Mark J. Flowers

Triplane fractures of the distal tibia requiring open reduction and internal fixation: Pre-operative planning using computed tomography

Computed tomography (CT) of triplane fractures provides useful information not available on conventional radiographs. Knowledge of the size and position of displaced fragments, the location of the intra-articular fracture and any associated articular incongruency is useful when undertaking pre-operative planning.A postal survey of surgeons revealed only 38% always requested CT scans before undertaking open reduction and internal fixation of displaced triplane fractures. Examples of the usefulness of CT scans in pre-operative planning is presented in two cases.

Closed reduction and stabilization of supracondylar fractures of the humerus in children: the crucial factor of surgical experience.

We reviewed the outcome following operative management of displaced (Gartland II and III) supracondylar fractures of the humerus in children over a 2-year period and tried to correlate the outcome with various factors including experience of the treating surgeon. Of the 71 children who formed the study group, 62 (87.3%) had a good outcome irrespective of the treatment modality. Closed reduction followed by plaster immobilization or percutaneous pinning resulted in a better outcome than open reduction. There was a direct involvement of the consultant in the primary management of these injuries in 17 cases (24%), none of which had a poor outcome. Of the 54 cases in whom the primary management was carried out independently by trainees without any consultant supervision, nine patients (17%) developed complications or needed reoperations. The proportion of unsatisfactory outcomes increased to 20.3% when failure to achieve a satisfactory reduction by closed means was also considered as a perioperative complication. There is a learning curve associated with percutaneous pinning after closed reduction and experience of the surgeon seems to be one of the factors that have an influence on the outcome.

Complex Primary Arthrodesis of the First Metatarsophalangeal Joint After Bone Loss

Background: Complications associated with a failed Keller procedure or joint replacement include bone loss and shortening of the first ray. We treated failed Keller resection arthroplasty and joint replacement arthroplasty cases with metatarsophalangeal joint arthrodesis, using an interpositional tricortical autograft from the iliac crest and a low-profile titanium plate. Methods: This was a retrospective case note review of the patients treated by four consultant surgeons in a university teaching hospital. A Keller procedure was considered to have failed when patients presented with a short, painful great toe with valgus cock-up deformity. Prosthetic joint replacements were considered to have failed based on the clinico-radiological loosening with associated pain. Metatarsophalangeal joint arthrodesis was carried out using an interpositional tricortical bone autograft and a titanium plate. Patients were assessed for resolution of pain, clinical and radiological evidence of fusion and complications. Ten operated feet in nine female patients, with a mean age of 55.9 (range, 37.8 to 80.2) years were followed for a mean of 12.6 (range, 6 to 26) months. Six patients presented with failed prosthetic joint replacements and four with failed Keller arthroplasty. Results: Full clinico-radiological union was achieved in nine of the ten patients as judged by an independent consultant musculo-skeletal radiologist. Four patients needed removal of implants, one for infection, two for prominent hardware and one for implant failure. Eight of the ten patients were satisfied with the relief of pain. Conclusion: Failed arthroplasty or Keller procedure is a difficult problem to manage. We recommend complex primary arthrodesis with an interpositional iliac crest autograft and a low profile plate as a salvage procedure. Level of Evidence: IV, Retrospective Case Series

Overcorrection and generalized joint laxity in surgically treated congenital talipes equino-varus.

Fifty patients with 70 previously operated clubfeet were assessed for overcorrection (using Tachdjians flat foot grade) and generalized joint laxity. Twenty-eight patients (40 feet) had signs of generalized joint laxity using the Biro score and of these 25 feet were overcorrected. Of the 22 patients (30 feet) who did not have signs of joint laxity, only three overcorrected. This difference was statistically significant (P<0.001). A significant correlation exists between flat foot grade and laxity score (P<0.01). Overcorrection is a complication largely ignored in the published literature but we believe it is a serious complication of open release often resulting in poor long-term function. For those patients requiring surgery, the authors urge caution and recommend a limited surgical release, particularly if joint laxity is suspected, or the Ponseti method of treatment, which will probably avoid this complication.

Scarf-Akin osteotomy for hallux valgus in juvenile and adolescent patients.

Hallux valgus (HV) has been reported to affect 22–36% of adolescents, with a recurrence rate of around 30–40%. Operative treatment may be indicated in symptomatic deformities where conservative management has failed to halt progression of the deformity. There remains genuine concern with respect to high complication rates including recurrence and stiffness of the metatarsophalangeal joint following operative treatment in adolescents. We report the clinical, functional and radiological outcomes of the Scarf–Akin procedure in the treatment of juvenile and adolescent HV. A review of single surgeon series was carried out of all children who underwent Scarf and Akin osteotomies as a combined procedure for HV between February 2001 and 2010. The preoperative and postoperative intermetatarsal angle (IMA1–2), hallux valgus angle, distal metatarsal articular angle and ratio of the length of first metatarsal to that of the second metatarsal were determined. The American Orthopaedic Foot and Ankle Score was used for functional assessment. Twenty-nine patients (47 feet) underwent Scarf–Akin osteotomies for moderate to severe HV. The average age of the patients at surgery was 11.7 years. The 6-week postoperative radiographs confirmed a significant improvement in the IMA, hallux valgus angle and distal metatarsal articular angle, in all the 47 feet, but 10 patients (14 feet, 29.8%) reported recurrence of hallux valgus at subsequent reviews. The radiological recurrence rate in our series was 29.8%, with 21.3% of patients symptomatic enough to require a revision operation. We report a high recurrence rate in hallux valgus operation in children and hence recommend postponement of correction until skeletal maturity.

Dorsal cortical comminution as a predictor of redisplacement of distal radius fractures in children.

BACKGROUND The purpose of this study was to evaluate the various factors, which could contribute towards redisplacement of distal radius fractures, including comminution of the dorsal cortex of the distal radius, treated in our department. METHODS In this retrospective study, we evaluated the risk of redisplacement of distal radius fractures in our department and also looked at the probable factors predisposing to this risk. A total of 134 fractures(129 children) were included in the study after exclusions. The variables that were assessed as possible causes of redisplacement were age, gender, fracture pattern (apex), degree of initial displacement,presence/absence of comminution, presence/absence of ulnar fracture, grade of surgeon, quality of initial reduction and Cast index. RESULTS After excluding the fractures without a known outcome, 124 fractures (120 children) were available for analysis. The average age of children was 10.6 years (range 2–16 years) with more boys (89)than girls (31). Redisplacement after an initial reduction occurred in 30 children (24%). Six of these children(4.8% of the entire study group) required further intervention. The factors associated with an increased risk of redisplacement were complete initial displacement of fracture (p = 0.02),dorsal bayonet fracture pattern(p = 0.007), presence of comminution (p = 0.001) and the quality of the initial reduction (p = 0.002).Forward stepwise logistic regression analysis revealed comminution at the fracture site to be the most significant factor associated with redisplacement, increasing the odds of redisplacement by 5.82 (95%confidence interval (CI): 2.08–16.22, p = 0.001). There seemed to be a trend towards a reduced risk of redisplacement when K-wiring was done in the presence of comminution (p = 0.12). CONCLUSION The presence of dorsal cortical comminution at the fracture site on initial radiographs should alert the treating surgeon to a significantly higher risk of redisplacement and supplemental K-wiring should be considered in this situation.

Proximal tibiofibular joint instability in a child: stabilization with Tightrope.

Proximal tibiofibular instability is a rarely reported clinical entity in children. In this case report, we describe such a case in an 8-year-old boy successfully stabilized using a minimally invasive technique with a Tightrope device. The child remained pain free and asymptomatic at 2 years of follow-up. The surgical technique is described as well as potential complications and a review of the literature.

Staff opinions on casting material brands: a prospective study.

AIM To determine staff opinions on the application of a sample of seven commercially available casting materials. METHODS The casting materials were supplied for an exclusive 6-week period to individual hospital departments for sole use in cast applications. Each time a staff member applied a cast they completed a blinded evaluation form to assess the following features of the materials performance: *ease with which the material unrolled; *ease with which the peg remained central on the roll; *effectiveness with which the POP casts adhered to the gauze; *stringiness of the material; *how well the material moulded; *how well the material set. The staff member also noted whether, based on their experience, they would be happy to use the material on a daily basis or not. RESULTS A total of 638 evaluation forms were completed for the purpose of this study. Of these, 183 related to POP and 455 were synthetic. Significant differences were identified between the application of POP and synthetic casts and also between the different types of material within each of these categories. Of those staff who expressed a preference, 78% said they would be happy to use POP casts on a daily basis compared to 44% happy to use synthetic casts daily. Of those happy to use POP casts 40% were happy to use Cellona, 90% Gypsona and 40% Conforma. Of those happy to use synthetic casts 20% were happy to use Cellacast, 38% Dynacast, 98% Scotchcast and 10% Deltalite. 22% of staff who expressed a preference objected to the daily use of POP casts compared to 56% who objected to synthetic casts. CONCLUSION This study has identified significant differences in application between POP casts and synthetic casts as well as between individual materials within each category. However, staff using casting materials can reach a consensus opinion on the best material to work with. When choosing a casting material, therefore, it is important to consider the application characteristics of the individual material in addition to other factors such as cost and strength. Overall, Gypsona and Scotchcast were the highest scoring materials.