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.
From mid-1992 to 2000 and in conjunction with our paediatric department, we have run a screening program to detect congenital orthopaedic abnormalities. Over this period, we have been referred 245 patients with a provisional diagnosis of clubfeet, of these 54 or 22% were true CTEV (78 feet) giving an incidence in the general population of 0.18% while the rest were diagnosed as having simple postural clubfoot (0.6%). Each patient was assessed clinically and classified according to the Harrold and Walker scale as well as being checked for other congenital/neurological abnormalities. 83% of patients were seen within two weeks of referral. Initial management entailed strapping for 6 weeks with further periods of plaster immobilization (required by 46%). Those who failed to respond or who deteriorated underwent surgical correction with sub-talar release. A small percentage required secondary procedures such as Tibialis Anterior transfer, Tendoachillis release and revision. Patients were continued in the program until at least 6 years of age. While there was a wide variation of other abnormalities in those with type 2 CTEV, those with type 3 had a high incidence of neurological conditions and in particular, arthrogryphosis (59%). These patients did worse and 55% required further surgery after the initial sub-talar release. We would like to present the findings of an 8.5 year prospective study looking at the incidence of the condition, the frequency of other abnormalities and the results of conservative and surgical treatment for each grade.
To determine whether reducing the splintage rate in DDH patients had any effect on the rate of surgical procedures for the treatment of DDH. . Since 1991, in the Blackburn region, there has been a limited target ultrasound screening programme for developmental dysplasia of the hip. The detailed records of the demographics, clinical and ultrasound findings, treatment and outcomes of all children screened by the senior author were reviewed. In 1996 and 1997 only those with persistent major dysplasia at 8 weeks and those with dislocatable hips were placed into Pavlik harnesses. In 1998 only those babies with persistent major dysplasia at 8 weeks of age, or persistent hip instability at 1–2 weeks were placed into Pavlik harnesses. The splintage rates, late dislocation rates (diagnosed after 6 mnths of age) and surgery rates were determined. During the study period 11164 babies were born in the region. 797 (7.1%) babies were seen by the senior author. Surgery in early irreducible hips is unavoidable. Surgery in late dislocators is only avoidable by changing from a selective ultrasound screening policy to performing ultrasound screening on every baby born. With a limited hip screening programme and clinical and ultrasound monitoring of patients, splintage rates can be minimised without increasing the rate of surgery for developmental dysplasia. No child who would have been splinted by the criteria used by other centres, and who wasn’t splinted in this series, required surgery.
Haemophilia is a rare cause of avascular necrosis of the femoral head. We report three cases from one centre, an incidence of 2.8%. All three cases presented "silently", and this makes the early diagnosis difficult. Awareness of the condition should lead to examination of the hips of haemophiliac patients at every outpatient visit and admission in the hope that hip disease can be diagnosed at an early stage. This may allow earlier treatment, less femoral head deformity, and an improvement in the long-term prognosis.
