The October 2024 Children’s orthopaedics Roundup. 360. looks at: Cost-effectiveness analysis of soft bandage and immediate discharge versus rigid immobilization in children with distal radius torus fractures: the FORCE trial; Percutaneous Achilles tendon tenotomy in clubfoot with a blade or a needle: a single-centre randomized controlled noninferiority trial; Treatment of hip displacement in children with cerebral palsy: a five-year comparison of proximal femoral osteotomy and combined femoral-pelvic osteotomy in 163 children; The Core outcome Clubfoot (CoCo) study: relapse, with poorer clinical and quality of life outcomes, affects 37% of idiopathic clubfoot patients; Retention versus removal of epiphyseal screws in paediatric distal tibial fractures: no significant impact on outcomes; Predicting the resolution of residual acetabular dysplasia after brace treatment in infant DDH; Low prevalence of acetabular dysplasia following treatment for neonatal hip instability: a long-term study; How best to distract the patient?

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The aim of this trial was to assess the cost-effectiveness of a soft bandage and immediate discharge, compared with rigid immobilization, in children aged four to 15 years with a torus fracture of the distal radius.

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The aim of this study was to explore parents’ experience of their child’s recovery, and their thoughts about their decision to enrol their child in a randomized controlled trial (RCT) of surgery versus non-surgical casting for a displaced distal radius fracture.

Aims. The aim of this study was to explore clinicians’ experience of a paediatric randomized controlled trial (RCT) comparing surgical reduction with non-surgical casting for displaced distal radius fractures. Methods. Overall, 22 staff from 15 hospitals who participated in the RCT took part in an interview. Interviews were informed by phenomenology and analyzed using thematic analysis. Results. Analysis of the findings identified the overarching theme of “overcoming obstacles”, which described the challenge of alleviating staff concerns about the use of non-surgical casting and recruiting families where there was treatment uncertainty. In order to embed and recruit to the Children’s Radius Acute Fracture Fixation Trial (CRAFFT), staff needed to fit the study within clinical practice, work together, negotiate treatment decisions, and support families. Conclusion. Recruiting families to this RCT was challenging because staff were uncertain about longer-term patient outcomes, and the difficulties were exacerbated by interdisciplinary tensions. Strong family and clinician beliefs, coupled with the complex nature of emergency departments and patient pathways that differed site-by-site, served as barriers to recruitment. Cementing a strong research culture, and exploring families’ treatment preferences, helped to overcome recruitment obstacles. Cite this article: Bone Jt Open 2024;5(4):324–334

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Post-traumatic periprosthetic acetabular fractures are rare but serious. Few studies carried out on small cohorts have reported them in the literature. The aim of this work is to describe the specific characteristics of post-traumatic periprosthetic acetabular fractures, and the outcome of their surgical treatment in terms of function and complications.

Displaced fractures of the distal radius in children are usually reduced under sedation or general anaesthesia to restore anatomical alignment before the limb is immobilized. However, there is growing evidence of the ability of the distal radius to remodel rapidly, raising doubts over the benefit to these children of restoring alignment. There is now clinical equipoise concerning whether or not young children with displaced distal radial fractures benefit from reduction, as they have the greatest ability to remodel. The Children’s Radius Acute Fracture Fixation Trial (CRAFFT), funded by the National Institute for Health and Care Research, aims to definitively answer this question and determine how best to manage severely displaced distal radial fractures in children aged up to ten years. Cite this article: Bone Joint J 2024;106-B(1):16–18

Musculoskeletal diseases are having a growing impact worldwide. It is therefore crucial to have an evidence base to most effectively and efficiently implement future health services across different healthcare systems. International trials are an opportunity to address these challenges and have many potential benefits. They are, however, complex to set up and deliver, which may impact on the efficient and timely delivery of a project. There are a number of models of how international trials are currently being delivered across a range of orthopaedic patient populations, which are discussed here. The examples given highlight that the key to overcoming these challenges is the development of trusted and equal partnerships with collaborators in each country. International trials have the potential to address a global burden of disease, and in turn optimize the benefit to patients in the collaborating countries and those with similar health services and care systems.

Cite this article: Bone Joint J 2023;105-B(7):719–722.

This study was conducted to investigate the characteristics, complications, radiologic features and clinical course of patients undergoing reduction of forearm fractures in order to better inform patient prognosis and postoperative management. We conducted a retrospective cohort study of 1079 pediatric patients treated for forearm fractures between January 2014 and September 2021 in a 327 bed regional medical center. A preoperative radiological assessment and chart review was performed. Percent fracture displacement, location, orientation, comonution, fracture line visibility and angle of angulation were determined by AP and lateral radiographs. Percent fracture displacement was derived by: (Displacement of Bone Shafts / Diameter) x 100% = %Fracture Displacement. Angle of angulation and percent fracture displacement were calculated by averaging AP and lateral radiograph measurements. 80 cases, averaging 13.5±8.3 years, were identified as having a complete fracture of the radius and/or ulna with 69 receiving closed reduction and 11 receiving fixation via an intramedullary device or percutaneous pinning. Eight patients (10%) experienced complications with four resulting in a refracture and four resulting in significant loss of reduction (LOR) without refracture. Fractures in the proximal ⅔s of the radius were associated with a significant increase in complications compared to fractures in the distal ⅓ of the radius (31.6% vs 3.4%) (P=.000428). Likewise, a higher percent fracture displacement was associated with a decreased risk of complications (28.7% vs 5.9% displacement)(P=0.0403). No elevated risk of complications was found based on fracture orientation, angulation, fracture line visibility, forearm bone(s) fractured, sex, age or arm affected. Our result highlights radius fracture location and percent fracture displacement as markers with prognostic value following forearm fracture. These measurements are simply calculated via pre-reduction radiographs, providing an efficient method of informing risk of complications following forearm fracture

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Wrist arthroscopy is a standard procedure in hand surgery for diagnosis and treatment of wrist injuries. Even though not generally recommended for similar procedures, general administration of perioperative antibiotic prophylaxis (PAP) is still widely used in wrist arthroscopy.

The February 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: Trends in management of paediatric distal radius buckle fractures; Pelvic osteotomy in patients with previous sacral-alar-iliac fixation; Sacral-alar-iliac fixation in patients with previous pelvic osteotomy; Idiopathic toe walking: an update on natural history, diagnosis, and treatment; A prediction model for treatment decisions in distal radial physeal injuries: a multicentre retrospective study; Angular deformities after percutaneous epiphysiodesis for leg length discrepancy; MRI assessment of anterior coverage is predictive of future radiological coverage; Predictive scoring for recurrent patellar instability after a first-time patellar dislocation.

Guidelines for the use of preoperative blood tests for elective surgery were established. However, there is less evidence and no guidelines regarding using these tests when a young, healthy patient undergoes minor orthopaedic trauma surgery. Bloodwork is often ordered routinely, regardless of medical history or the nature of the injury. We hypothesized that unnecessary blood work is requested for younger pre-operative patients, and their results will not change peri-operative management. This practice is not a judicious use of healthcare resources. This study aimed to evaluate the frequency, type, cost, and impact on clinical decisions if standard preoperative bloodwork was completed in healthy patients requiring surgical management of a minor fracture or dislocation. After the approval of our institutional ethics board, a retrospective chart review was conducted. Inclusion criteria were patients aged 18-60 years, who had an isolated minor orthopaedic trauma requiring outpatient surgery, who were American Society of Anesthesiologists (ASA) class 1. ASA class 1 is defined as “a normal healthy patient, without any clinically important comorbidity and without a clinically significant past/present medical history.” Data records from January 1, 2016, to December 31, 2018, were extracted from a provincial database (the Analytics Data Integration, Measurement and Reporting) for five hospitals. Data including demographics, surgical treatment, type and number of blood tests ordered, and ordering physician were collected. Any abnormal test results were checked to see whether they led to a change in patient management or related to a postoperative adverse event. Independent samples t-tests and Chi-square tests were used to compare the characteristics of patients who had preoperative bloodwork versus those who did not. The cost of preoperative blood work was estimated. During these two years, 627 patients met inclusion criteria, and 27% (n=168) of these patients had bloodwork completed pre-operatively, while only 34% (n=57) of these had one or more abnormal laboratory parameters. These abnormalities were minor and did not alter clinical management or result in repeated bloodwork peri-operatively. Patients who had bloodwork were significantly older (40.2 years) compared with patients without preoperative blood work (37.8 years; p=0.03), but there was no difference in sex between those who had bloodwork (53.4% male) and those who did not (51.4% male; p=0.63). The most common blood test ordered was a complete blood count, and the most commonly abnormal result was a mildly elevated white blood cell count (19%; n= 29). The most common patients to receive bloodwork were those with ankle (34%) and distal radius (34%) fractures. The bloodwork was primarily ordered by clinical associates (26%; n=46) and emergency department physicians (22%; n=38). Without considering lab personnel, consumables, and analysis time, the cost of this bloodwork was approximately $7685, an average of $45 per patient. Pre-operative bloodwork in young, healthy, asymptomatic patients requiring outpatient surgery for minor orthopaedic trauma had no clinical significance and did not change patient management. Rigorous prospective research is warranted to establish national guidelines for appropriate pre-operative bloodwork ordering to minimize unnecessary and costly investigations

Timely and competent treatment of paediatric fractures is paramount to a healthy future working population. Anecdotal evidence suggests that children travel greater distances to obtain care compared to adults causing economic and geographic inequities. This study aims to qualify the informal regionalization of children's fracture care in Ontario. The results could inform future policy on resource distribution and planning of the provincial health care system. A retrospective cohort study was conducted examining two of the most common paediatric orthopaedic traumatic injuries, femoral shaft and supracondylar humerus fractures (SCH), in parallel over the last 10 years (2010-2020) using multiple linked administrative databases housed at the Institute for Clinical Evaluative Sciences (ICES) in Toronto, Ontario. We compared the distance travelled by these pediatric cohorts to clinically equivalent adult fracture patterns (distal radius fracture (DR) and femoral shaft fracture). Patient cohorts were identified based on treatment codes and distances were calculated from a centroid of patient home forward sortation area to hospital location. Demographics, hospital type, and closest hospital to patient were also recorded. For common upper extremity fracture care, 84% of children underwent surgery at specialized centers which required significant travel (44km). Conversely, 67% of adults were treated locally, travelling a mean of 23km. Similarly, two-thirds of adult femoral shaft fractures were treated locally (mean travel distance of 30km) while most children (84%) with femoral shaft fractures travelled an average of 63km to specialized centers. Children who live in rural areas travel on average 51km more than their adult rural-residing counterparts for all fracture care. Four institutions provide over 75% of the fracture care for children, whereas 22 institutions distribute the same case volume in adults.?. Adult fracture care naturally self-organizes with proportionate distribution without policy-directed systemization. There is an unplanned concentration of pediatric fracture care to specialized centers in Ontario placing undue burden on pediatric patients and inadvertently stresses the surgical resources in a small handful of hospitals. In contrast, adult fracture care naturally self-organizes with proportionate distribution without policy-directed systemization. Patient care equity and appropriate resource allocation cannot be achieved without appropriate systemization of pediatric fracture care

Aims. The aim of this study was to compare the cost-effectiveness of surgical fixation with Kirschner (K-)wire ersus moulded casting after manipulation of a fracture of the distal radius in an operating theatre setting. Methods. An economic evaluation was conducted based on data collected from the Distal Radius Acute Fracture Fixation Trial 2 (DRAFFT2) multicentre randomized controlled trial in the UK. Resource use was collected at three, six, and 12 months post-randomization using trial case report forms and participant-completed questionnaires. Cost-effectiveness was reported in terms of incremental cost per quality-adjusted life year (QALY) gained from an NHS and personal social services perspective. Sensitivity analyses were conducted to examine the robustness of cost-effectiveness estimates, and decision uncertainty was handled using confidence ellipses and cost-effectiveness acceptability curves. Results. In the base case analysis, surgical fixation with K-wire was more expensive (£29.65 (95% confidence interval (CI) -94.85 to 154.15)) and generated lower QALYs (0.007 (95% CI -0.03 to 0.016)) than moulded casting, but this difference was not statistically significant. The probability of K-wire being cost-effective at a £20,000 per QALY cost-effectiveness threshold was 24%. The cost-effectiveness results remained robust in the sensitivity analyses. Conclusion. The findings suggest that surgical fixation with K-wire is unlikely to be a cost-effective alternative to a moulded cast in adults, following manipulation of a fracture of the distal radius in a theatre setting. Cite this article: Bone Joint J 2022;104-B(11):1225–1233

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The aim of this study was to report a complete overview of both incidence, fracture distribution, mode of injury, and patient baseline demographics of paediatric distal forearm fractures to identify age of risk and types of activities leading to injury.

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The distal radius is a major site of osteoporotic bone loss resulting in a high risk of fragility fracture. This study evaluated the capability of a cortical index (CI) at the distal radius to predict the local bone mineral density (BMD).

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Following cast removal for nonoperatively treated distal radius fractures, rehabilitation facilitated by advice leaflet and advice video were compared to a course of face-to-face therapy.