In 2017, the British Society for Children’s Orthopaedic Surgery engaged the profession and all relevant stakeholders in two formal research prioritization processes. In this editorial, we describe the impact of this prioritization on funding, and how research in children’s orthopaedics, which was until very recently a largely unfunded and under-investigated area, is now flourishing. Establishing research priorities was a crucial step in this process.

Cite this article: Bone Joint J 2024;106-B(5):422–424.

Aims

The aim of this study was to determine the consensus best practice approach for the investigation and management of children (aged 0 to 15 years) in the UK with musculoskeletal infection (including septic arthritis, osteomyelitis, pyomyositis, tenosynovitis, fasciitis, and discitis). This consensus can then be used to ensure consistent, safe care for children in UK hospitals and those elsewhere with similar healthcare systems.

Acute bone and joint infections in children are serious, and misdiagnosis can threaten limb and life. Most young children who present acutely with pain, limping, and/or loss of function have transient synovitis, which will resolve spontaneously within a few days. A minority will have a bone or joint infection. Clinicians are faced with a diagnostic challenge: children with transient synovitis can safely be sent home, but children with bone and joint infection require urgent treatment to avoid complications. Clinicians often respond to this challenge by using a series of rudimentary decision support tools, based on clinical, haematological, and biochemical parameters, to differentiate childhood osteoarticular infection from other diagnoses. However, these tools were developed without methodological expertise in diagnostic accuracy and do not consider the importance of imaging (ultrasound scan and MRI). There is wide variation in clinical practice with regard to the indications, choice, sequence, and timing of imaging. This variation is most likely due to the lack of evidence concerning the role of imaging in acute bone and joint infection in children. We describe the first steps of a large UK multicentre study, funded by the National Institute for Health Research, which seeks to integrate definitively the role of imaging into a decision support tool, developed with the assistance of individuals with expertise in the development of clinical prediction tools.

Cite this article: Bone Joint J 2023;105-B(3):227–229.

Aims

A national screening programme has existed in the UK for the diagnosis of developmental dysplasia of the hip (DDH) since 1969. However, every aspect of screening and treatment remains controversial. Screening programmes throughout the world vary enormously, and in the UK there is significant variation in screening practice and treatment pathways. We report the results of an attempt by the British Society for Children’s Orthopaedic Surgery (BSCOS) to identify a nationwide consensus for the management of DDH in order to unify treatment and suggest an approach for screening.

Aims

The aim of this study was to gain an agreement on the management of idiopathic congenital talipes equinovarus (CTEV) up to walking age in order to provide a benchmark for practitioners and guide consistent, high-quality care for children with CTEV.

Abstract

Aims

To assess if older symptomatic children with club foot deformity differ in perceived disability and foot function during gait, depending on initial treatment with Ponseti or surgery, compared to a control group. Second aim was to investigate correlations between foot function during gait and perceived disability in this population.

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.

Introduction

Joint preserving procedures have gained popularity in an attempt to delay arthroplasty in young, dysplastic hips. Excellent results can be achieved with peri-acetabular osteotomy (PAO) in congruent non-arthritic hips. The role of salvage procedures such as the Shelf acetabuloplasty remains undefined. This study aims to determine the long-term survival and functional outcome following Shelf acetabuloplasty and to identify factors that influence outcome.

The purpose of the study was to identify risk factors that are associated with re-displacement of the hip after surgical reconstruction in cerebral palsy.

Retrospective review of children with cerebral palsy who had hip reconstruction with proximal femoral varus derotation osteotomy (VDRO) and Dega-type pelvic osteotomy, between 2005–2012, at a UK and European institution, was performed. Patient demographics, GMFCS, clinical and radiological outcome were assessed as well as the presence of pelvic obliquity and significant scoliosis (Cobb angle > 10 degrees). Redisplacement was defined as Reimer's Migration Index (MI) >30% at final follow-up. Logistic regression analysis was used to assess which factors were predictive of redisplacement and adjusted for clustered variables (α = 0.05).

Eighty hips were identified in 61 patients. The mean age at surgery was 8.8 years (± 3.3). Mean MI pre-op was 68% (± 23%) and post-op was 8% (± 12%). At a mean follow-up, of 3.2 years (± 2.0), 23 hips had a MI >30%. Of these; five were symptomatic, and one had required a salvage procedure. Metalwork removal was undertaken in 14 hips. Logistic regression demonstrated that the pre-operative MI and the percentage of acute correction were significant predictors of re-displacement. If the pre-operative MI was greater than 65 percent, the odds ratio (OR) for redisplacement was 5.99 (p = 0.04). If correction of the MI was less than 90% of the pre-operative MI, the OR for re-displacement was 4.6 (p = 0.03). Age at the time of surgery, GMFCS, pelvic obliquity and scoliosis were not predictive of re-displacement.

These results, firstly, highlight the importance of hip surveillance in children with cerebral palsy to allow timely intervention to ensure adequate radiological outcomes. Secondly, as in developmental hip dysplasia, full concentric reduction is essential to reduce the risk of re-displacement, with its associated clinical consequences.

Aim

Paediatric fractures are common but those occurring in non-ambulant children are associated with higher rates of Non Accidental Injury (NAI). There is little published on the mechanisms of injury associated with accidental fracture in young children. This study explores the aetiology of long bone fractures in non-ambulant children.

Purpose

The purpose of this study was to assess the accuracy of three-dimensional camera technology when monitoring deformity correction by an Ilizarov frame and to compare it to manual measurements.

Purpose of study

To assess the risk of early re—dislocation following closed reduction (CR) of the hip for idiopathic developmental dysplasia of the hip (DDH).

Introduction: Fibular hemimelia (FH) is a congenital limb reduction deficiency characterised by partial or complete absence of the fibula and a spectrum of associated anomalies. For children with a major anticipated limb length discrepancy and severe foot deformity, management (amputation or limb reconstruction) is controversial.

Materials and Methods: 8 children who are now adults (average age 28 years) underwent limb reconstruction as children in one of two UK centres for severe fibular hemimelia. All 8 participants were recalled to our institution for instrumented gait analysis. The SF-36 and lower limb domains of the Toronto Extremity Salvage Score (TESS) questionnaires were also administered.

Results: Partcipants scored well for general health but had functional limitations reflected in lower TESS scores. Kinematic analysis revealed decreased sagittal knee motion and valgus knee alignment. Also ubiquitous were anterior pelvic tilt and obliquity with incomplete hip extension and reduced range of hip abduction. Kinetic analysis showed reduced peak plantar flexion moment with reduced push-off power and an internal hip adduction moment in late stance. These parameters are compared to control data for below knee amputees.

Discussion and conclusions: Although the number of participants is small, this is the first study to use instrumented gait analysis for severe fibular hemimelia managed with limb reconstruction. The results add objective data to the debate over limb reconstruction or amputation in this group of children.

Purpose: The aim of this research was to characterize the correlation of magnetic resonance image (MRI) measurements of femoral anteversion and tibial torsion with transverse plane kinematics from the gait analysis of ten healthy and nine cerebral palsy (CP) children.

Methods: The bone morphologies of nine spastic diplegic CP and ten healthy children were obtained by analysis of 3D MRIs. Location of anatomical landmarks along the femur and tibia were detected using medical imaging software. Each point was then defined with respect to bone-embedded femoral and tibial Cartesian coordinates, allowing 3D reorientation of the bone independent of the patient position within the scanner. Femoral anteversion was defined as the angle between the femoral neck and the transcondylar plane. Tibial torsion was defined as the angle between the transcondylar axis of the proximal tibia and the bi-malleolar axis.

Three-dimensional motion of the lower limbs was measured using gait analysis. Transverse plane kinematics, including hip rotation and foot progression angles were recorded.

Results: A moderate correlation was found between femoral anteversion, and maximum and average hip rotation in CP children (0.64 and 0.65). A high correlation was also seen between tibial torsion and maximum and average values of hip rotation for CP children (0.71 and 0.74). In healthy children, the only correlation observed was between femoral anteversion and average foot progression in stance (0.75).

Discussion: In healthy children, femoral anteversion appears to influence foot progression angle, implying that this can lead to an internally rotated gait. In CP children, the correlation between femoral anteversion and hip rotation is only moderate. The interaction between different joints is more complex and the rotation of joints is determined by multiple factors. This study showed that tibial torsion also plays a role in determining hip rotation during gait.

Introduction: Young active patients with malignant tumours arising in the distal fibula, requiring bone and soft tissue excision, present a challenge to the treating surgeon. Wide local excision is advocated, to achieve clearance, however, disruption of the ankle mortise results and fusion is often required to restore stability. The loss of movement is poorly tolerated in the younger patient and leads to progressive degenerative changes in surrounding joints.

Method: Excision of the distal fibula lesion followed by rotation of the proximal fibula on its vascular pedicle recreates the ankle mortise with consequent restoration of ankle stability and retaining ankle movement.

Results: Between 2000 and 2008, we have performed this technique on four patients, (2F, 2M) mean age 21 (13–33). Diagnoses were that of chondrosarcoma, parosteal osteosarcoma, Ewings sarcoma and osteofibrodysplasia. Follow up at 5 years (18m-8 year) with no evidence of local or distant recurrence. One case was complicated by deep infection requiring surgical debridement and antibiotic therapy. In all cases the fibula grafts survived. Good to excellent functional results were achieved (Toronto Extremity Salvage Scores, mean 88 range 82–94).

Discussion: We will present the technical aspects of this procedure with particular reference to the most recent case, performed on a young female patient with parosteal osteosarcoma.

We believe this technique provides good oncological and functional results and recommend this treatment option is considered in young active patients required distal fibula excisions for sarcoma.

Young active patients with malignant tumours arising in the distal fibula, requiring excision, present a challenge to the treating surgeon. Wide local excision is advocated, to achieve clearance, however, disruption of the ankle mortise results and fusion is often required to restore stability. The loss of movement is poorly tolerated in the younger patient and leads to progressive degenerative changes in surrounding joints.

Excision of the distal fibula lesion followed by harvesting of the proximal fibula and using this graft to recreate the ankle mortise restores ankle stability and retains ankle movement.

Between 1998 and 2007, we have performed this technique on 4 patients. Diagnoses were Ewing’s sarcoma, chondrosarcoma, parosteal osteosarcoma and osteofibrous dysplasia. To date there has been no evidence of distant or local recurrence. One case was complicated by infection, which resolved with radical debridement and antibiotics; the other three fibula grafts survived. Good to excellent results were achieved.

We will present the technical aspects of this procedure, with particular reference to the most recent case, performed on a young female patient with parosteal osteosarcoma.

We believe this technique provides good oncological and functional results and recommend this treatment option is considered in young active patients requiring distal fibula excisions for sarcoma.

Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon.

Purpose of Study:

To describe the degree and type of disability experience by patients with combined postero-lateral corner and posterior cruciate ligament knee injuries

Methods and Results: After rigorous exclusion criteria were instituted twelve patients were identified as having the required combined knee ligament injuries. These patients underwent functional assessment, clinic examination and gait analysis at the Oxford Gait Laboratory.

Significant functional disability was noted in all patients. Characteristic gait abnormalities identified included hyperextension and dynamic varus deformity with a corresponding increase in the internal valgus knee moment. Electromyographic data revealed early and prolonged contraction of the medial hamstrings and gastrocnemius muscles.

Conclusion: These results suggest the presence of compensatory mechanisms of the musculature around the knee and suggest direction in rehabilitation programs in patients with combined injuries to the posterior cruciate ligament and posterolateral corner of the knee. The results also provide baseline data that will be useful when evaluating the post-operative outcomes in patients undergoing knee ligament reconstruction in the future.

The management of pathological fractures in children remains controversial. The indications for surgical treatment are unclear and the need for histological diagnosis before or after definitive treatment is not clearly defined.

We reviewed retrospectively the records of all patients under the age of 16 years who presented over the past 7 years with a fracture as the first manifestation of bone pathology. There were 26 patients (19 boys and 7 girls) of an average age of 12 years and 2 months (range 4.1–15.8 years).

There were 9 cases of fracture through a simple bone cyst, 6 in the humerus and 3 in the femur. In all cases the fracture was treated conservatively initially. Subsequent management included needle biopsy in all, followed by bone marrow injection under the same anaesthetic. The patients suffered a refracture and were treated with flexible intra-medullary nail fixation.

There were 5 cases of fibrous dysplasia, of which 2 in the femur, 2 in the tibia and one in the proximal radius. Histological diagnosis was obtained in all cases prior to definitive treatment. This included a locked intra-medullary nail in one patient and flexible nailing in another two. The remaining two patients are still under observation.

There were 2 patients with giant cell tumour, 3 patients with aneurysmal bone cyst and one patient with chondroblastoma. Histological diagnosis preceded treatment with curettage and grafting in all these cases. There were 6 patients with malignant primary bone tumour, 1 adamantinoma, 2 osteosarcoma, and 3 with Ewings Sarcoma.

The 3 patients with Ewing’s sarcoma involved the femur. One had extensive local disease and early intra-medullary nailing was performed for palliative reasons. The second patient was treated conservatively initially. Definitive surgery was performed after fracture healing and included segmental resection and vascularised fibular graft. The third patient was initially treated elsewhere. She was thought to have a benign lesion and internal fixation with a screw/plate device was performed. Histology from intra-operative specimens confirmed Ewing’s sarcoma. Definitive surgery required extensive resection and prosthetic replacement.

The 2 patients with osteosarcoma had fracture of proximal humerus and distal femur. The former was treated by forequarter amputation as there was tumour involvement of brachial plexus and remains AWND at 7 years. The latter had resection and EPR of the distal femur.

One patient with adamantinoma underwent segmental resection and reconstruction with VFFG

We recommend that primary fixation of pathological fractures should be avoided until histological diagnosis is obtained. However, if radiographic appearances are reassuringly benign, biopsy can be delayed until conservative fracture management is completed. Definitive treatment of benign lesions with protective intramedullary nailing or curettage and grafting can follow frozen section under the same anaesthetic.

Aim: To describe the clinical, radiological and pathological features of this rare subtype of osteoblastoma diagnosed pre-operatively and treated by excision.

Conclusion: Toxic osteoblastoma is a benign bone forming tumour that presents with systemic symptoms of fever, anorexia and weight loss.

It has a characteristic radiographic appearance with marked periostitis in the involved bone mimicking osteosarcoma and associated focal abnormality in juxtaposed skeletal sites.

With the help of two previously reported cases from the literature of aggressive bone forming tumours in children who presented with marked anorexia and cachexia diagnosed as osteomyelitis and osteosarcoma and treated by ablative surgery this tumour was correctly diagnosed with planned subtotal scapulectomy and reconstruction enabling a good functional result. The systemic symptoms fully resolved following surgery with return of appetite and weight gain.