A retrospective review of 42 patients from 1999 to 2008 with at least 1-year follow-up was performed. The type and location of epiphysiodesis, average operative time and hospital stay, complications, timing and the final limb length discrepancy (LLD) were recorded. Computer tomography scanograms and mechanical axis view with grids were done to assess LLD. Twenty-six patients underwent Canale type epiphysiodesis compared with 14 receiving Metaizeau screw epiphysiodesis. The average operation time for Canale type was 42 and 45 min for screw epiphysiodesis. In the Canale group, there was a mean reduction in 2.5 cm in LLD from 3.7 to 1.2 cm over an average follow-up of 2.1 years. There were 4 minor and 2 major complications with a 92 % success rate defined as achieving the desired discrepancy correction. In the screw epiphysiodesis group, the mean change was 1.8 cm from 3.2 to 1.4 cm, over 2.2 years with 2 minor and 2 major complications and a success rate of 85 %. Percutaneous epiphysiodesis by any method is a reliable, minimally invasive method with minimal morbidity and an acceptable complication rate when compared to a corrective osteotomy or an open Phemister-type epiphysiodesis. This study has led to our preference for the Canale method, which in our hands has fewer complications and is more successful at reaching the desired discrepancy correction.

Torsional deformities of the femur and/or tibia often go unrecognized in adolescents and adults who present with anterior knee pain, and patellar maltracking or instability. While open and arthroscopic surgical techniques have evolved to address these problems, unrecognized torsion may compromise the outcomes of these procedures. We collected a group of 16 consecutive patients (23 knees), with mean age of 17, who had undergone knee surgery before torsion was recognized and subsequently treated by means of rotational osteotomy of the tibia and/or femur. By follow-up questionnaire, we sought to determine the role of rotational correction at mean 59-month follow-up. We reasoned that, by correcting torsional alignment, we might be able to optimize long-term outcomes and avert repeated knee surgery. Knee pain was significantly improved after torsional treatment (mean 8.6 pre-op vs. 3.3 post-op, p < 0.001), while 70 % of patients did have some continued knee pain postoperatively. Only 43 % of patients had continued patellar instability, and 57 % could trust their knee after surgery. Activity level remained the same or increased in 78 % of patients after torsional treatment. Excluding planned rod removal, subsequent knee surgery for continued anterior knee pain was undertaken on only 3 knees in 2 patients. We believe that malrotation of the lower limb not only raises the propensity for anterior knee symptoms, but is also a under-recognized etiology in the failure of surgeries for anterior knee pain and patellar instability. Addressing rotational abnormalities in the index surgery yields better clinical outcomes than osteotomies performed after other prior knee surgeries.

Indications and techniques of locked plate fixation for the treatment of challenging fractures continue to evolve. As design variant of classic locked plates, the polyaxial locked plate has the ability to alter the screw angle and thereby, enhance fracture fixation. The aim of this observational study was to evaluate clinical and radiographic results in 89 patients with 90 fractures of the distal femur treated, between June 2006 and November 2011, with such a polyaxial locked plating system (Polyax™ Locked Plating System, DePuy, Warsaw, IN, USA). Seventy-seven fractures formed the report of this study. These cases were followed up until complete fracture healing or for a mean time of 77 weeks. At the time of last follow-up, 58 of 77 fractures (75.3 %) progressed to union without complication and radiographic healing occurred at a mean time of 16.3 weeks. Complications occurred in ten fractures that did not affect the healing and in nine fractures that showed delayed or non-union. The mean American Knee Society Score at the time of final follow-up was 83 for the Knee Score and 71.1 for the Functional Score. In conclusion, there is a high union rate for complex distal femoral fractures associated with a good clinical outcome in this series.

The patella plays an important role in the knee joint extension, and a patella fracture requires surgical treatment when it is accompanied by displacement of bone fragments and a joint surface gap. In patella fractures, there is disruption of the soft tissue structures that support the knee extension mechanism. We use a method of percutaneous cerclage wiring to fix the patella and include the peripatellar soft tissues in five patients. All cases were closed fractures, and the AO classification was type A in 1 and type C in 4. At a mean follow-up of 11.2 months, union was achieved in four cases with failure in one inferior pole fracture avulsion. There was no extensor lag noted in any patient, with mean flexion at 141° (120–160). As this percutaneous cerclage wiring method includes soft tissue approximation in the wiring, it may be especially suitable for comminuted fractures for which classic tension band wiring techniques cannot be used. We employed this procedure to atraumatically manipulate peripatellar soft tissues together with the fracture fragments in order to obtain optimal restoration of continuity of the extensor mechanism.

Bicondylar tibial plateau fractures are serious injuries to a major weight-bearing joint. These injuries are often associated with severe soft tissue injuries that complicate surgical management. We reviewed 54 consecutive patients who sustained bicondylar tibial plateau fractures that were treated with limited open reduction and cannulated screw fixation combined with fine-wire circular external fixation. Forty-six patients met the inclusion criteria of this retrospective review. Eight patients were excluded because they did not complete a minimum of 1-year follow-up. Thirty-six patients had Schatzker type-VI, and ten patients had Schatzker type-V fractures. All fractures were united without loss of reduction; there were no incidences of wound complications, osteomyelitis or septic arthritis. The average Knee Society Clinical Rating Score was 81.6, translating to good clinical results. Minor pin track infection was the most common complication encountered. This review concludes that fine-wire circular external fixation, combined with limited open reduction and cannulated screw fixation, consistently produces good functional results without serious complications.

The management of tibial non-union is challenging with protracted, often arduous, treatments. The purpose of this study was to assess patient-reported outcomes following treatment of tibial non-union in circular external fixators. Twenty-one patients with tibial non-unions who successfully completed treatment at a mean of 10.1 months (range 6–20) in a circular external fixator were sent questionnaires utilising the Enneking scoring system and Euroqol EQ-5D. There were 14 responses. The mean Enneking score was 58.0 % (34.3–77.1). Two patients were enthusiastic about their treatment, while three accepted but would not repeat the treatment. The Euroqol questionnaire found that 8 patients had difficulty with mobility, 10 had difficulty with usual activities and 12 had moderate pain. There was no statistically significant difference in the EQ VAS score of overall health state for treated patients compared with predicted scores for an age- and sex-matched UK population (77.7 vs 83.1, p = 0.07).

During the initial fragmentation stage of Perthes disease, the principle focus is to achieve containment of the femoral head within the acetabulum. Whether by bracing, abduction casts, femoral and/or pelvic osteotomy, the goals are to maximize the range of hip motion and to avoid incongruity, hoping to avert subsequent femoro-acetabular impingement or hinge abduction. A more subtle and insidious manifestation of the disease relates to growth disturbance involving the femoral neck. We have chosen to tether the greater trochanteric physis, combined with a medial soft tissue release, as part of our non-osteotomy management strategy for select children with progressive symptomatology and related radiographic changes. In addition to providing containment, we feel that this strategy addresses potential long-range issues pertaining to limb length and abductor mechanics, while avoiding iatrogenic varus deformity caused by osteotomy. This is a retrospective review of 12 patients (nine boys, three girls), average age 7.3 years old (range 5.3–9.7), who underwent non-osteotomy surgery for Perthes disease. An eight-plate was applied to the greater trochanteric apophysis at the time of arthrogram, open adductor and iliopsoas tenotomy, and Petrie cast application. We compared clinical and radiographic findings at the outset to those at an average follow-up of 49 months (range 14–78 months). Six plates were subsequently removed; the others remain in situ. Eleven of twelve patients experienced improvement in pain, and alleviation of limp and Trendelenburg sign at latest follow-up. The majority had improved or maintained range of motion and prevention of trochanteric impingement demonstrated by near normalization of abduction. Neck-shaft angles, Shenton's line, extrusion index, center edge angles and trochanteric height did not change significantly. One patient underwent subsequent trochanteric distalization and no other patients have undergone subsequent femoral or periacetabular osteotomies. Leg length discrepancy worsened in four patients and was treated with contralateral eight-plate distal femoral epiphysiodesis. As a group the mean leg length discrepancy did not change significantly. There were no perioperative complications. six trochanteric plates were subsequently removed after an average of 43.7 months (range 28–69) due to irritation of hardware; the others remain in situ, pending further growth. We employed open adductor and iliopsoas tenotomy and Petrie cast application and guided growth of the greater trochanter as a means of redirecting the growth of the common proximal femoral chondroepiphysis. The accrued benefits of preventing relative trochanteric overgrowth with a flexible tether are the avoidance of iatrogenic varus and weakening of the hip abductors. The goals are to preserve abductor strength and avoid trochanteric transfer or intertrochanteric osteotomy.

Evaluation of the material properties of regenerate bone is of fundamental importance to a successful outcome following distraction osteogenesis using an external fixator. Plain radiographs are in widespread use for assessment of alignment and the distraction gap but are unable to detect bone formation in the early stages of distraction osteogenesis and do not quantify accurately the structural properties of the regenerate. Dual X-ray absorptiometry (DXA) is a widely available non-invasive imaging modality that, unlike X-ray, can be used to measure bone mineral content (BMC) and density quantitatively. In order to be useful as a clinical investigation; however, the structural two-dimensional geometry and density distributions assessed by DXA should reflect material properties such as modulus and also predict the structural mechanical properties of the regenerate bone formed. We explored the hypothesis that there is a relationship between DXA assessment of regenerate bone and structural mechanical properties in an animal model of distraction osteogenesis. Distraction osteogenesis was carried out on the tibial diaphysis of 41 male, 12 week old, New Zealand white rabbits as part of a larger study. Distraction started after a latent period of 24 h at a rate of 0.375 mm every 12 h and continued for 10-days, achieving average lengthening of 7.1 mm. Following an 18-day period of consolidation, the regenerate bone was subject to bone density measurements using a total body dual-energy X-ray densitometer. This produced measurement of BMC, bone mineral density (BMD) and volumetric bone mineral density (vBMD). The tibiae were then disarticulated and cleaned of soft tissue before loading in compression to failure using an Instron mechanical testing machine (Instron Corporation, Massachusetts USA). Using Spearman rank correlation and linear regression, there was a significant correlation between vBMD and the Modulus of Elasticity, Yield Stress and Failure Stress of the bone. No correlation was seen between BMC, BMD, vBMR and any mechanical parameter. DXA is a promising tool for the assessment of regenerate bone formed by DO during limb lengthening and requires further investigation.

The purpose of this study was to evaluate the results of our correction osteotomies of distal radial malunions without a bone graft. Eleven consecutive patients (mean age 52 years, range 18–71) were treated. A dorsal approach was utilised to perform an opening-wedge osteotomy which then was stabilised with two dorsal columnar plates without filling the osteotomy gap. All patients went on to radiographic union with a filling of the osteotomy gap within a mean period of 3 months (range 2–6 months). All patients had satisfactory results in terms of function and pain. Correction osteotomy and stabilisation with bicolumnar locked plate fixation without a bone graft provides sufficient stability to allow the highly vascularised metaphysis to heal. In patients without risk factors predisposing to non-union, this procedure is safe and feasible.

Perforator flaps have been introduced for coverage of local and distant defects. Various designs of this flap are possible, but their role in the setting of trauma is debated. We report that it is possible to raise these flaps in cases of post-traumatic lower limb reconstruction with good results. Consideration must be given to the type of movement that is planned vis-a-vis the number of perforators identified.