Aim. The use of intraoperative cell salvage as a tool for reducing allogenic transfusion has been demonstrated in pelvic osteotomies. The aims of this audit were to identify any problems or complications with cell salvage, reduction in allogenic transfusion and identify procedures that would benefit. Methods. The use of cell salvage and allogenic transfusions were prospectively recorded over a 27-month period for all those who had major non spinal surgery looking at whether cell-salvage reduced allogenic transfusions and where cell salvage was used it was matched to procedure, diagnosis and age with cases where it was not used over the same time period. Results. Cell salvage was used in 61 cases. For these, average blood loss was 624mls and re-transfused volume 176mls (range=0-888mls). There were no complications. 4 problems occurred, 2 where suction became desterilised and 2 with insufficient sample to process. Of those that were matched, 3/55 cases required allogenic transfusion versus 11/55 that did not have cell salvage (p=0.03). Sub group analysis according to procedure did not reach significance. Excluding those with osteogenesis imperfecta, no isolated femoral osteotomy required allogenic transfusion (total number=48). Conclusion. Overall its use has reduced the number of children receiving allogenic blood and negates the need to cross match preoperatively. Group and save sample is probably sufficient for most major paediatric orthopaedic surgery with cell salvage. The specific indications for cell salvage have not been identified by this study, though useful in OI

There have been major changes in practice in Orthopaedics and Anaesthetics in Britain over recent years. The Royal College of Anaesthetists in Britain in its document on the provision of paediatric services stated that the anaesthetic service for children should be led by consultants who anaesthetise children regularly. This has affected the range of conditions that Orthopaedic Surgeons in District General Hospitals have been able to operate.

The Children’s Orthopaedic Group in the North West Region of England was surveyed in 1996 and 2001. Age limits for elective procedures and the range of procedures performed were analysed. The orthopaedic procedures looked at were for scoliosis, DDH / Dysplasia, Perthes’ disease, CTEV, Leg lengthening and genu varum/valgum.

The demographic map of the region was studied. This highlighted the variation in Children’s Orthopaedic Services in the region. Some large population centres had minimal Paediatric Orthopaedic Services.

In 1996, 91% of non children’s hospitals could perform elective surgery on children under 1 compared to 60% in 1996. The average minimum age for elective surgery in District General Hospitals increased from 8.5 months in 1996 to 17 months in 2001.

Baseline services are needed at each DGH to support the paediatric units. These services should include gait abnormalities, conservative treatment of CTEV, postural problems, straight forward cerebral palsy, assessment of hip instability and Perthes disease. Paediatric physiotherapists and Community Paediatricians may be involved in this aspect of care as part of the Multidisciplinary team. A hub and spoke regional service may be required where paediatric orthopaedic specialists undertake outreach clinics in District General Hospitals in order to assess more complex problems such as resistant CTEV, DDH and complex Cerebral Palsy. Such a system already exists in other specialities such as paediatric neurology. Clinical networks may improve service standards.

The aim of this study is to present and discuss some preliminary applications of tricalcium phosphate “Norian” in children and adolescents with different skeletal disorders. From 1997 to 2002 Norian was used as a biological bone substitute in 10 patients (six girls and four boys; mean age 11 years). The indications were four calcaneal cysts, one phalangeal enchondroma of the hand, one chondromyxoid fibroma of the tibia, one eosino-philic granuloma of the femur and one aneurysmal cyst of the tibia. Norian was also used as a bone graft in two Dega’s pelvic osteotomies. Follow-up was performed radiologically and clinically.

There was one deep infection in a calcaneal cyst which completely healed after curettage and antibiotic therapy and one soft tissue transitory painful reaction to Norian. All cases healed without complication and there was progressive osteointegration at radiological follow-up.

This preliminary study, even with different pathologies and a short follow-up, shows good biocompatibility of the material in the short- and mid-term, with satisfactory clinical results. Mechanical stability under compressive and shearing loads was detected when load bearing was allowed after 30 days in all cases.

Norian tricalcic phosphate is a good and strong bone substitute when a large autologus graft is needed as seen with distal fractures of the radius, tibial plateau and Dega’s pelvic osteotomy.

Aims

The aim of this study was to identify the information topics that should be addressed according to the parents of children with developmental dysplasia of the hip (DDH) in the diagnostic and treatment phase during the first year of life. Second, we explored parental recommendations to further optimize the information provision in DDH care.

The purpose of the study was to investigate the incidence of surgical site infection following elective paediatric orthopaedic surgery. A pro forma adopted from a pilot study was filled out preoperatively for each elective operation performed during the study period. Each patient was then followed up for six weeks postoperatively to record any SSI that developed. Data collected included patient demographics, type of operation, grade of Surgeon, type of procedure, wound length, skin preparations, use of tourniquet, any antibiotic prophylaxis and length of operation. This study collated data on 334 operations with 410 procedural sites over a six month period. Infection were recorded in 19 sites equivalent to a SSI rate of 4.63%. None of the patients developed long-term complications. The mean age of the participants in the study was 11 years (range 0.5 to 17 years), 57% were males and 43% were females. The infection were detected between 1 and 38 days after surgery. The outcome was not compromised in any of the patients as none of them required long-term treatment. Statistical analysis was undertaken. The study proves that the surgical site infection after elective paediatric orthopaedic surgery is low and serve as a bases for consenting patients for surgery

There is currently no standardised complication grading classification routinely used for paediatric orthopaedic surgical procedures. The Clavien-Dindo classification used in general surgery was modified and validated in 2011 by Sink et al. and has been used regularly to classify complications following hip preservation surgery. The aim of this study was to adapt and validate Sink et al.'s modification of the Clavien-Dindo classification system for grading complications following surgical interventions of the upper and lower extremities and spine in paediatric orthopaedic patients. Sink et al.'s modification of the Clavien-Dindo classification system was further modified for paediatric orthopaedic procedures. The modified grading scheme was based on the treatment required to treat the complication and the long term morbidity of the complication. Grade I complications do not require deviation from standard treatment. Grade II complications deviate from the normal post-operative course and require outpatient treatment. Grade III complications require investigations, re-admission or re-operation. Grade IV complications are limb or life threatening or have a potential for permanent disability (IVa: with no long term disability and IVb: with long-term disability). Grade V complications result in death. Forty-five complication scenarios were developed. Seven paediatric orthopaedic surgeons were trained to use the modified system and they each graded the scenarios on two occasions. The scenarios were presented in a different random order each time they were graded. Fleiss' and Cohen's k statistics were performed to test for inter-rater and intra-rater reliabilities, respectively. The overall Fleiss' k value for inter-rater reliability was 0.772 (95% CI, 0.744–0.799). The weighted k was 0.765 (95% CI, 0.703–0.826) for Grade I, 0.692 (95% CI, 0.630–0.753) for Grade II, 0.733 (95% CI, 0.671–0.795) for Grade III, 0.657(95% CI, 0.595–0.719) for Grade IVa, 0.769 (95% CI, 0.707–0.83) for Grade IVb and 1.000 for Grade V (p value <0.001). The Cohen's k value for intra-rater reliability was 0.918 (95% CI, 0.887–0.947). These tests show that the adapted classification system has high inter- and intra-rater reliabilities for grading complications following paediatric orthopaedic surgery. Given the high intra- and inter-rater reliability and simplicity of this system, adoption of this grading scheme as a standard of reporting complications in paediatric orthopaedic surgery could be considered. Since the evaluation of surgical outcomes should include the ability to reliably grade surgical complications, this reproducible, reliable system to assess paediatric surgical complications will be a valuable tool for improving surgical practices and patient outcomes

Paediatric musculoskeletal (MSK) disorders often produce severe limb deformities, that may require surgical correction. This may be challenging, especially in case of multiplanar, multifocal and/or multilevel deformities. The increasing implementation of novel technologies, such as virtual surgical planning (VSP), computer aided surgical simulation (CASS) and 3D-printing is rapidly gaining traction for a range of surgical applications in paediatric orthopaedics, allowing for extreme personalization and accuracy of the correction, by also reducing operative times and complications. However, prompt availability and accessible costs of this technology remain a concern. Here, we report our experience using an in-hospital low-cost desk workstation for VSP and rapid prototyping in the field of paediatric orthopaedic surgery. From April 2018 to September 2022 20 children presenting with congenital or post-traumatic deformities of the limbs requiring corrective osteotomies were included in the study. A conversion procedure was applied to transform the CT scan into a 3D model. The surgery was planned using the 3D generated model. The simulation consisted of a virtual process of correction of the alignment, rotation, lengthening of the bones and choosing the level, shape and direction of the osteotomies. We also simulated and calculated the size and position of hardware and customized massive allografts that were shaped in clean room at the hospital bone bank. Sterilizable 3D models and PSI were printed in high-temperature poly-lactic acid (HTPLA), using a low-cost 3D-printer. Twenty-three operations in twenty patients were performed by using VSP and CASS. The sites of correction were: leg (9 cases) hip (5 cases) elbow/forearm (5 cases) foot (5 cases) The 3D printed sterilizable models were used in 21 cases while HTPLA-PSI were used in five cases. customized massive bone allografts were implanted in 4 cases. No complications related to the use of 3D printed models or cutting guides within the surgical field were observed. Post-operative good or excellent radiographic correction was achieved in 21 cases. In conclusion, the application of VSP, CASS and 3D-printing technology can improve the surgical correction of complex limb deformities in children, helping the surgeon to identify the correct landmarks for the osteotomy, to achieve the desired degree of correction, accurately modelling and positioning hardware and bone grafts when required. The implementation of in-hospital low-cost desk workstations for VSP, CASS and 3D-Printing is an effective and cost-advantageous solution for facilitating the use of these technologies in daily clinical and surgical practice

The objectives of this study are to ascertain primary caregivers' understanding of risks associated with home trampoline use; to educate caregivers in regard to documented literature based risks associated with home trampoline use; and to evaluate if this information will have any influence on their future regulation of home trampoline use for their children. One hundred primary caregivers of patients treated in the paediatric orthopaedic surgery outpatient clinic at London Health Sciences centre were surveyed. All caregivers in clinic were invited to participate. The only exclusion criteria was the inability to provide consent. Caregivers' baseline perceptions on the risks associated with home trampoline use were assessed using a questionnaire. Caregivers then received an information pamphlet outlining documented trampoline safety data. They were then sent the same questionnaire to complete within one week of reading the pamphlet. Using our research electronic database capture (Redcap), the results of the surveys were compiled and analysed using spss 22, paired t-test and repeated measures anova. A sample size of 55 was calculated to result in a power of 80%. Of primary caregivers surveyed, 36% owned a home trampoline, and only 5% had personal experiences with their child sustaining a trampoline injury. Pre-education, when caregivers were asked on a scale of one (not dangerous) to 10 (very dangerous) how dangerous they felt a trampoline was for their child, the average response was six. Post-education, this number changed to eight. Providing education to primary caregivers significantly changed their perceptions on all sections of the questionnaire, yet 47% of primary caregivers were willing to allow their child to use a trampoline at home despite their new understanding of trampoline injury and safety. Providing education to primary caregivers significantly changed their perceptions on all trampoline safety questions, indicating effective comprehension. Despite caregivers' understanding of the risks associated with home trampoline use, approximately half of the study population continue to permit this activity for their children. There is potential to reduce paediatric orthopaedic injuries associated with home trampoline use if safer trampoline related practices are implemented based on information provided

Identification of the paediatric orthopaedic patient at high risk of venous thromboembolism (VTE) can allow a targeted approach to thromboprophylaxis. There is currently no national consensus on the correct method of risk assessment in this patient group. The Royal National Orthopaedic Hospital has developed a guideline using the evidence available to allow stratification of risk for the paediatric orthopaedic patient. A list of departments offering specialist paediatric orthopaedic surgery was obtained from the member list of the British Society of Paediatric Orthopaedic Surgeons (BSCOS). These hospitals were contacted via telephone interview to determine if they have a specific guideline or risk assessment proforma for paediatric VTE risk. A total of 74 hospitals were identified with a specialist paediatric orthopaedic practice in the United Kingdom. A response rate was gained from 100% of these hospitals. Only 3/74 of these hospitals had a guideline or protocol in place for the formal assessment of VTE risk in the paediatric patient (Royal National Orthopaedic Hospital, Stanmore; Sheffield Children's Hospital; Barts & the London NHS Trust). All three hospitals were able to provide details of their guideline. Both the RNOH and Barts & the London commented that their guideline was based on that of the Sheffield group, with adaptations for their own requirements. The majority of hospitals in the UK with a paediatric orthopaedic interest do not have guidance available for the management of VTE risk. Presented here is the outcome of using the limited evidence available, in combination with expert opinion, to develop a guideline suitable for the requirements of a paediatric unit in an orthopaedic hospital. This may be of benefit to other units producing their own guidelines, producing thought and discussion as to the specific requirements of paediatric patients undergoing orthopaedic procedures

Aim: Controversy remains regarding the complications/necessity for removal of metalwork used in the fixation of paediatric orthopaedic surgery owing to potential complications of removal. It was the aim of this study to review all cases of metalwork removal performed in a prescribed year in order to ascertain the reasons for removal and complications of these surgeries. Methods: All cases of metalwork removal performed under GA, from 1st January 2006 until 31st December 2006 in a regional paediatric orthopaedic unit, were reviewed. Data were obtained from case notes, computer and theatre records and radiographs. Details were obtained regarding demographic details, anatomic site, implant used, reasons for removal, problems of initial fixation and complications after removal. Results: 34 buried kirschner wires were removed under general anaesthetic. Of other metal work, 38 implants were removed; 22 in males and 16 in females. The commonest age distribution was the 11–15 age groups. The most common anatomic site for removal was the forearm (42%) followed by the femur (18%) and ankle (18%). The most common implant removed was plate (53%), followed by Nancy nails (18%). Problems following initial insertion were found in 4 patients (10.5%) including re-fracture distal to forearm plates (both in patients with co-existing osteopaenia), bowing of forearm and decreased sensation over the thumb. Metal work was removed for symptoms in 13 cases (34%) and the rest for patient request or clinical indications. Complications after metalwork removal occurred in 8 (21%) patients and included re-fracture of forearm (2), hypertrophic scar, abscess, skin reaction, wound breakdown, excessive bruising and discomfort. Conclusion: As routine removal of metalwork is generally considered not necessary, metalwork removal is often carried out for symptoms, at patient request as well as in patients with osteopaenia who have risk of fracture at the ends of metalwork. Parents need to be made aware of possible complications shown in the study, in order to give informed consent

Aims

The aim of this study was to evaluate the epidemiology and treatment of Perthes’ disease of the hip.

Aims

To identify the minimum set of outcomes that should be collected in clinical practice and reported in research related to the care of children with idiopathic congenital talipes equinovarus (CTEV).

Aims

Open reduction in developmental dysplasia of the hip (DDH) is regularly performed despite screening programmes, due to failure of treatment or late presentation. A protocol for open reduction of DDH has been refined through collaboration between surgical, anaesthetic, and nursing teams to allow same day discharge. The objective of this study was to determine the safety and feasibility of performing open reduction of DDH as a day case.

Aims

Temporary epiphysiodesis (ED) is commonly applied in children and adolescents to treat leg length discrepancies (LLDs) and tall stature. Traditional Blount staples or modern two-hole plates are used in clinical practice. However, they require accurate planning, precise surgical techniques, and attentive follow-up to achieve the desired outcome without complications. This study reports the results of ED using a novel rigid staple (RigidTack) incorporating safety, as well as technical and procedural success according to the idea, development, evaluation, assessment, long-term (IDEAL) study framework.

Aims

Magnetically controlled growing rods (MCGR) have been gaining popularity in the management of early-onset scoliosis (EOS) over the past decade. We present our experience with the first 44 MCGR consecutive cases treated at our institution.

Aims

High-quality clinical research in children’s orthopaedic surgery has lagged behind other surgical subspecialties. This study used a consensus-based approach to identify research priorities for clinical trials in children’s orthopaedics.

Objectives

Lengthening osteotomies of the calcaneus in children are in general grafted with bone from the iliac crest. Artificial bone grafts have been introduced, however, their structural and clinical durability has not been documented. Radiostereometric analysis (RSA) is a very accurate and precise method for measurements of rigid body movements including the evaluation of joint implant and fracture stability, however, RSA has not previously been used in clinical studies of calcaneal osteotomies. We assessed the precision of RSA as a measurement tool in a lateral calcaneal lengthening osteotomy (LCLO).

The August 2014 Children’s orthopaedics Roundup³⁶⁰ looks at: Conservative treatment still OK in paediatric clavicular fractures; Femoral anteversion not the usual suspect in patellar inversion; Shoulder dislocation best treated with an operation; Perthes’ disease results in poorer quality of adult life; Physiotherapy little benefit in supracondylar fractures; Congenital vertical talus addressed at the midtarsal joint; Single-sitting DDH surgery worth the effort; and cubitus valgus associated with simple elbow dislocation