Bone growth following lengthening for congenital shortening of the lower limb.

Bone and limb growth velocity ratios were studied in patients undergoing lengthening for unilateral congenital shortening of the lower limb. In 15 patients before lengthening, the length ratio (LR) between the normal and short sides remained constant with age. Consequently, the growth velocity ratio (GVR) between the normal and short sides also remained constant and equal to the LR. In 20 children, no significant change in GVR was observed after lengthening was carried out at a mean age of 9.6 years. Our results suggest that final limb length remains reasonably predictable and that an acceptable discrepancy can be expected, especially following lengthening after age 9 years.

Open fractures of the tibia in children.

We describe the results of treatment of open tibial fractures in 92 children; 22 fractures were Gustilo type I, 51 type II and 19 type III. All children received tetanus prophylaxis, systemic antibiotics for 48 hours and thorough debridement and irrigation of the wound. Fifty-one wounds with minimal soft-tissue injury were closed primarily. The other 41 were initially left open; of these, 18 small wounds were allowed to heal secondarily and 23 larger wounds required split skin grafts or soft-tissue local or microvascular free flaps. Stable fractures were reduced and immobilised in an above-knee plaster cast (71%) and external fixation (28%) was used for unstable fractures, extensive soft-tissue injury and multiple injuries. Short-term complications included compartment syndrome (4%), superficial infection (8%), deep infection (3%), delayed union (16%), nonunion (7.5%) and malunion (6.5%): these incidences are similar to those reported in adults. Selective primary closure of wounds did not increase the incidence of infection. External fixation was associated with a greater occurrence of delayed and nonunion than plaster immobilisation, but this technique was used most often for the more severe injuries. Late review, at 1.5 to 9.8 years, showed a high incidence of continuing morbidity including pain at the healed fracture site (50%), restriction of sporting activity (23%), joint stiffness (23%), cosmetic defects (23%) and minor leg-length discrepancies (64%). Open tibial fractures in children are associated with a high incidence of early and late complications, which are more frequent in children with Gustilo type III injuries. The Gustilo classification was a useful guide for predicting the outcome and planning treatment.

Biodegradable pin fixation of elbow fractures in children. A randomised trial.

A prospective randomised clinical trial was undertaken to compare biodegradable polyglycolic acid pins with standard Kirschner wires used to fix displaced elbow fractures in children. Twenty-four children were enrolled in the trial; 14 had fractures of the lateral condyle of the humerus, eight of the medial epicondyle and two had olecranon fractures. Eleven fractures were fixed with Kirschner wires and 13 with polyglycolic acid pins. Fracture union with full function occurred in all cases within six months. Kirschner wires caused problems including infection in three cases, soft-tissue ossification in one and they required removal under general anaesthesia in nine cases. No such complications occurred with polyglycolic acid pins but one patient in this group developed avascular necrosis and premature fusion of the medial epicondyle.

Arthroscopy in children.

Arthroscopy was performed on the knees of 67 children aged 2-16 years with an overall clinical diagnostic accuracy of 45%. The most common clinical diagnoses were meniscal tear and patello-femoral pain and the accuracy of these diagnoses was 33% and 59% respectively. Diagnostic accuracy seemed unrelated to age. Arthroscopy led to definitive treatment which relieved symptoms in 21 (31%) of cases, revealed a diagnosis only in 43 (64%), and was non-contributory in 3 (4.5%). The procedure did not significantly help patients with patello-femoral pain.

Deep infection of cemented total hip arthroplasties caused by coagulase-negative staphylococci.

We reviewed a series of 91 patients with deep infection of a cemented total hip arthroplasty caused by coagulase-negative staphylococci (C-NS). Of these, 72 were treated by one-stage exchange arthroplasty with a failure rate of 13% due to recurrence of infection. The other 19 patients have started or completed treatment by a two-stage exchange without failure to date. In 27 of the 91 patients multiple strains of C-NS were discovered, many being resistant to previously used antibiotics. The use of gentamicin-containing cement in the primary arthroplasty was significantly associated with the emergence of gentamicin-resistant C-NS in subsequent deep infection. Bacteriological diagnosis of such infections must take into consideration the possibility that multiple strains of the organism are involved.

Anterior interosseous nerve palsy following internal fixation of the proximal radius.

Three cases of anterior interosseous nerve palsy were diagnosed after internal fixation of fractures of the proximal radius. The suggestion that the nerve was injured at operation by bone-holding forceps was supported by operations on 12 cadaver forearms, in which the nerve was frequently trapped. Care should be taken to place such forceps in a subperiosteal plane.

The da Silva method of incisional hernia repair.

A technique of incisional hernia repair originally devised by da Silva is described. The operation was performed on 30 patients and no recurrence was found in the 27 cases examined 1 to 4.5 (mean 2.5) years later.

Carcinoid tumor arising in a cystic duplication of the small bowel.

We describe a unique case of carcinoid tumor arising in a cystic duplication of the ileum, and review the literature of malignancy associated with small-bowel duplication.