Between 1990 and 2001, 24 children aged between 15 months and 11 years presented with late orthopaedic sequelae after meningococcal septicaemia. The median time to presentation was 32 months (12 to 119) after the acute phase of the disease. The reasons for referral included angular deformity, limb-length discrepancy, joint contracture and problems with prosthetic fitting. Angular deformity with or without limb-length discrepancy was the most common presentation. Partial growth arrest was the cause of the angular deformity. Multiple growth-plate involvement occurred in 14 children. The lower limbs were affected much more often than the upper. Twenty-three children underwent operations for realignment of the mechanical axis and limb-length equalisation. In 15 patients with angular deformity around the knee the deformity recurred. As a result we recommend performing a realignment procedure with epiphysiodesis of the remaining growth plate when correcting angular deformities.

An audit of general practitioner (GP) Paediatric orthopaedic referrals to our hospital (1996) revealed that the average waiting time was 84 weeks for non-urgent simple conditions. A physiotherapy specialist clinic was set up to reduce waiting times for non-urgent, new general practitioner Paediatric Orthopaedic referrals.

To review the outcome at a minimum of 12 months of 1046 consecutive referrals to the Physiotherapy Specialist clinic and to analyse its effectiveness.

114 patients failed to attend the clinic. The remaining 932 patients form the basis of this study. Outcome measures included reduction in the waiting times, patient satisfaction, number of re-referrals to the clinic from the general practitioners and cost-effectiveness. 93% of these patients were managed without direct consultant intervention 71. 6% with advice and reassurance, 16. 9% by referral to the physiotherapy department and 4% with surgical appliances. Only 7% needed consultant evaluation. Waiting time for non-urgent conditions was reduced from 84 weeks in May 1996 to 5 weeks in May 1999. A majority of the parents were satisfied with the clinic. The clinic was found to be cost-effective.

The physiotherapy specialist clinic was effective in reducing waiting times for new non-urgent Paediatric Orthopaedic referrals. The success of the clinic was attributable to good co-operation between the consultant and physiotherapist and a well-defined protocol for assessment and management of patients.

The purpose of this retrospective study was to analyze the risk factors, causes, bacteriology of deep infection following extensible endoprosthetic replacement for bone tumours in children and to review our experience in the treatment of 20 patients with infected prostheses.

123 patients with extensible endoprostheses were treated between 1983 and 1998. Three types of prostheses, which differed in the lengthening mechanism used, were implanted. 20 of these were diagnosed to have deep infection. Patients were divided into 3 groups: group I 5 patients were treated with a single stage revision, group 11– 13 patients were treated with a two stage revision procedure, group Ill- 2 patients had a primary amputation. Control of infection was assessed clinically and with inflammatory markers. Function was assessed using the MSTS score.

The overall incidence of infection was 16%. The incidence of infection at the proximal tibia and distal femur was 27% and 14% respectively. Staphylococcus epidermidis was the most common organism. The most common clinical features were pain and swelling around the prostheses. Infection in most cases was immediately preceded by an operative procedure or by distant a focus of infection. The number of operative procedures and the site of the prosthesis were significant risk factors. The success rate was 20% in Group 1 and 84% in Group II. Amputation was the salvage procedure of choice for failed revision procedures. The mean MSTS functional score was 83% in patients in whom the infection was controlled.

The incidence of deep infection is high following extensible endoprostheses. The site of the prosthesis and the number of operative procedures are significant risk factors. The type of prosthesis used is not a risk factor. Two-stage revision is successful in controlling infection in a majority of these cases.

The purpose of this retrospective study was to analyze the indications for spinal instrumentation, report the clinical features, operative details and outcome in 16 patients with active pyogenic spinal infection.

Between January 1991 to October 1999, 81 patients with spontaneous pyogenic spinal infection were treated at the authors’ institution. Surgery (other than biopsy) was indicated in 24 patients for neurological deterioration, deformity or instability. Sixteen of these patients were treated with instrumentation in the presence of active spinal infection. Six patients underwent combined anterior and posterior procedures. 10 had a posterior procedure only. Outcomes assessed were control of infection, neurology, fusion, back pain and complications.

At a mean follow up period of 26. 9 months, all surviving patients were free of clinical infection. None of the patients had neurological deterioration. All patients who had neurological deficit preoperatively improved by at least one Frankel grade. A solid fusion was achieved in 15 patients. 12/15 patients remained asymptomatic or had very little pain. The remaining 3 patients had mild to moderate back pain. The mean correction of the kyphotic deformity was 18. 92 degrees. Postoperative complications included bronchopneumonia, nonfatal pulmonary embolism and seizures in 3 patients. One patient developed progressive kyphosis despite instrumentation but eventually fused in kyphus.

Given early recognition of pyogenic spinal infection, most cases can be managed non-operatively. Our results support that instrumented fusion with or without decompression may be used safely when indicated without the risk of recurrence of infection. Instrumentation facilitates nursing care and allows early mobilisation. For biomechanical reasons, a combined procedure is probably indicated for lesions above the conus. For lesions below the conus, we were able to achieve successful results with posterior approach only.

This retrospective clinical study describes our experience of the use of growing endoprostheses in children with primary malignant tumours of the proximal femur and analyses the results.

Between 1983 and 1996 we treated nine children with primary bone tumors of the proximal femur by resection and proximal femoral extensible replacements. Outcomes measured were function of the limb using Musculoskeletal Tumor Society score, oncologic outcome, complications and equalization of limb length. Results: Four patients died as a result of pulmonary metastases. The remaining five patients were observed for an average follow-up period of 7. 6 years (range 11–12. 7 years). One patient had a hindquarter amputation for uncontrolled infection. In these five patients we performed an average of 10. 2 operative procedures per patient (range of 3–17 procedures) including 5 lengthening procedures (range of 1–8 procedures) and a mean total extension of 69. 7 mm per patient. Acetabular loosening and hip dislocations were the most frequent complications. Only two patients have not had a revision or a major complication. Despite this, 4 children are alive with a functioning lower limb and a mean Musculoskeletal Tumour Society functional score of 77. 6%. The limb length discrepancy was less than 1 0 mm in three of these patients. The remaining patient has a discrepancy of 50 mm and is awaiting further limb equalization procedures.

Extendible endoprostheses of the proximal femur in selected children is a viable reconstructive procedure. It allows for equalization of limb length and the ability to walk without the use of mobility aids.

34 two-stage revision procedures were carried out between 1989 and 1998 for controlling deep infection following resection of bone tumours and reconstruction with endoprostheses. In 4 cases the procedure failed with early recurrent infection. In six others infection reappeared after further operative procedures. Six of these ten patients required amputation. The success of the procedure in controlling infection was 75% at 5 years. Two stage revision procedures have proved effective in controlling infection in massive endoprostheses but the risk of re-infection appears to be much greater in patients requiring further surgery for any cause.