Titanium plate artefact mimicking popliteal artery dissection on digital subtraction CT angiography.

Titanium plates used for the internal fixation of long bone fractures cause significant artefact on CT scans but have not been reported to affect digital subtraction CT angiography. We present a patient with clinical suspicion of popliteal artery injury following a high tibial osteotomy. The osteotomy was stabilised with a titanium locking plate. During the digital subtraction process used to produce reconstruction CT angiography, removal of artefact caused by the titanium plate produced CT images mimicking the appearance of a popliteal artery dissection. The imaging inaccuracy was realised prior to the patient undergoing further intervention. We highlight the potential error caused by titanium plates on digital subtraction CT angiography and recommend careful analysis of such images prior to further treatment.This article is freely available via Open Access. Click on the 'Additional Link' above to access the full-text from the publisher's site

The "ischial limb": a landmark on anterior ultrasound scanning used to assess reduction in developmental dysplasia of the hip

BACKGROUND: Early recognition of failure of reduction during abduction splinting in developmental dysplasia of the hip (DDH) is essential to avoid inappropriate prolonged damaging harness use. Graf ultrasound scanning (USS) is an accepted gold standard for assessing neonatal hip dysplasia but cannot verify reduction in the abducted position of a neonatal hip in a Pavlik harness. We describe a new anatomic landmark of the hip using anterior USS-the "ischial limb," correlate this to the position of the femoral head in reduced and dislocated positions, and assess the application of this in the assessment of DDH. METHODS: A porcine model was used to identify anatomic, radiologic, and ultrasonic features comparable to the human neonatal hip. A pilot clinical study was conducted of 50 neonates (11M:39F) treated for DDH in Pavlik harness, utilizing weekly anterior USS to determine the concentricity of femoral head reduction relative to the ischial limb and whether this could identify any failures to achieve reduction. RESULTS: The animal model identified an ultrasound landmark, termed the ischial limb that represents the ossification zone of the ischial contribution to the tri-radiate acetabular cartilage, and approximates to the center of the acetabulum. Anterior USS clearly demonstrated this ischial limb in clinical practice and its relation to the femoral head in all dysplastic hips (n=79). Immediate concentric reduction was observed in 11 patients, more gradual reduction over 3 weeks in 37 patients, and failure to achieve stable reduction was verified in 2 patients. The technique was reproducible in 100% of patients (n=50). Mean additional clinic time was 5 minutes per visit. CONCLUSIONS: The ischial limb, identified on anterior hip USS, delineates the position of the tri-radiate cartilage. This technique efficiently assesses hip reduction during Pavlik harness treatment and can differentiate between failure to achieve reduction or maintain a stable reduction at an earlier stage than conventional US methods. LEVEL OF EVIDENCE: Development of diagnostic criteria on basis of consecutive patients: level 2 evidence

Alternative technique in atypical spinal decompression: the use of the ultrasonic scalpel in paediatric achondroplasia.

Spinal stenosis can be a very disabling condition. Surgical decompression carries a risk of dural tear and neural injury, which is increased in patients with severe stenosis or an atypical anatomy. We present an unusual case of symptomatic stenosis secondary to achondroplasia presenting in a paediatric patient, and highlight a new surgical technique used to minimise the risk of dural and neural injury during decompression.This article is available to RD&E staff - click on the 'Additional Link' above and log in with NHS OpenAthens if prompted.Accepted manuscript (no embargo

Broken pedicle screw thread extraction from within the pedicle.

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The costs of late detection of developmental dysplasia of the hip

PURPOSE: Debate currently exists regarding the economic viability for screening for developmental dysplasia of the hip in infants. METHODS: A prospective study of infant hip dysplasia over the period of 1998-2008 (36,960 live births) was performed to determine treatment complexity and associated costs of disease detection and hospital treatment, related to the age at presentation and treatment modality. The involved screening programme utilised universal clinical screening of all infants and selective ultrasound screening of at-risk infants. RESULTS: One hundred and seventy-nine infants (4.8/1,000) presented with hip dysplasia. Thirty-four infants presented late (> 3 months of age) and required closed or open reduction. One hundred and forty-five infants presented at < 3 months of age, 14 of whom failed early Pavlik harness treatment. A detailed cost analysis revealed: 131 early presenters with successful management in a Pavlik harness at a cost of pound601/child; 34 late presenters who required surgery (36 hips, 19 closed/17 open reductions, one revision procedure) at a cost of pound4,352/child; and 14 early presenters with failed management in a Pavlik harness requiring more protracted surgery (18 hips, four closed/14 open reductions, seven revision procedures) at a cost of pound7,052/child. CONCLUSIONS: Late detection causes increased treatment complexity and a sevenfold increase in the short-term costs of treatment, compared to early detection and successful management in a Pavlik harness. DISCUSSION: Improved strategies are needed for the 10 % of early presenting infants who fail Pavlik harness treatment and require the most complex and costly interventions.This article is available via Open Access. Please click on the 'Additional Link' above to access the full-text

Complications associated with opening wedge high tibial osteotomy - A review of the literature and of 15years of experience.

Complication rates following opening wedge high tibial osteotomy (OWHTO) is an issue that has not been comprehensively addressed in current literature