The aim was to assess contemporary management of slipped capital femoral epiphysis (SCFE) by surveying members of the British Society of Children's Orthopaedic Surgery (BSCOS).

A questionnaire with 5 case vignettes was used. Two questions examined the timing of surgery for an acute unstable SCFE in a child presenting at 6 hours and at 48 hours after start of symptoms. Two further questions explored the preferred method of fixation in mild and severe stable SCFE. The final question examined the management of the contralateral normal hip. Responses were entered into an Excel spreadsheet and the data w analysed using a chi-squared test.

The response rate was 56% (110/196). 88.2% (97/110) responded that if a child presented with an acute unstable SCFE within 6 hours, they would treat it within 24 hours of presentation, compared with 40.9% (45/110) for one presenting 48 hours after the onset of symptoms (P<0.0001). 52.6% (58/110) of surveyed BSCOS members would offer surgery for an unstable SCFE between 1 and 7 days after onset of symptoms. Single screw fixation in situ was advocated by 96.4% (106/110) and 70.9% (78/110) while corrective osteotomy was preferred by 1.8% (2/110) and 26.4% (29/110) of respondents for the mild and the severe stable slips respectively (P<0.0001). Surgeons preferring osteotomy are more likely to perform an intracapsular technique. Prophylactic fixation of the contralateral normal hip was performed by 27.3% (30/110) of participants.

There are significant differences in opinions between BSCOS members as to the optimal management of SCFE in children. This reflects the variable recommendations and quality in the current scientific literature. Further research is therefore required to determine best practice and enable consensus to be reached.

A group of UK paediatric surgeons (the UK SCFE Study Group) convened to design pertinent trials in slipped capital femoral epiphysis (SCFE), twelve centres across the UK reviewed the demographics and management of children with SCFE.

At all contributing centres with digital PACS records, a search for terms relating to SCFE were performed. From the results, radiographs and electronically stored clinic letters were assessed to confirm the diagnosis and ascertain age at presentation, incidence of bilaterality, chronicity, stability, management and complications.

A total of 601 SCFEs presented between 2007 and 2012 to the twelve units. The mean age at presentation was 12.5 years. The left hip was nearly twice as commonly involved compared to the right (R: L = 3.3: 5.1), with bilateral presentation in 22% of patients. The most common mode of presentation was acute-on-chronic. Stable slips were over twice as common as unstable. The most common intervention was percutaneous pinning in situ. Open reduction was required in 24% of cases. The commonest complication was osteonecrosis (10.5%).

This data concurs with earlier smaller audits and highlights current demographics and contemporary management of SCFE throughout the UK and informs the subject and content of potential future randomized control trials.

Background

Congenital vertical talus (CVT) is a rare deformity of the foot. It has been historically treated with extensive soft tissue releases with significant associated complications. Recently, reverse Ponseti-type casting followed by minimally invasive or percutaneous reduction and fixation has been described with excellent results in separate cohorts of either idiopathic or teratologic cases of CVT. There are currently no studies that compare the outcomes between the two types.

Aim

The current literature indicates that hip arthroscopy is safe in both adolescents and adults with good early outcomes but there are no available studies that directly compare the outcomes of this procedure for mixed indications between these two groups.

Aim

To inform a working group of UK paediatric surgeons (the UK SCFE Study Group) convened to design pertinent trials in slipped capital femoral epiphysis (SCFE), three centres (Bristol, Newcastle and Barts and The London) reviewed the demographics and management of children with SCFE presenting between 2007 and 2012.

Aim

This pilot study aimed to identify the important symptomatic, functional and psychosocial aspects of hip disorders from the perspective of adolescent patients and their families in order to begin developing a patient-focused instrument (Bridging Adolescent Self-Reported Hip – BASH - score).

Introduction

Albania is one of the poorest countries in Western European with a GDP per capita standing at 26 percent of the EU average in 2010. Whilst there is government-funded universal free provision of healthcare, it is accepted that delivery is patchy, not accessible to all and lacking expertise for more complex paediatric orthopaedic conditions. With the sponsorship of a UK-based charity, we have set up and completed 5 visits to Albania (3 assessment and 2 operative) to provide additional expertise for paediatric orthopaedic disorders running parallel to and utilising currently available local services. We present the results of this treatment and training programme to date.

The aims of this study were (1) to assess whether rotational stability testing in Gartland III supracondylar fractures can be used intra-operatively in order to assess fracture stability following fixation with lateral-entry wires and (2) to quantify the incidence of rotational instability following lateral-entry wire fixation in Gartland type III supracondylar humeral fractures in children.

Twenty-one consecutive patients admitted with Grade III supracondylar fractures at the Children's Hospital at Westmead were surgically treated according to a predetermined protocol. Following closed fracture reduction, 2 lateral-entry wires were inserted under radiographic control. Stability was then assessed by comparing lateral x-ray images in internal and external rotation. If the fracture was found to be rotationally unstable by the operating surgeon, a third lateral-entry wire was inserted and images repeated. A medial wire was used only if instability was demonstrated after the insertion of three lateral wires.

Rotational stability was achieved with two lateral-entry wires in 6 cases, three lateral-entry wires in 10 cases and with an additional medial wire in 5 cases. Our results were compared to a control group of 24 patients treated at our hospital prior to introduction of this protocol. No patients returned to theatre following introduction of our protocol as opposed to 6 patients in the control group. On analysis of radiographs, the protocol resulted in significantly less fracture position loss as evidenced by change in Baumann's angle (p<0.05) and lateral rotational percentage (p<0.05).

We conclude that the introduction of rotational stability testing allows intra-operative assessment of fracture fixation. Supracondylar fractures that are rotationally stable intra-operatively following wire fixation are unlikely to displace post-operatively. Only a small proportion (26%) of these fractures were rotationally stable with 2 lateral-entry wires. This may be a reflection of either the fracture configuration or inability to adequately engage the medial column.

Background: The treatment of congenital vertical talus has traditionally consisted of manipulation and application of casts followed by extensive soft-tissue releases. However, this treatment is often followed by severe stiffness of the foot and other complications. The purpose of this study was to evaluate a new method of manipulation and cast immobilization, based on principles used by Dobbs et al in patients with idiopathic congenital vertical talus, but applied in teratologic congenital vertical talus.

Methods: Five consecutive cases of teratologic congenital vertical talus deformity were prospectively followed at a minimum of nine months post treatment with serial casting and limited surgery consisting of percutaneous Achilles tenotomy, fractional lengthening of the anterior tibial tendon, and percutaneous pin fixation of the talonavicular joint. The principles of manipulation and application of the plaster casts were similar to those used by Ponseti to correct a clubfoot deformity, but the forces were applied in the opposite direction. Clinical and radiographic assessments were carried out at the initial, immediate postoperative and the latest follow-up.

Results: Initial correction was obtained both clinically and radiographically in all five feet. A mean of eight casts was required for correction. At the final evaluation, the mean ankle dorsiflexion was 20° and the mean plantar flexion was 31°. Radiographically, dorsal subluxation of the navicular recurred in one patient, but was functionally insignificant as the patient was a non-ambulator and required treatment for seating purposes only. At the time of the latest follow-up, there was a significant improvement in all of the measured radiographic parameters compared with the pretreatment values.

Conclusions: Serial manipulation and cast immobilization followed by talonavicular pin fixation and percutaneous tenotomy of the Achilles tendon provides excellent results, in terms of the clinical appearance of the foot, and deformity correction, in patients with teratologic congenital vertical talus.

Introduction: The Foundation Programme was implemented across the United Kingdom in 2005 and aims to “bridge the gap between medical school and specialty/general practice training.” Musculoskeletal complaints are the single most common reason for patients seeking medical attention and it is imperative that all clinicians should have at least a basic competency in musculoskeletal medicine.

Aim: To determine if Foundation Programmes give junior doctors sufficient training to deal competently with musculoskeletal complaints.

Methods: We prospectively enrolled junior doctors at the completion of their Foundation Programme. They were assessed using the Freedman and Bernstein musculoskeletal examination tool- the only validated method of assessing musculoskeletal medicine knowledge currently available. Passing this test only implies a basic level of competence in musculoskeletal medicine.

Results: We recruited 112 junior doctors from across the United Kingdom. Only 8.9% of those recruited passed the assessment. Significantly higher mean scores were obtained by those with Foundation Programme exposure to Orthopaedics- 62% vs. 51.6% (p=0.005), an interest in Orthopaedics as a career- 64.8% vs. 52.8% (p=0.026) and those who felt that they had gained adequate Foundation Programme exposure to musculoskeletal medicine- 64% vs. 51.6% (p=0.0014). Those who were interested in General Practice obtained significantly lower scores than the rest of the group- 48.4% vs. 55.6% (p=0.009).

Orthopaedics, internal medicine and general practice were the future specialty interest of 6%, 29% and 36% respectively. Only 15% had any Foundation Programme exposure to Orthopaedics and only 13% felt they had been given adequate exposure to musculoskeletal medicine.

Conclusions: Foundation Programmes are currently failing to ensure junior doctors entering specialty training have a basic competence in musculoskeletal medicine. Given the high prevalence of musculoskeletal conditions encountered by most clinicians this is unacceptable and steps must be taken to improve the quality of Foundation Programme training in musculoskeletal medicine.

Background: Traumatic femoral head osteonecrosis in adolescents has a poor prognosis due to collapse and subsequent degenerative change. There are currently no satisfactory treatments available for this condition. Bisphosphonate therapy has improved outcome in animal models of osteonecrosis. We have evaluated bisphosphonate therapy as a novel strategy for adolescent traumatic osteonecrosis.

Methods: We established a protocol of identification of adolescents with osteonecrosis utilizing bone scans immediately after surgical treatment for hips at risk of osteonecrosis after trauma. Of a consecutive group of twenty-eight patients with either unstable slipped capital femoral epiphyses (SCFE) (22), femoral neck fracture (4) or hip dislocation (2), seventeen patients with osteonecrosis were identified. These patients (13 boys and 4 girls, mean age 12.6 years) and their families consented for treatment with intravenous bisphosphonates based on animal experimental evidence. Of the patients with osteonecrosis, twelve had presented with unstable SCFE, four with femoral neck fractures and one following traumatic hip dislocation. The average length of bisphosphonate treatment was 20.3 months (range 7 to 39). All patients were followed for at least 2 years.

Results: At mean follow-up of 38.7 months, fourteen patients (82%) were pain free. Clinically, all patients had a good to excellent outcome. The mean Harris Hip Score was 91.1, the Iowa Hip Rating was 92.1 and the Global PODCI score was 91.5. On radiographs, nine patients (53%) were rated as Stulberg I–II, six (35%) as Stulberg III, and two (12%) as Stulberg V.

Conclusion: Bisphosphonates therapy may play an adjunctive role in the treatment of adolescents with traumatic osteonecrosis.

Background: Recombinant bone morphogenic proteins (BMPs) are potent bone anabolic agents suggested for the treatment of orthopaedic complications associated with neurofibromatosis type 1 (NF1), in particular, congenital pseudarthrosis of the tibia. We have explored the effect of Nf1 haploinsufficiency on ex vivo and in vivo models of BMP-induced bone formation in Nf1+/− mice.

Methods: Using an Nf1+/− knockout mouse model, we expanded primary cell cultures from calvarial and long bone osteoblasts and measured osteogenic markers, such as alkaline phosphatase and mineralization using Alizarin Red staining, and the responses of these markers to BMP-2 treatment. We also developed an in vivo muscle pouch heterotopic ossification model to assess the ability of BMP-2 to form bone.

Results: Primary osteoblast cultures from Nf1+/− mice showed reduced ALP staining, ALP activity and mineralization, denoting an anabolic deficiency. Nf1+/− osteoblasts responded to BMP-2 treatment, although osteogenic markers were reduced compared to BMP-2 treated Nf1+/+osteoblasts. Heterotopic bone was induced in both genotypes by surgically implanting BMP-2, however less bone was formed in Nf1+/− mice than Nf1+/+ controls.

Conclusion: These data indicate that BMP therapies have potential utility in treating orthopaedic defects in children with NF1, but that dosing may need to be optimized for this patient subgroup or that catabolism may need to be also controlled.

The aim of this study was to compare the accuracy of image guided (ultrasound or CT) percutaneous needle biopsy to percutaneous needle biopsy without image guidance in diagnosis of soft tissue tumours.

Eighty-eight consecutive patients with soft tissue lesion who were referred to the soft tissue tumour unit underwent percutaneous needle biopsies of their lesion either with image guidance or without. Sixty-one out of these 88 patients subsequently underwent excision of their lesion and the excised specimen was then subjected to histological examination. The accuracy of image guided percutaneous needle biopsy and percutaneous needle biopsy without image was then calculated by comparing the histological results of the needle biopsy to that of excision biopsy.

The diagnosis accuracy of image guided percutaneous needle biopsy was 92% (34 out 37) compared to 79% (22 out of 28) for percutaneous needle biopsy without image. In 3 out of the 28 patients who had percutaneous needle biopsy without image guidance, there was insufficient material obtained from the needle biopsy to allow a histological diagnosis. This was not the case with any of the patients who had image guided percutaneous needle biopsy.

Conclusion: Using image guidance, either USS or CT scan, improves the diagnostic accuracy of percutaneous needle biopsy and should be the gold standard technique in management of soft tissue tumours. However, if the lesion is palpable and not mobile, the accuracy of percutaneous needle biopsy without image guidance can be up to 79%.

Objective: The reported incidences of traumatic and iatropathic nerve injuries with supracondylar fractures in children are 12–16% and 6% respectively, with the majority recovering spontaneously. We performed a retrospective review of lesions referred to our tertiary unit to determine the incidence of surgical intervention.

Methods: Between 1997 and 2002, 37 neuropathies (associated with 32 supracondylar fractures) in 19 males and 13 females with an average age of 7.9 years were referred for further management. 8 fractures were classified as Gartland grade 2 and 24 as grade 3. All fractures were closed, with 2 treated non-operatively, 20 by closed reduction and percutaneous pinning and 10 by open reduction and internal fixation at the referring hospitals.

Results: The ulnar nerve was the most frequently injured (51.4%), followed by median (27%) and radial (21.6%) nerve palsies. 14 (37.8%) neuropathies were related to the fracture, while 23 (62.2%) were iatropathic. 10 patients (31.3%) required operative exploration while 3 (9.4%) were listed for surgery but were cancelled as they were recovering. Nerve grafting was used in 4 of the 10 operated cases, the donor nerve being the medial cutaneous nerve of the forearm in 3 and the superficial radial nerve in one. 26 patients (81.3%) had excellent outcomes, 5 (15.6%) good and 1 (3.1%) fair.

Conclusion: Although most had excellent outcomes, surgical exploration was required for nearly a third of the cases referred to our unit. This is in contrast to the current literature, which suggests that the majority of supracondylar neuropathies recover spontaneously.

Purpose: Congenital proximal radioulnar synostosis is a rare anomaly of failure of segmentation of the radius and ulna resulting in a fixed rotational position of the forearm from neutral to maximum pronation. Several surgical options have been proposed for the treatment of this condition. We have treated six forearms in five children with pronation deformity using derotational osteotomies of the radius and ulna with postoperative wire stabilisation of the ulna. The surgical technique and results of treatment with this method are presented.

Methods: With this technique, osteotomies were performed at the midshaft of the ulna and the distal diaph-yseal-metaphyseal junction of the radius. The insertion of intramedullary Ilizarov wires facilitated manual derotation of the radius and ulna to a functional position of 100 supination of the forearm. Postoperatively, the forearm was immobilised in a cast for an average of 6.3 weeks and the wire was removed when there was evidence of union. 3 boys and 2 girls with a mean age of 4.9 years underwent surgery with this method and were followed-up for an average of 29 months (range 12 to 43 months).

Results: Forearm position improved from an average pronation deformity of 68.3 degrees to the pre-planned position of 100 degrees supination in all cases. Bone union was achieved in all six forearms by 6.3 weeks. At their most recent follow-up, there was no loss of correction evident in any of the patients. There was one complication, namely haematoma formation at the radial osteotomy site mimicking compartment syndrome and requiring exploration, although no soft tissue compromise was evident.

Conclusion: The principal advantages of this technique include the ease of the surgical approach for the distal radial osteotomy, the longterm maintenance of rotational correction and the need for single wire stabilisation of the ulna only, which in theory reduces the potential risk of implant-related complications. We conclude that this modified forearm derotational osteotomy with wire stabilisation of the ulna alone is a safe and effective method for treating pronation deformity in children with congenital proximal radioulnar synostosis, although vigilance for early soft tissue complications is necessary.

Normal acetabular development in developmental dysplasia of the hip (DDH) depends upon early and maintained congruent reduction. Computed tomography is an accepted method for evaluating this and attempts to quantify hip reduction, by various angular and linear measurements, have been reported.

The aim of this study was to assess initial CT scans, following open reduction in the older child with DDH, with comparison of outcome to evaluate prognostic value.

Method: Thirty consecutive patients underwent open reduction for DDH, with a mean age of 25.9 months at the time of operation. Acetabular morphology and the position of the femoral head were evaluated on the initial CT scan, taken on the first postoperative day, and AP pelvic radiograph taken at the latest follow-up.

Results: The acetabulae of the dislocated hips were found to be significantly more anteverted than the normal. The dislocated hips also had significantly increased lateral displacement both initially and at latest follow-up. Posterior displacement of the proximal femoral metaphysis should raise concern due to an association with the need for further surgical intervention. These results did not however correlate with outcome.

In conclusion, despite the significant differences noted between DDH and normal hips they did not predict acetabular development or persistent acetabular dysplasia.

Introduction: Traumatic and iatropathic nerve injuries complicate 6–16% of paediatric supracondylar extension fractures of the humerus. The majority recover spontaneously. This retrospective review of lesions referred to our tertiary unit determined the incidence of surgical intervention.

Methods: Between 1997–2002, 37 neuropathies (32 fractures) in 19 males and 13 females (mean age 7.9yrs) were referred for further management. 8 fractures were Gartland grade 2 and 24 grade 3. All fractures were closed. Two were originally treated non-operatively, 20 by closed reduction and percutaneous pinning and 10 by open reduction and internal fixation.

Results: The ulnar nerve was most frequently injured (19, 51.4%), followed by median (10, 27%) and radial (8, 21.6%) nerve palsies. 14 (37.8%) neuropathies were fracture-related but 23 (62.2%) were treatment-related. 10 patients (31.3%) required operative exploration. Three (9.4%) were listed for surgery but cancelled due to nerve recovery. Nerve grafting using either the forearm medial cutaneous nerve or the superficial radial nerve was necessary in 4 of 10 operated cases. 26 patients (81.3%) had excellent outcomes, 5 (15.6%) good and 1 (3.1%) fair.

Discussion: In contrast to current literature suggesting that 86 to 100% of supracondylar associated neuropathies recover spontaneously within 2 to 3 months, surgical exploration was required in over 30% of cases.

Introduction: To determine the aetiology of peripheral nerve injuries presenting to a specialist centre, identify the management strategies employed and discuss the functional outcome achieved.

Methods: Retrospective review of all children referred to this hospital between 1996–2003 with an acquired nerve injury. Obstetrical brachial plexus palsy was excluded.

Results: 100 nerve injuries (94 patients) were identified. The mean age was 9.9yrs (0.5–16yrs). 81 injuries involved the upper limb, 19 the lower limb. Most were due to low energy trauma and associated with fractures or their surgical management. 16% presented with autonomic sympathetic dysfunction, 10% with neuropathic pain. 43 patients underwent at least one surgical procedure. The operation was classified diagnostic in 5 (no surgically remediable lesion identified), therapeutic in 33 (surgical procedure could be expected to aid recovery) and reconstructive in 5 (no improvement in nerve function could be achieved; functional improvement achieved by other means). Excellent functional outcome only occurred in conservatively treated cases and in some treated by neurolysis. Nerve grafts and direct repairs were associated with good outcomes. Delayed surgery was associated with fair outcomes.

Discussion: Peripheral nerve injuries in children as in adults require careful, prompt attention to obtain the best outcome. Iatropathic injuries must be acknowledged.