Aims

The Bracing Adolescent Idiopathic Scoliosis (BASIS) study is a randomized controlled non-inferiority pragmatic trial of ‘full-time bracing’ (FTB) compared to ‘night-time bracing’ (NTB) for the treatment of adolescent idiopathic scoliosis (AIS). We anticipated that recruiting patients to BASIS would be challenging, as it is a paediatric trial comparing two markedly different bracing pathways. No previous studies have compared the experiences of AIS patients treated with FTB to those treated with NTB. This qualitative study was embedded in BASIS to explore families’ perspectives of BASIS, to inform trial communication, and to identify strategies to support patients treated in a brace.

In podiatric medicine, diagnosis of foot disorders is often merely based on tests of foot function in static conditions or on visual assessment of the patient's gait. There is a lack of tools for the analysis of foot type and for diagnosis of foot ailments. In fact, static footprints obtained via carbon paper imprint material have traditionally been used to determine the foot type or highlight foot regions presenting excessive plantar pressure, and the data currently available to podiatrists and orthotists on foot function during dynamic activities, such as walking or running, are scarce. The device presented in this paper aims to improve current foot diagnosis by providing an objective evaluation of foot function based on pedobarographic parameters recorded during walking. 23 healthy subjects (16 female, 7 males; age 35 ± 15 years; weight 65.3 ± 12.7; height 165 ± 7 cm) with different foot types volunteered in the study. Subjects' feet were visually inspected with a podoscope to assess the foot type. A tool, comprised of a 2304-sensor pressure plate (P-walk, BTS, Italy) and an ad-hoc software written in Matlab (The Mathworks, US), was used to estimate plantar foot morphology and functional parameters from plantar pressure data. Foot dimensions and arch-index, i.e. the ratio between midfoot and whole footprint area, were assessed against measurements obtained with a custom measurement rig and a laser-based foot scanner (iQube, Delcam, UK). The subjects were asked to walk along a 6m walkway instrumented with the pressure plate. In order to assess the tool capability to discriminate between the most typical walking patterns, each subject was asked to walk with the foot in forcibly pronated and supinated postures. Additionally, the pressure plate orientation was set to +15°, +30°, −15° and −30° with respect to the walkway main direction to assess the accuracy in measuring the foot progression angle (i.e. the angle between the foot axis and the direction of walk). At least 5 walking trials were recorded for each foot in each plate configuration and foot posture. The device allowed to estimate foot length with a maximum error of 5% and foot breadth with an error of 1%. As expected, the arch-index estimated by the device was the lowest in the cavus-feet group (0.12 ± 0.04) and the highest in the flat-feet group (0.29 ± 0.03). These values were between 4 – 10 % lower than the same measurements obtained with the foot scanner. The centre of pressure excursion index [1] was the lowest in the forcibly-pronated foot and the largest in the supinated foot. While the pressure plate used here has some limitations in terms of spatial resolution and sensor technology [2], the tool appears capable to provide information on foot morphology and foot function with satisfying accuracy. Patient's instrumental examination takes only few minutes and the data can be used by podiatrists to improve the diagnosis of foot ailments, and by orthotists to design or recommend the best orthotics to treat the foot condition

Aim. Following successful adoption of the Ponseti method for clubfoot treatment, a team of physiotherapists and orthotists and one surgeon in Jalalabad, Afghanistan have begun to treat Congenital Vertical Talus (CVT) by the technique described by Dodds et al, adapted to locally available resources. We have reviewed the outcome. Method. Since 2010, 38 feet in 31 patients have been treated. Diagnosis of CVT is confirmed with a stress radiograph. The underlying conditions are diverse. The technique involves serial passive stretches and plaster of Paris casts. Once the talo-navicular joint is judged to be reduced, the joint if fixed with a percutaneous pin under local anaesthetic and an Achilles tenotomy performed. Post-operative treatment is as per the Iowa technique with night-time bracing and an AFO for ambulant patients. Results. There have been no major complications and no complete relapses. The result was compromised in 6 patients at the beginning of the series by omission of talo-navicular fixation or tenotomy, since which time the protocol has been followed more closely with improved results. All patients are reported to be wearing normal footwear with no complaints of pain. Conclusion. Specialist surgical treatment for children is not readily available in Afghanistan and the risk of postoperative infection is very high. Effective physiotherapy and orthotic services are available however, typically supported by foreign NGOs, and the Ponseti technique for clubfoot treatment is now successfully applied across the country. This case series from Jalalabad shows that the outcome of treatment of CVT in an out-patient setting can be very good and a significant improvement on the alternatives available. It also demonstrates that this treatment method can be adapted for use in the developing world

Aims

Scoliosis is a lateral curvature of the spine with associated rotation, often causing distress due to appearance. For some curves, there is good evidence to support the use of a spinal brace, worn for 20 to 24 hours a day to minimize the curve, making it as straight as possible during growth, preventing progression. Compliance can be poor due to appearance and comfort. A night-time brace, worn for eight to 12 hours, can achieve higher levels of curve correction while patients are supine, and could be preferable for patients, but evidence of efficacy is limited. This is the protocol for a randomized controlled trial of ‘full-time bracing’ versus ‘night-time bracing’ in adolescent idiopathic scoliosis (AIS).

Introduction: The management of spasticity of children with cerebral palsy is often complex and challenging. Effective treatment requires a multidisciplinary approach involving paediatricians, orthotists, occupational therapists, physiotherapists and orthopaedic surgeons. Botulinum toxin A therapy in the lower limb has been shown to relieve spasticity and to improve the function in the short term. However, the use of Botulinum toxin A in the upper limb remains controversial. Aim: To assess any improvement following upper limb Botulinum toxin A injections and to evaluate patient’s and parents’ expectation and satisfaction of the procedure. Method: During 2007 a total of 36 spastic cerebral palsy patients underwent 47 episodes of Botulinum toxin A injections to the upper limb. There were 22 male and 14 female with a mean age of 6 years old. A questionnaire was devised to assess the outpatient consultation, peri-operative care and the post-operative outcome. Subjective improvement and the patient’s and parents’ evaluation of the procedure were also recorded. Results: Good to excellent results were achieved in most areas. Daily activities were improved by 52% with an average duration of 4 months. The majority of the patient achieved their expectation. Most patients/parents were satisfied with the procedure and would consider further injections. Conclusions: Botulinum toxin A injection to the upper limb was generally well received with good short term results. Most would consider further injections

The management of spasticity of children with cerebral palsy is often complex and challenging. Effective treatment requires a multidisciplinary approach involving paediatricians, orthotists, occupational therapists, physiotherapists and orthopaedic surgeons. Botulinum toxin A therapy in the lower limb has been shown to relieve spasticity and to improve the function in the short term. However, the use of Botulinum toxin A in the upper limb remains controversial, moreover only selected few orthopaedic surgeons have experience in managing it. The aim is to assess the functional improvement following an upper limb Botulinum toxin A injections to the upper limb and then to evaluate the patient’s and parents’ satisfaction after the procedure. During 2007 a total of 36 spastic cerebral palsy patients underwent 47 episodes of Botulinum toxin A injections to the upper limb. There were 22 male and 14 female with an age range between 2 to 17 years (average age was 2 years). Following the surgery, all patients received a course of an intense exercise regime with the physiotherapist and occupational therapist. All patients were prospectively followed-up by the clinic with no loss to follow-up. We also assessed the functional movement of the patients as well as the patient’s and parents’ subjective evaluation of the procedure. Overall, the range of movement of the upper limb has improved following the Botulinum toxin A injection. Most patients/parents were satisfied with the procedure and would consider further injection in the future. Botulinum toxin A injection to the upper limb is generally well received with good short term results. Many would consider further injections to sustain improve function

Aim and method We report the outcomes of 100 consecutive diabetic patients who had been prescribed diabetic footwear for 10 years. A podiatrist and orthotist reviewed them at a dedicated clinic. The study aim was to assess footwear efficacy and prevention of ulcers, re-ulceration and amputations. Conclusion Protective footwear is essential in maintaining healthy diabetic feet. Amputations were only due to vascular complications. All 56 patients who attended remained intact at 2 years. Of the seven ulcerations at 5 years, three went onto below-knee amputation. At 10 years, there were a further three ulcerations, resulting in one minor black toe and one further BK amputation. Adherence with follow up including footwear review minimises risk. Re-ulceration at 5 years is associated with risk of amputation. Ten-year mortality is high due to vascular complications. Summary Continued patient adherence with Orthotic therapy confers benefit and minimised re-ulceration. Follow up by Orthotists is an under-utilised resource

Purpose. To correlate the initial brace correction with quantity and quality of brace wear within the first 6 months for the treatment of adolescent idiopathic scoliosis (AIS). Method. Brace treatment for AIS has been debated for years. Prediction of treatment outcomes is difficult as the actual brace usage is generally unknown. As technology became more advanced, electronic devices were able to measure adherence in both quantity (how much time the brace has been worn) and quality (how tightly the brace has been worn) of brace usage without need for patient interaction. The developed adherence monitor consisted of a force sensor and a data acquisition unit. Subjects were monitored within the first 6 months of brace wear. The data sample rate was set to be one sample per minute. Data was downloaded at the patients routine clinical visits. The prescription, first in-brace and first follow-up out-of-brace Cobb angles were measured. Twelve AIS subjects (10F, 2M), age between 9.8 and 14.7 years, average 11.9 1.5 years, who were prescribed a new TLSO and full-time brace wear (23 hours/day) participated. All braces were made by the same orthotist. The force value at the major pressure pad at the prescribed tightness level was recorded as the individualized reference value. The normalized force value (measured force magnitude relative to the individualized reference value) was used for the quality factor. The time of brace usage relative to the prescribed time was used as the quantity factor. Results. The first in-brace follow-up visit was approximately 2 months after the brace fitting session and the first out-of-brace follow-up visit was scheduled after 4 months. The Cobb angle of the major curve prior to bracing, in-brace and at the first follow-up out-of-brace were 31.3 6.2, 16.5 8.7 and 31.8 7.1 degrees, respectively. The mean reference force value was 1.1 0.23N. The average quantity and quality of the brace usage were 61.2 12.2% and 63.4 8.8%, respectively. A relationship was found between wear time with a change in Cobb angle (pre brace – the first follow-up out-of-brace) (r = 0.77). The more time that the brace was worn resulted in a better treatment result. A moderate correlation was found between the force value at the major pressure pad and the in-brace correction (r = 0.40). Also, a moderate relationship was found between wear quality during daytime with a change in Cobb angle (r = 0.67). The more time that the brace was worn close to the prescribed tightness level during the daytime resulted in a better outcome. Conclusion. This study showed the brace effectiveness is dependent on both the quantity and quality of brace usage

Aim: The study of quality of life in adolescents with Idiopathic Scoliosis (IS) that are treated conservatively with a brace. Introduction: Study of patients’ quality of life, especially of those suffering a chronic disease that requires long term treatment, is of great interest in recent years. Although there are a lot of studies for psycological sequences in IS, only a few papers in the available literature are dealing with quality of life measurement. SF-36 generic questionnaire provides the physician with valuable outcomes of treatment in patients over 14 years old. Material-Method: Inclusion criteria were diagnosis of IS, a curve between 20o–40o, age of the child between 14–16 years old, follow up by the same physician or team, conservative treatment of IS and minimum duration of brace treatment for 2 years. Twenty-eight children, 25 girls with a mean age 14.8 years old and 3 boys with a mean age 15 years old were included in the study and filled the form of SF-36 questionnaire. All children are still wearing the brace. A control group of 30 children were also filled SF-36 form. Results: Mean score of SF-36 questionnaire was 76.29 (SD 9.105). Most negatively affected domains are Mental Health (mean score 54.3, SD 11.5) and Vitality (mean score 62.86, SD 16.5). Physical Functioning (mean score 79.3, SD 20.7), Role limitation due to Emotional problems (mean score 76.3, SD 25.23), Social Functioning (mean score 77.9, SD 17.13), Bodily Pain (mean score 79.6, SD 19.5) and General Health Perception (mean score 77.1, SD 19.94) are less affected domains. Best scores are achieved in Role limitation due to Physical problems (mean score 96.4, SD 9.45) and Change in Health (mean score 82.1, SD 23.78) domains. Discussion-Conclusion: This report appears that brace treatment has negative effect on childrens’ quality of life. The use of SF-36 questionnaire through detection of most affected domains provides the physician a measurable outcome for child’s quality of life in order to 1) interfere with the selected method of conservative treatment and its modalities in a way that it would less affect the child and 2) provide the child specific psychological support by the doctor, the orthotist, the parents and the various voluntary organizations

Aims

The aim of this study was to assess the ability of morphological spinal parameters to predict the outcome of bracing in patients with adolescent idiopathic scoliosis (AIS) and to establish a novel supine correction index (SCI) for guiding bracing treatment.

Aim: This study involved a postal questionnaire survey to know the attitude of consultant orthopaedic surgeons in U.K. with regards to their postoperative management of Dupuytren’s surgery patients. Methods & Results: A questionnaire was sent to Orthopaedic surgeons practising in UK. 573 consultants replied to the questionnaire. 169 surgeons (29.49%) stated to have special interest in hand surgery. 357 surgeons (62.3%) stated having no interest in hand surgery. 43 surgeons did not reply to the questionnaire. 81 surgeons (14.13%) always used post operative splintage.109 surgeons (19.03) used splintage most of the time, 126 surgeons (21.98%) rarely used it and 89 surgeons (15.53%) stated never using any form of splintage. Most of them used static splintage (45.20%) and only 5.23% used dynamic splintage.11 surgeons stated using both the types of splintage. 267 surgeons did not questionnaire. Majority of the surgeons applied a static splint (pop slab, thermoplastic splint) after the surgery while others applied it after reducing the dressing within 2 weeks of the operation. 264 (46.07%) surgeons did not reply to the question. In majority of cases the splint was applied by the occupational therapist. The surgeon, physiotherapist, and orthotist in some cases also applied the splint. Individual comments from surgeons made an interesting reading. After an initial period of continuous splintage majority of the surgeons used night splintage only. 265 surgeons did not reply to the question. Mostly the splint-age was used for 4–6 weeks. Although the spectrum of splintage varied from 2 weeks to 24 weeks. Some of the surgeons stated their own clinical practice in their comments. 179 surgeons stated always referring their patient for postoperative physiotherapy. 13 surgeons (2.26%) never referred their patients for physiotherapy. 77 surgeons on very odd occasions had postoperative physiotherapy for their patients. Majority of surgeons started the physiotherapy between 1 and 2 weeks, after the stitches have been removed. 107 surgeons favoured early commencement of hand exercises within first week of surgery. 224 surgeon did not reply to this question. Most of the surgeons followed the patients for two to four months. Longer follow up was done for patients with recurrence, severe or bilateral disease. Also those patients, who had proximal interphalangeal joint contracture and other risk factors, were followed for a longer period. Some of the surgeons commented following them for life in their clinical practice. Conclusion: This survey revealed interesting facts regarding the management of Dupuytren’s contracture surgery patients. The disparity in reply clearly indicates the need for further research with attention to long term funtional results

Aims

Diabetic foot care is a significant burden on the NHS in England. We have conducted a nationwide survey to determine the current participation of orthopaedic surgeons in diabetic foot care in England.

We live in troubled times. Increased opposition reliance on explosive devices, the widespread use of individual and vehicular body armour, and the improved survival of combat casualties have created many complex musculoskeletal injuries in the wars in Iraq and Afghanistan. Explosive mechanisms of injury account for 75% of all musculoskeletal combat casualties. Throughout all the echelons of care medical staff practice consistent treatment strategies of damage control orthopaedics including tourniquets, antibiotics, external fixation, selective amputations and vacuum-assisted closure. Complications, particularly infection and heterotopic ossification, remain frequent, and re-operations are common. Meanwhile, non-combat musculoskeletal casualties are three times more frequent than those derived from combat and account for nearly 50% of all musculoskeletal casualties requiring evacuation from the combat zone.