured (Ultimate Tensile Strength/UTS) at a mean Tensile Force of 5863N (Range 3140 – 8730N). There was a subgroup of incomplete fractures – extra-articular fractures – which fractured at 6542N (Range 5085 – 9180N). The remaining specimens failed to fracture. Comparing the UTS and the patellar dimensions, using Weibull’s Statistical Analysis we demonstrated that less than 60% bone plug resection carried a very low probability of fracture. This study demonstrates the safe criteria for bone – tendon graft harvesting from both the proximal and distal poles of the patella. With regards to a normal human patella, a 40% bone – bridge is approximately a 20mm bone – bridge. We conclude that the simultaneous harvesting of Bone – Patellar Tendon – Bone and Quadriceps Tendon – bone grafts from a patella has no significant increase in the fracture risk of the patella.
