Biomedical subjects
Publications and source records attributed to J A Fixsen.
We report two cases of deformity of the ankle caused by physeal damage secondary to extravasation of an intravenous infusion in infancy. The possible mechanisms of injury to the physis are discussed.
We report a review of 33 hips (32 patients) which had required repeat open reduction for congenital dislocation of the hip. They were followed up for a mean of 76 months (36 to 132). Factors predisposing to failure of the initial open reduction were simultaneous femoral or pelvic osteotomy, inadequate inferior capsular release, and inadequate capsulorrhaphy. Avascular necrosis had developed in more than half the hips, usually before the final open reduction. At review, 11 of the hips (one-third) were in Severin grade 3 or worse; five had significant symptoms and only ten were asymptomatic and radiographically normal. Once redisplacement has occurred after primary open reduction, attempts to reduce the head by closed means or by pelvic or femoral osteotomy are usually unsuccessful and a further open reduction is necessary.
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The appearance of regenerate bone during the process of limb lengthening using a mono-axial device was studied using radiographs and ultrasound scanning in nine patients. The corticotomy site initially appeared as a sonolucent area. Poorly organized echogenic foci were detectable 2 weeks after the distraction was begun. After 4 weeks, these areas became aligned. At 7-8 weeks, a clear impression of a new cortical margin was seen. The formation of a medullary canal started at this point, progressing to a radiographically evident canal. Ultrasound scanning can reduce considerably exposure to ionising radiation in patients undergoing limb lengthening. Accurate measurements are possible in the early stages, and ossification can be monitored. Axial deviation can be seen but not evaluated. The maturity of the regenerate bone still has to be assessed clinically.
Seventeen patients were reviewed after callotasis lengthening for congenital limb length discrepancy. The average age at lengthening was 10.8 years. Length discrepancy before lengthening ranged from 4.5 cm to 12 cm for the leg, and 24 mm to 30 mm for the forearm. At completion of the lengthening process, all but one patient had their discrepancy corrected successfully. The difficulties encountered were classified into problems, obstacles and complications. All patients suffered from superficial infection, but in only one case did this become a complication, resulting in a residual femoral discrepancy of 2 cm. Of the other three patients who suffered a complication, one fractured through the newly formed bone. The fracture was treated conservatively. In two further femoral lengthenings, the fixator had to be exchanged under general anaesthesia because it had reached its maximum excursion. Callotasis appears to be a safe and reliable method for correcting congenital limb length discrepancy in children.
Nine patients (age 8.9, range 6.5 to 9.5 years) with idiopathic haemihypertrophy were followed at six month intervals for two years. The isometric voluntary contraction strength of the elbow flexors and knee extensors was measured bilaterally, and expressed per unit of muscle and bone cross sectional area of the upper arm (elbow flexors) and of the mid thigh (knee extensors). In absolute terms, the hypertrophic side was always stronger, and the increase in strength was strongly correlated with the increase in limb size bilaterally (P less than 0.01). The hypertrophic limb always exerted greater isometric strength, but if strength was standardized for an anthropometric estimate of upper arm and mid thigh cross sectional area, the normal and hypertrophic side were not significantly different. The limb length discrepancy, when expressed in percentage, remained constant at approximately 3%.
Limb lengthening in nine patients was monitored by radiographs and by ultrasound scans. The distraction gap appeared as a sonolucent area within which echogenic foci developed soon after distraction commenced. By seven weeks a new cortex was detected, and medullary canal began to develop between seven and eight weeks. Ultrasound scanning can be used to measure distraction, but it was not as useful as radiographs in detecting angulation. Its use in patients undergoing limb lengthening could reduce their exposure to radiation.
Tibial dysplasia is a rare congenital deformity which must be distinguished from the more common fibular dysplasia. We have reviewed 24 patients with 35 affected legs. The classification system of Kalamchi and Dawe (1985) was found to be preferable to that of Jones, Barnes and Lloyd-Roberts (1978) as a guide to prognosis and management. We discuss the outcome of surgical treatment, recommending selective amputation for most cases.
Four children suffering from neurofibromatosis with ulnar pseudarthrosis and progressive reabsorption of the middle and distal thirds of the ulna are reported. None had any pain or sensory loss, but all had progressive deformity of the forearm. Instability of the elbow and wrist were present in three cases, while one case showed good stability and function. A cross-union of the ulna with the radius to produce a one-bone forearm was accomplished using screw fixation and iliac bone grafting, and a one-bone forearm was achieved in three cases. Non-operative management was decided on in the patient with slow ulna reabsorption. The creation of a one-bone forearm is more likely to produce sound union, thus avoiding the need for further operations, while conservative management should be reserved for patients with a slowly progressive condition.
We describe 11 children with fibular hypoplasia and three- or four-ray feet, two bilaterally. This deformity is a less severe form of the better known congenital short tibia with absent or dysplastic fibula. If the leg-length discrepancy is minor, no treatment or a simple orthosis are used. Epiphysiodesis or leg lengthening by callotasis is appropriate for mild to moderate discrepancy. If the foot is non-functional, or the projected leg-length discrepancy is too great, early amputation and a prosthesis are advised.
We have treated 11 patients aged three days to 15 years with bladder exstrophy by horizontal osteotomies of the innominate bones. The operation was originally used for older patients with severe deformity or failed previous surgery but is now applied as a primary procedure in the first week of life. The osteotomies enable the complex malformations to be corrected in a single operation without turning the patient: the pubic bones can be brought together, the abdominal wall repaired and the bladder closed with reconstruction of the urethra and external genitalia. The early results have been very satisfactory in all cases with only minor complications; we felt that a preliminary report should be made, despite a mean follow-up of only seven months.
Four cases of limb shortening presenting in childhood are described. All four children had been managed in a neonatal intensive care unit and had developed complications following the insertion of intravascular cannulae. In two, lower limb shortening and deformity were secondary to direct epiphyseal damage following extravasation of calcium or dextrose from a peripheral venous line. In the other two, forearm shortening followed ischaemia, secondary to either radial artery thrombosis from a radial artery cannula or spasm of the brachial artery following extravasation from a venous cannula in a neonate who also had a radial artery cannula. These cases highlight an important complication of the use of vascular cannulae in neonates and the problems this may pose to the orthopaedic surgeon.
We report the case of a 16-year-old girl suffering from painful hypertrophic non-union of the ulnar styloid. She fractured the distal end of the radius four years before and had been treated conservatively. The non-union was painful and severely limited the range of movement of the wrist. Excision of the hypertrophied styloid was performed and the patient promptly resumed her activities. We believe this is the first such case reported in an adolescent.
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Upper femoral osteotomy is a recognised treatment for selected patients with Perthes' disease. The results of this procedure were investigated at skeletal maturity in 44 patients (48 hips). The indication for operation was Catterall group II, III, and IV hips with 'head-at-risk' signs. Harris and Iowa scores were calculated clinically, and each hip was assigned radiographically to one of the five Stulberg classes, its initial Catterall grading checked and other relevant indices measured. Results showed excellent clinical function. Shortening was present in 14 hips (29%) and a positive Trendelenburg's sign was seen in 12 (25%). On radiographic assessment 58% of hips were Stulberg class I or II, with a good prognosis. The results of femoral osteotomy were better than those for conservatively treated hips in all age groups except those under five years.
A case of osteomyelitis of the proximal radial epiphysis in a 6-year-old boy is presented. The effect on the cartilaginous tissues and the potential for growth of the epiphysis must be considered.
Two male infants were noted at birth to have open wounds involving a forearm. These have been associated with abnormal bone modelling and growth. The cause of these appearances remains unclear and no similar cases have been reported.
The case of an adolescent BMX rider suffering from bilateral intraarticular loose bodies of the elbow is reported. He underwent surgery to remove these. He is now asymptomatic and has resumed BMX riding. This is the first overuse injury to be ascribed to this sport. It is probably due to repetitive valgus compression stresses at the radiocapitellar joint during the acrobatic manoeuvres of a typical BMX riding session.