Purpose

To analyse the effectiveness of using outpatient management of paediatric bone and joint infections with parenteral antibiotic therapy in terms of its efficacy, safety and cost-effectiveness compared to prolonged inpatient treatment.

The purposes of this study were to investigate whether twins and multiple births have a higher incidence of Developmental Dysplasia of the Hip (DDH), and whether universal ultrasound scanning would be beneficial in this population.

The purpose of this study was to investigate if there is a relationship between the timing of reduction of displaced supracondylar humerus fractures in children and post-operative complications and open reduction rate and to evaluate the usefulness of the definition of early (eight hours or less following injury) and delayed (more than eight hours following injury) treatment used in the literature.

The case notes of children who were treated at our institution for a Gartland grade 2b and 3 supracondylar humerus fracture between July 1995 and June 2002 were reviewed.

We identified 431 patients with a Gartland grade 3 and 141 patients with a Gartland grade 2b fracture. The time from injury to surgery ranged from 2 hours to 13 days. The average time to reduction was 12 hours for grade 3 injuries and 21 hours for grade 2b injuries. None of the patients had an initial closed reduction in the emergency department. 229 patients were treated early with two compartment syndromes, five ulnar nerve, one lateral cutaneous nerve of the forearm, one median nerve - and one radial nerve palsy, one septic arthritis, one pin site infection, six open reductions; one re-manipulation was required for loss of reduction. The delayed group consisted of 343 patients with six ulnar nerve, three median nerve, one radial nerve and one lateral cutaneous nerve of the forearm palsy, three pin site infections, five open reductions; re-manipulation was required in one patient. All nerve palsies recovered post-operatively. The open reduction rate was two percent. The majority of displaced supracondylar humerus fractures in children do not need to be operated on as an emergency. Operation of fractures not associated with a neurovascular compromise within eight hours of the injury does not seem to reduce the rate of significant complications and open reduction rate. In contrary the most severe complication, the development of a compartment syndrome was only seen in the early group. We did not identify an association between complication rateS and a time threshold. Therefore the differentiation between early and delayed treatment used in the literature seems to be arbitrary and not useful.

We present our data on a cohort of 25 patients who had an arthroscopy of their hip between the ages of 12 and 17 out of over 1100 hip arthroscopies performed.

All patients presented with pain and marked restriction of activities. Either a CT (before MRI was available) or MRI scan was done pre-operatively. 10 patients presented with a history of either Perthes disease, DDH or a defined injury causing their symptoms. In the remaining the onset of symptoms was spontaneous. The intra-operative diagnosis varied: normal (6), labral tear (6), loose bodies (2), debris and/or chondromalacia (8), synovitis (2) and damaged ligamentum teres (1). None of the patients developed a complication. The pre-operative Harris Hip Score ranged from 0 to 40 (mean 21) for pain and 0 to 47 (mean 35) for function. The follow-up ranged from 6 weeks to 9years (mean 3 years). Harris Hip Score at latest follow-up ranged from 10 to 44 (mean 33) for pain and from 31 to 47 (mean 43) for function.

Conclusion: Hip arthroscopy is a very useful tool as part of the investigation and treatment of hip problems in carefully selected children and adolescents.

Aims: The purpose of this retrospective study was to determine if open reduction, with pelvic and femoral osteotomy, for a dislocated hip in children with severe spastic quadriplegia alters the function or symptoms of the patient and to determine radiographic factors that correlate with sypmtoms. Methods: The validated Pediatric Evaluation of Disability Inventory (PEDI) and a self-constructed questionnaire asking about pain, hygiene, sitting status and ambulatory status were sent to the caregivers of 52 patients who were operated on. Radiographs were reviewed for changes in centre edge angle, acetabular index, migration index and femoral head defect. Results: 27 caregivers completed the questionnaires. Complete pre-operative radiographs and radiographs from latest follow-up were available in 42 patients and complete radiographs and completed questionnaires were available for 21 patients. The average age at surgery was 9 years with a mean follow-up of 5.5 years. The results of the PEDI did not change signiþcantly following surgery. The second questionnaire showed an improvement of hygiene care for 11 patients, weight bearing for transfers for seven, sitting status for 10 and sitting tolerance for 18. Pain improved for 17 and deteriorated for two patients. There was no correlation between radiographic measures and function or symptoms. Conclusions: Open reduction with pelvic and femoral osteotomy for dislocated hips in children with severe cerebral palsy can result in a decrease in pain and a modest improvement in function.

This study was undertaken to assess the long term results of treatment of club foot by modified Turco’s Procedure.

Thirty patients with 50 feet were treated by serial casting and postero-medial release for club feet, by modified Turco’s procedure. All patients treated from January 1980 to January 1983 were included in the study. Eighteen patients with 33 club feet were available for the final follow-up. They were followed up for an average of 13.8 years, range of 10 – 16 years. There were two females while the remaining 16 males. Only three patients had unilateral affection and all were males. Only patients with idiopathic club feet were chosen for this study. All patients underwent serial plaster correction after birth till undergoing surgical correction. All procedures were carried by the senior surgeon, using the same technique. All patients were operated between the ages of 6 – 9 months, depending on the severity of deformity and correction achieved with serial plaster. A modified Turco’s technique was used. A longer incision extending to the lateral border of tendoachilles was used. The abductor hallucis was completely excised. All patients had a subtalar release as well. No K wire was used for holding the correction. All children were left in plaster till they started walking. No Dennis-Browne Splint was used, but a modified splint and correction shoes were used in the postoperative period. There were no wound problems in any cases, either at the time of wound closure or later on. They were followed with clinical and radiological examinations. There were no wound problems which is a frequent problem in most series. Three (9%) cases each had recurrence of heel varus and forefoot adduction. The forefoot adduction was less than as compared to other studies. Three cases had some cavus deformity while four cases had flat foot. All patients were noted to have calf muscle wasting. The results were assessed using Ponseti’s score. The average Ponseti’s score was 87.2 (range 49 – 98). Two feet out of 33 had recurrence of all the deformities. There were 27 good to excellent results. The most common problem was terminal restriction of dorsiflexion, but most of the patients were happy with the results. We believe that our treatment is safe, simple, giving satisfactory results in more than 80% and with minimal complications. The results are maintained over a long follow up period. We think that this modified approach helped reduce one of the common deformities to recur.

All supracondylar humeral fractures managed with closed or open reduction and pin fixation at the Hospital for Sick Children between 1995 and 2002 were retrospectively reviewed. Time from injury to treatment, post reduction complications and need for open reduction were recorded. Fractures treated ≥ 8 hours from injury were considered in the early treatment group while > 8 hours were considered in the late treatment group. Fractures presenting with a cold hand (four patients) were taken to the operating room as quickly as possible and were excluded from the study.

There were 431 patients with a Gartland grade 3 and 141 patients with a Gartland grade 2b. The time from injury to surgery ranged from 2 hours to 13 days. The average time to reduction was 12 hours for grade 3 injuries and 21 hours for grade 2b injuries. None of the patients had an initial closed reduction in the emergency department. The early treatment group consisted of 230 patients with two compartment syndromes, six ulnar-, one superficial radial-, one median- and one radial nerve palsy, one septic arthritis, one pin site infection, six open reductions and one re-manipulation was required for loss of reduction. The late treatment group consisted of 342 patients with six ulnar-, three median-, one radial nerve palsy and one lateral cutaneous nerve of the forearm palsy, three pin site infections, five open reductions and re-manipulation was required in one patient. All nerve palsies recovered post-operatively.

Conclusion: There was no significant difference in the proportion of complications between the early and late treatment group, but the most severe complication, the development of a compartment syndrome was only seen in the early group. Delayed treatment of supracondylar humeral fractures seems to be safe in a large number of patients, and in fact, most of our patients were treated more than eight hours from the injury. Early operation of fractures not associated with a neurovascular compromise also does not seem to reduce the complication rate. Nevertheless the decision when to operate needs to be decided for each patient individually.

The purpose of this retrospective study was to determine if open reduction, with pelvic and femoral osteotomy, for a dislocated hip in children with severe spastic quadriplegia alters the function or symptoms of the patient, and to determine radiographic factors that correlate with symptoms.

Between 1989 and 1997 56 patients/hips were operated on. The validated Pediatric Evaluation of Disability Inventory (PEDI) and a self-constructed questionnaire asking about pain, hygiene, sitting status, sitting tolerance, weight bearing for transfers, and ambulatory status were sent to all families. Radiographs were reviewed for changes in the centre edge angle (CE), acetabular index (AI), migration index (MI) and femoral head defect (FHD). 27 caregivers completed the questionnaires. Radiographs (pre-operative – latest follow-up) were available for 42 patients. 21 patients had both questionnaire and radiograph information.

Logistic regressions were used to test whether the radiographic measures could predict each of the questionnaire outcomes which were grouped as ‘improved’ and ‘not improved’.

The average age at surgery was 8.9 years (n=56: 1.8 – 16.5) for all patients, for patients with a completed questionnaire 9.4 years (n=27: 4.2–15.4). Time from surgery to follow-up was in average 5.5 years (1.8–9.5).

All but 2 of the patients with completed questionnaire were nonambulatory (2 were functional ambulatory). As a group, the results of the PEDI did not significantly change following surgery. From the results of the second questionnaire: hygiene care improved for 11 patients, weight bearing for transfers improved for 7, sitting status improved for 10, and sitting tolerance improved for 18 patients.

At follow-up, pain worsened in 2 patients, did not improve in 2 patients, and the remainder were pain free. The ability to provide hygiene care worsened for the 2 patients with worsening pain. Weight bearing for transfers and sitting status worsened in 3 patients, 2 of who were the patients with worsening pain, and the other had an unreduced dislocation of the opposite hip. Sitting tolerance worsened in 3 patients, 2 of who were the patients with worsening pain.

Four patients who did not have femoral head defects prior to surgery developed them after surgery. Two of these four patients were the ones who developed worsening pain but had normal CE, AI and MI measures. Other radiographic measures of the hips did not correspond with function or symptoms. Eight patients had a femoral head defect prior to surgery and none were symptomatic at follow-up.

Our assessment method shows that open reduction for the dislocated hip in children with severe cerebral palsy can result in a decrease in pain and a modest improvement in function. However, the postoperative development of a femoral head defect is associated with worse pain and poorer function. A pre-existing femoral head defect is not a contraindication to surgery.

The purpose of this study was to determine the surgical risks and recurrence rate associated with the excision of osteochondroma from the long bones most frequently operated on in our institution; the femur, tibia, humerus and fibula.

Two hundred and twenty four osteochondromata were excised in total between July 1992 and January 2001. The medical records and radiographs of 126 patients who had 147 osteochondromata excised from the femur, tibia, humerus and fibula were reviewed. Of these, 30 patients presented with multiple osteochondromata, accounting for 48 of the 147. Fifty three involved the femur (2 proximal), 55 the tibia (16 distal), 12 the fibula (2 distal) and 27 the proximal humerus. The mean age at excision was 12.5 years (2–18 years) and the mean follow-up was five years (1 to 10 years).

There were 15 surgical complications (10% of excisions) including one compartment syndrome, five superficial wound infections, two haematoma formations which required evacuation, one partial wound dehiscence, one deep infection with sinus formation which required excision, one sural nerve and one saphenous nerve neuropraxia, one cutaneous nerve entrapment and two hypertophic scar/keloid formations.

The patient with the compartment syndrome had excision of a distal femoral, proximal tibial and fibular osteochondroma during the same procedure and was diagnosed to have won Willebrand disease after the surgery. There were eight recurrences involving five patients with multiple osteochondromata and three in whom the excision was incomplete due to the proximity to neurovascular structures.

Surgical risks related to excision of osteochondroma are relatively frequent and must not be underestimated. Excision should therefore only be performed if strongly indicated. The recurrence rate (5.5%) seems to be higher than previously reported in the literature (2%) and generally affects patients with multiple osteochondromata. Incomplete excision resulted in recurrence in all our cases.

In this study we highlight the advantages supported by long term results of using our external fixator system for femoral derotation osteotomy as part of our management regime for developmental dysplasia of the hip. Out of all the children in the East Kent area who present with a dislocated hip each year about 4 require a femoral derotation osteotomy in order to maintain a good position after either open or closed reduction.

The system has been used since 1981. 51 patients (56 hips) were reviewed with a follow up between 5 and 18 years with a mean of 11 years. The age at diagnosis ranged from shortly after birth to 42 months with a mean of 12 months. The treatment involved a protocol in which traction was applied for 4 weeks preoperatively if the hip was high and open or closed reduction was selected according to the result of an arthrogram. 33 of the 51 patients received traction and 23 patients (25 hips) had an open reduction. Following reduction the hips were immobilized in a spica for 6 weeks after which the femoral osteotomy using the fixator was performed. A second 6 week period of spica immobilization followed after which the fixator and spica were removed. We had 16 complications including 3 patients who developed AVN of the femoral head. 8 patients required an additional 16 operations.

We assessed the patients clinically and radiologically using the Severin’s grading system. At final follow up over 85% of patients were assessed to have a clinical grade of 1 and 2 and over 70% a radiological grade of 1 and 2.

Our technique of external fixation has several advantages over conventional methods of fixation of the femur: a) the avoidance of a 2nd open procedure to remove the implant, b) the accuracy of the femoral derotation using the goniometer and c) the achievement of femoral fixation without the need for image intensifier screening.