Cerebral Palsy (CP) is a group of disorders that affect movement and posture caused by injury to the developing brain. While prematurity and low birth weight are common causes in developed countries, birth asphyxia, kernicterus, and infections have been identified as predominant aetiologies in Africa. There is, however, very little information on the aetiology of CP in South Africa. The purpose of this study was to determine the aetiology, severity, and topographical distribution of CP in children undergoing orthopaedic surgery at our tertiary paediatric unit.

A retrospective folder review was performed for patients with CP that underwent orthopaedic surgery from July 2018 to June 2022. Data was collected on perinatal circumstances, aetiology or risk factors for developing CP, severity of disability as classified by the Gross Motor Function Classification Scale (GMFCS) and topographical distribution. Descriptive analysis was performed.

Two-hundred-and-thirty-four patients were included in the analysis. No specific aetiology could be identified in 51 (21.9%) patients. Hypoxic ischaemic encephalopathy (HIE) accounted for 23.6% of patients and was the most common aetiology across the different categories except for patients graded as GMFCS 2, in whom prematurity was the most common aetiology. Congenital brain malformations (10.5%) and cerebral infections, including HIV encephalopathy (11.4%) were the next most frequent aetiologies, followed by prematurity (7.6%), ischaemic stroke (6.8%) and intraventricular haemorrhage (6.3%). Fifty-two percent of patients were classified as GMFCS 4 or 5. There was a predominance of quadriplegic patients (37%) compared to hemiplegics (29%), diplegics (30%) and monoplegics (4%).

Most patients undergoing orthopaedic surgery for musculoskeletal sequelae of CP were severely disabled quadriplegic patients in whom HIE was the predominant cause of CP. This emphasises the need for intervention at a primary care level to decrease the incidence of this frequently preventable condition.

Increasing innovation in rapid prototyping (RP) and additive manufacturing (AM), also known as 3D printing, is bringing about major changes in translational surgical research.

This review describes the current position in the use of additive manufacturing in orthopaedic surgery.

Cite this article: Bone Joint J 2018;100-B:455-60.

Background

Distal radius fractures are among the most common fractures encountered in the clinical setting, with a reported incidence of 17%. Of these common fractures, it has been said 60% are intra-articular in nature. Intra-articular or unstable and comminuted fractures represent severe, high energy injuries. There is a considerable amount of controversy as to which fixation method is superior. Even the OA concludes; “comparing external fixation (EF) with open reduction and internal fixation (ORIF) for the treatment of intra-articular distal radius fractures described no consistent benefit of one treatment over another”. There are only a few randomised control trials that go beyond one year to cover the long-term follow up (over two years). There has yet to be a meta-analysis of the long-term outcomes of open reduction internal fixation (ORIF) versus external fixation. We aim to show from this meta-analysis if there is any significant difference in the outcomes of either fixation method in the long-term.

Lateral clavicular physeal injuries in adolescents are frequently misinterpreted as acromioclavicular dislocations. There are currently no clear guidelines for the management of these relatively rare injuries. Non-operative treatment can result in a cosmetic deformity, warranting resection of the non-remodelled original lateral clavicle. However, fixation with Kirschner (K)-wires may be associated with infection and/or prominent metalwork. We report our experience with a small series of such cases.

Between October 2008 and October 2011 five patients with lateral clavicular physeal fractures (types III, IV and V) presented to our unit. There were four boys and one girl with a mean age of 12.8 years (9 to 14). Four fractures were significantly displaced and treated operatively using a tension band suture technique. One grade III fracture was treated conservatively. The mean follow-up was 26 months (6 to 42).

All patients made an uncomplicated recovery. The mean time to discharge was three months. The QuickDASH score at follow-up was 0 for each patient. No patient developed subsequent growth disturbances.

We advocate the surgical treatment of significantly displaced Grade IV and V fractures to avoid cosmetic deformity. A tension band suture technique avoids the problems of retained metalwork and the need for a secondary procedure. Excellent clinical and radiological results were seen in all our patients.

Cite this article: Bone Joint J 2013;95-B:664–7.

Introduction

The elbow is the second most common site of non prosthetic joint dislocation. Simple elbow dislocation alone contributes to 11-28% of all elbow injuries. Post-reduction treatment methods include traditional plaster of Paris (POP) immobilisation followed by physiotherapy, sling application followed by early mobilisation and rapid motion. The aim of the study was to evaluate the final outcome and cost-effectiveness of the pop and the sling groups.

The purpose of this study was to investigate the safety and outcome of bilateral simultaneous ACL reconstruction. In patients presenting with an ACL-deficient knee, 2 – 4% have bilateral ACL deficiency. A staged or simultaneous approach can be adopted when the patient requires reconstructive surgery for both knees. We report a case series of 8 patients (6 male, 2 female, average age 30.4 years) who underwent bilateral simultaneous ACL reconstruction.

Simultaneous or bilateral ACL reconstruction using ipsilateral patella tendon graft has been reported as a safe procedure with outcome and complication rate no different to unilateral procedures. Considerable cost savings of simultaneous over staged procedures have also been described. There are no case series in the published literature that describe the use of hamstring tendon autograft for bilateral simultaneous ACL reconstruction.

We used two camera stack systems and instrument sets to allow for simultaneous bilateral surgery by two surgical teams. Quadrupled hamstring tendon graft was used in 4 patients although in one patient patella tendon graft was used on the second side due to poor quality of hamstring tendons. Patella tendon graft was also used in a further 4 patients. At two weeks all patients were able to discard crutches and were independent in mobility. There was no difference in outcome at one year between those patients undergoing bilateral simultaneous ACL reconstruction in comparison to the outcomes of unilateral ACL reconstruction with respect to Lysholm, Tegner and IKDC scores. The mean follow up period was 2.3 years.

Our results demonstrate that bilateral simultaneous ACL reconstruction is safe and cost effective. A simultaneous approach also has the benefit of reducing the overall period of rehabilitation required by the patient. We report good short-term functional outcome but no long-term data is yet available.

Aim: To assess the results and complications of the opening wedge form of distal femoral varus osteotomy (DFVO) in treating valgus arthritis and ligament instability of the knee.

Methods: Patients undergoing DFVO were assessed prospectively using validated scoring systems and pre/post operative alignment radiographs. All had failed non operative and arthroscopic procedures and were keen to avoid arthroplasty. The lateral based opening wedge osteotomy aimed to correct the weight bearing line to position 50% medial to lateral and was held with either the Puddu femoral plate (Arthrex UK) or the Tomofix plate (Synthes UK).

Results: 26 distal femoral osteotomies were performed in 23 patients with a mean age of 34 (16 –58). The mean duration of follow up is 32.5 months (1–72). 8 were undertaken for primary valgus malalignment, and 15 for secondary valgus with OA due to previous lateral menisectomy. Simultaneous additional procedures included microfracture (3), MACI (1), meniscal transplantation (1), and MCL advancement (1). Mean hospital stay was 4 days (2–6). Post op alignment was out by greater than 10% of intended in 2/3. 3 early major complications required re-operation: 2 for plate and screw cut out and 1 for infection. 2 developed delayed union requiring bone grafting. Failure with conversion to arthroplasty has occurred in 2 (1 lateral UKA, 1 TKA), and 2 patients are awaiting either multi-ligament reconstruction or collagen meniscal implantation. The overall mean Tegner score is 4 (2–6), and 20 of the 23 patients feel satisfied with the outcome having avoided arthroplasty.

Conclusion: Opening wedge DFVO is a technically difficult procedure with significant complications, but in the right indication offers long lasting pain relief and joint preservation prior to arthroplasty. New techniques including accurate closing wedge fixation systems and computer guided operative planning and surgery may offer improvements to this vital surgical option.

Introduction: Fracture classification systems help in communication, treatment planning, assessing prognosis and form standards to report treatment results. The ideal classification system should be reliable, reproducible, all-inclusive, mutually exclusive, logical and clinically useful. The aim of our study was to assess the inter observer reliability and intra observer variability for the AO, Schatzker and Hohl and Moore classification systems.

Materials and Methods: We randomly selected fifty sets of radiographs of tibial plateau fractures occurred between 2000 and 2005. Exclusion criteria: Only one available view, inadequate films. Four orthopaedic surgeons at various level of experience i.e. one senior senior house officer, two registrars and a trauma consultant classified the fractures. Radiographs were blinded and each time the radiographs were presented to the observers in a different order. Radiographs were viewed at two separate sittings 8 weeks apart. The data was analysed using kappa statistics through SPSS version 14. The Kappa co-efficients were interpreted according to Landis and Koch grading. (< 0.00=poor; 0.0–0.2=slight, 0.21–0.4=fair, 0.41–0.60=moderate, 0.61–0.8=substanti al,> 0.8=excellent)

Results: For the AO classification the mean kappa co-efficients for inter-observer and intra-observer reliability were 0.36 (0.33–0.39) and 0.83(0.61–1.00) respectively. For the Schatzker classification the mean kappa co-efficients for inter-observer and intra-observer reliability were 0.47(0.45–0.49) and 0.90(0.75–1.00) respectively. For the Hohl& Moore classification mean kappa values for inter-observer and intra-observer variability were 0.14 and 0.81(0.59–1.00) respectively. According to Landis and Koch grading, AO classification is fair in terms of interobserver reliability, the Schatzker classification is moderate and the Hohl& Moore is slight.

Conclusions: None of the three systems fulfils the criteria for an ideal classification system. However, the Schatzker classification system was found to be superior. The Hohl& Moore system was least reliable of all. Hence, we recommend usage of Schatzker classification system in tibial plateau fractures both in clinical practice and clinical studies until a superior classification system evolves.

Between 1994 and 2006, 58 patients underwent decompression of radial tunnel. The senior author using an anterior approach performed all procedures. 43 patients were available for follow-up evaluation at an average of 47.3 months (12–156 months). The average age of patients was 49.7 years (35 – 72 years) and the mean duration of their symptoms was 18 months (6 – 56 months). There were 12 patients (13 extremities) over 5 years follow-up. All had a trial of conservative treatment with steroid injections, physiotherapy and ultrasound therapy. All except 2 had nerve conduction studies which were inconclusive. The results were evaluated using Mayo elbow scores and DASH scores. Mayo scores improved from a mean of 62.37 pre-op to 87.13 post-op (p< 0.05) and DASH scores improved from 67.58 pre-op to 40.12 post-op (p< 0.04). 35 patients (81.3%) were satisfied with the surgery while 8 patients were not (4 patients had other pathologies). There were few complications – neuropathic pain-1, neuropraxia – 1 and residual pain – 2. Six patients who had simultaneous release of lateral epicondylar muscles and radial tunnel did extremely well and were satisfied. Hence there is a role for simultaneous decompression of tennis elbow and radial tunnel as recent studies suggest that extensor carpi radialis brevis tendon forms a continuous fascial sheath from lateral epicondyle to radial tunnel structures blending with supinator muscle. Based on our results, surgical decompression of radial tunnel gives good results in majority of patients with persistent radial tunnel symptoms with long-term relief.

Between 1994 and 2006, 83 patients (84 elbows) underwent the Outerbridge-Kashiwagi (OK) procedure by the senior author. Of these, 30 patients with over 5 years follow-up where available for review. There were 24 males and 6 females mean age 59.8 (range 34 – 81). 27 patients had primary osteoarthritis and the rest developed post-traumatic arthritis. Mean duration of symptoms was 25.5 (range 12 – 72) months. 30 patients had more than 5-year follow-up with a mean of 96 months (range 60–150) months. Their mean pre-operative flexion improved from 115° (range 90° – 150°) to 134° (range 100° – 160°) post-operatively (p< 0.001) and mean pre-operative extension deficit improved from 28° (range 10° – 50°) to 13° (range 5° – 30°) post-operatively (p< 0.001). The mean MEPS improved from 52 (range 25 – 70) pre-operatively to 84 (range 55 – 100) post-operatively (p< 0.038). The mean pre-operative DASH score improved from 63 (range 37 – 92) to 41 (range 24 – 75) postoperatively (p< 0.001). The mean pre-operative DEORS improved from 6.3 to 4.9 post-operatively (p< 0.001). Majority of the patients [22 patients (73.3%)] returned to their previous work including all 5 professional sportsmen. There were few complications -2 superficial wound infections, and numbness along ulnar nerve distribution in 1 patient. Of the 17 patients who had recurrence after 5 years, 4 patients had to undergo revision surgery (3 improved). 23 patients (76.6%) were satisfied with the results of the surgery. Conclusions: The OK procedure gives excellent to good results in 70.9% of patients at a mean of 9 years. Both flexion and extension improved significantly with very few complications with this open surgical technique. Although 17 out of 30 patients had recurrence on X ray beyond 5 years, only 4 required revision procedures.

Aim: To determine the need for caudal epidural steroid injections to be administered with a mixture containing local anaesthetic.

Patients: 100 consecutive patients listed for caudal epidural by two spinal orthopaedic consultants with lum-bosacral radiculopathic pain. 19 patients did not fulfil the criteria for the trial.

Methods: Subjects randomised to either steroid injection (80mg triamcinolone) with 18mls 0.25% bupivicaine or steroid injection with 18mls Normal saline. Pre-injection maximal (Pmax) and average (Pav) pain scores and Oswestry Disability Index (ODI) scores were obtained for each patient. Pain scores were repeated at 48 hours, 2 weeks and 8 weeks with a second ODI.

Results: A significant improvement in both Pav and Pmax were seen over the study period for both groups. There was no significant difference in either group for ΔPav. or ΔPmax at any stage of the study. Those patients who received a mixture containing bupivicaine underwent a significant improvement in their ODI in contrast to those who were injected with the saline mixture. There was also a significant difference in the ΔODI between groups.

Conclusion: Epidural bupivicaine injection appears to enhance the effect of epidural steroid injection with adequate levels of monitoring and access to specialist support. There may be a beneficial effect on the local pain pathways by the local anaeasthetic that outlasts the direct pharmacolgical effect.

Background: Total elbow prostheses are broadly classified into linked and the unlinked categories. We have looked at long-term results of unlinked Kudo 5 total elbow replacement used in the treatment of patients with rheumatoid arthritis in 2 hospitals.

Methods: 87 Kudo 5 Total elbow replacements in 70 patients with adult rheumatoid arthritis were performed at Wexham Park Hospital, Slough and City Hospital, Nottingham by 2 specialist elbow surgeons, the senior authors. 16 patients had died and 8 patients were lost to follow up. 62 elbow replacements in 46 patients were evaluated at a mean follow up of 79 months [29–137 months] using the Mayo Clinic Performance Index. Postoperative radiographs were also reviewed for loosening using standard anteroposterior and lateral films

Results: Preoperatively 6 had moderate pain and 56 had severe pain. Postoperatively the pain was rated as none or mild by 58 and moderate by 4. The average Mayo Elbow Score improved from 37 preoperatively to 86 postoperatively. The mean arc of flexion/extension improved from 60 to 99 degrees. There were 14 complications including ulnar neuropraxia, fracture, dislocation, triceps rupture and loosening. 4 cases were revised, 2 for aseptic and 2 for septic loosening. Postoperative radiographs showed 5 cases with loosening around the ulna component.

Conclusions: The long-term results using the Kudo 5 elbow prosthesis in patients with rheumatoid arthritis are acceptable and comparable to other series reported of this implant. To date this is the largest series reported with the longest follow up using this implant.

To date there has been only one published series of elbow arthroplasty in patients with Juvenile Idiopathic arthritis. These patients pose particular problems because of the size and variable shape of the humerus and ulna together with the soft tissue contractures and bony erosion which can sometimes be severe. We have reviewed the results of elbow arthroplasty using the unlinked Kudo 5 and the linked Coonrad-Morrey implants which in our practice have different indications dependent upon bone stock and stability.

Methods 19 total elbow replacements in 13 patients with juvenile idiopathic arthritis were performed by 1 specialist elbow surgeon, the senior author. 13 of these are Kudo 5 and 6 are Coonrad-Morrey implants. The mean age at operation was 39 years. 6 of the elbow replacements had undergone previous surgery, 4 had an interposition arthroplasty and 2 a synovectomy and radial head excision. No patients were lost to follow up. All were evaluated at a mean follow up of 49 months [6–84 months] using the Mayo Clinic Performance Index. Postoperative radiographs were also reviewed for loosening using standard anteroposterior and lateral films.

Results Preoperatively 7 had moderate pain and 12 had severe pain. Postoperatively the pain was rated as none by 13 and mild by 6. The average Mayo Elbow Score improved from 26 preoperatively to 81 postoperatively. The mean arc of flexion/extension improved from 85 to 108 degrees.12 elbow replacements had intra and post-operative complications and 2 elbows have been revised.

Conclusions The medium-term results of Total Elbow Replacements in patients with Juvenile Chronic Arthritis are acceptable and comparable to the only other published series which also records a high complication rate.

The Copeland Shoulder Arthroplasty is a cementless, pegged humeral head surface replacement. The design is based on the principle of minimal bone resection and has been in clinical use since 1986. The only published series to date, that of Levy and Copeland, reported results for 103 patients which were comparable to those obtained with stemmed implants. We report the outcome at our institution using the same prosthesis with a hydroxyapatite coating.

81 shoulders (74 patients) underwent resurfacing hemiarthroplasty through an anterior deltopectoral approach. Preoperative diagnoses were: osteoarthritis (39), rheumatoid arthritis (29), rotator cuff arthropathy (1), post-traumatic arthrosis (2). They were followed for an average 28 months. 10 were lost to follow-up (8 deaths).

Constant scores improved from a mean preoperative figure of 15.7 to 54.0 (p< 0.01) at last follow-up. For rheumatoid arthritis and osteoarthritis the scores improved from 15.2 to 50.4 (p< 0.01) and 16.0 to 55.4 (p,< 0.01) respectively.

There was a 13% complication rate with one case requiring revision for loosening to a stemmed implant. Most were cases requiring subsequent acromioplasty. In one case the glenoid rim was fractured during head dislocation. There was a low rate of perioprosthetic radiolucency (4.2%) which may relate to the hydroxyappatite coating within the shell of the prosthesis. Ipsilateral stemmed elbow replacement was performed in some cases without a double stress riser effect. Periprosthetic humeral neck fracture as managed non-operatively with uneventful union.

Conclusion: The good outcome reported in Copeland’s own series has been replicated in the early to medium term at our institution. The surface replacement system is simpler, accurate and preserves bone stock.

Background: Total elbow prostheses are broadly classified into linked and the unlinked categories. We have looked at long-term results of unlinked Kudo 5 total elbow replacement used in the treatment of patients with rheumatoid arthritis in 2 hospitals.

Methods: 87 Kudo 5 Total elbow replacements in 70 patients with adult rheumatoid arthritis were performed at Wexham Park Hospital, Slough and City Hospital, Nottingham by 2 specialist elbow surgeons, the senior authors.

16 patients had died and 8 patients were lost to follow up. 62 elbow replacements in 46 patients were evaluated at a mean follow up of 79 months [29–137 months] using the Mayo Clinic Performance Index. Postoperative radiographs were also reviewed for loosening using standard anteroposterior and lateral films.

Results: Preoperatively 6 had moderate pain and 56 had severe pain. Postoperatively the pain was rated as none or mild by 58 and moderate by 4. The average Mayo Elbow Score improved from 37 preoperatively to 86 postoperatively. The mean arc of flexion/extension improved from 60 to 99 degrees. There were 14 complications including ulnar neuropraxia, fracture, dislocation, triceps rupture and loosening. 4 cases were revised, 2 for aseptic and 2 for septic loosening. Postoperative radiographs showed 5 cases with loosening around the ulna component.

Conclusions: The long-term results using the Kudo 5 elbow prosthesis in patients with rheumatoid arthritis are acceptable and comparable to other series reported of this implant. To date this is the largest series reported with the longest follow up using this implant.

Replacement of the shoulder in juvenile idiopathic arthritis is not often performed and there have been no published series to date.

We present nine glenohumeral hemiarthroplasties in eight patients with systemic or polyarticular juvenile idiopathic arthritis. The mean follow-up was six years (59 to 89 months). The mean age at the time of surgery was 32 years. Surgery took place at a mean of 27 years after diagnosis. The results indicated excellent relief from pain. There was restoration of useful function which deteriorated with time, in part because of progression of the systemic disease in this severely affected group. No patient has required revision to date and there has been no radiological evidence of loosening or osteolysis around the implants.

We discuss the pathoanatomical challenges unique to this group. There was very little space for a prosthetic joint and, in some cases, bony deformity and the small size necessitated the use of custom-made implants.

A 5 year review into the workload and subsequent financial implications of pelvic and acetabular reconstruction at a regional tertiary referral centre.

To ascertain the level and means of financial recompense for performing pelvic/acetabular reconstruction on patients from other healthcare trusts at a tertiary referral centre.

The records of all 120 patients who underwent either pelvic or acetabular reconstruction between 1995–2000 were examined. Epidemiological data and information on all possible costs of their stay was accumulated (itemised finance department figures were used).

The individual patient billing system of ECRs (Extra Contractual Referrals) was changed in 1998 and replaced by the OATs system (Out of Area Treatments) whereby an annual lump sum was received based on historic referral patterns. We investigated the financial effects that occurred.

60 out of 120 patients treated, were from other health-care trusts. From 1995–1998, 25 ECR patients were treated at an estimated cost of £480, 000. The trust received £280, 000, a net loss of £200, 000. From 1998–2000, 34 OATS patients were treated at an estimated cost of £650, 000, amounting to a net gain of £1. 15 million pounds.

‘Out of area’ referrals for pelvic and acetabular reconstruction have increased by 50 % in the last 2 years. However the new payment system i. e. OATS has resulted in the tertiary referral centre being generously rewarded, unlike prior to 1998 and the old ECR system. It is therefore recommended that annual review must be carried out to ensure that funding will meet the demand for specialist services in the future and prevent subsidisation of some centres by other trusts.

Purpose: To describe the characteristic examination findings post whiplash injury of relevance to the shoulder surgeon and an injection test, which can be used to abolish these signs and distinguish neck from shoulder pathology.

5A large amount has been written about whiplash injuries of the neck, but many of these patients are often referred to shoulder units for assessment either acutely or years after the accident because of continuing symptoms. Although neck pain is the commonest complaint tenderness on examination is sided and within the trapezius muscle in virtually all cases. Pain referred to the shoulder is also reported in 36 – 67% whilst interscapular pain occurs in 20 – 72%, depending on the time from injury.

We have reviewed a personal series of the senior author of over 700 cases. The consistent finding in these patients is tenderness localised to a specific part of the trapezius in the base of the neck, which is sided. Tenderness on the same side is also present along the vertebral border of the scapula to its lower pole in over 90%, provided the scapula is protracted. A further finding in some patients is a high arc of pain on abducting the arm, thus simulating an acromioclavicular joint problem, but in these cases the pain is localised to the trapezius. These findings are in addition to those of the neck, which may show some restricted movement due to pain.

The trapezius tenderness can be abolished by the injection of local anaesthetic into the trigger spot at the base of the neck (whiplash injection test), which also resolves most of the above signs and allows further assessment of the shoulder without the referred pain from the injected area.

Conclusions: Shoulder examination in patients who have suffered whiplash injuries is often difficult due to referred pain. Knowledge of the signs specifically due to the whiplash injury is required so that shoulder pathology is not assumed. A new whiplash injection test not previously described has been found very useful in abolishing the whiplash signs to enable accurate shoulder assessment in our practice.

The purpose of this study was to look at the results of using the Copeland surface replacement in the treatment of arthritis of the shoulder.

We report the results of 61 Type 3 Copeland surface replacements in 57 patients. Operations were performed in 33 cases of Rheumatoid Arthritis, 27 cases of Osteoarthritis and 1 case of posttraumatic arthritis. Hemiar-throplasty was performed via a Deltopectoral approach by the senior author in all cases. There were 38 females and 19 males with a minimum follow up of 1 year and a mean follow up of 26 months (range 12–65). Patients were scored pre and post operatively using the Constant score. Average pre-op score was 15.6 and post-operatively was 52.5. There was one case of loosening ( ? secondary to infection) requiring revision to a stemmed implant. Two patients required Sub-Acromial decompression for postoperative impingement. All patients considered their shoulder improved following this procedure. There was no evidence of radiolucency in any postoperative radiograph.

Cementless surface replacement arthroplasty in our series show similar results to previously reported series of stemmed implants and to the published results available for this implant.

In the last six months 6 cases of subacute epiphyseal osteomyelitis have presented to the Paediatric Orthopaedic Department at the University Hospital of Wales, Cardiff. We present a clinical review of these cases illustrating the salient points in their varied presentation and management, together with the results of a retrospective analysis of the incidence of this rare condition. We ask “is there an increasing incidence of this rare condition or have we become increasingly aware of this potential diagnosis in children?”