Ankle fractures are common injuries and the third most common fragility fracture. In all, 40% of ankle fractures in the frail are open and represent a complex clinical scenario, with morbidity and mortality rates similar to hip fracture patients. They have a higher risk of complications, such as wound infections, malunion, hospital-acquired infections, pressure sores, veno-thromboembolic events, and significant sarcopaenia from prolonged bed rest. A modified Delphi method was used and a group of experts with a vested interest in best practice were invited from the British Foot and Ankle Society (BOFAS), British Orthopaedic Association (BOA), Orthopaedic Trauma Society (OTS), British Association of Plastic & Reconstructive Surgeons (BAPRAS), British Geriatric Society (BGS), and the British Limb Reconstruction Society (BLRS).Aims
Methods
Perception of ACL injury prevention programs amongst professional netball players and coaches has not been studied. We investigated (1) level of awareness and experience of ACL injury prevention programs; (2) use of ACL injury prevention programs; and (3) barriers to implementing ACL injury prevention program in netball. Female netball players representing Welsh senior and under-21 teams and elite and amateur coaches were invited electronically to this web-based study between 1st May–31st July 2021. Information on ACL injury susceptibility and seriousness, knowledge, experience, and implementation of ACL injury prevention programs were ascertained.Introduction
Methodology
Anterior Cruciate Ligament (ACL) injury prevention programs can reduce injury risk in various sports. The perception of ACL injury prevention programs amongst professional netball players and coaches has not been studied. The purpose of the study was to determine (1) level of awareness and experience of ACL injury prevention programs; (2) use of ACL injury prevention programs; and (3) barriers and potential facilitators to implementing a sustainable ACL injury prevention program in netball. This cross-sectional observational study was undertaken using the CHERRIES checklist. Female netball players representing Welsh senior and under-21 teams and elite and amateur coaches were invited electronically to participate in this web-based study between 1st May – 31st July 2021. Information on ACL injury susceptibility and seriousness, knowledge, experience, and implementation of ACL injury prevention programs were ascertained.Introduction
Methods
Child abuse is an essential discussion within society and poses many challenges. The international literature describes patient and family based risk factors and suspicious injuries. We have created a protocol for the identification and investigation of children with suspected non-accidental injuries. The paediatric orthopaedic ward experiences many children being delayed in the ward once fit for discharge. This study aimed to quanitify those delayed discharges and describe the demographics and risk factors for abuse within the local population. After obtaining ethics clearance, we conducted a retrospective review of records from the Teddy Bear Clinic, as well as admission records. The study examined demographic characteristics, family, injury characteristics and referral to Child Welfare. The delay of discharge from hospital was quantified and was compared to those characteristics. Records were collected from 1 January 2015 to 31 December 2021. Seventy-nine complete records were included. There were 40 males and 39 females with an average age of 20 months. 75.9% were under 36 months old. 94.1% of the cases sustained lower limb fractures. Fifty-two cases had a delayed discharge. The delay ranged from 1 to 233 days. There was an association between an age less than 36 months and delayed discharge. There were no significant correlations between caregiver characteristics and delayed discharge. The later the completion of investigations, the more likely there would be a delay. There was also a significant correlation between referral to Child Welfare and delayed discharge. Children under 36 months on this remain at highest risk for non-accidental injury. Delayed discharge was associated with age less than 36 months, upper limb fractures and referral to Child Welfare. Despite the delayed discharge, most children returned to the same home environments
Perception of ACL injury prevention programs amongst professional netball players and coaches has not been studied. We investigated (1) level of awareness and experience of ACL injury prevention programs; (2) use of ACL injury prevention programs; and (3) barriers to implementing ACL injury prevention program in netball. Female netball players representing Welsh senior and under-21 teams and elite and amateur coaches were invited electronically to this web-based study between 1st May–31st July 2021. Information on ACL injury susceptibility and seriousness, knowledge, experience, and implementation of ACL injury prevention programs were ascertained.Abstract
Introduction
Methodology
Virtual fracture clinics (VFC's) aim to reduce the number of outpatient appointments while improving the clinical effectiveness and patients experience through standardisation of treatment pathways. With 4.6% of ED admissions due to trauma the VFC prevents unnecessary face to face appointments providing a cost savings benefit to the NHS. This project demonstrates the importance of efficient VFC process in reducing the burden on the fracture clinics. We completed preformed a retrospective cross-sectional study, analysing two cycles in May (n=305) and September (n=332) 2021. We reviewed all VFC referrals during this time assessing the quality of the referral, if they went on to require a face to face follow up and who the referring health care professional was. Following the cycle in May we provided ongoing education to A&E staff before re-auditing in September.Introduction
Methods
Cerament, a bioresorbable hydroxyapatite and calcium sulfate cement, is known to be used as a bone-graft substitute in traumatic bone defect cases. However, its use in open fractures has not previously been studied. Retrospective, single-centre review of cases between November 2016 and February 2021. Open fractures were categorised according to the Orthopaedic Trauma Society classification (OTS). Cases were assessed for union, time to union, and associated post-operative complications.Introduction
Materials and Methods
In the young and highly active population of military patients, femoroacetabular impingement can be a source of serious disability as well as a threat to their career. This morbidity can be treated with hip arthroscopy with debridement of cam lesion, and excision or repair of a corresponding labral tear. We report on the long term outcomes (>1 year) of 26 military cases who underwent hip arthroscopy for femoroacetabular impingement, in a single surgeon's series. Twenty two patients (four bilateral cases) underwent hip arthroscopy as a day case procedure during the period February 2013 to October 2014. Non-Arthritic Hip Scores (NAHS) were obtained from patients pre-operatively, at two months, four months and at least one year post-operatively. There was a significant improvement in NAHS at two months (75.6)(p<0.05), four months (85.1)(p<0.001) and one year (84.8)(p<0.001), compared to pre-operative NAHS (65.8). There was no significant change in NAHS beyond four months. Only three out of the 22 patients were medically discharged secondary to persistent hip symptoms. Hip arthroscopy for femoroacetabular impingement is an effective, viable procedure for military patients. Mobility, pain and function is significantly improved after surgery. This improvement is sustained in the long term up to and beyond one year.
In 2009 a combined clinic was formed by the orthopaedic Surgeons and Developmental Paediatricians in our hospital. The aim was to help improve the assessment and management of patients with Cerebral Palsy. Included in the assessment team, are the paediatric orthopaedic surgeons, the developmental paediatricians, physiotherapists and occupational therapists. Our aim was to audit the patients presenting to this clinic over a 15 month period to look at the demographic data, clinical severity and decisions taken for these patients. We looked at patients seen in the clinic from January 2013 to March 2014. We recorded the age, gender and primary caregiver. We also recorded the reason for referral. Clinically we wanted to know the type and distribution of the CP, GMFCS score, attainment of milestones and type of schooling. We recorded underlying aetiologies and HIV status of the patients. Finally the access the patients had to physiotherapy and Occupational therapy.Background and Aims:
Methods:
Blount's disease can be defined as idiopathic proximal tibial vara. Several etiologies including the mechanical theory have been described. Obesity is the only causative factor proven to be associated with Blount disease. Varus deformity is also a clinical feature of rickets and 31% of children with vitamin D deficiency rickets presented with varus deformities to the local Metabolic Bone clinics. The aim of this study is to assess if there is an association between vitamin D and Blount's disease. We hypothesize that children with Blount disease are more likely to be vitamin D deficient. This a retrospective study of pre-operative and post-operative patients with Blount's disease who were screened for vitamin D deficiency. Patients with known vitamin D deficiency and rickets were excluded. The study patients had the following blood tests: calcium, phosphate, alkaline phosphatase, parathyroid hormone and 25-hydroxyvitamin D. Body mass index (BMI) was also assessed.Introduction:
Method:
Forearm fractures are common in the paediatric population and most are treated in a moulded plaster of Paris (POP) cast. It is our concern that many casts applied by our registrars are sub-optimal and that we need to improve our training process. The aim of our study was to review the adequacy of forearm cast application in paediatric patients at our institution and to identify if there is a need for a more formal training program with regard to plaster cast application. A retrospective review of control x-rays of forearm fractures treated at our institution was undertaken. X-rays that were reviewed were done as part of the routine treatment protocol. X-ray measurements to assess POP application were the cast index and the gap index. A cast index of > 0.81 and Gap index of > 0.15 were regarded as an indication of poor cast application.Background and Aims:
Methods:
Non accidental injury is an under diagnosed problem worldwide. It is for this reason that all healthcare workers should be equipped in making the diagnosis and be aware of their obligation according to the Children's Act. The aim of the study was to determine if child abuse is adequately diagnosed at our institution and to identify areas of weakness in our current management protocol.Introduction
Purpose
A previous study in South Africa showed the prevalence of HIV related osteo-articular sepsis in children to be around 20% with a high prevalence of Streptococcus pneumoniae (38%) in HIV positive patients. This initial study was conducted at the same time that the polyvalent S pneumoniae vaccine was introduced to the EPI in South Africa (2009). The aim of the current study was to review the epidemiology of osteo-articular infections at two hospitals after the introduction of this vaccine. A retrospective review of patients presenting to two hospitals, between July 2009 and January 2013, with acute osteo-articular sepsis and pus at arthrotomy. The NHLS laboratory results were reviewed for microscopy, culture and sensitivity as well as white cell count (WCC), C reactive protein (CRP) and erythrocyte sedimentation rate (ESR).Introduction
Methods
The burden of Tuberculosis (TB) in South Africa is significant with recent reports showing an increase in the incidence of multi-drug resistant (MDR) TB. Little is known of the incidence and epidemiology, especially of MDR Tuberculous arthritis in children in the South African setting. The purpose of this study is to identify the number of TB cases identified with positive histology, culture and sensitivity. A retrospective review of laboratory results of children under the age of 14 years with Tuberculous arthritis at a South African Hospital between January 2008 and December 2012 was performed. The data was extracted from the NHLS data base for all synovium, bone or joint fluid collected for TB culture, sensitivity and histology.Purpose and Introduction
Methods
The gold standard of care of clubfoot is the Ponseti method of serial manipulation and casting, followed by percutaneous tendo-achilles tenotomy. In our setting, registrars work in district hospitals where they run Ponseti clubfoot clinics with little or no specialist supervision. They use the Pirani score to serially assess improvement of the deformity during casting and to determine whether the foot is ready for tenotomy. To test the inter-observer reliability of the Pirani score, and whether it can be used by non-specialist doctors running Ponseti clubfoot clinics.Background
Purpose of Study
Congenital hallux varus is a rare condition presenting with medial deviation of the big toe. It consists of 2 variants: classical congenital hallux varus caused by an abnormal metatarsal-phalangeal articulation, and a more recently described variant due to a “bracket physis” of the first metatarsal. Our aim was to perform an audit of the spectrum of presentation of congenital hallux varus with its management and complications in our unit over a five year period. A retrospective review of congenital hallux varus treated by a single surgeon was performed. Clinical notes, photographs and x-rays were reviewed. Two surgical methods of treatment were used as directed by clinical and radiological findings.Purpose of study:
Description of methods:
Presenters Position: To perform a retrospective audit of the spectrum of management of tibial pseudarthrosis by a single surgeon over a seven year time period. All discharge summaries and operation logs from 2004 to 2011 were reviewed to identify patients, and their case notes and x-rays were examined. Patients were contacted telephonically for follow-up examination.Purpose of Study:
Description of Methods:
The management of idiopathic clubfoot has changed substantially over the past fifty years with the Ponseti method of treatment gaining increasing popularity in recent years. The advantages of this method are its simplicity and minimal resource requirements with high published success rates. One of the disadvantages is that unless treatment protocols are meticulously adhered to, especially in the bracing stage, recurrence will occur. This study explores the demographics and highlights existing barriers to successful clubfoot treatment outcomes at two academic hospitals. A cross sectional study was conducted of all children undergoing clubfeet treatment between June and December 2011. A stratified questionnaire was used at two academic hospitals.Purpose of Study
Description of Methods
Research projects are a compulsory part of the postgraduate curriculum in most Academic Departments. To not only fulfil study requirements, but to ensure noteworthy and accurate results meticulous and reliable data collection is necessary. Our aim was to better understand what preferences health care professionals have in undertaking data collection. We did a choice based conjoint analysis with an online data collection survey. This study type allows the evaluation of the relative importance of component attributes. We used 4 major criteria to evaluate preferences when performing data collection. These were: 1. Time to complete the form, 2. Remuneration and recognition, 3. Study design and 4. Responsibilities at the time of collection. We sent electronic questionnaires to doctors in the Orthopaedic, Ophthalmology and Plastic Surgery Departments at a Johannesburg Academic Institution.Aim
Methods
Multiple measurements have been described for the assessment of developmental dysplasia of the hip (DDH). In particular, the centre edge angle (CEA) has been described by Wiberg to assess the position of the femoral head in relation to the acetabular edge in patients over the age of five years. The purpose of this study is twofold. Firstly to assess the reliability of all measurements available in the literature and secondly to evaluate whether or not the CEA can be reliably measured below five years of age. Eighty seven patients were included for assessment. Radiographs were measured within six months of spica cast/Batchelor cast removal, depending on whether closed or open reduction was performed. A web based computer programme was used to store the radiographs electronically and with the help of an electronic template the following measurements were recorded: CEA, AI, centre head distance discrepancy ratio (CHDDR), Smith's c/b and h/b ratios. Three readers recorded measurements at two intervals, to determine intra and inter reader reliability.Purpose of Study
Methods
To describe four South African patients (including a sibling pair) with pycnodysostosis and to highlight the importance of a comprehensive assessment of the patient, and not just the fracture. To emphasise the significance of the input of a multidisciplinary team which should include a medical geneticist, in order to provide optimal care for patients and their families. A comprehensive evaluation of the clinical and radiological features of these four patients was undertaken and the orthopaedic complications documented, with the times from presentation to definitive diagnosis.Aims
Methods
Severe osteo-articular infection can be a devastating disease causing local complications, multiple organ failure and death. The aim of this study is to highlight the potential severity and subsequent sequelae of osteo-articular infections in children and to determine causative factors leading to this devastating condition. We retrospectively report on six cases treated at two academic hospitals. We included all patients with osteo-articular infections who had multi-organ involvement. All patients had more than one joint as well as another organ involved as a direct result of the bacteraemia. All patients with single organ involvement were excluded. The patient files were recorded as part of a previously published study. Data capture included X-rays, serology for blood culture, FBC, ESR, CRP and HIV. Ultrasound of involved joints, technetium bone scans, echocardiograms and computed tomography of the brain were performed when indicated.Purpose
Methods
The TruFit® plug is a cylindrical scaffold designed to bridge defects in articular cartilages. It is a porous structure with interconnected pores, which gives it the capability of providing a framework for the ingrowth new tissue and remodelling to articular cartilage and bone. The aim of this study was to assess the radiological incorporation of TruFit® Plugs using MRI. Between December 2007 & August 2009, 22 patients underwent treatment of a chondral or osteochondral lesion using one or more TruFit Plugs. At a minimum of 2 years, 10 patients (12 lesions) were MRI scanned and assessed with a modified MOCART Scoring system by an independent Consultant Musculoskeletal Radiologist. 8 patients were no longer contactable and 4 patients declined MRI as their knee was asymptomatic. 8 of 12 lesions showed congruent articular cartilage cover with a surface of a similar thickness and signal to the surrounding cartilage and reconstitution of the subchondral bone plate. 2 lesions had a thicker congruent articular surface with a similar signal to the surrounding articular cartilage without restoration of the subchondral bone plate. 2 lesions showed no graft incorporation at all and were filled with granulation tissue. Full incorporation of the bony portion of the plug had occurred in only 3 lesions with partial incorporation in 7 lesions. The remaining portion of these 7 lesions looked cystic on MRI. The MRI appearances of the TruFit® Plug at 2 years are encouraging with the majority (83%) showing good restoration of the articular surface with tissue of similar thickness, congruity and signal as the surrounding articular cartilage. However complete incorporation of the TruFit® Plug is rare and cystic change is common. The significance of this cystic change is not clear.
Displaced mid-shaft clavicle fractures have traditionally been treated non-operatively. New evidence supports the use of operative treatment with better functional results although with some risk of adverse complications. The patient's opinion in choosing one or the other option of treatment is important especially when a new therapeutic philosophy is introduced. We aimed to obtain the patients' preference based on their opinion of various possible outcomes of each treatment method. A clinical decision tree was constructed based on probabilities for various outcomes from the current literature. We used clinical decision analysis based on Bayesian logic. A similar clinical decision analysis was done for a cohort of orthopaedic surgeons. We interviewed 20 patients to obtain their health preferences on a numerical rating scale for each of the six possible outcomes for the conservative and operative treatments. Similar health preferences were obtained from 20 orthopaedic surgeons. The cohort of patients were young (age range: 13 – 21, mean: 16 years) males involved in active sport. The results of the decision analysis demonstrated a strong preference for operative management in this cohort of patients (combined probability of 0.81 for operative treatment versus 0.61 for non-operative). The cohort of orthopaedic surgeons were either career orthopaedic trainees or qualified orthopaedic surgeons with an age range of 28 – 41 years (mean age: 35 years). The results of the decision analysis demonstrated a weak preference for operative management in this cohort of surgeons (combined probability of 0.84 for operative treatment versus 0.77 for non-operative management). Overall the young active patient is eight times more likely to prefer operative treatment over non-operative management compared to the well informed orthopaedic surgeon. Patient education is the key to a better informed patient who can make a balanced decision. Clinical decision analysis can be a useful tool in this process.Abstract
Recently biodegradable synthetic scaffolds (Trufit plug) have provided novel approach to the management of chondral and osteochondral lesions. The aim of this study was to assess our 2 year experience with the Trufit plug system. 22 patients aged 20 to 50 years old all presenting with knee pain over a 2 year period were diagnosed either by MRI or arthroscopically with an isolated chondral or osteochondral lesion and proceeded to either arthroscopic or mini arthrotomy Trufit plug implantation. In 5 patients plug implantation was undertaken along with ACL reconstruction (3), medial meniscal repair (1) and contralateral knee OCD screw fixation (1). Pre and post operative IKDC scores were obtained to assess change in knee symptoms and function. At a mean follow up of 15 months (range 2 – 24 months) improved IKDC scores were achieved with the scores improving with time. 2 patients have had a poor result and have had further surgery for their chondral lesions. One patient had failure of graft incorporation at second look arthroscopy and went onto to have a good result after ACI. The second patient had good graft incorporation on second look but had progression of osteoarthritic degeneration throughout the other compartments of the knee which were not initially identified at the time of Trufit plugging. We conclude that Trufit plug is an alternative method for managing isolated chondral and osteochondral lesions of the knee which avoids harvest site morbidity or the need for staged surgery.
Involvement of Patellofemoral joint (PFJ) has significant bearing in the management of osteoarthritis of the knee. The aim of this study is to assess the relationship between skyline radiographs, MRI and arthroscopic findings in the patellofemoral joint. Data was collected prospectively from fifty-three patients who underwent arthroscopy. There were 36 males and 17 females in the group with mean age of 48 years (range 18-71). Arthroscopically PFJ arthritis was classified based on Outerbridge grading system. Patients with Outerbridge grade III and IV lesions were considered to have significant arthritis of the PFJ. Kellgren-Lawrence grading system was used to assess the skyline radiographs. Radiographically patients with grade III and IV Kelgren-Lawrence changes were considered to have significant osteoarthritis of the PFJ. MRI scans were also studied to assess involvement of PFJ. Thirty-two patients had MRI scan and 20 patients had skyline views done as part of preoperative work up. Arthroscopic findings were considered as gold standard. MRI scan had specificity of 75%, sensitivity of 81%, positive predictive value of (PPV) 77 and negative predictive value of (NPV) 80% in diagnosing significant PFJ arthritis. Skyline radiographs had specificity of 100%, sensitivity of 50%, PPV of 100% and NPV of 57%. The overall accuracy of skyline radiographs in predicting significant PFJ arthritis was 70% and for MRI was 78%. We conclude that skyline radiographs has some value in he diagnosis of PFJ arthritis, however the sensitivity and negative predictive value is very is poor.
Twenty one (2.2 %) cases were identified with CTPA confirmed PE. Of the various risk factors studied, delay in postoperative mobilization was the only significant risk factor for PE (p=0.019). None of the other risk factors were significant for PE. Postoperative pain was the commonest reason for delayed mobilisation followed by lower limb paraesthesia from regional nerve blocks.
358 patients, 190 SB and 168 DB were considered for statistical analysis from these five papers. Outcome measures assessed included pivot shift testing, KT1000 arthrometer testing and IKDC knee scores. Using Review Manager 4.2 for statistical analysis; for dichotomous data, odds ratios and 95% confidence intervals were calculated and for continuous data, weighted mean difference and 95% confidence intervals were calculated. Patients in the double bundle group were significantly less likely to have a positive pivot shift test (P<
0.0001). KT1000 arthrometer testing demonstrated greater antero-posterior stability with the DB group (P=0.002). There was no difference between the groups in terms of IKDC score.
We aimed to determine the reliability, accuracy and consequently the clinical role of digital templating in the pre-operative work up for total knee arthroplasty patients. With the increasing use of digital radiology images, analogue templating may soon be defunct. Digital templating is a more recent development and its role is yet to be determined. Ten pre-operative digital radiographs were templated by four independent observers. Inter-observer and intra-observer reliability was assessed using the kappa measure of concordance. Subsequently, 40 consecutive total knee arthroplasty patients underwent pre-operative digital templating. This was a blinded process by a consultant surgeon not involved with the operation. Each patient underwent TKR using the PFC Sigma System sized intra-operatively, without the operating surgeon having knowledge of the pre-operative templating result. Comparison was made between the pre-operative digital templates and the blinded intra-operative sizing. For both the femoral and tibial templating there was good to very good inter- and intra-observer agreement. For the femoral component the templating was correct in 47.5% (± 1 size difference 97.5%). The tibial templating was correct in 55% (± 1 size difference 100%). The inter- and intra-observer reliability of digital templating process has been shown to be acceptable but the correlation between digital templating and the actual size implanted is poor. Our series shows a similar accuracy to the published data on analogue templating for the same implant. Like analogue templating, its clinical role remains uncertain and its poor correlation to the actual implant sizes limits its usefulness.
We aimed to determine the reliability, accuracy and the clinical role of digital templating in the pre-operative work-up for total knee replacement. Initially a sample of ten pre-operative digital radiographs were templated by four independent observers to determine the inter- and intra-observer reliability of the process. Digital templating was then performed on the radiographs of 40 consecutive patients undergoing total knee replacement by a consultant surgeon not involved with the operation, who was blinded to the size of the implant inserted. The Press Fit Condylar Sigma Knee system was used in all the patients. The size of the implant as judged by templating was then compared to that of the size used. Good inter- and intra-observer agreement was demonstrated for both femoral and tibial templating. However, the correct size of the implant was predicted in only 48% of the femoral and 55% of the tibial components. Albeit reproducible, digital templating does not currently predict the correct size of component often enough to be of clinical benefit.
The authors evaluate the incidence, patterns and causative factors of avascular necrosis (AVN) in patients with developmental dysplasia of the hip (DDH) and to follow up these patients to determine what their long term functional and radiological outcome is. All patients treated for DDH by the same consultant with the subsequent development of AVN were assessed. Outcome was assessed by grading the AVN using the Kalamchi and McEwan classification at final follow up. A group of 250 hips with DDH were treated over a 16 year period and reviewed. All hips that developed AVN were studied. AVN was seen in 15% of hips treated with closed reduction and 62% of hips after open reduction–32% of the hips treated in the open reduction group were treated elsewhere and subsequently referred. If use of a Pavlik harness fails, children with DDH should be treated with pre reduction traction, closed reduction and spica cast after the age of 4 months. In the surgical group a capsulorrhaphy should be avoided. Poor radiological outcome at final follow up was not necessarily equivalent to a poor clinical outcome.
We present the clinical and radiographic outcome of 68 consecutive primary total hip replacements performed in 54 patients under the age of 55 years using a hydroxyapatite-coated femoral component and threaded cup with a modular ceramic head (JRI-Furlong). We reviewed 62 (91%) hips at a median follow-up of 8.8 years (5 to 13.8) after implantation; six (9%) were lost to follow-up. At review there had been four (6%) revisions but only one for aseptic loosening (acetabulum). Radiographic review of the remaining hips did not identify any evidence of femoral or acetabular loosening. The median Harris and Merle d’Aubigné and Postel hip scores were 95.9 (42.7 to 100) and 17 (3 to 18) respectively. The JRI-Furlong hip gives promising functional and radiographic results in young patients in the medium term.
In a radiological study, we evaluated the outcome of the Chiari osteotomy as a primary method of femoral head containment in a distinct group of patients with Perthes’ disease. Even when Salter’s prerequisites are met, the results of a Salter osteotomy are known to be poor in this particular group of patients. At the time of operation, the mean age of the 13 patients who underwent Chiari osteotomy was 9 years 4 months. The osteotomy was performed early in the disease process, before femoral head deformity had occurred. The hip was considered to be at risk because of the relatively late onset of the disease. Measurements were made on the preoperative and latest follow-up X-rays, and on the preoperative arthrogram. Patients were followed up for a mean of 3 years 4 months. On the preoperative arthrogram there was no femoral head deformity or hinging on abduction. At the time of surgery, it was too early to assign a hip reliably to a particular lateral or Herring lateral pillar group. However, during the follow-up period, 12 of the hips manifested as Catterall group IV and one as Catterall group II. Further, 11 hips advanced to become lateral pillar type B, and two to become lateral pillar type C. At follow-up, nine hips could be reliably graded according to the Stulberg classification: five were Stulberg type II and four Stulberg type III. It was clear that none of the remaining hips would be Stulberg type IV or V. The Chiari osteotomy achieves a congruent hip in a specific group of patients where a poor outcome would otherwise be anticipated.
Intramedullary fixation of the long bones is commonly used to prevent and treat fractures and subsequent deformities in patients with osteogenisis imperfecta. However, there is little in the literature about the management of deformities of the proximal femur, such as coxa vara secondary to malunited proximal fractures. This paper presents a simple surgical technique that holds the femoral neck in a valgus position in osteogenisis imperfecta. Four patients (five hips) presented with an acute fracture of the upper femur and complex proximal deformity with coxa vara. All patients, whose mean age at operation was 6.5 years, were classified as Sillence type III, and none had previously undergone surgery. The femoral deformity was corrected and the femur stabilised with a Williams rod. The unstable proximal segment and femoral neck were fixed with K-wires, which were then bent and secured to the femoral shaft with two cerclage wires. Patients were followed up to radiological union. Pre-operatively the mean neck-shaft angle was 70°, and there were associated complex deformities of the proximal femur and femoral shaft. At the time of surgery, a mean correction of neck-shaft angle of 60( was achieved, giving a mean valgus angle of 130°. The correction was maintained at follow-up. One patient remained ambulant after surgery, two subsequently became ambulant with elbow crutches and one remained non-ambulant.
