Paul Gibbons

Fibular hemimelia: a preliminary report on management of the severe abnormality.

The introduction of Ilizarov leg lengthening techniques has allowed a change in philosophy in treatment of fibular hemimelia. Between January 1990 and October 1993, eight patients with 10 involved extremities underwent correction of severe grades of fibular hemimelia by the Ilizarov technique. Mean follow-up from operation was 26.7 months. Because the lengthening desired was achieved in all cases, this form of treatment is an attractive alternative to the more traditional Symes amputation. However, complications are common. Frequency and severity of complications apparently is less in younger patients who require less extensive, staged lengthening.

Posterior sloping angle of the capital femoral physis: interobserver and intraobserver reliability testing and predictor of bilaterality.

The management of the contralateral hip after unilateral slipped capital femoral epiphysis (SCFE) is controversial. The aims of this study were to assess the interobserver and intraobserver reliability of the posterior sloping angle (PSA) as described by Barrios et al (J Pediatr Orthop. 2005;25:445-449) and whether it can be used as a predictor of need for prophylactic pinning of the contralateral hip. The PSA was measured by 4 different surgeons on 2 separated occasions in 47 unaffected contralateral hips after unilateral SCFE. The interobserver intraclass correlation coefficient (ICC) was 0.83 (excellent) for the first set of measurements and 0.74 (fair to good) for the second set of measurements. Measurement of the intraobserver ICC revealed an excellent agreement (ICC > 0.75) in 3 of the 4 surgeons and fair to good agreement in 1 of the surgeons (ICC between 0.4 and 0.74). Comparison of the PSA measurements of the first author (M.Z.) with a control group of 20 hips revealed that the PSA was significantly higher (P < 0.05) in the group of patients that eventually had a contralateral slip when compared with the PSA of patients in the study group who did not slip and with normal hips in the control group. Patients with contralateral SCFE that did not slip had a significantly higher PSA (P < 0.05) when compared with normal individuals. A PSA of 14.5 degrees or more is recommended for prophylactic pinning of the contralateral hip. The number needed to treat (NNT) at this cut off to avoid 1 future slip was calculated to be 1.9.

Is Tibialis Anterior Tendon Transfer Effective for Recurrent Clubfoot

BackgroundTibialis anterior tendon transfer surgery forms a part of Ponseti management for children with congenital talipes equinovarus who, after initial correction, present with residual dynamic supination. Although retrospective studies support good outcomes, prospective longitudinal studies in this population are lacking.Questions/purposesWe assessed strength, plantar loading, ROM, foot alignment, function, satisfaction, and quality of life in patients with clubfoot that recurred after Ponseti casting who met indications for tibialis anterior tendon transfer surgery, and compared them with a group of patients with clubfoot treated with casting but whose deformity did not recur (therefore who were not indicated for tibialis anterior tendon transfer surgery).MethodsTwenty children with idiopathic congenital talipes equinovarus indicated for tibialis anterior tendon transfer surgery were recruited. Assessment at baseline (before surgery), and 3, 6, and 12 months (after surgery) included strength (hand-held dynamometry), plantar loading (capacitance transducer matrix platform), ROM (Dimeglio scale), foot alignment (Foot Posture Index©), function and satisfaction (disease-specific instrument for clubfoot), and quality of life (Infant Toddler Quality of Life Questionnaire™). Outcomes were compared with those of 12 age-matched children with congenital talipes equinovarus not indicated for tibialis anterior tendon transfer surgery. Followup was 100% in the control group and 95% (19 of 20) in the tibialis anterior transfer group.ResultsAt baseline, the tibialis anterior tendon transfer group had a significantly worse eversion-to-inversion strength ratio, plantar loading, ROM, foot alignment, and function and satisfaction. At 3 months after surgery, eversion-to-inversion strength, plantar loading, and function and satisfaction were no longer different between groups. Improvements were maintained at 12 months after surgery (eversion-to-inversion strength mean difference, 8% body weight; 95% CI, −26% to 11%; p = 0.412; plantar loading, p > 0.251; function and satisfaction, p = 0.076). ROM remained less and foot alignment more supinated in the tibialis anterior tendon transfer group between baseline and followup (p < 0.001, p < 0.001).ConclusionsTibialis anterior tendon transfer surgery was an effective procedure, which at 12-month followup restored the balance of eversion-to-inversion strength and resulted in plantar loading and function and satisfaction outcomes similar to those of age-matched children with congenital talipes equinovarus who after Ponseti casting were not indicated for tibialis anterior tendon transfer.Level of EvidenceLevel III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Compass elbow hinge: short-term results in five adolescents.

The Compass Elbow Hinge (Smith and Nephew, Memphis, Tennessee, USA) was developed in the late 1990s as a mean of treating elbow contractures, utilizing Ilizarovs principles of distraction histeogenesis and a circular frame external fixator. Subsequent reports were published on its use for treating elbow ankylosis and instability in adults. Since 1999 five paediatric patients (aged from 12 to 15 years) have been treated by this device in our institute. The indications were post-traumatic elbow stiffness in four patients and elbow ankylosis following septic arthritis in one patient. Application of the elbow hinge was accompanied by open soft tissue contracture release, both anteriorly and posteriorly. Elbow mobilization and physiotherapy were commenced immediately postoperatively. The hinge was removed after 6–8 weeks. Follow-up ranged from 5 to 36 months. Complications were limited to simple pin track infection in three patients, and transient ulnar neuropraxia in one. The Compass Elbow Hinge (Smith & Nephew) application was successful in improving the arc of motion in three patients out of five.

Update on clubfoot

Congental talipes equinovarus, or clubfoot, remains one of the commonest congenital limb deformities. The genetics of this condition are not yet fully understood. It is increasingly being diagnosed on prenatal ultrasound with implications for prenatal counselling. With the widespread acceptance of the Ponseti method of clubfoot treatment major surgical interventions are needed much less frequently and long‐term outcomes are improved.

Twelve-month outcome following septic arthritis in children.

There are very few literature data from the last two decades on the rate of complications following septic arthritis in children. This retrospective chart review shows that 10% of children admitted for septic arthritis to our institution suffered from clinically significant complications at 12 months following diagnosis. Forty-four children met our inclusion criteria, of whom 59% were male and 57% were culture positive. The most common causative organism was Staphylococcus aureus (76%), of which only 8% were methicillin-resistant S. aureus. Poor prognostic factors were culture positivity, infancy (<2 years) and male sex. Our rate of dysfunction is lower than most published rates, which have historically been in the range 15 to 49% in developed countries.

Unilateral versus bilateral clubfoot: an analysis of severity and correlation.

This study compares the severity of unilateral and bilateral clubfoot, and the correlation between right and left feet of bilateral cases. Sixty-six unilateral and 75 bilateral clubfoot patients were assessed for severity using the Pirani score at an average age of 12.9 days (SD 9 days). In bilateral cases, the severity of right and left feet was highly correlated (r=0.68). The odds of being very severe were 2.6 (95% confidence interval 1.3–5.1) times higher in bilateral cases (P=0.007). Bilateral and unilateral clubfeet present with differing severity. Right and left feet from bilateral cases are highly correlated. Researchers need to address these issues during study design and analysis.

An olecranon chondral flap and osteochondral coronoid fracture in a spontaneously reduced elbow dislocation in a child.

Elbow injuries in children are very common and radiographs are often difficult to interpret because of the radiolucency of the cartilaginous anlage and the progressive appearance of multiple secondary ossification centres. Elbow dislocations are rare injuries in children. Coronoid fractures can occur during dislocation or relocation of the elbow and can be the only hallmark of a severe injury. The understanding of the mechanics of these injuries has undergone considerable evolution over the past decade. Intra-articular chondral flap fractures are a traumatic elevation of the hyaline cartilage from the subchondral bone. They are also rare injuries in children but should be included in the differential when examining an injured joint. The infrequency of these injuries provides little opportunity to become accustomed to the radiographic signs. We present a case report of a 4-year-old boy with both an olecranon chondral flap and coronoid cartilaginous fracture after a joint dislocation. We present his plain radiography and MRI with illustrated photographic records of the operative findings. This injury has been little described in the literature and never with such imaging to aid understanding of both the pathology and the injury mechanism.

Ureteral triplication: A rare anomaly with a variety of presentations

Ureteral triplication remains a very rare congenital malformation of the urinary tract with a wide spectrum of presentation. The sporadic nature of this condition and its association with other anomalies makes evidence-based management difficult. We report two cases of triplication in association with the VACTERL syndrome, one developing pelvi-ureteric junction obstruction and the other vesico-ureteric reflux.

Biomechanical assessment of children requiring tibialis anterior surgical tendon transfer for residual congenital talipes equinovarus

Congenital talipes equinovarus (CTEV) is a deformity in which the foot is in structural equinus, varus, adductus and cavus and occurs in approximately 1 per 1000 births [1]. Despite good initial correction with the Ponseti technique, a tibialis anterior tendon transfer (TATT) is required in 20-25% of cases to correct residual dynamic supination observed during gait. Currently, no reliable or valid biomechanical measures exist to assess the need for, or effectiveness of, surgery.