Aims. Magnetically controlled growing rods (MCGRs) allow non-invasive correction of the spinal deformity in the treatment of early-onset scoliosis. Conventional growing rod systems (CGRS) need repeated surgical distractions: these are associated with the effect of the ‘law of diminishing returns’. The primary aim of this study was to quantify this effect in MCGRs over sequential distractions. . Patients and Methods. A total of 35 patients with a maximum follow-up of 57 months were included in the study. There were 17 boys and 18 girls with a mean age of 7.4 years (2 to 14). True Distraction (TD) was determined by measuring the expansion gap on fluoroscopy. This was compared with Intended Distraction (ID) and expressed as the ‘T/I’ ratio. The T/I ratio and the Cobb angle were calculated at several time points during follow-up. Results. The mean follow-up was 30 months (6 to 57). There was a significant decrease in the mean T/I ratio over time (convex rod at 3 months 0.81, . sd. 0.58 vs 51 months 0.17, . sd . 0.16, p = 0.0001; concave rod at 3 months 0.93, . sd. 0.67 vs 51 months 0.18, . sd. 0.15, p = 0.0001). A linear decline of the mean T/I ratios was noted for both convex rods (r. 2. = 0.90, p = 0.004) and concave rods (r. 2. = 0.81, p = 0.015) over 51 months. At the 24-month follow-up stage, there was a significant negative correlation between the mean T/I ratio of the concave rod with weight (r = -0.59, p = 0.01), age (r = -0.59, p = 0.01), and BMI of the child (r = -0.54, p = 0.01). Conclusions. The ‘law of diminishing returns’ is also seen after serial distraction using MCGR. Compared to previously published data for CGRS, there is a gradual linear decline rather than a rapid initial decline in lengthening. In older, heavier children a reduced distraction ratio in the concave rod of the MCGR device is noted over time. Cite this article: Bone Joint J 2017;99-B:1658–64

Aims

Hip arthroplasty does not always restore normal anatomy. This is due to inaccurate surgery or lack of stem sizes. We evaluated the aptitude of four total hip arthroplasty systems to restore an anatomical and medialized hip rotation centre.

Aims . To assess the effect of high tibial and distal femoral osteotomies (HTO and DFO) on the pressure characteristics of the ankle joint. Materials and Methods. Varus and valgus malalignment of the knee was simulated in human cadaver full-length legs. Testing included four measurements: baseline malalignment, 5° and 10° re-aligning osteotomy, and control baseline malalignment. For HTO, testing was rerun with the subtalar joint fixed. In order to represent half body weight, a 300 N force was applied onto the femoral head. Intra-articular sensors captured ankle pressure. Results. In the absence of restriction of subtalar movement, insignificant migration of the centre of force and changes of maximal pressure were seen at the ankle joint. With restricted subtalar motion, more significant lateralisation of the centre of force were seen with the subtalar joint in varus than in valgus position. Changes in maximum pressure were again not significant. . Conclusion. The re-alignment of coronal plane knee deformities by HTO and DFO altered ankle pressure characteristics. When the subtalar joint was fixed in the varus position, migration of centre of force after HTO was more significant than when the subtalar joint was fixed in valgus. Cite this article: Bone Joint J 2017;99-B:59–65

Severe hallux valgus deformity is conventionally treated with proximal metatarsal osteotomy. Distal metatarsal osteotomy with an associated soft-tissue procedure can also be used in moderate to severe deformity. We compared the clinical and radiological outcomes of proximal and distal chevron osteotomy in severe hallux valgus deformity with a soft-tissue release in both. A total of 110 consecutive female patients (110 feet) were included in a prospective randomised controlled study. A total of 56 patients underwent a proximal procedure and 54 a distal operation. The mean follow-up was 39 months (24 to 54) in the proximal group and 38 months (24 to 52) in the distal group. At follow-up the hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle, tibial sesamoid position, American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal score, patient satisfaction level, and complications were similar in each group. Both methods showed significant post-operative improvement and high levels of patient satisfaction. Our results suggest that the distal chevron osteotomy with an associated distal soft-tissue procedure provides a satisfactory method for correcting severe hallux valgus deformity. Cite this article: Bone Joint J 2013;95-B:510–16

Aims

Open tibial fractures are limb-threatening injuries. While limb loss is rare in children, deep infection and nonunion rates of up to 15% and 8% are reported, respectively. We manage these injuries in a similar manner to those in adults, with a combined orthoplastic approach, often involving the use of vascularised free flaps. We report the orthopaedic and plastic surgical outcomes of a consecutive series of patients over a five-year period, which includes the largest cohort of free flaps for trauma in children to date.

Deformity of the forearm due to growth disturbance of the ulna occurs in a number of conditions such as ulnar deficiency, multiple exostoses, and neurofibromatosis. We report a previously unrecognised form, caused by focal cortical indentation. We have treated five children with this condition, three girls and two boys; the mean age at presentation was 5 years (2 to 8). The deformity was first recognised about the age of two years, and progressed gradually. The radiological findings were the same in all cases. The focal cortical indentation was seen at the distal end of the ulna with anteromedial bowing and dysplasia. The radial head was dislocated posterolaterally. In one patient the histological findings at the site of indentation were of a fold of tissue resembling periosteum, which interfered with enchondral ossification. Treatment by ulnar lengthening using an external fixator and osteotomy which corrected both the ulnar deformity and reduced the dislocated radial head in two cases gave the best results

Achieving arthrodesis of the ankle can be difficult in the presence of infection, deformity, poor soft tissues and bone loss. We present a series of 48 patients with complex ankle pathology, treated with the Ilizarov technique. Infection was present in 30 patients and 30 had significant deformity before surgery. Outcome was assessed clinically and with patient-reported outcome measures (Modified American Orthopaedic Foot and Ankle Society (MAOFAS) scale and the Short-Form (SF-36)). Arthrodesis was achieved in 40 patients with the Ilizarov technique alone and in six further patients with additional surgery. Infection was eradicated in all patients at a mean follow-up of 46.6 months (13 to 162). Successful arthrodesis was less likely in those with comorbidities and in tibiocalcaneal fusion compared with tibiotalar fusion. These patients had poor general health scores compared with the normal population before surgery. The mean MAOFAS score improved significantly from 24.3 (0 to 90) pre-operatively to 56.2 (30 to 90) post-operatively, but there was only a modest improvement in general health; the mean SF-36 improved from 44.8 (19 to 66) to 50.1 (21 to 76). There was a major benefit in terms of pain relief. Arthrodesis using the Ilizarov technique is an effective treatment for complex ankle pathology, with good clinical outcomes and eradication of infection. However, even after successful arthrodesis general health scores remain limited. Cite this article: Bone Joint J 2013;95-B:371–7

Deformity after slipped upper femoral epiphysis (SUFE) can cause cam-type femoroacetabular impingement (FAI) and subsequent osteoarthritis (OA). However, there is little information regarding the radiological assessment and clinical consequences at long-term follow-up. We reviewed 36 patients (43 hips) previously treated by in situ fixation for SUFE with a mean follow-up of 37 years (21 to 50). Three observers measured the femoral head ratio (FHR), lateral femoral head ratio (LFHR), α-angle on anteroposterior (AP) and frog-leg lateral views, and anterior femoral head–neck offset ratio (OSR). A Harris hip score < 85 and/or radiologically diagnosed osteoarthritis (OA) was classified as a poor outcome. Patients with SUFE had significantly higher FHR, LFHR and α-angles and lower OSR than a control group of 22 subjects (35 hips) with radiologically normal hips. The interobserver agreement was less, with wider limits of agreement (LOA), in hips with previous SUFE than the control group. At long-term follow-up abnormal α-angles correlated with poor outcome, whereas FHR, LFHR and OSR did not. We conclude that persistent deformity with radiological cam FAI after SUFE is associated with poorer clinical and radiological long-term outcome. Although the radiological measurements had quite wide limits of agreement, they are useful for the diagnosis of post-slip deformities in clinical practice

Aims

Pelvic tilt (PT) can significantly change the functional orientation of the acetabular component and may differ markedly between patients undergoing total hip arthroplasty (THA). Patients with stiff spines who have little change in PT are considered at high risk for instability following THA. Femoral component position also contributes to the limits of impingement-free range of motion (ROM), but has been less studied. Little is known about the impact of combined anteversion on risk of impingement with changing pelvic position.

Aims

This study aimed to evaluate whether an enhanced recovery protocol (ERP) for arthroplasty established during the COVID-19 pandemic at a safety net hospital can be associated with a decrease in hospital length of stay (LOS) and an increase in same-day discharges (SDDs) without increasing acute adverse events.

Aims

The patient-acceptable symptom state (PASS) is a level of wellbeing, which is measured by the patient. The aim of this study was to determine if the proportion of patients who achieved an acceptable level of function (PASS) after medial unicompartmental knee arthroplasty (UKA) was different based on the status of the anterior cruciate ligament (ACL) at the time of surgery.

Limb alignment in total knee arthroplasty (TKA) influences periarticular soft-tissue tension, biomechanics through knee flexion, and implant survival. Despite this, there is no uniform consensus on the optimal alignment technique for TKA. Neutral mechanical alignment facilitates knee flexion and symmetrical component wear but forces the limb into an unnatural position that alters native knee kinematics through the arc of knee flexion. Kinematic alignment aims to restore native limb alignment, but the safe ranges with this technique remain uncertain and the effects of this alignment technique on component survivorship remain unknown. Anatomical alignment aims to restore predisease limb alignment and knee geometry, but existing studies using this technique are based on cadaveric specimens or clinical trials with limited follow-up times. Functional alignment aims to restore the native plane and obliquity of the joint by manipulating implant positioning while limiting soft tissue releases, but the results of high-quality studies with long-term outcomes are still awaited. The drawbacks of existing studies on alignment include the use of surgical techniques with limited accuracy and reproducibility of achieving the planned alignment, poor correlation of intraoperative data to long-term functional outcomes and implant survivorship, and a paucity of studies on the safe ranges of limb alignment. Further studies on alignment in TKA should use surgical adjuncts (e.g. robotic technology) to help execute the planned alignment with improved accuracy, include intraoperative assessments of knee biomechanics and periarticular soft-tissue tension, and correlate alignment to long-term functional outcomes and survivorship.

Aims

The aim of the study was to compare two methods of calculating pelvic incidence (PI) and pelvic tilt (PT), either by using the femoral heads or acetabular domes to determine the bicoxofemoral axis, in patients with unilateral or bilateral primary hip osteoarthritis (OA).

Aims

The purpose was to evaluate early clinical, patient-reported, and radiological outcomes of the scapholunate ligament 360° tenodesis (SL 360) technique for treatment of scapholunate (SL) instability.

There is much debate about the nature and extent of deformities in the proximal femur in children with cerebral palsy. Most authorities accept that increased femoral anteversion is common, but its incidence, severity and clinical significance are less clear. Coxa valga is more controversial and many authorities state that it is a radiological artefact rather than a true deformity. We measured femoral anteversion clinically and the neck-shaft angle radiologically in 292 children with cerebral palsy. This represented 78% of a large, population-based cohort of children with cerebral palsy which included all motor types, topographical distributions and functional levels as determined by the gross motor function classification system. The mean femoral neck anteversion was 36.5° (11° to 67.5°) and the mean neck-shaft angle 147.5° (130° to 178°). These were both increased compared with values in normally developing children. The mean femoral neck anteversion was 30.4° (11° to 50°) at gross motor function classification system level I, 35.5° (8° to 65°) at level II and then plateaued at approximately 40.0° (25° to 67.5°) at levels III, IV and V. The mean neck-shaft angle increased in a step-wise manner from 135.9° (130° to 145°) at gross motor function classification system level I to 163.0° (151° to 178°) at level V. The migration percentage increased in a similar pattern and was closely related to femoral deformity. Based on these findings we believe that displacement of the hip in patients with cerebral palsy can be explained mainly by the abnormal shape of the proximal femur, as a result of delayed walking, limited walking or inability to walk. This has clinical implications for the management of hip displacement in children with cerebral palsy

Guiding growth by harnessing the ability of growing bone to undergo plastic deformation is one of the oldest orthopaedic principles. Correction of deformity remains a major part of the workload for paediatric orthopaedic surgeons and recently, along with developments in limb reconstruction and computer-directed frame correction, there has been renewed interest in surgical methods of physeal manipulation or ‘guided growth’. Manipulating natural bone growth to correct a deformity is appealing, as it allows gradual correction by non- or minimally invasive methods. This paper reviews the techniques employed for guided growth in current orthopaedic practice, including the basic science and recent advances underlying mechanical physeal manipulation of both healthy and pathological physes

Aims. There is no consensus about the best method of achieving equal leg lengths at total hip arthroplasty (THA) in patients with Crowe type-IV developmental dysplasia of the hip (DDH). We reviewed our experience of a consecutive series of patients who underwent THA for this indication. Patients and Methods. We retrospectively reviewed 78 patients (86 THAs) with Crowe type-IV DDH, including 64 women and 14 men, with a minimum follow-up of two years. The mean age at the time of surgery was 52.2 years (34 to 82). We subdivided Crowe type-IV DDH into two major types according to the number of dislocated hips, and further categorised them into three groups according to the occurrence of pelvic obliquity or spinal curvature. Leg length discrepancy (LLD) and functional scores were analysed. Results. Type-I included 53 patients with unilateral dislocation, in which 25 (category A) had no pelvic obliquity or spinal deformity, 19 (category B) had pelvic obliquity with a compensated spinal curvature and nine (category C) had pelvic obliquity and decompensated spinal degenerative changes. Type-II included 25 patients with one dislocated and one dysplastic hip, in which there were eight of category A, 15 of category B and two of category C. Pre-operatively, there were significant differences between the anatomical and functional LLD in type-IB (p = 0.005) and -IC (p < 0.001), but not in type-IA, -IIA or -IIB. Post-operatively, bony LLD increased significantly in types-IB, -IC and -IIB, whereas functional LLD decreased significantly in each type except for IIA. The mean functional LLD decreased from 30.7 mm (standard deviation (. sd. ) 18.5) pre-operatively to 6.2 mm (. sd. 4.4) post-operatively and the mean anatomical LLD improved from 35.8 mm (. sd. 19.7) pre-operatively to 12.4 mm (. sd. 8.3) post-operatively. Conclusion. Pelvic and spinal changes are common in patients with Crowe type-IV DDH and need to be taken into consideration when planning THA, in order to obtain equal leg lengths post-operatively. The principal subdivisions of Crowe type-IV DDH which we describe proved effective in achieving equal leg lengths and satisfactory outcomes. Cite this article: Bone Joint J 2017;99-B:872–9

Aims

To explore staff experiences of a multicentre pilot randomized controlled trial (RCT) comparing intramedullary nails and circular frame external fixation for segmental tibial fractures.