The management of the orthopaedic sequelae of meningococcal septicaemia: patients treated to skeletal maturity.

Septicaemia resulting from meningococcal infection is a devastating illness affecting children. Those who survive can develop late orthopaedic sequelae from growth plate arrests, with resultant complex deformities. Our aim in this study was to review the case histories of a series of patients with late orthopaedic sequelae, all treated by the senior author (CFB). We also describe a treatment strategy to address the multiple deformities that may occur in these patients. Between 1997 and 2009, ten patients (seven girls and three boys) were treated for late orthopaedic sequelae following meningococcal septicaemia. All had involvement of the lower limbs, and one also had involvement of the upper limbs. Each patient had a median of three operations (one to nine). Methods of treatment included a combination of angular deformity correction, limb lengthening and epiphysiodesis. All patients were skeletally mature at the final follow-up. One patient with bilateral below-knee amputations had satisfactory correction of her right amputation stump deformity, and has complete ablation of both her proximal tibial growth plates. In eight patients length discrepancy in the lower limb was corrected to within 1 cm, with normalisation of the mechanical axis of the lower limb. Meningococcal septicaemia can lead to late orthopaedic sequelae due to growth plate arrests. Central growth plate arrests lead to limb-length discrepancy and the need for lengthening procedures, and peripheral growth plate arrests lead to angular deformities requiring corrective osteotomies and ablation of the damaged physis. In addition, limb amputations may be necessary and there may be altered growth of the stump requiring further surgery. Long-term follow-up of these patients is essential to recognise and treat any recurrence of deformity.

Late orthopaedic sequelae following meningococcal septicaemia. A multicentre study.

Between 1990 and 2001, 24 children aged between 15 months and 11 years presented with late orthopaedic sequelae after meningococcal septicaemia. The median time to presentation was 32 months (12 to 119) after the acute phase of the disease. The reasons for referral included angular deformity, limb-length discrepancy, joint contracture and problems with prosthetic fitting. Angular deformity with or without limb-length discrepancy was the most common presentation. Partial growth arrest was the cause of the angular deformity. Multiple growth-plate involvement occurred in 14 children. The lower limbs were affected much more often than the upper. Twenty-three children underwent operations for realignment of the mechanical axis and limb-length equalisation. In 15 patients with angular deformity around the knee the deformity recurred. As a result we recommend performing a realignment procedure with epiphysiodesis of the remaining growth plate when correcting angular deformities.

Use of distraction osteogenesis techniques in skeletal dysplasias.

The authors report the results of 63 operations performed on patients with skeletal dysplasias using the techniques of distraction osteogenesis. There were a total of 26 patients (16 males, 10 females) with a mean age of 12.5 years. The group had 13 different skeletal dysplasias. In 55 of 63 (87%) of the procedures, the objectives of surgery were achieved. The authors review their results with reference to the type of fixator used and the underlying diagnosis. Circular frames were associated with improved results. Spondylometaphyseal dysplasia and Jeune syndrome were the only dysplasias treated that were associated with significant complications.

Residual bone cysts after Ilizarov treatment of relapsed clubfeet.

The Ilizarov technique is well established as an effective method of treating clubfoot deformities. A complication of this method is the development of cysts in the bones of the foot. The purpose of this study was to clarify the incidence, presentation, and etiology of these cysts. The radiographs of 17 feet that had undergone Ilizarov treatment for a clubfoot deformity were reviewed. In nine of the feet, discrete, well demarcated lucencies of bone were detected. They occurred in both tarsal and metatarsal bones, but most commonly in the base of the fifth metatarsal. Magnetic resonance imaging examination of two feet demonstrated a normal marrow signal. suggesting that the cysts are due to localized trabecular resorption with the space being filled with marrow fat.

The Ilizarov method in the management of relapsed club feet.

We present the results of the management of 17 relapsed club feet in 12 children using the Ilizarov method with gradual distraction and realignment of the joint. Review at a mean of three years after surgery showed maintenance of correction with excellent or good results in 13 feet. Five mobile feet which had been treated by a split transfer of the tibialis anterior tendon two weeks after removal of the frame had an excellent result.

Primary sternal osteomyelitis in infants: a report of two cases.

Primary sternal osteomyelitis in infants, older children, and adults is rare. Secondary sternal osteomyelitis, however, is more common because of the increased frequency of cardiothoracic surgery and intravenous drug abuse. Primary sternal osteomyelitis is reviewed, two infants with further cases of primary sternal osteomyelitis are presented, and diagnosis and management are discussed.

[Management of fibular hemimelia]. / Die Behandlung der fibularen Hemimelie.

Fibular hemimelia is a congenital longitudinal deficiency that represents a spectrum of deformities. The management of this condition is controversial and our treatment options are changing with developments in limb reconstruction techniques. For the severely affected child with a predicted limb length discrepancy greater than 25 cm at maturity and with a poor foot and ankle amputation is generally agreed to be the best option. For less severely affected limbs, particularly those with a predicted limb discrepancy of 10 cm or less and with a foot with 3 or more rays which can be made plantigrade, limb reconstruction is recommended. Controversy remains about the best way to manage children with an intermediate deformity.

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 Syme's amputation. However, complications are common. Frequency and severity of complications apparently is less in younger patients who require less extensive, staged lengthening.

Do nonorganic signs help to predict the return to activity of patients with low-back pain?

The value of the nonorganic signs in predicting return to activity following an initial episode of low-back pain was determined. One hundred and twenty patients were assessed within 6 months of the onset of their first episode of disabling low-back pain and again at a mean of 15.3 months following injury. No correlation was found between the presence of nonorganic signs at initial assessment and either return to activity or resolution of the patient's symptoms.

Tibia vara due to focal fibrocartilaginous dysplasia. The natural history.

We report five patients with tibia vara due to focal fibrocartilaginous dysplasia of the medial aspect of the proximal tibia. In three patients spontaneous correction occurred, while in one of the remaining two treated by operation, a valgus deformity and neurological complications resulted. Conservative management is therefore recommended.

Distal femoral replacement by custom-made prostheses. Clinical follow-up and survivorship analysis.

We report the long-term clinical follow-up and survivorship analysis of 40 distal femoral replacements performed between 1964 and 1980 for traumatic, locally aggressive and malignant conditions. Custom-made prostheses with fully-constrained knee joints were used to replace a mean of 42% of the length of the femur. Survivorship analysis showed a cumulative success rate of 80% at eight years, with no subsequent deterioration at 18 years. Clinical assessment revealed 78% excellent or good results. Failure was due to infection in three cases, and in two to fracture of a now-outmoded femoral stem.

Angiosarcoma arising in a patient with Maffucci syndrome.

Maffucci syndrome comprises multiple enchondromas together with cutaneous haemangiomas. Review of the literature shows a 15-20% incidence of sarcomatous change in one or more of the enchondromas. Malignancy arising from the vascular component, however, has only been reported in one case. We present a further case where a patient with Maffucci syndrome presented with multifocal angiosarcoma.

Carpal tunnel syndrome in patients on haemodialysis.

Eight cases of carpal tunnel syndrome are reported, all of which developed in patients on haemodialysis for chronic renal failure. In each case the arm involved had been used for a fistula. The aetiology of the syndrome in these patients is discussed; it is multifactorial, but related to the sites of arteriovenous fistulae. Decompressing the carpal tunnel provides effective and lasting relief.