Introduction. Plantar fasciopathy is a common cause of heel pain, and is usually treated in primary practice with conservative measures. Intractable cases can prove very difficult to treat. Currently plantar fasciopathy is not routinely imaged and treatment is empirical. At the Royal Surrey County Hospital patients with intractable plantar fasciopathy are managed in a unique ‘one-stop’ Heel Pain clinic. Here they undergo clinical assessment, ultrasound scanning and targeted therapy. Methods. Patients referred to the clinic since 2009, with symptoms lasting longer than 6 months and failed conservative management, were prospectively followed. Plantar fasciopathy was confirmed on ultrasound scanning. The ultrasound scans were used to classify the disease characteristics of the plantar fascia. Results. 125 feet (120 patients) were found to have plantar fascia disease. Ultrasound scans demonstrated 64% with typical insertional pathology only. The remaining 36% had atypical distal fascia involvement, with either pure distal disease or a combination of insertional and distal disease. Patients with atypical distal disease were found to have either distal thickening or discrete fibromata. Conclusion. The high proportion of atypical (non-insertional) disease in this cohort shows that ultrasound scanning is valuable in determining location and characterising the pathology in the plantar fascia. Atypical pathology would otherwise not be detected. We propose a new classification for plantar fasciopathy; insertional fasciopathy or non-insertional fasciopathy. This is in keeping with current classification of achilles tendinopathy. The main benefit of this Guildford Classification is in determining optimum treatments for recalcitrant plantar fasciopathies. Empirical treatment is not adequate for recalcitrant cases

Aim. The present study aimed to assess the accuracy of preoperative departmental ultrasound scans in identifying rotator cuff tears at our institution. Methods. Preoperative ultrasound scan reports were obtained from 64 consecutive patients who subsequently underwent arthroscopic subacromial decompression and/or rotator cuff repair. Data was collected retrospectively using our 2010 database. The ultrasound reports were compared with the arthroscopic findings. The presence or absence of partial and full thickness rotator cuff tears was recorded. Results. Ultrasound correctly identified 30/43 (70%) of all tears, 18/30 (60%) of full thickness tears but only 1/13 (8%) of partial tears seen at arthroscopy. Of the remaining 12 partial tears seen at surgery, 6 were misdiagnosed as full thickness tears on ultrasound and 6 were not picked up at all. Five partial thickness tears were repaired and the rest were debrided. If both full and partial thickness tears are counted as true positives, ultrasound had a sensitivity of 70%, a specificity of 67%, a positive predictive value of 81%, a negative predictive value of 51% and an overall accuracy of 69%. If only partial tears are counted as true positives sensitivity decreases to 8% and positive predictive value to 10%. Conclusion. In this series a preoperative departmental ultrasound scan identified 70% of the actual rotator cuff tears present at arthroscopy. However ultrasound was not accurate in identifying partial thickness tears or distinguishing them from full thickness defects. Due to this relatively low sensitivity, we question the usefulness of routine preoperative departmental ultrasound scans in the evaluation of suspected cuff tears

Eighty-two consecutive patients with forefoot pain and clinical signs strongly suggesting a neuroma all underwent ultrasound scan of both feet using a 10-5 MHz transducer where a well defined hypoechoic area defined a neuroma . All ultrasound positive feet had the lump excised surgically for histological studies. Plain x-rays were done on all symptomatic feet to exclude other pathology. Sixty-four feet had an ultrasound positive diagnosis. Of these, there were 82.3% female and 17.1% male (ratio 4.8:1 , p< 0.001). Thirty-six percent had bilateral neuromata but with only one side being symptomatic.59.5% of the neuroma were located in the interspace between the third and fourth toes whilst 41.5% were found in the interspace between the second and third toes. The size of the lesions varied from 3 to 11mm with a mean of 6.86mm. No lesion less than 5mm was symptomatic in our series. One false positive was noted in the series giving the test a sensitivity of 97.9% but the specificity was low at 50% as the scan negative feet were not surgically explored for ethical reasons. All surgically explored patients had become asymptomatic at an average of 5.3 weeks (range 4–24 weeks) post surgery. Thirty-three ultrasound negative patients treated non-operatively were completely asymptomatic at an average of 30 weeks (range 6–50 weeks). We conclude that an ultrasound scan is a cheap, non-invasive, time-efficient test useful in identifying interdigital neuroma as a cause of forefoot pain

Background The ossific nucleus of the femoral head is usually present ultrasonographically around 12 weeks of age. It has been considered that the presence of an ossific nucleus in the femoral head is an indication of hip stability. In the ultrasound scan clinic for the assessment of developmental dysplasia of the hip at Sheffield Children’s Hospital, we have identified unstable hips with ossific nuclei, as well as, the appearance of ossific nuclei at as early as 2 weeks of age. These observations suggested the need to clarify the initial considerations that the ossific nucleus appeared ultrasonographically around 12 weeks of age and was an indicator of hip stability. Aim To determine the relationship, if any, between the presence of the ossific nucleus of the femoral head ultrasonographically and stability of the hip. Patient selection We have included in our study all the children who have had an ultrasound scan of their hips from 1996 to 1999 at Sheffield Children’s Hospital for suspected developmental dysplasia. Methodology We have retrospectively reviewed reports of ultrasound scans performed for developmental dysplasia of the hip between 1996 and 1999. We have looked at the report for both the hips of each child. We have collected and analyzed data with regard to the age of the child at the time of the scan, the depth of the acetabulum, the shape of the femoral head, the presence or absence of an ossific nucleus, the dynamic stability of the hips and the congruity of the joint as reported on the ultrasound report. We report the findings in the first 318 hips of the 627 available patients in the study period. Results The ossific nucleus can appear as early as 2 weeks and yet may not be visible until 24 weeks. In the 318 hips examined the ossific nucleus was present in 46 (14.47%). The age range for these scans was 1–40 weeks after birth. Of the 318 hips 252 (79.24%) were stable on dynamic screening, 274 (86.16%) had a normal(spherical) appearance of the femoral head, 209 (65.72%) had normal acetabular development and 263 (82.7%) demonstrated congruence of the hip joint. These data have been analyzed using Microsoft excel at confidence intervals of 0.8, which suggest no relationship between the presence of the ossific nucleus and hip stability. Conclusion The limited early results of this study have shown that the ossific nucleus of the femoral head can appear from a very early age, may not appear until well after 12 weeks of age and is not an indicator of hip stability. Its presence on ultrasound scan does not exclude developmental dysplasia of the hip

The diagnosis of a meniscal tear may require MRI, which is costly. Ultrasonography has been used to image the meniscus, but there are no reliable data on its accuracy. We performed a prospective study investigating the sensitivity and specificity of ultrasonography in comparison with MRI; the final outcome was determined at arthroscopy. The study included 35 patients with a mean age of 47 years (14 to 73).

There was a sensitivity of 86.4% (95% confidence interval (CI) 75 to 97.7), a specificity of 69.2% (95% CI 53.7 to 84.7), a positive predictive value of 82.6% (95% CI 70 to 95.2) and a negative predictive value of 75% (95% CI 60.7 to 81.1) for ultrasonography. This compared favourably with a sensitivity of 86.4% (95% CI 75 to 97.7), a specificity of 100.0%, a positive predictive value of 100.0% and a negative predictive value of 81.3% (95% CI 74.7 to 87.9) for MRI.

Given that the sensitivity matched that of MRI we feel that ultrasonography can reasonably be applied to confirm the clinical diagnosis before undertaking arthroscopy. However, the lower specificity suggests that there is still a need to improve the technique to reduce the number of false-positive diagnoses and thus to avoid unnecessary arthroscopy.

The deltopectoral approach is a common approach for Shoulder joint replacements where a normal subscapularis tendon is divided. Despite meticulous attention to the subscapular repair, suboptimal return of function was found on clinical examination in 92% of patients (Miller S L: Journal of Shoulder & Elbow Surgery. 12(1): 29–34, February 2003). Therefore the aim was to study the integrity of the Subscapularis tendon in patients with Shoulder joint Replacements both clinical and ultrasound examination

Methods: A cohort of 25 subjects who had undergone Copeland Shoulder replacements through deltopectoral approach were included. All patients had same technique of tendon-to-tendon repair and postoperative rehabilitation. After ethics committee approval subjects were evaluated prospectively with Lift off test, Belly press test and the Constant score. Average follow-up was 29.6 months. An experienced Radiologist performed the Ultrasound examination

Results: Ultrasound examination showed 8 % (2 of 25) had full thickness rupture of subscapularis with 44% (11 of 25) showed mild to moderate atrophy of subscapularis muscle and 12%(3 of 25) severe atrophy. 20%(5 of 25) had Lift off test and Belly press test positive. 40%(10 of 25) had either or both of these tests positive. 60%(15 of 25) had clinical or radiological evidence of reduced function (Fisher exact test, P < 0.01). Constant score are 37.5 with full thickness tears compared to 59.4 with intact subsapularis tendon

Conclusion: Subscapularis tendon function following shoulder replacement had received poor attention. It is deficient in over 60% of patients with joint replacement through Deltopectoral approach with tendon-to-tendon repair. We therefore conclude for this study that alternative techniques of subscapularis tendon repair or alternative approaches to the shoulder joint need to be considered to improve the functional outcome in these patients

Aims

Studies of infant hip development to date have been limited by considering only the changes in appearance of a single ultrasound slice (Graf’s standard plane). We used 3D ultrasound (3DUS) to establish maturation curves of normal infant hip development, quantifying variation by age, sex, side, and anteroposterior location in the hip.

We test the clinical validity and financial implications of the proposed Choosing Wisely statement: “Using ultrasound as a screening test for shoulder instability is inappropriate in people under 30 years of age, unless there is clinical suspicion of a rotator cuff tear.”. A retrospective chart review from a specialist shoulder surgeon's practice over a two-year period recorded 124 patients under the age of 30 referred with shoulder instability. Of these, forty-one had already had ultrasound scans performed prior to specialist review. The scan results and patient files were reviewed to determine the reported findings on the scans and whether these findings were clinically relevant to diagnosis and decision-making. Comparison was made with subsequent MRI scan results. The data, obtained from the Accident Compensation Corporation (ACC), recorded the number of cases and costs incurred for ultrasound scans of the shoulder in patients under 30 years old over a 10-year period. There were no cases where the ultrasound scan was considered useful in decision-making. No patient had a full thickness rotator cuff tear. Thirty-nine of the 41 patients subsequently had MRI scans. The cost to the ACC for funding ultrasound scans in patients under 30 has increased over the last decade and exceeded one million dollars in the 2020/2021 financial year. In addition, patients pay a surcharge for this test. The proposed Choosing Wisely statement is valid. This evidence supports that ultrasound is an unnecessary investigation for patients with shoulder instability unless there is clinical suspicion of a rotator cuff tear. Ultrasound also incurs costs to the insurer (ACC) and the patient. We recommend x-rays and, if further imaging is indicated, High Tech Imaging with MRI and sometimes CT scans in these patients

Abstract. Introduction. The Wells score is commonly used to assess the risk of proximal Deep Vein Thrombosis (DVT) following Knee Arthroplasty (KA). The National Institute for Health and Care Excellence (NICE) guidelines recommend an Ultrasound scan in patients with a Wells score of 2 points or more. We wanted to assess how often this protocol resulted in a scan being done and how many were negative. Methodology. Details of all postoperative Ultrasound scans performed up to 90 days were audited in a high-volume unit between 1st January 2016 and 31st December 2020. This included all Lower Limb Arthroplasty patients. Results. Out of a total of 4955 KA (4506 Total Knee Arthroplasty, 449 Unilateral Knee Arthroplasty), 449 (9.1%) had a total of 561 scans, with 17 (3.0%) scans demonstrating a proximal DVT. Thus 97.0% of Ultrasound scans were negative. Conclusion. The present NICE guidelines with the two-Level DVT Wells score are inappropriate for the management of suspected proximal DVT following KA. We propose that swelling that fails to reduce after 4 hours of elevation, or new swelling after a period of recumbent rest, would be more appropriate indications for a scan and negative scans should not be repeated without a change in symptoms. Unless there are pressing clinical indications, therapeutic anticoagulation should not commence in the absence of a diagnosis

Abstract. Aims. The association between body mass index (BMI) and venous thromboembolism (VTE) is well studied, but remains unclear in the literature. We aimed to determine whether morbid obesity (BMI≥40) was associated with increased risk of VTE following total knee arthroplasty (TKA) or unicompartmental knee arthroplasty (UKA), compared to those of BMI<40. Methods. Between January 2016 and December 2020, our institution performed 4506 TKAs and 449 UKAs. 450 (9.1%) patients had a BMI≥40. CT pulmonary angiography (CTPA) for suspected pulmonary embolism (PE) and ultrasound scan for suspected proximal deep vein thrombosis (DVT) were recorded up to 90 days post-operatively. Results. When comparing those of BMI<40 to those with BMI≥40, there was no difference in incidence of PE (1.0% vs 1.1%, p=0.803) or proximal DVT (0.4% vs 0.2%, p=0.645). There was no difference in number of ultrasound scans ordered (p=0.668), or number of CTPAs ordered for those with a BMI≥40 (p=0.176). The percentage of patients with a confirmed PE or proximal DVT were 24.2% and 3.9% respectively in the BMI<40 group, compared to 20.0% (p=0.804) and 2.3% (p=0.598) in the BMI≥40 group. Conclusion. Morbid obesity was not associated with increased risk of PE or proximal DVT within 90 days of TKA or UKA. Overall, 76.3% of CTPAs and 96.2% of ultrasound scans were negative. Increasing the threshold for VTE investigation would reduce the rate of negative investigations. Establishing more effective risk stratification protocols, to guide investigation, would likely reduce unnecessary imaging

The diagnostic sub-categorization of cauda equina syndrome (CES) is used to aid communication between doctors and other healthcare professionals. It is also used to determine the need for, and urgency of, MRI and surgery in these patients. A recent paper by Hoeritzauer et al (2023) in this journal examined the interobserver reliability of the widely accepted subcategories in 100 patients with cauda equina syndrome. They found that there is no useful interobserver agreement for the subcategories, even for experienced spinal surgeons. This observation is supported by the largest prospective study of the treatment of cauda equina syndrome in the UK by Woodfield et al (2023). If the accepted subcategories are unreliable, they cannot be used in the way that they are currently, and they should be revised or abandoned. This paper presents a reassessment of the diagnostic and prognostic subcategories of cauda equina syndrome in the light of this evidence, with a suggested cure based on a more inclusive synthesis of symptoms, signs, bladder ultrasound scan results, and pre-intervention urinary catheterization. Cite this article: Bone Joint J 2024;106-B(3):227–231

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. Methods. A Delphi consensus study was performed among the membership of BSCOS. Statements were generated by a steering group regarding aspects of the management of DDH in children aged under three months, namely screening and surveillance (15 questions), the technique of ultrasound scanning (eight questions), the initiation of treatment (19 questions), care during treatment with a splint (ten questions), and on quality, governance, and research (eight questions). A two-round Delphi process was used and a consensus document was produced at the final meeting of the steering group. Results. A total of 60 statements were graded by 128 clinicians in the first round and 132 in the second round. Consensus was reached on 30 out of 60 statements in the first round and an additional 12 in the seond. This was summarized in a consensus statement and distilled into a flowchart to guide clinical practice. Conclusion. We identified agreement in an area of medicine that has a long history of controversy and varied practice. None of the areas of consensus are based on high-quality evidence. This document is thus a framework to guide clinical practice and on which high-quality clinical trials can be developed. Cite this article: Bone Joint J 2023;105-B(2):209–214

Aims. The aim of this study was to investigate the agreement in interpretation of the quality of the paediatric hip ultrasound examination, the reliability of geometric and morphological assessment, and the relationship between these measurements. Methods. Four investigators evaluated 60 hip ultrasounds and assessed their quality based the standard plane of Graf et al. They measured geometric parameters, described the morphology of the hip, and assigned the Graf grade of dysplasia. They analyzed one self-selected image and one randomly selected image from the ultrasound series, and repeated the process four weeks later. The intra- and interobserver agreement, and correlations between various parameters were analyzed. Results. In the assessment of quality, there a was moderate to substantial intraobserver agreement for each element investigated, but interobserver agreement was poor. Morphological features showed weak to moderate agreement across all parameters but improved to significant when responses were reduced. The geometric measurements showed nearly perfect agreement, and the relationship between them and the morphological features showed a dose response across all parameters with moderate to substantial correlations. There were strong correlations between geometric measurements. The Graf classification showed a fair to moderate interobserver agreement, and moderate to substantial intraobserver agreement. Conclusion. This investigation into the reliability of the interpretation of hip ultrasound scans identified the difficulties in defining what is a high-quality ultrasound. We confirmed that geometric measurements are reliably interpreted and may be useful as a further measurement of quality. Morphological features are generally poorly interpreted, but a simpler binary classification considerably improves agreement. As there is a clear dose response relationship between geometric and morphological measurements, the importance of morphology in the diagnosis of hip dysplasia should be questioned. Cite this article: Bone Joint J 2023;105-B(10):1123–1130

Aims. The aim of this study was to review the value of accepting referrals for children with ‘clicky hips’ in a selective screening programme for hip dysplasia. Patients and Methods. A single-centre prospective database of all referrals to the hip clinic was examined to identify indication for referrals, diagnosis, and treatment. All patients referred received a standardized ultrasound scan and clinical examination by an orthopaedic consultant. Results. There were 5716 children referred to the orthopaedic hip clinic between 1 June 2014 and 26 September 2018. In all, 1754 children (30.1%) were referred due to ‘clicky hip’ with no additional risk factors or indications for ultrasound scan. A total of 123 children (7.1%) referred with ‘clicky hip’ and no additional risk factors or examination findings had an abnormal initial hip ultrasound, including 16 children (0.9%) with dysplastic hips. Of the 141 children who required treatment in a Pavlik harness during the study period, 23 (16%) had been referred with a ‘clicky hip’ and no additional risk factors or examination findings, including six children with Graf 3 or 4 hips. Conclusion. There is significant value in reviewing children with an isolated ‘clicky hip’. Many children who require treatment are referred to the orthopaedic service as ‘clicky hip’ with no additional risk factors. In a pragmatic pathway with a diverse population of clinicians performing baby checks, ‘clicky hip’ is an important indication for referral and should not be discarded. Cite this article: Bone Joint J 2019;101-B:635–638

Aims. To monitor the performance of services for developmental dysplasia of the hip (DDH) in Northern Ireland and identify potential improvements to enhance quality of service and plan for the future. Methods. This was a prospective observational study, involving all infants treated for DDH between 2011 and 2017. Children underwent clinical assessment and radiological investigation as per the regional surveillance policy. The regional radiology data was interrogated to quantify the use of ultrasound and ionizing radiation for this population. Results. Evidence-based changes were made to the Northern Ireland screening programme, including an increase in ultrasound scanning capacity and expansion of nurse-led screening clinics. The number of infant hip ultrasound scans increased from 4,788 in 2011, to approximately 7,000 in 2013 and subsequent years. The number of hip radiographs on infants of less than one year of age fell from 7,381 to 2,208 per year. There was a modest increase in the treatment rate from 10.9 to 14.3 per 1,000 live births but there was a significant reduction in the number of closed hip reductions. The incidence of infants diagnosed with DDH after one year of age was 0.30 per 1,000 live births over the entire period. Conclusion. Improving compliance with the regional infant hip screening protocols led to reduction in operative procedures and reduced the number of pelvic radiographs of infants. We conclude that performance monitoring of screening programmes for DDH is essential to provide a quality service. Cite this article: Bone Joint J 2020;102-B(4):495–500

Aims. The aim of this study was to establish a reliable method for producing 3D reconstruction of sonographic callus. Methods. A cohort of ten closed tibial shaft fractures managed with intramedullary nailing underwent ultrasound scanning at two, six, and 12 weeks post-surgery. Ultrasound capture was performed using infrared tracking technology to map each image to a 3D lattice. Using echo intensity, semi-automated mapping was performed to produce an anatomical 3D representation of the fracture site. Two reviewers independently performed 3D reconstructions and kappa coefficient was used to determine agreement. A further validation study was undertaken with ten reviewers to estimate the clinical application of this imaging technique using the intraclass correlation coefficient (ICC). Results. Nine of the ten patients achieved union at six months. At six weeks, seven patients had bridging callus of ≥ one cortex on the 3D reconstruction and when present all achieved union. Compared to six-week radiographs, no bridging callus was present in any patient. Of the three patients lacking sonographic bridging callus, one went onto a nonunion (77.8% sensitive and 100% specific to predict union). At 12 weeks, nine patients had bridging callus at ≥ one cortex on 3D reconstruction (100%-sensitive and 100%-specific to predict union). Presence of sonographic bridging callus on 3D reconstruction demonstrated excellent reviewer agreement on ICC at 0.87 (95% confidence interval 0.74 to 0.96). Conclusion. 3D fracture reconstruction can be created using multiple ultrasound images in order to evaluate the presence of bridging callus. This imaging modality has the potential to enhance the usability and accuracy of identification of early fracture healing. Cite this article: Bone Joint Res 2021;10(12):759–766

Aims. The early diagnosis of cauda equina syndrome (CES) is crucial for a favourable outcome. Several studies have reported the use of an ultrasound scan of the bladder as an adjunct to assess the minimum post-void residual volume of urine (mPVR). However, variable mPVR values have been proposed as a threshold without consensus on a value for predicting CES among patients with relevant symptoms and signs. The aim of this study was to perform a meta-analysis and systematic review of the published evidence to identify a threshold mPVR value which would provide the highest diagnostic accuracy in patients in whom the diagnosis of CES is suspected. Methods. The search strategy used electronic databases (PubMed, Medline, EMBASE, and AMED) for publications between January 1996 and November 2021. All studies that reported mPVR in patients in whom the diagnosis of CES was suspected, followed by MRI, were included. Results. A total of 2,115 studies were retrieved from the search. Seven fulfilled the inclusion criteria. These included 1,083 patients, with data available from 734 being available for meta-analysis. In 125 patients, CES was confirmed by MRI. The threshold value of mPVR reported in each study varied and could be categorized into 100 ml, 200 ml, 300 ml, and 500 ml. From the meta-analysis, 200 ml had the highest diagnostic accuracy, with 82% sensitivity (95% confidence interval (CI) 0.72 to 0.90) and 65% specificity (95% CI 0.70 to 0.90). When compared using summative receiver operating characteristic curves, mPVR of 200 ml was superior to other values in predicting the radiological confirmation of CES. Conclusion. mPVR is a useful tool when assessing patients in whom the diagnosis of CES is suspected. Compared with other values a mPVR of 200 ml had superior sensitivity, specificity, and positive and negative predictive values. In a patient with a suggestive history and clinical findings, a mPVR of > 200 ml should further raise the suspicion of CES. Caution is recommended when considering the mPVR in isolation and using it as an ‘exclusion tool’, and it should only be used as an adjunct to a full clinical assessment. Cite this article: Bone Joint J 2023;105-B(5):487–495

We have examined the accuracy of 143 consecutive ultrasound scans of patients who subsequently underwent shoulder arthroscopy for rotator-cuff disease. All the scans and subsequent surgery were performed by an orthopaedic surgeon using a portable ultrasound scanner in a one-stop clinic. There were 78 full thickness tears which we confirmed by surgery or MRI. Three moderate-size tears were assessed as partial-thickness at ultrasound scan (false negative) giving a sensitivity of 96.2%. One partially torn and two intact cuffs were over-diagnosed as small full-thickness tears by ultrasound scan (false positive) giving a specificity of 95.4%. This gave a positive predictive value of 96.2% and a negative predictive value of 95.4%. Estimation of tear size was more accurate for large and massive tears at 96.5% than for moderate (88.8%) and small tears (91.6%). These results are equivalent to those obtained by several studies undertaken by experienced radiologists. We conclude that ultrasound imaging of the shoulder performed by a sufficiently-trained orthopaedic surgeon is a reliable time-saving practice to identify rotator-cuff integrity

Introduction. There is little evidence surrounding the clinical implications of a diagnosis of IIa hip dysplasia with no consensus as to its efficacy as a predictor pathological dysplasia or treatment. Therefore, we evaluated the importance of categorising 2a hip dysplasia in to 2a- and 2a+ to better understand the clinical outcomes of each. Methods. A 9-year retrospective cohort study of patients with a diagnosis of type IIa hip dysplasia between 2011 – 2020 (n=341) in our centre. Ultrasound scans were graded using Graf's classification, assessment of management and DDH progression was completed through prospective data collection by the authors. Results. The prevalence of IIa hip dysplasia within our population was 6.7/1000 live births. There was significantly higher incidence of treatment in the IIa- (31.4%, n=17/54) group when compared to the 2a+ group (10%, n=28/287), (p<0.01). In those that had an abnormality (torticollis and/or foot abnormality) treatment rates (24% n=7/29) were significantly (p<0.05) higher than those without anatomical abnormality (15%, n=48/312). Conclusion. This study has demonstrated the significant clinical impact of a IIa- diagnosis on progression to pathological dysplasia and therefore higher rates of treatment in IIa- hips. Furthermore, we have demonstrated the importance of detection of IIa hips through a national screening program, to allow for timely intervention to prevent missing the acetabular maturation window. Therefore, it is our recommendation that all patients with additional anatomical abnormalities and those with a diagnosis of type IIa- hip dysplasia be considered for immediate treatment or urgent follow up following their diagnosis to prevent late conservative intervention

Abstract. Introduction. 30-day emergency readmission is an indicator of treatment related complication once discharged, resulting in readmission. A board-approved quality improvement pathway was introduced to reduce elective re-admissions. Method. The pathway involved telephone and email contact details provision to patients for any non-life threatening medical assistance, allowing for initial nurse led management of all issues. A new clinic room available 7 days, and same day ultrasound scanning for DVT studies were introduced. A capability, opportunity and behavior model of change was implemented. Readmission rates before and six months after implementation were collected from Model Hospital. A database used to document patient communications was interrogated for patient outcomes. Results. Prior to implementation, readmission rates following elective primary total knee replacement (TKR) at the 1st business quarter of 2021 (April – June 2021), was 8.7%, (benchmark 3.8%). Following implementation, readmission rates decreased to 4.1% (October – December 2021). 54% of patients making contact were managed with telephone advice. 15% of patients required face-to-face clinic. 32% of those required a same day scan to exclude DVT (1/4). 20 out of 684 TKRs performed following protocol introduction were re-admitted within 30 days. Readmissions were 41% surgical, 29% medical. 52% were unaware of the newly implemented protocol. Further improvements have been made to the protocol based on these findings. Implementation of a suitable pathway can significantly reduce re-admission rates in our center and could be used to reduce readmission rates in other national elective treatment centers

Aims. The significance of the ‘clicky hip’ in neonatal and infant examination remains controversial with recent conflicting papers reigniting the debate. We aimed to quantify rates of developmental dysplasia of the hip (DDH) in babies referred with ‘clicky hips’ to our dedicated DDH clinic. Patients and Methods. A three-year prospective cohort study was undertaken between 2014 and 2016 assessing the diagnosis and treatment outcomes of all children referred specifically with ‘clicky hips’ as the primary reason for referral to our dedicated DDH clinic. Depending on their age, they were all imaged with either ultrasound scan or radiographs. Results. There were 69 ‘clicky hip’ referrals over the three-year period. This represented 26.9% of the total 257 referrals received in that time. The mean age at presentation was 13.6 weeks (1 to 84). A total of 19 children (28%) referred as ‘clicky hips’ were noted to have hip abnormalities on ultrasound scan, including 15 with Graf Type II hips (7 bilateral), one Graf Type III hip, and three Graf Type IV hips. Of these, ten children were treated with a Pavlik harness, with two requiring subsequent closed reduction in theatre; one child was treated primarily with a closed reduction and adductor tenotomy. In total, 11 (15.9%) of the 69 ‘clicky hip’ referrals required intervention with either harness or surgery. Conclusion. Our study provides further evidence that the ‘clicky hip’ referral can represent an underlying diagnosis of DDH and should, in our opinion, always lead to further clinical and radiological assessment. In the absence of universal ultrasound screening, we would encourage individual units to carefully assess their own outcomes and protocols for ‘clicky hip’ referrals and tailor ongoing service provision to local populations and local referral practices. Cite this article: Bone Joint J 2018;100-B:1249–52

Data was collected for patients referred to the orthopaedic department at Forth Valley Royal Hospital with metatarsalgia who subsequently received an ultrasound. Patients found to have a Morton's neuroma were divided into groups based on its size. A total of 90 patients received an ultrasound scan and neuroma was confirmed in 58 with an alternative diagnosis found in 32 patients and a total of 42 were included in the final analysis. All 14 patients with neuroma < 6mm reported resolution of symptoms. 4 (28.5%) underwent surgical excision as first line, 1 (7%) received a single corticosteroid injection and 9 (64%) were treated with metatarsal bars. There were 27 patients with neuroma > 6mm; 8 (29.6%) underwent surgical excision as first line treatment, 5 (18.5%) received metatarsal bars and 14 (51.9%) received injections. 7 (25.9%) patients reported resolution of symptoms after 1 injection, 1 (3.7%) patient required 2 injections and 1 (3.7%) patient required 3 injections to achieve resolution. 5 (18.5%) patients required surgical excision following ongoing symptoms despite non-surgical treatment. 9 (33.3%) reported resolution of symptoms following injection. 5 (18.5%) reported resolution of symptoms following use of metatarsal bars. A total of 71% of patients with a neuroma measuring < 6mm reported full resolution of symptoms with non-surgical treatment. For patients with neuroma >6mm, 64.3% had resolution of symptoms with injections alone and 18.5% required surgical excision despite injection. In conclusion, there is a benefit to offering non-surgical treatment as first line in patients with a neuroma regardless of size

The primary aim was to assess the reliability of ultrasound in the assessment of humeral shaft fracture healing. The secondary aim was to estimate the accuracy of ultrasound assessment in predicting humeral shaft nonunion. Twelve patients (mean age 54yrs [20–81], 58% [n=7/12] female) with a non-operatively managed humeral diaphyseal fracture were prospectively recruited and underwent ultrasound scanning at six and 12wks post-injury. Scans were reviewed by seven blinded observers to evaluate the presence of sonographic callus. Intra- and inter-observer reliability were determined using the weighted kappa and intraclass correlation coefficient (ICC). Accuracy of ultrasound assessment in nonunion prediction was estimated by comparing scans for patients that united (n=10/12) with those that developed a nonunion (n=2/12). At both six and 12wks, sonographic callus was present in 11 patients (10 united, one developed a nonunion) and sonographic bridging callus (SBC) was present in seven patients (all united). Ultrasound assessment demonstrated substantial intra- (6wk kappa 0.75, 95% CI 0.47-1.03; 12wk kappa 0.75, 95% CI 0.46-1.04) and inter-observer reliability (6wk ICC 0.60, 95% CI 0.38-0.83; 12wk ICC 0.76, 95% CI 0.58-0.91). Absence of sonographic callus demonstrated a sensitivity of 50%, specificity 100%, positive predictive value (PPV) 100% and negative predictive value (NPV) 91% in nonunion prediction (accuracy 92%). Absence of SBC demonstrated a sensitivity of 100%, specificity 70%, PPV 40% and NPV 100% (accuracy 75%). Of three patients at risk of nonunion based on reduced radiographic callus formation (Radiographic Union Score for HUmeral fractures <8), one had SBC on 6wk ultrasound (and united) and the other two had non-bridging or absent sonographic callus (both developed a nonunion). Ultrasound assessment of humeral shaft fracture healing was reliable and predictive of nonunion, and may be a useful tool in defining the risk of nonunion among patients with reduced radiographic callus formation

Though retear rates following rotator cuff repair are well established, we set out to review current literature to determine when early retears occurred (defined as <12m following surgery), and examine which pre- and post-operative variables might affect outcome. Pubmed, Medline, and CINAHL were searched for literature published from 2011 to 2021 using specific search terms. The inclusion criteria were studies reporting retear rates within 12 months of initial surgical repair. Exclusionary criteria were studies that included partial thickness tears, and studies that did not use imaging modalities within 12 months to assess for retears. PRISMA guidelines were followed, identifying a total of 10 papers. A combined total of 3372 shoulders included (Mean age 56 −67 years). The most common modality used to identify early retears were ultrasound scan and MRI. 6 of the 10 studies completed imaging at 0-3 months, 6 studies imaged at 3-6 months and 6 studies imaged at 6-12 months. Across all studies, there was a 17% early retear rate (574 patients). Of these, 13% occurred by 3 months, whilst the peak for retears occurred at 3-6 months (82%) and 5% occurred at 6-12 months. The risk of retear was higher in larger tears and extensive tendon degeneration. All studies apart from one documented a return to work/sport at 6 months post-operatively. Postoperative rehabilitation does not appear to alter retear rate, although data is limited with only 1 of 10 studies allowing active range of movement before 6 weeks. Retorn tendons had poorer functional outcomes compared to intact tendons at 12m following initial repair. The majority of early retears occur at 3-6 months and this time period should be prioritised both in rehabilitation protocols and future research. Age, tear size, and tendon degeneration were found to influence likelihood of early retears

16 to 34% of the population suffer from shoulder pain, the most common cause being rotator cuff tears. NICE guidance recommends using ultrasound scan (USS) or MRI to assess these patients, but does not specify which is preferable. This study assesses the accuracy of USS and MRI in rotator cuff tears in a DGH, to establish the most appropriate imaging modality. Patients who had at least two of shoulder ultrasound, MRI or arthroscopy within a seven month period (n=55) were included in this retrospective study. Sensitivity, Specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) were calculated using arthroscopy as the true result, and kappa coefficients calculated for each pairing. 59 comparisons were made in total. Sensitivity for MRI in full supraspinatus tears was 0.83, and for USS 0.75. Specificity for MRI in these tears was 0.75, and for USS 0.83. Values were much lower in other tears, which occurred less frequently. USS and MRI completely agreed with each other 61.3% of the time. Both modalities were only completely accurate 50% of the time. Kappa coefficient between arthroscopy and MRI for supraspinatus tears was 0.658, and for USS was 0.615. There was no statistical difference between MRI and USS sensitivity or specificity (p=1), suggesting that one modality cannot be recommended over the other for full supraspinatus tears. They also do not tend to corroborate one another, suggesting that there is no benefit from doing both scans. Further research is needed to see how both modalities can be improved to increase their accuracy

The purposes of this study were to investigate whether twins and multiple births have a higher incidence of Developmental Dysplasia of the Hip (DDH), and whether universal ultrasound scanning would be beneficial in this population. Methods. Records of all twin and multiple births between 1st January 2004 and 31st December 2008 at Addenbrooke's Hospital were obtained. Information regarding sex, gestation, birth weight, DDH risk factors, results of the neonatal hip examination and of any ultrasound scans were analysed. The incidence of DDH in singletons born during the same period was calculated from birth records and the DDH database. Results. Of the 990 twin and multiple births, 267 had ultrasound scans. Of those scanned, over 92% had a normal (bilateral Graf I) scan initially. Within the study cohort there was one case of DDH diagnosed on ultrasound and successfully treated with Pavlik harness. There were two cases of late presenting DDH, one at 8 months and one at 14 months old. Both had no risk factors, a normal neonatal examination and consequently had not had an ultrasound scan. Conclusion. In our study, twins did not have a significantly higher incidence of DDH compared to singletons. However, ultrasound screening of twins would have detected the two late presenting cases of DDH earlier. It remains to be seen whether universal scanning would be cost-effective

Aims. Functional rehabilitation has become an increasingly popular treatment for Achilles tendon rupture (ATR), providing comparably low re-rupture rates to surgery, while avoiding risks of surgical complications. Limited evidence exists on whether gap size should affect patient selection for this treatment option. The aim of this study was to assess if size of gap between ruptured tendon ends affects patient-reported outcome following ATR treated with functional rehabilitation. Methods. Analysis of prospectively collected data on all 131 patients diagnosed with ATR at Royal Berkshire Hospital, UK, from August 2016 to January 2019 and managed non-operatively was performed. Diagnosis was confirmed on all patients by dynamic ultrasound scanning and gap size measured with ankle in full plantarflexion. Functional rehabilitation using an established protocol was the preferred treatment. All non-operatively treated patients with completed Achilles Tendon Rupture Scores (ATRS) at a minimum of 12 months following injury were included. Results. In all, 82 patients with completed ATRS were included in the analysis. Their mean age was 51 years (standard deviation (SD) 14). The mean ATRS was 76 (SD 19) at a mean follow-up of 20 months (SD 11) following injury. Gap inversely affected ATRS with a Pearson’s correlation of -0.30 (p = 0.008). Mean ATRS was lower with gaps > 5 mm compared with ≤ 5 mm (73 (SD 21) vs 82 (SD 16); p = 0.031). Mean ATRS was lowest (70 (SD 23)) with gaps > 10 mm, with significant differences in perceived strength and pain. The overall re-rupture rate was two out of 131 (1.5%). Conclusion. Increasing gap size predicts lower patient-reported outcome, as measured by ATRS. Tendon gap > 5 mm may be a useful predictor in physically demanding individuals, and tendon gap > 10 mm for those with low physical demand. Further studies that control for gap size when comparing non-operative and operative treatment are required to assess if these patients may benefit from surgery, particularly when balanced against the surgical risks. Cite this article: Bone Joint J 2020;102-B(11):1535–1541

Sonographic callus may enable assessment of fracture healing. The aim of this study was to establish a reliable method for three-dimensional reconstruction of sonographic callus. Patients that underwent non-operative management of displaced midshaft clavicle fractures and intramedullary nailing of tibia fractures were prospectively recruited and followed to union. Ultrasound scanning was performed at periodical time points following injury. Infra-red tracking technology was used to map each image to a three-dimensional lattice. Criteria was fist established for two-dimensional bridging callus detection in a pilot study. Using echo intensity of the ultrasound image, semi-automated mapping was used to create an anatomic three-dimensional representation of fracture healing. Agreement on the presence of sonographic bridging callus was assessed using the kappa coefficient and intra-class-correlation (ICC) between observers. 112 clavicle fractures and 10 tibia fractures completed follow-up at six months. Sonographic bridging callus was detected in 62.5% (n=70/112) of the clavicles at six weeks post-injury. If present, union occurred in 98.6% of the fractures (n=69/70). If absent, nonunion developed in 40.5% of cases (n=17/42)(73.4%-sensitive and 100%-specific to predict union). Out of 10 tibia fractures, 7 had bridging callus of at least one cortex at 6 weeks and when present all united. Of the three patients lacking sonographic bridging callus, one went onto a nonunion (77.8%-sensitive and 100%-specific to predict union). The ICC for sonographic callus between four reviewers was 0.82 (95% CI 0.68–0.91). Three-dimensional ultrasound reconstruction of bridging callus has the potential to identify impaired fracture healing at an early stage in fracture management

Aims. Diagnosis of cauda equina syndrome (CES) remains difficult; clinical assessment has low accuracy in reliably predicting MRI compression of the cauda equina (CE). This prospective study tests the usefulness of ultrasound bladder scans as an adjunct for diagnosing CES. Methods. A total of 260 patients with suspected CES were referred to a tertiary spinal unit over a 16-month period. All were assessed by Board-eligible spinal surgeons and had transabdominal ultrasound bladder scans for pre- and post-voiding residual (PVR) volume measurements before lumbosacral MRI. Results. The study confirms the low predictive value of ‘red flag’ symptoms and signs. Of note ‘bilateral sciatica’ had a sensitivity of 32.4%, and a positive predictive value (PPV) of only 17.2%, and negative predictive value (NPV) 88.3%. Use of a PVR volume of ≥ 200 ml was a demonstrably more accurate test for predicting cauda equina compression on subsequent MRI (p < 0.001). The PVR sensitivity was 94.1%, specificity 66.8%, PPV 29.9% and NPV 98.7%. The PVR allowed risk-stratification with 13% patients deemed ‘low-risk’ of CES. They had non-urgent MRI scans. None of the latter scans showed any cauda equina compression (p < 0.006) or individuals developed subsequent CES in the intervening period. There were considerable cost-savings associated with the above strategy. Conclusion. This is the largest reported prospective evaluation of suspected CES. Use of the PVR volume ≥ 200 ml was considerably more accurate in predicting CES. It is a useful adjunct to conventional clinical assessment and allows risk-stratification in managing suspected CES. If adopted widely it is less likely incomplete CES would be missed. Cite this article: Bone Joint J 2020;102-B(6):677–682

ECSWT has been on the medical horizon for last 30 years mainly in urology for urolithiasis and has found a parallel use in orthopaedics for various chronic soft tissue conditions like Tendoachilles tendinoses and plantar fasciitis etc. ECSWT acts a piezoelectric device releasing acoustic energy and causing micro-trauma activating cytokine mediated response stimulating local angiogenesis and tissue repair. Methodology. 56 patients were recruited for the trial after ethics approval was achieved. The diagnosis was confirmed with ultrasound scan and measuring the width of the swelling and the local hypervascularity. The cohort of the patients was randomised in groups for physiotherapy [n=23] and shockwave therapy [n= 23]. The patient groups with shockwave therapy received a 3-week treatment with typical 2000 impulses per session once a week and physiotherapy group was subjected to eccentric loading exercises. Patients were assessed at 12 week with AOFAS, VISA-A scores and repeat ultrasound scan. Results. The average age of the average age was 51 years [36- 73 years] Mean duration of symptoms prior to treatment was 25 months (range 6-60 months). AOFAS scores increased in both groups: from 64□86 in the ECSWT group and 72□79 in the physiotherapy group. VISA-A scores also increased in both groups from 39□73 in the ECSWT group and from 36□56 in the physiotherapy group. Scores were significantly higher in the ECWST group post treatment. The ultrasound scan findings suggested the tendon girth receding from 10.9 mm□9.9 mm in physiotherapy group while 9.8 mm□8.7 mm in the ECSWT group with hypervascularity decreasing from marked to mild in both groups. Statistical significance was established using SPSS 16 p < 0.001in post treatment group. Conclusion. Clinically significant improvement was found in the patients treated with ECSWT as compared to the physiotherapy sessions while radiological evidence showed parallel improvement in both the groups

Abstract. Objectives. Three-dimensional visualisation of sonographic callus has the potential to improve the accuracy and accessibility of ultrasound evaluation of fracture healing. The aim of this study was to establish a reliable method for producing three-dimensional reconstruction of sonographic callus. Methods. A prospective cohort of ten patients with a closed tibial shaft fracture managed with intramedullary nailing were recruited and underwent ultrasound scanning at 2-, 6- and 12-weeks post-surgery. Ultrasound B-mode capture was performed using infrared tracking technology to map each image to a three-dimensional lattice. Using echo intensity, semi-automated mapping was performed by two independent reviewers to produce an anatomic three-dimensional representation of the fracture. Agreement on the presence of sonographic bridging callus on three-dimensional reconstructions was assessed using the kappa coefficient. Results. Nine of the ten patients achieved union at six months. At six weeks, seven patients had bridging callus at ≥1 cortex on the three-dimensional reconstruction; when present all united. Compared to radiographs, no bridging callus was present in any patient. Of the three patients lacking sonographic bridging callus, one went onto a nonunion (77.8%-sensitive and 100%-specific to predict union). At twelve weeks, nine patients had bridging callus at ≥1 cortex on three-dimensional reconstruction and all united (100%-sensitive and 100%-specific to predict union). Compared to radiographs, seven of the nine patients that united had bridging callus. Three-dimensional reconstruction of the anteromedial and anterolateral tibial surface was achieved in all patients, and detection of sonographic bridging callus on the three-dimensional reconstruction demonstrated substantial inter-observer agreement (kappa=0.78, 95% confidence interval 0.29–1.0, p=0.011). Conclusions. Three-dimensional fracture reconstruction can be created using multiple ultrasound images in order to evaluate the presence of bridging callus. This imaging modality has the potential to identify impaired healing at an early stage in fracture management. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Congenital talipes equinovarus is a common anomaly which can now be diagnosed prenatally on a routine ultrasound scan at 20 weeks of gestation. Prenatal counselling is increasingly offered to parents with affected fetuses, but it is difficult to counsel parents if there is a chance that the fetus may not have talipes. Our study correlates the prenatal ultrasound findings of 14 infants diagnosed as having unilateral or bilateral talipes during their routine 20-week ultrasound scan with their clinical findings at birth and the treatment received. No feet diagnosed as talipes on the ultrasound scan were completely normal at birth and therefore there were no true false-positive results. One foot graded as normal at 20 weeks was found to have a mild grade-1 talipes at birth, but did not require treatment other than simple stretches. A total of 32% of feet required no treatment and so could be considered functional false-positive results on the scan. Serial casting was required by 13% of feet and surgical treatment by 55%. The severity of the talipes is difficult to establish before birth. A number of patients are likely to need surgical treatment, but a proportion will have talipes so mildly that no treatment will be required. In counselling parents at 20 weeks, orthopaedic surgeons need to know whether or not there is a small chance that the ultrasound diagnosis could be wrong and also that the talipes may be so mild that the foot will not require treatment

A challenging problem in ultrasound based orthopaedic surgery is the identification and interpretation of bone surfaces. Recently we have proposed a new fully automatic ultrasound bone surface enhancement filter in the context of spine interventions. The method is based on the use of a Gradient Energy Tensor filter to construct a new feature enhancement metric, which we call the Local Phase Tensor. The goal of this study is to provide further improvements to the proposed filtering method by incorporating a-priori knowledge about the physics of ultrasound imaging and salient grouping of enhanced bone features. Typical ultrasound scan of the spine, there is a large soft tissue interface present close to the transducer surface with high intensity values similar to those of the bone anatomy response. Typical ultrasound image segmentation or enhancement methods will be affected by this thick soft tissue response. In order to weaken this soft tissue interface we calculate a new transmission map where features deeper in the ultrasound image have higher transmission values and shallow features have lower transmission values. The calculation of this new US transmission/attenuation map allows the proposed image enhancement method to mask out erroneous regions, such as the soft tissue interface, and improve the accuracy and robustness of the spine surface enhancement. The masked US images were used as an input to the LPT image enhancement method. In order to provide a more compact spine surface representation and further reduce the typical US imaging artifacts and soft tissue interfaces we calculate saliency Local Phase Tensor features. The saliency images are computed using Difference of Gaussian filters. Qualitative results, obtained from in vivo clinical scans, show a strong correspondence between enhanced features and the actual bone surfaces present in the ultrasound scans. Future work will include the extension of the proposed method to 3D and validation of the method in the context of intra-operative ultrasound image registration in CAOS applications

We present a case of late dislocation of the hip in a 30-month-old girl. Her hip was clinically stable at birth and an ultrasound scan at six weeks was normal. She had no additional risk factors for developmental dysplasia. She underwent anterior open reduction with a femoral osteotomy

Twins are often considered to be at an increased risk of developmental dysplasia of the hip (DDH); we therefore investigated whether multiple births have a higher incidence of DDH, and if selective ultrasound scanning should be considered for these infants. We reviewed our records of all live births between 1 January 2004 and 31 December 2008 and included 25 246 single and 990 multiple births. Multiple births did not have a significantly higher incidence of DDH compared with single births (0.0030 vs 0.0023, p = 0.8939). Of the 990 multiple births, 267 had neonatal ultrasound scans and one case of DDH was diagnosed and treated successfully with a Pavlik harness. There were two late-presenting cases at eight and 14 months of age, neither of whom had risk factors for DDH and consequently had not had a neonatal scan. Whereas selective ultrasound scanning of multiple births would have led to earlier detection and treatment of the late-presenting cases, they did not have a significantly higher incidence of DDH compared with single births. We conclude that being a twin or triplet in itself is not a risk factor for DDH and that selective ultrasound scanning is not indicated for this population. Cite this article: Bone Joint J 2013;95-B:132–4

Aim. To review the infants in our district general hospital receiving delayed treatment for DDH i.e. those infants who had more than one ultrasound scan prior to diagnosis and treatment. In this group all scans were abnormal at the time of treatment but the scans at first presentation were normal for age when reviewed by our senior radiologist. Method. An audit was performed of all the children attending our institution from 2008–2011 for treatment of DDH following diagnosis with clinical examination and dynamic ultrasound. A senior radiologist and consultant orthopaedic surgeon independently assessed the scans. Two questions were asked (a) were the scans at the time of treatment normal or abnormal and (b) in those who were treated following a repeat scan, was the initial scan normal. Results. 33 infants were treated for DDH, 8 of whom received treatment after more than one scan. In 3 cases the child had evidence of instability at first examination, 1 had limited abduction and 1 had asymmetrical thigh creases. The remaining 3 had scans that were deemed normal for age by the radiologist but due to suspicion from the treating surgeon they had a repeat examination and scan. Conclusion. This study although small in numbers highlights the need for a completely normal examination in the presence of a normal ultrasound scan before the diagnosis of DDH can be dismissed

We present the results of treatment of developmental dysplasia of the hip in infancy with the Pavlik harness using a United Kingdom screening programme with ultrasound-guided supervision. Initially, 128 consecutive hips in 77 patients were reviewed over a 40-month period; 123 of these were finally included in the study. The mean age of the patients at the start of treatment was five weeks (1 to 12). All hips were examined clinically and monitored with ultrasound scanning. Failure of treatment was defined as an inability to maintain reduction with the harness. All hips diagnosed with dysplasia or subluxation but not dislocation were managed successfully in the harness. There were 43 dislocated hips, of which 39 were reducible, but six failed treatment in the harness. There were four dislocated but irreducible hips which all failed treatment in the harness. One hip appeared to be successfully treated in the harness but showed persistent radiological dysplasia at 12 and 24 months. Grade 1 avascular necrosis was identified radiologically in three patients at 12 months

Limb lengthening in nine patients was monitored by radiographs and by ultrasound scans. The distraction gap appeared as a sonolucent area within which echogenic foci developed soon after distraction commenced. By seven weeks a new cortex was detected, and medullary canal began to develop between seven and eight weeks. Ultrasound scanning can be used to measure distraction, but it was not as useful as radiographs in detecting angulation. Its use in patients undergoing limb lengthening could reduce their exposure to radiation

Of the 30585 births (from 1997–2002) in the population served by our NHS trust, 2742 babies (8.96%) were referred to the hip screening clinic by the neonatologists and general practitioners. They were examined clinically and by US scans by the specialist consultants. The findings were documented prospectively. 233 hips were identified as abnormal by ultrasound scans (Graf). 45% (106) of these were normal on clinical examination. None of the hips identified as abnormal on clinical examination were normal on US scans. In 38% (88) clinical examination could not be reliably performed as the babies were tense. Of the 1862 hips which were clinically normal, 106 (5.69%) had abnormal ultrasound findings. Furthermore, of the 841 babies who were tense on clinical examination, 88 (10.46%) babies had abnormal ultra-sonographic findings. Ultrasound scanning of hips in at-risk babies by an experienced paediatric radiologist will identify all the abnormal hips. This will release the paediatric orthopaedic surgeon from routine clinical examination of all these babies. This time can be utilised for running other clinics. Babies found to have abnormal hips on US scanning may be seen by the orthopaedic surgeon for treatment and follow-up. Parents of babies with normal hip US scans may be reassured by a nurse practitioner or a paediatric physiotherapist

Background: The necessity for radiographic follow up of infants with hip clicks and normal ultrasound is not clear. Materials and methods: Infants referred to a paediatric hip clinic whose sole risk factor for DDH was a soft tissue hip click who had a normal ultrasound scan on initial assessment were identified. A follow up six month AP pelvis radiograph was assessed and acetabular index(A.I), position of femoral ossific nucleus and Shen-ton’s line measured. Infants with rotated pelvis Xrays were excluded. Inter-observer variability for acetabular index was measured and dysplasia defined according to Tonnis. Results: 171 infants (193 clicking hips) met the criteria for inclusion. 48 male and 109 female with unilateral clicks (57 right, 64 left) and 36 bilateral clicks. 10 were excluded due to rotation of the AP pelvis Xray. Inter-observer error for A.I. was 4°. All A.I. were within normal ranges. Shenton’s line was unbroken and all hips were located. Conclusion: In this study infants with soft tissue hip clicks and a normal ultrasound scan on initial assessment had a normal Xray at six months

Morton’s syndrome is an entrapment of a digital nerve between the metatarsal heads in the foot causing pain between the metatarsal heads. 41 subjects with signs and symptoms of Morton’s syndrome were prospectively examined with an ultrasound scan and the size of the bifurcation of the interdigital nerve was recorded if it was visible. Each subject completed a Visual Analogue Scale and short form McGill Pain Questionaire before an injection of local anaesthetic and corticosteroid was administered. The subjects were reviewed after 6 weeks and the pain scores repeated. 26 subjects had positive ultrasounds with a mean width of 5.1 mm, range 2.7–9.8 mm and 15 subjects had negative ultrasounds. Differences in mean ranks of VAS scores between the two groups were borderline statistically significant for scores before injection (p=0.064). Difference in mean rank of VAS score was significant after injection (p=0.013). Differences in mean ranks of MPQ scores were borderline statistically significant for changes in scores (p=0.062). Difference in mean rank of MPQ score was significant after injection (p=0.007). None of the correlations between nerve width and any of VAS or MPQ outcome measures were statistically significant. This study demonstrates that the larger the neuroma on the ultrasound, the more painful it is for the patient. This study suggests that patients who have a small or absent neuroma demonstrated on the ultrasound scan are more likely to have their pain reduced to an acceptable level with an injection of local anaesthetic and corticosteroid than those patients with a large neuroma. Ultrasound examination is a useful tool in the management of patients with Morton’s syndrome

Aims: Acute lateral dislocation of the patella has been associated with disruption of the medial restraints of the patella and following non-operative management, a redislocation rate of up to 44%. Methods: Ten patients who presented to the Accident and Emergency dept. following acute patella dislocation had an ultrasound scan (USS) performed by an experienced musculoskel-etal radiologist. Each patient had an arthroscopy and washout of the knee and repair of ruptured structures. The ultrasound reports have now been compared to the surgical findings to determine the effectiveness of this investigation. Results: The ultrasound scans identified deficiencies in the ligamentous attachments to the medial border of the patella in eight patients and these were confirmed at operation in the same eight. The USS diagnosis of haematoma or torn fibres in the vastus medialis obliquus (VMO) (5 patients) corresponded with tearing of this muscle at operation; however the degree of muscle injury was underestimated in two. The USS finding of free fluid around the medial collateral ligament (MCL) at the adductor tubercle in three patients was associated with the operative finding of disruption of the femoral origin of the medial patellofemoral ligament (MPFL). Haematomata detected on USS along the adductor longus in two patients proved to have disruption of the VMO attachment. Conclusions: We recommend the use of ultrasound for assessment of all patella dislocations to accurately locate tears of the retinaculum and help clinicians to understand the severity of injury to the soft tissue restraints of the patella

Club foot was diagnosed by ultrasonography in 91 feet (52 fetuses) at a mean gestational age of 22.1 weeks (14 to 35.6). Outcome was obtained by chart review in 26 women or telephone interview in 26. Feet were classified as normal, positional deformity, isolated club foot or complex club foot. At initial diagnosis, 69 feet (40 fetuses) were classified as isolated club foot and 22 feet (12 fetuses) as complex club foot. The diagnosis was changed after follow-up ultrasound scan in 13 fetuses (25%), and the final ultrasound diagnosis was normal in one fetus, isolated club foot in 31 fetuses, and complex club foot in 20 fetuses. At birth, club foot was found in 79 feet in 43 infants for a positive predictive value of 83%. Accuracy of the specific diagnosis of isolated club foot or complex club foot was lower; 63% at the initial ultrasound scan and 73% at the final scan. The difference in diagnostic accuracy between isolated and complex club foot was not statistically significant. In no case was postnatal complex club foot undiagnosed on fetal ultrasound and all inaccuracies were overdiagnoses. Karyotyping was performed in 25 cases. Abnormalities were noted in three fetuses, all with complex club foot and with additional findings on ultrasound

This study evaluates the position of the long head of biceps tendon using ultrasound following simple tenotomy, in patients with arthroscopically repaired rotator cuff tears. In total, 52 patients with a mean age of 60.7 years (45 to 75) underwent arthroscopic repair of the rotator cuff and simple tenotomy of the long head of biceps tendon. At two years post-operatively, ultrasound revealed that the tendon was inside the bicipital groove in 43 patients (82.7%) and outside in nine (17.3%); in six of these it was lying just outside the groove and in the remaining three (5.8%) it was in a remote position with a positive Popeye Sign. A dynamic ultrasound scan revealed that the tenotomised tendons had adhered to the surrounding tissues (autotenodesis).The initial condition of the tendon influenced its final position (p < 0.0005). The presence of a Popeye sign was statistically influenced by the pre-operative co-existence of supraspinatus and subscapularis tears (p < 0.0001). It appears that the natural history of the tenotomised long head of biceps tendon is to tenodese itself inside or just outside the bicipital groove, while its pre-operative condition and coexistent subscapularis tears play a significant role in the occurrence of a Popeye sign

Introduction: Several institutes in continental Europe and the US now prescribe low molecular weight heparin for patients with ankle fractures being treated in a below knee plaster cast. Jorgensen et al reported an incidence of deep venous thrombosis (DVT) of up to 20% in patients treated in a cast. However, their study included patients with variable diagnoses, ranging from tendon ruptures to fractures. The aim of our study was to assess the incidence of DVT in patients with ankle fractures that have been treated conservatively in a below knee cast. Method: We performed an ultrasound scan on patients with conservatively ankle fractures at the time of removal of the cast. The same ultrasound technician performed all the scans. The local regional ethics committee had approved this study. Results: So far we have performed an ultrasound scan on 98 patients with ankle fractures. We are likely to complete the study in November 2006 (120 patients). We have encountered only 2 below knee DVTs (2.04 %). None of them involved the popliteal vein. Both patients were completely asymptomatic and were full weight bearing in the cast. A repeat scan showed no evidence of progression. None of the patients had an above knee DVT or a pulmonary embolism. Discussion: The risk of deep venous thrombosis is said to be higher in patients with a plaster cast because of the decreased ability of the calf muscles to pump the venous blood back to the heart. Though some studies have indicated an incidence of up to 20%, the incidence in our population was only about 2%Thus, DVT is a rare event in patients with ankle fractures. Though it is a serious event, its rarity does not justify a blanket prophylaxis regimen for all patients with ankle fractures

Use of shoulder manipulation in the treatment of frozen shoulder (FS) remains controversial. One of the purported risks associated with the procedure is the development of a rotator cuff tear. However the incidence of iatrogenic rotator cuff tears has not been reported. The purpose of the study was to assess the effect of manipulation of the shoulder on the integrity of the rotator cuff. In a prospective study 20 consecutive patients (21 shoulders) with FS underwent manipulation of the shoulder under anaesthesia (MUA). The average duration of symptoms was 7.3 months (4–18 months). Patients were assessed pre and post manipulation using the Constant score. An ultrasound scan of the rotator cuff was performed before and at 3 weeks after manipulation. In all patients, pre and post manipulation ultrasound scans showed the rotator cuff to be intact. At 12 weeks after manipulation all patients indicated that they had none or only occasional pain. The mean improvement in motion was 83 degrees (range, 20 – 100°) for flexion, 95 degrees (range, 20 – 120°) for abduction, 58 degrees (range, 0 – 80°) for external rotation and 3 levels of internal rotation (range 3–5 levels). These gains in motion were all significant (p < 0.01). No fractures, dislocations or nerve palsies were observed. In conclusion manipulation under anaesthesia for treatment of frozen shoulder resulted in significant improvements in shoulder function and pain relief as early as 3 weeks after surgery and was not associated with rotator cuff tears. When performed carefully this procedure is safe and leads to early improvements in pain relief, range of movement and shoulder function

Introduction: It is common practice to screen the hips of infant with a family history of DDH clinically and ultra-sonographically in selective screening programmes. The practice of regular radiographic follow-up of infants with a positive family history of Developmental Hip Dysplasia (DDH) is based on the widespread belief that Primary Acetabular Dysplasia is a genetic disorder that can occur in the absence of frank hip subluxation or dislocation. 1. It has been our practice to obtain a 6 – 12 month screening radiograph in such patients but this practice is not conclusively supported in the literature. Materials and Methods: We reviewed all such infants who had a normal clinical and ultrasound examination of the hips at the 6–8 week screening examination but who, because of the family history underwent further radiographic screening after a 6–12 month interval. The radiographs of all such infants (n=77) were analysed for any signs of late hip dysplasia. Results and Discussion: Sixty six infant had normal X rays at the 6–8 month assessment and were discharged. The remaining eleven patients had acetabular angles at the upper end of the normal range for age and were reviewed again with further radiographs at 12 months. At this stage ten patients were normal and were discharged. The remaining patient was reviewed again at 18 months and 24 months and finally proved to be normal and was discharged. The result of a postal survey has suggested that majority of BSCOS members do not get follow up x-ray done if the clinical and ultrasound scan is normal at screening visit. Conclusion: All of the seventy seven patients eventually developed normal radiographs and we question the need for radiographic follow up of infants with a family history of DDH but who have a normal clinical examination and ultrasound scan at 6–8 weeks

Introduction: Infants referred under the Hip Screening Programme undergo both a clinical and ultrasonic assessment of hip stability. The majority are reviewed for repeat clinical assessment and X-ray of the hips before a diagnosis of DDH will be excluded. If we could safely rely on the ultrasound findings, then the number of children routinely reviewed with a hip radiograph could be reduced. As a result, many children would avoid the unnecessary and potentially harmful exposure to radiation. In addition, the burden on both the Orthopaedic Outpatients Department and the Radiology Department could be eased. Objective: The aim of the study was to assess the sensitivity of the ultrasound screening programme for DDH over a four year period. Study Design: A retrospective review of the 501 infants referred for hip screening between January 1997 and December 2000. Results: 28 patients were treated for DDH during the period of January 1997 to December 2000. Thirteen patients (46.4%) of those treated for DDH were referred via the Hip Screening Programme after their initial baby check by the paediatricians showed that they had a risk factor. The risk factors include Family History, Breech Deliver, and clinical instability. The remaining fifteen patients (53.6%) were referred via GP’s, Health Visitors and Paediatricians, following abnormal clinical findings ranging from ‘clicky hip’, abnormal skin creases, and decreased hip abduction at follow up baby checks. The average age of the infant in this group was 5.5 months. These 15 were diagnosed with X-ray only. All patients (501 patients) referred via the Hip screening programme underwent an ultrasound scan of both hips initially, and a pelvic X-ray 4–6 months after this. We identified 5 cases where the ultrasound had originally been interpreted as normal, yet the infant developed DDH as diagnosed by a later X–ray. Five infants (38.5%) of the thirteen diagnosed with DDH via the screening programme is unacceptable. These five infants could easily have been missed until they were a lot older, and subsequently their prognoses would have been worse. Three (20%) of the fifteen patients diagnosed with DDH which were not referred via the Hip Screening Programme had an identifiable risk factor at birth, yet were not sent for orthopaedic review and ultrasound examination via the Screening Programme. Conclusion: Normal ultrasound scan does not exclude a subsequent diagnosis of Developmental Dysplasia of the hip. X-ray is still considered the gold standard in assessing a child’s hips. Both the performance and interpretation of the hip ultrasound is skill with a steep learning curve and, for the meantime, will have to go hand in hand with pelvic X-rays in diagnosing DDH

Stable fractures of the ankle can be successfully treated non-operatively by a below-knee plaster cast. In some centres, patients with this injury are routinely administered low-molecular-weight heparin, to reduce the risk of deep-vein thrombosis (DVT). We have assessed the incidence of DVT in 100 patients in the absence of any thromboprophylaxis. A colour Doppler duplex ultrasound scan was done at the time of the removal of the cast. Five patients did develop DVT, though none had clinical signs suggestive of it. One case involved the femoral and another the popliteal vein. No patient developed pulmonary embolism. As the incidence of DVT after ankle fractures is low, we do not recommend routine thromboprophylaxis

Aims

The Birmingham Hip Resurfacing (BHR) arthroplasty has been used as a surgical treatment of coxarthrosis since 1997. We present 20-year results of 234 consecutive BHRs performed in our unit.

We have conducted a prospective study to assess the mid-term clinical results following arthroscopic repair of the rotator cuff. Patients were evaluated using the Constant score, subjective satisfaction levels and post-operative ultrasound scans. Of 115 consecutive patients who underwent arthroscopic repair of the rotator cuff at our institution, 102 were available for follow-up. The mean period of follow-up was for 35.8 months (24 to 73). The mean age of the patients was 57.3 years (23 to 78). There were 18 small (≤ 1 cm in diameter), 44 medium (1 cm to 3 cm in diameter), 34 large (3 cm to 5 cm in diameter) and six massive (> 5 cm in diameter) tears. There was a statistically significant increase in the size of the tear with increasing age (p = 0.0048). The mean pre-operative Constant score was 41.4 points (95% confidence interval, 37.9 to 44.9), which improved to 84.5 (95% confidence interval, 82.2 to 86.9). A significant inverse association (p = 0.0074), was observed between the size of the tear and the post-operative Constant score, with patients having smaller tears attaining higher Constant scores after repair. Post-operatively, 80 patients (78.4%) were able to resume their occupations and 84 (82.4%) returned to their pre-injury leisure activities. Only eight (7.8%) of 102 patients were not satisfied with the outcome. Recurrent tears were detected by ultrasound in 19 (18.6%) patients, and were generally smaller than the original ones. Patients with recurrent tears experienced a mean improvement of 31.6 points (95% confidence interval, 23.6 to 39.6) in their post-operative Constant scores. Those with intact repairs had significantly improved (p < 0.0001) Constant scores (mean improvement 46.3 points, 95% confidence interval, 41.9 to 50.6). Patient satisfaction was high in 94 cases (92%), irrespective of the outcome of the Constant score. Recurrent tears appear to be linked to age-related degeneration. Arthroscopic repair of the rotator cuff leads to high rates of satisfaction (92%) and good functional results, albeit with a recurrence rate of 18.6% (19 of 102)

Tropical pyomyosistis is an uncommon condition in the United Kingdom. Early diagnosis and appropriate treatment are crucial for a good outcome. We had seen 13 cases in our previously published series from 1998 to 2009. This is an update showing a significantly increased incidence from 2010 to 2016. A retrospective review of all cases of pelvic pyomyositis in our centre from January 2010 to April 2016 was undertaken from case notes and radiology reports. All children with clinical and radiographic evidence of pyomyositis were included. Since our previous publication we had changed our practice to get an MRI scan in all children who presented with a limp, fever and raised inflammatory markers, and had no effusion in the hip ultrasound scan. We identified 24 children with a mean age of 7 years (range, 1 week to 14 years). MSSA (Methicillin-Sensitive Staphylococcus aureus) was the most common cultured organism (n=8). Median hospital stay was 9 days (3 to 12). Obturator internus was the most common muscle affected. All patients had appropriate antibiotics with 2 patients requiring surgical drainage of abscesses. The majority of children (n=22) showed a complete recovery with antibiotics only. Incidence of pyomyositis has increased dramatically in our population and early diagnosis can result in a good outcome. We recommend MRI scan in all patients who present with a clinical picture of septic arthritis of the hip but with no effusion

Treatment of Tendo Achilles (TA) ruptures can result in considerable morbidity and has significant socio-economic implications. The ideal management of these injuries has yet to be defined. Recent studies have demonstrated that non-surgical treatment with accelerated rehabilitation may have comparable outcomes to surgery. The aim of this study was to evaluate current management and outcomes of TA ruptures at a tertiary referral centre, with a view to developing contemporary treatment guidelines. A retrospective review of TA ruptures over a 12-month period was undertaken. Patients were managed on an individual based approach with no strict management algorithm followed. Data collection included pre-injury activity level, ultrasound findings and treatment methodology. Outcome data collected included return to activity, incidence of DVT and re-rupture. Patients were followed up for an average of 2 years. Data was collected in 49 patients. 31 (63%) of these were managed non-surgically. Ruptures were most common in men (65%) at an average age of 44 yrs. Ultrasound scan at initial diagnosis was performed in 28 patients. There was an average gap in equinus of 34mm in the surgical group, while the average gap within the non-surgical group was 24mm (p=0.23). There was no association between the gap observed on ultrasound and re-rupture rate. At a median of 2 year follow up, there was no significant reduction in average time spent immobilised in a below knee splint in the surgically treated group (10.2 weeks) compared to non-surgical group (10.9 weeks, p=0.35). 86.3% of patients returned to pre-injury level of activity in the non-surgical group and 86.7% in the surgery group (p=1.0). Complications within this patient cohort consisted of one superficial wound infection and one re-rupture, both occurring within the surgical group. Within the surgical group patients were treated with direct primary repair or primary reconstruction using FHL augmentation in cases of delayed presentation. DVT was not observed in either group. Only 22.6% received thromboprophylaxis in non-surgical group compared to 61.1% in surgical group. We observed that patients within the non-surgical group demonstrated the same return to pre-injury activity as the surgically treated group and had fewer complications. The time spent immobilised was also comparable. Based on these findings, we modified guidelines and now recommend that surgery should be limited to patients with gap of greater than 20 mm in full equinus on ultrasound and in those with delayed diagnosis. We also recommend thromboprophylaxis for 2 weeks in non-surgical group

Background. Patients presenting with an acute tendoachilles (TA) rupture are managed in a dedicated clinic led by a Foot & Ankle Consultant and specialist physiotherapist. The diagnosis is made clinically and no ultrasound scan is performed. All management, rehabilitation and follow-up is undertaken within this clinic by the specialist physiotherapist, with Consultant support as required. Patients are offered a choice of conservative or surgical management (percutaneous TA repair). Both groups undergo a standardised functional rehabilitation regimen. Methods. All patients treated through our dedicated clinic between May 2010 and April 2016 were identified. Patient outcomes were reported using the validated Achilles Tendon Repair Score (ATRS). ATRS scores were collected at 3, 6 and 12 months post-injury. Re-rupture and complication rates were also documented. Results. 167 patients were identified. 79 patients underwent a percutaneous repair and 88 patients opted for conservative management. Mean age of patients undergoing percutaneous repair was 46 years (21–77 years) and 52 years (19–88 years) in the conservatively managed group. Male to female ratios were equal between both groups. Mean ATRS scores at 3, 6 and 12 months were 41.6, 69.5 and 85.3 respectively for the percutaneous repairs and 45.4, 69.0 and 77.1 respectively for the conservatively managed group. The re-rupture rate was 4.2% (3 patients) in the conservative group and 0% in our surgical group. In the surgical group, 1 patient developed a PE and 1 had a wound complication. Discussion. Our dedicated clinic for managing TA ruptures has proved popular with patients, with a patient satisfaction score of 98.7%. By standardising our rehabilitation regimen we believe our outcomes have improved. Our percutaneous repair group has an improved ATRS score compared to our conservative group at 12 months post injury. We believe that any fit active individual should be offered a percutaneous repair irrespective of age

Aims

Early detection of developmental dysplasia of the hip (DDH) is associated with improved outcomes of conservative treatment. Therefore, we aimed to evaluate a novel screening programme that included both the primary risk factors of breech presentation and family history, and the secondary risk factors of oligohydramnios and foot deformities.

Aims

Steroid injections are used for subacromial pain syndrome and can be administered via the anterolateral or posterior approach to the subacromial space. It is not currently known which approach is superior in terms of improving clinical symptoms and function. This is the protocol for a randomized controlled trial (RCT) to compare the clinical effectiveness of a steroid injection given via the anterolateral or the posterior approach to the subacromial space.

Aims

The Birmingham Hip Resurfacing (BHR) was introduced in 1997 to address the needs of young active patients using a historically proven large-diameter metal-on-metal (MoM) bearing. A single designer surgeon’s consecutive series of 130 patients (144 hips) was previously reported at five and ten years, reporting three and ten failures, respectively. The aim of this study was to extend the follow-up of this original cohort at 25 years.

Since the establishment of our department a multi-modal approach to thromboprophylaxis that uses aspirin for chemical prophylaxis was adopted. In accordance with the latest national recommendations, our routine chemical prophylaxis following arthroplasty was changed to rivaroxaban in 2012 and then dalteparin in 2013. This study aimed to compare venous thromboembolism (VTE) rates during the use of the aspirin-based protocol used from 2004 to 2011 with recent, rivaroxaban and dalteparin-based guidelines. Outcome data from ISD Scotland was retrieved and radiology reports performed for CT pulmonary angiograms and lower limb doppler ultrasound scans in our institution were assessed to identify cases of VTE following primary hip or knee arthroplasty. The incidence of pulmonary embolism (PE) and proximal deep venous thrombosis (DVT) was calculated for each year and compared using a Chi-squared test. Additionally, the change in extended thromboprophylaxis regimen was surveyed by recording the discharge prescriptions for consecutive arthroplasty patients for March every year. There were 90 radiologically confirmed cases of DVT or PE between 2004 and 2011 (incidence of 0.71%). The DVT/PE rate was subsequently 0.67% in 2012 and 0.69% in 2013, with a further 29 cases identified. This does not represent a significant change in the venous thromboembolism rates and remains below the national incidence of VTE (1.06%). Aspirin alone was used as chemical thromboprophylaxis in 80.8% of patients from 2004 to 2011, 50.9% in 2012, and 12.1% in 2013. The incidence of VTE at our centre remains favourable to national figures, but the modification of thromboprophylaxis guidelines will incur additional financial costs and has not had a significant reduction on the rate of VTE

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

Frozen shoulder is a common, painful condition that results in impairment of function. Corticosteroid injections are commonly used for frozen shoulder and can be given as glenohumeral joint (GHJ) injection or suprascapular nerve block (SSNB). Both injection types have been shown to significantly improve shoulder pain and range of motion. It is not currently known which is superior in terms of relieving patients’ symptoms. This is the protocol for a randomized clinical trial to investigate the clinical effectiveness of corticosteroid injection given as either a GHJ injection or SSNB.

Introduction:. Primary functions of heel and forefoot fat pad - shock absorber at heel strike, energy dissipation, load bearing, grip and insulation. •Reliability of weight bearing heel pad thickness measurements by ultrasound has been determined by Rome et al. Importance of soft tissue fillers has been recently popularised by Coleman. Methods and materials:. Harvesting done by standard low pressure liposuction using small cannula. Grafting using small needle depositing the small globules of fat in multiple layers of soft tissue. There is an expectation that up to 50% of the fat will be lost and so upto 19mls of fat placed per foot. Patients were kept NWB for 4–6 weeks post op and then allowed to mobilise fully. Case notes were prospectively collated and analysed. Pre and post-op ultrasound scans were performed to document the depth of the heel/forefoot fat pad. Clinical pictures were taken and post-op patient satisfaction scores were done as well. Results:. We treated 9 feet in 5 patients. 5 heel fat pad transfers and 4 forefoot. Pain completely relieved in all feet. No complications. Average pre-op VAS - 3/ Post-op – 9. Average pre-op AOFAS score - 70/ post-op - 105. Follow-up 6months - maximum 23 months. Conclusion:. Fat transfer is usually used for cosmetic reasons and occasionally to improve scars. Very few reports from South America have been published for patients using high heels giving pain but none for patients with a pathological anomaly. The technique seems to highly effective with no complications so far. It is currently being used on other painful problems in other areas of the sole with equal success. Abdominal fat transfer is an innovative technique aimed at getting rid of the ‘heel pad syndrome’

Purpose: to alert readers to the possibility of a ruptured abdominal aortic aneurysm presenting with femoral neuropathy and back pain. Method: Our patient presented with a short history of left leg weakness, numbness and back pain but was otherwise in a stable condition. An MR of his lumbar spine was initially performed on a 1T GE scanner and this was followed by an abdominal ultrasound scan and a spiral CT on a Siemen’s Somatom with reconstructions. Results: The MR unexpectedly demonstrated a large abdominal aortic aneurysm and swelling of the left psoas muscle. These features were observed easily as the saturation band was placed anterior to the retroperitoneum. Ultrasound confirmed these findings and the subsequent CT demonstrated precisely the point of rupture with contrast entering the left psoas muscle. Conclusion: Rupture of an abdominal aortic aneurysm may present to the orthopaedic team with back pain and femoral neuropathy. This demands a high index of suspicion as timely intervention saves lives

Applying the concept of a regional trauma network to the UK paediatric trauma population has unique difficulties in terms of low patient volume and variation in paediatric service provision. In addition, no consensus exists as to which radiological investigations should be employed and an increasing trend towards computerised tomography raises concerns over radiation exposure. We carried out a retrospective review of all paediatric trauma calls from April 2010 and March 2013 around becoming a Major Trauma Centre. We aim to analyse the impact this has on trauma calls and assess the radiological investigations currently used in this population. The number of yearly paediatric trauma calls doubled during our study and totalled 132. The commonest mechanisms of injury were road traffic collisions, fall from a height or fall off a horse. 91.7% of children had some form of radiological investigation; 67% plain radiograph, 37.1% trauma CT, 21.2% focused CT and 5.3% abdominal ultrasound scan. Of the 77 CT scans performed 57.1% were reported as normal and 54.5% of these patients were discharged home the same day. Five children re-attended the emergency department within 30 days with two positive findings; a subdural haematoma and a tibial plateau fracture. The current use of harmful radiological investigations in paediatric trauma patients is not uniform. We propose implementation of radiology protocols and clinical guidance to imaging in paediatric trauma to limited radiation exposure

INTRODUCTION. Tranexamic Acid (TA) has been shown to decrease peri-operative bleeding in primary Total Knee Replacement (TKR) surgery. There are still concerns with regards to the increased risk of thromboembolic events with the use of TA. The aim of this study was to assess whether the use of pre-operative TA increased the incidence of Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) in TKR. METHODS. Patients who underwent primary TKR between August 2007 and August 2009 were identified from the databases of three surgeons within the lower limb arthroplasty unit. A retrospective case notes analysis was performed. DVT was diagnosed on Duplex Ultrasound Scan and PE on CT Pulmonary Angiogram. A positive result was a diagnosis of DVT or PE within 3 months of surgery. RESULTS. 322 patients underwent primary TKR over the 2 year period. 131 patients received TA pre-operatively. 191 patients did not receive TA prior to surgery. A total of 4 (3.1%) patients who received TA were diagnosed with either a DVT (2) or PE (2) post operatively. In those patients not receiving TA, 6 had a DVT and 2 had a PE, a total of 8 (4.2%). CONCLUSION. Pre-operative use of Tranexamic Acid in primary Total Knee Replacement does not increase the incidence of DVT and PE

INTRODUCTION. Tranexamic Acid (TA) has been shown to decrease peri-operative bleeding in primary Total Knee Replacement (TKR) surgery. There are still concerns with regards to the increased risk of thromboembolic events with the use of TA. The aim of this study was to assess whether the use of pre-operative TA increased the incidence of Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) in TKR. METHODS. Patients who underwent primary TKR between August 2007 and August 2009 were identified from the databases of three surgeons within the lower limb arthroplasty unit. A retrospective case notes analysis was performed. DVT was diagnosed on Duplex Ultrasound Scan and PE on CT Pulmonary Angiogram. A positive result was a diagnosis of DVT or PE within 3 months of surgery. RESULTS. 322 patients underwent primary TKR over the 2 year period. 131 patients received TA pre-operatively. 191 patients did not receive TA prior to surgery. A total of 4 (3.1%) patients who received TA were diagnosed with either a DVT (2) or PE (2) post operatively. In those patients not receiving TA, 6 had a DVT and 2 had a PE, a total of 8 (4.2%). CONCLUSION. Pre-operative use of Tranexamic Acid in primary Total Knee Replacement does not increase the incidence of DVT and PE

Introduction:. Plantar Fasciitis is an extremely common and challenging problem that presents itself to foot and ankle practitioners. Many different treatment modalities are available for this condition, with little proven benefit. ECSWT was approved for use by the FDA for the treatment of chronic proximal plantar fasciitis in 2002 and NICE published guidance in 2009 recommending its use in refractory cases. Methods:. Patients who diagnosed with ultrasound scan, and for whom other treatments were unsuccessful, underwent treatment on an outpatient basis. They had three 4–5 minute sessions, once a week. A Spectrum machine was used delivering 10 Hz waves in 500 preset pulses at 2 bar pressure, followed by 2000 preset pulses at 2.5 bar pressure. Pre- and 3 month post-treatment pain levels were recorded using a 10 point Visual Analogue Scale. Results:. 210 courses of treatment have been performed on 181 feet belonging to 135 patients. 46 patients have had treatment to both feet. 121 treatments have paired pre and postoperative VAS scores. 79 had a reduced score post treatment (65.2%), 17 had an increased score (14%), and 24 had a score which remained unchanged (19.8%). 65.8% subjectively felt they had improved. Overall there was an average reduction in VAS score from 7 to 4.975, a reduction of 2.025 points (p=0.000000000151). Discussion:. The majority of patients show a benefit in terms of an overall reduction in pain score, though it is not clear how many patients would have improved spontaneously in that time. However, there is further work to do in terms of a more detailed evaluation of the effect on foot function: anecdotally the treatment may significantly improve start up pain. We would also like to see if we can establish a benefit for the therapy earlier in the disease process

Image-free navigation technology relies heavily on the surgeon carefully registering bony anatomical landmarks, a critical step in achieving accurate registration which affects the entire procedure. Currently this step may depend on placing a pointer superficially, with soft-tissue and skin obscuring these bony landmarks. We report initial results of using newly developed experimental software which automatically recognises the bone soft-tissue interface. This is the first critical step in development of automatic computer generation of the bone surface topography from ultrasound scanning. Individual 2D ultrasound images (n=651) of the anterior femoral condyles and trochlear notch were used. Images were taken from 29 volunteers (20 male, 9 female). The software extracted bone-soft tissue interface by a two-step method based on a gradient evaluation and the elimination of false-positives with a graph closure. The trochlear notch was automatically defined by geometrical modelisation. Coordinates of both bone interface and trochlear notch position for each separate image were compared to a separate analysis performed manually by a single investigator. Error was calculated using root mean squared (RMS). Median error (RMS) in locating bone soft-tissue interface was 0.67 mm, (mean 0.93 mm, SD 0.84 mm). Median error for trochlear notch topography was 1.01mm, (mean 1.41 mm, SD 1.37 mm). Bone soft-tissue interface can be accurately defined and displayed by this software. Direct visualisation of critical bony landmarks could replace the current comparatively subjective placement of a pointer on superficial tissues. This has powerful application in both non-invasive and surgical computer-assisted acquisition of knee kinematics, and may have further applications in orthopaedic surgery

The measurements of the angle of anteversion of the femoral neck by ultrasound scanning is described. The method was compared with direct measurement in 30 dried femora, and was then used in 18 normal volunteers and eight patients. The method is non-invasive, accurate and easily applicable. Findings in normal subjects included variation of the angle of anteversion from 10 to 34 degrees with a maximal difference between sides of six degrees. The expected rotational deformity of the femur was found in patients with unilateral intoeing

Ultrasound scans were made of the hips of 209 neonates born consecutively over a two-week period. Of the 418 scans, 62 images were selected at random and 25 of these were duplicated to give a total of 87 scans. These static images were then presented to five experienced observers who each made nine different assessments and measurements. Interobserver and intraboserver agreement was calculated and expressed as kappa values. Our results showed poor reliability on both counts

Stable ankle fractures can be successfully treated non-operatively with a below knee plaster cast. In some European centres it is standard practice to administer thromboprophylaxis, in the form of low molecular weight heparin, to these patients in order to reduce the risk of deep venous thrombosis (DVT). The aim of our study was to assess the incidence of DVT in such patients in the absence of any thromboprophylaxis. We designed a prospective study, which was approved by the local ethics committee. We included 100 consecutive patients with ankle fractures treated in a below knee plaster cast. At the time of plaster removal (6 weeks), patients were examined for signs of DVT. A colour doppler duplex ultrasound scan was then performed by one of the two experienced musculoskeletal ultrasound technicians. We found that 5 patients developed a DVT. Two of these were above knee, involving the superficial femoral vein and popliteal vein respectively. The other three were below knee. None of the patients had any clinical symptoms or signs of DVT. None of the patients developed pulmonary embolism. Of these five patients, four had some predisposing factors for DVT. The annual incidence of DVT in the normal population is about 0.1%. This can increase to about 4.5% by the age of 75. DVT following hip and knee replacement can occur in 40-80% of cases. Routine thromboprophylaxis may be justified in these patients. However, with a low incidence of 5% following ankle fractures treated in a cast, we believe that routine thromboprophylaxis is not justified

Among 41 adult haemophiliacs 15 suffered from shoulder symptoms. We examined 12 patients by radiography and ultrasound. Four had bilateral symptoms making a total of 16 symptomatic shoulders. Of these, 10 had abnormal ultrasound scans with eight having evidence of rotator cuff tears. Evidence of bicipital tendonitis was found in two. Pain with loss of range of movement and a positive impingement sign was the most reliable clinical indicator of a cuff tear. Joint incongruity and superior migration of the humeral head were the best radiographic indicators. Rotator cuff tears are a common component of haemophilic arthropathy of the shoulder

Introduction. The standard plane imaging of Graf and the dynamic methods of Harcke are well established methods in assessing hip dysplasia but give limited information in the flexed-abducted treatment position used in the Pavlik harness. The femoral head may sit on the edge of the acetabulum in a flexed position and only reduce when the hips are abducted. This may mean that hips, which reduce when abducted in the Pavlik harness, appear subluxed when scanned in neutral abduction. Harness treatment may thereby be abandoned prematurely due to the failure to confirm reduction. This study identifies ultrasound landmarks on an anterior hip scan which could be used to confirm reduction of the hip in Pavlik Harness. Materials and method. Hips of a newborn piglet were scanned, imaged with magnetic resonance and x-rayed both before and after anatomical dissection. Radiographic markers delineated the position of the tri-radiate cartilage and potential ultrasound landmarks identified to help confirm hip reduction in the flexed-abducted position. Porcine imaging was then compared with that of a human newborn. Results. The porcine model corresponded well to human imaging and we were able to establish a landmark, the ‘Ischial Limb’, which corresponds to the ossification front delineating the posterior ischial edge of the tri-radiate cartilage. This could clearly be seen on anterior hip ultrasound of both the porcine and human hip. This landmark can be used to confirm the hip is reduced by reference to the centre of the femoral head. Discussion and conclusion. We would recommend anterior hip scanning using the ‘Ischial Limb’ as a reference point to confirm hip reduction in Pavlik harness. This simple method is a useful adjunct to conventional ultrasound scanning in the harness treatment of hip instability

Introduction/Aim. Thromboembolism is a significant cause of patient morbidity and mortality, the risk of which increases in orthopaedic patients with lower limb immobilisation. It was therefore, our aim to identify a difference in symptomatic thromboembolism by treating acute Achilles tendon rupture patients with conventional non-weight bearing plaster versus functional weight bearing mobilisation. Methodology. The notes of 91 consecutive patients with acute Achilles tendon rupture were reviewed. The patients demographics, treatment modality (non-weight bearing plaster versus weight bearing boot), and predisposing risk factors were analysed. From the 91 patients, 50 patients with acute Achilles tendon rupture were treated conservatively in a non-weight bearing immobilisation cast. From these 50 patients, 3 then underwent surgery and were therefore excluded from the results. 41 patients were treated with functional weight bearing mobilisation. Patients who did have a symptomatic thromboembolic event had an ultrasound scan to confirm a deep vein thrombosis of the lower limb, or a CT-scan to confirm pulmonary embolism. Results. Out of the 47 patients who were treated conservatively in a non-weight bearing plaster cast, 9 patients (19.1 %) had a thromboembolic event. Out of the 41 patients who were treated with functional weight bearing mobilisation, 2 patients (4.8%) had a thromboembolic event. Thus, patients who were treated in a non-weight bearing plaster had a significantly higher risk of developing thromboembolism (p value of <0.05) and an increased risk ratio of 24% compared to those who were treated with functional weight bearing mobilisation. Conclusion. There is a significant decrease in the clinical incidence of thromboembolic events in patients treated conservatively with early mobilisation in the functional weight bearing boot compared to those treated in a non-weight bearing cast

There is debate regarding the most appropriate treatment of calcific tendinitis. Minimally-invasive techniques with image-guided needling of the deposits have been developed to provide an alternative solution. We present the results of fluoroscopically-guided barbotage in 100 patients. One hundred patients with acute or chronic shoulder pain, visible on plane radiographs or ultrasound scan, were referred from the Orthopaedic Department for barbotage over a six-year period. This study is a retrospective review of the results of barbotage in these patients, using a patient-based questionnaire. Forty three patients ultimately required arthroscopy of their painful shoulder. However, at surgery, the calcific deposits were noted to have dispersed in the majority of these patients. In addition there was often a long symptom-free period between the initial barbotage and recurrence of pain. In many cases the nature of their symptoms had changed and at arthroscopy signs of impingement or rotator cuff tears were common. Barbotage eliminated the need for more invasive surgery in over half of the patients in this study. It should be considered in all patients with calcific tendinitis refractory to non-operative treatment

Background. Ultrasound and MRI are recommended tools in evaluating postoperative pain in metal-on-metal hip (MoM) arthroplasty. Aim. To retrospectively compare MRI and ultrasound results of the hip with histopathology results in failed (MoM) hip arthroplasty. Methods. 25 hips (16 patients) who underwent revision hip surgery for painful (MoM) hip replacement/resurfacing were included in this study (March 2011 to May 2012). Average age 50.4 yrs (37–69y). Blood test for cobalt and chromium levels, ultrasound and MRI were done prior to revision surgery. 23 hips had ultrasound scan. 21 of these hips also had MRI scan prior to surgery. Scans were done at an average of 50 months from primary metal-on-metal surgery. All the ultrasound & MRI were done and reported by a single musculo-skeletal radiologist. During surgery multiple tissue samples were taken from acetabulum, capsule as well as tissue surrounding the femoral neck and sent for histopathology. 21 hip histopathology results were positive for metalosis. 2 hip histopathology results were negative for metalosis. Metalosis as defined by our histopathologist as that which is showing the presence of sheets of macrophages with dark brown pigmentation in their cytoplasm under polarized light. Results. Ultrasound examination was positive for fluid collection in 18 (78.2%). MRI was positive in 16 (76.1%). 4 patients (19%) had negative ultrasound and MRI results but were revised due to pain and were found to have histopathology positive metalosis. One patient had ultrasound positive for fluid collection with negative MRI. One patient was MRI positive for fluid but normal ultrasound findings. Conclusion. Although ultrasound and MRI are useful in screening of MoM patients still there are a significant percentage of hips, which failed with negative radiology findings

We describe five patients, seen since 1984, with posterior shoulder pain and isolated wasting and weakness of the infraspinatus. In four of these a ganglion in the spinoglenoid notch was demonstrated by MRI and in one recent case ultrasound scans were positive. Three patients have been treated by operation, but there was recurrence in one after five years. In each confirmed case, the ganglion straddled the base of the spine of the scapula, extending into both supraspinatus and infraspinatus fossae. The nerve was either compressed against the spine or stretched over the posterior aspect of the ganglion. Adequate surgical exposure is essential to preserve the nerve to the infraspinatus and to allow complete removal of the ganglion. This is difficult because of the location and thin-walled nature of the cysts

Ultrasound imaging has become an essential adjunct to clinical examination when assessing a patient with suspected rotator cuff pathology. With the new high-resolution portable machines it has become feasible for the shoulder surgeon to perform the scans himself in the clinic and save a great deal of time. This study was conducted to examine the accuracy of the ultrasound scans performed by a single surgeon over a period of four years (2001-2004). The ultrasound findings were uniformly documented and collected prospectively. Out of a total of 364 scanned patients we selected 143 who ultimately received an operation and we compared the surgical findings with the ultrasound reports. The intra-operative findings included 77 full thickness supraspinatus tears, 24 partial thickness tears and 42 normal cuffs. Three full thickness tears were missed on ultrasound and reported as normal/ partially torn. Four normal/ partially torn cuffs were thought to have a full thickness tear. This presents 96.3% sensitivity and 94.3% specificity for full thickness tears. Three partial thickness tears were reported normal on ultrasound and eight normal cuffs were thought to have partial thickness tears. This presents 89% sensitivity and 93.7% specificity for partial thickness tears. The size estimation of full thickness tears was more accurate for large/massive tears (96%) than moderate (82%) and small/pinhole tears (75%). The tear sizes were more often underestimated which may partly reflect disease progression during the unavoidable time lag between scan and surgery. We conclude that shoulder ultrasound performed by a sufficiently trained orthopaedic surgeon is a safe and reliable practice to identify rotator cuff tears

Aims

Access to total knee arthroplasty (TKA) is sometimes restricted for patients with severe obesity (BMI ≥ 40 kg/m²). This study compares the cost per quality-adjusted life year (QALY) associated with TKA in patients with a BMI above and below 40 kg/m² to examine whether this is supported.

Introduction: Limb schwannomas are benign nerve sheath tumours. They typically present with a cystic swelling or palpable lump. They may also present with symptoms relating to the affected nerve. If the lesion is solitary there is no malignant potential. Clinically the lump will be freely mobile except in the plane of the longitudinal course of the nerve and may have a positive Tinnel’s test. Magnetic resonance imaging or ultrasound scanning are key adjuncts to diagnosis. Treatment is excision of the lump by incising the epineurium, “shelling out” the lesion and preserving unaffected nerve fascicles. We present a case series from a regional soft tissue tumour centre that shows the excellent outcome that can be achieved with these methods. Methods: We retrospectively analysed the case notes of 16 cases of schwannoma who had surgical excision and preservation of the parent nerve. Our outcome measures were resolution of symptoms, post-operative neurological function and recurrence. Results: Of 16 patients, 12 had no neurological deficit. 1 had motor weakness (foot drop) and 1 had residual par-aesthesia post-operatively. 2 patients declined surgery. In addition, 2 patients had persistent pain post-operatively, but at reduced levels to their pre-operative pain. There were no cases of recurrence. Discussion: The diagnosis of schwannoma should be considered in patients with a lump associated with neurological symptoms. Following confirmation of diagnosis with appropriate radiology, surgical excision should be carried out as detailed above to minimise morbidity. This should be performed by a surgeon skilled in dealing with soft tissue tumours

Introduction/Aim. Thromboembolism is a significant cause of patient morbidity and mortality, the risk of which increases in orthopaedic patients with lower limb immobilisation. It was therefore, our aim to identify a difference in symptomatic thromboembolism by treating acute Achilles tendon rupture patients with conventional non- weight bearing plaster versus functional weight bearing mobilisation. Methodology. The notes of 91 consecutive patients with acute Achilles tendon rupture were reviewed. The patients' demographics, treatment modality (non- weight bearing plaster versus weight bearing boot), and predisposing risk factors were analysed. From the 91 patients, 50 patients with acute Achilles tendon rupture were treated conservatively in a non- weight bearing immobilisation cast. From these 50 patients, 3 then underwent surgery and were therefore excluded from the results. 41 patients were treated with functional weight bearing mobilisation. Patients who did have a symptomatic thromboembolic event had an ultrasound scan to confirm a deep vein thrombosis of the lower limb, or a CT-scan to confirm pulmonary embolism. Results. Out of the 47 patients who were treated conservatively in a non-weight bearing plaster cast, 9 patients (19.1 %) had a thromboembolic event. Out of the 41 patients who were treated with functional weight bearing mobilisation, 2 patients (4.8%) had a thromboembolic event. Thus, patients who were treated in a non-weight bearing plaster had a significantly higher risk of developing thromboembolism (p value of <0.05) and an increased risk ratio of 24% compared to those who were treated with functional weight bearing mobilisation. Conclusion. There is a significant decrease in the clinical incidence of thromboembolic events in patients treated conservatively with early mobilisation in the functional weight bearing boot compared to those treated in a non- weight bearing cast

Aim. Congenital Talipes Equinovarus (CTEV) has been excluded from the standards set by the NHS fetal anomaly screening programme (NHS FASP) for the 18. +0. –20. +6. week fetal ultrasound scan (USS). Whilst adhering to NHS FASP guidelines, the antenatal ultrasound department at our centre performs “incidental screening” for CTEV; parents are informed if CTEV is noted incidentally during the scan and referral made to the fetal medicine department. Our aim was to investigate the effectiveness of incidental antenatal screening for structural CTEV. Method. The database of the antenatal ultrasound department was interrogated for all suspected cases of CTEV on the 18. +0. –20. +6. week USS, between August 2006 and June 2012. Terminations, stillbirths and outside referrals were excluded. Our Ponseti-service database was searched to identify all patients treated for structural CTEV between January 2007 and November 2012. Cases were excluded if the mother did not receive antenatal-care at our centre. Results from the two searches were cross-referenced, and statistical analysis performed. Results. 30077 18. +0. –20. +6. week USS were performed on 24282 patients, with CTEV diagnosed in 74 patients. After exclusions, there were 39 patients. 54 patients were treated for structural CTEV with 37 patients (54 feet, CTEV-incidence 0.001) after exclusions; 25 (67.5%) diagnosed pre-natally (15 unilateral, 10 bilateral), and 12 (32.5%) diagnosed post-natally (5 unilateral, 7 bilateral). Sensitivity of screening for CTEV was 67.5%, specificity 99.8%, positive predictive value (PPV) 64.1% and negative predictive value 99.9%. The proportion of cases detected antenatally has reduced since introduction of NHS-FASP. Conclusion. This data is important and necessary to comprehensively counsel our patients. We are unable to find similar contemporary data from other units within the NHS for comparison. NHS-FASP guidelines seem to have reduced the efficacy of antenatal detection of CTEV at our unit, and further prospective study is required to determine the value of screening for patients

Background. The aim of this prospective study was to assess the effectiveness of a single ultrasound-guided steroids injection in the treatment of Morton's neuromas and whether the response to injection correlates with the size of neuroma. Methods. Forty three patients with clinical features of Morton's neuroma underwent ultrasound scan assessment. Once the lesion was confirmed in the relevant web space, a single corticosteroids injection was given using 40 mg Methylprednisolone along with 1% Lidocaine. All scans and injections were performed by a single musculoskeletal radiologist. Patients were divided into two groups based on the size of the lesion measured on the scan. Group 1 included patients with neuromas of 5mm or less and Group 2 patients had neuromas larger than 5mm. The Visual Analogue Scale (Scale:0 to 10), the American Orthopaedic Foot and Ankle Society score (AOFAS) and the Johnson satisfaction scale were used to assess patients prior to injection and then at 6 weeks, 6 months and 12 months following the injection. Results. Thirty nine patients had confirmed neuromas. Group 1 (lesion ≤5mm) included 17 patients (mean age, 30 years) (7 males, 10 females) and Group 2 (lesion >5mm) had 22 patients (mean age, 33 years) (8 males, 14 females). VAS scores, AOFAS scores and Johnson scale improved significantly in both groups at 6 weeks (p < 0.0001). At 6 months post-injection, this improvement remained significant only in group 1 with regards to all scores (p < 0.001). At 12 months, there was no difference between both groups and outcome scores nearly approached pre-injection scores. The need for surgical treatment for persistent symptoms was similar in both groups (p = 0.6). Conclusion. A single ultrasound-guided corticosteroids injection offers generally a short-term pain relief for symptomatic Morton's neuromas. The effectiveness of the injection is likely to be more significant and long-lasting for lesions smaller than 5mm

Developmental dysplasia of the hip (DDH) is the commonest musculoskeletal condition diagnosed in neonates. Two previous studies showed no statistical advantage with the addition of ultrasound to clinical screening. In the UK, the Standing Medical Advisory Committee (SMAC) (1969) recommended clinical examination at birth and at 6 weeks. The Newborn Infant Physical Examination (NIPE) (2008) guidelines in addition advised ultrasound scanning for clinically unstable hips or for those with risk factors (breech presentation or family history). We compared SMAC and NIPE in the two main hospitals of the East Lancashire Hospitals NHS Trust: Burnley General Hospital (BGH) and the Royal Blackburn Hospital (RBH), respectively. Our outcome measure was the number of irreducible hip dislocations over a two year period (2007–2008). The records of the lead Paediatric Orthopaedic Surgeon were used to identify all cases of irreducible hip dislocations born in 2007 and 2008. Maternity records provided information on birth statistics. Syndromal cases were excluded from further analysis. BGH had 5382 live births and 7 irreducible hip dislocations (incidence 1.3/1000 births). 4/7 met SMAC recommendations and 6/7 met NIPE guidelines. 2/7 had equivocal clinical examinations at birth. 13 children were referred to the clinic with unstable hips (2.42/1000 births). RBH had 7899 total births and 3 irreducible hip dislocations (incidence 0.38/1000 births). 2/3 met NIPE guidance and 1/3 met SMAC recommendations. 33 were referred to the clinic with unstable hips (4.18/1000 births). The difference in the numbers of irreducible hips did not reach statistical significance (p=0.12). This study found no statistically significant advantage with the addition of selective ‘at risk’ ultrasound screening to clinical screening alone. Confounding factors in this study included the age of referral of cases to clinic and the numbers of cases referred as primary instability. These findings are in keeping with two previous studies in Norway

The indication for rotator cuff repair in elderly patients is controversial. Methods. Consecutive patients over the age of 70 years, under the care of a single surgeon, receiving an arthroscopic rotator cuff repair were reviewed. Predominantly, a single row repair was performed using one (34 cases) or two (30) 5mm Fastin, double-loaded anchors. Double-row repair was performed in four cases. Subacromial decompression and treatment of biceps pathology were performed as necessary. Data were collected from medical records, digital radiology archives and during clinic appointments. Pain, motion, strength and function were quantified with the Constant-Murley Shoulder Outcome Score, administered pre operatively and at 1-year post operatively. Ultrasound scans were performed at one year to document integrity of the repair. Results. Sixty-nine arthroscopic cuff repairs were identified in 68 patients. The mean age was 77 years (70–86). The median ASA grade was 2 (79%). The dominant side was operated on in 68% of cases. A range of tear sizes were operated on (5 small, 17 moderate, 29 large and 18 massive). The tendons involved in the tear also varied (supraspinatus 12, supra and infraspinatus 53, supraspinatus and subscapularis 2, supraspinatus infraspinatus and subscapularis 2). Re-rupture occurred in 20 cases (29%). The mean Constant score increased from 23 (95% CI 19–26) to 59 (54–64) (P< 0.001). Where the repair remained sound, Constant score improved 42 points (95%CI 36–48). If the cuff re-ruptured, constant score also increased on average 12 points (95% CI 2–21). Re-rupture rate was highest for massive cuff repairs: ten out of eighteen (56%). Conclusion. Arthroscopic rotator cuff repair in the elderly is a successful procedure. Approximately seven out of ten repairs remained intact after one year. Even where re-rupture occurs, a significant improvement in the Constant score was found

Introduction. We examined the effect on blood loss of two standardised intravenous bolus doses of 500 mg of Tranexamic Acid, a fibrinolytic inhibitor that reduces blood loss following Knee Arthroplasty (KA). Materials and Methods. Our study included one hundred consecutive patients undergoing primary cemented KA, who received two standarised bolus doses of 500 mg of Tranexamic Acid. The first dose was administered at induction to anaesthetic and the second dose was administered just before the closure. Data, which included Haemoglobin (Hb), Haematocrit (Hct), Length of Hospital Stay (LOS) and complications, was collected prospectively by an independent observer. Routine blood tests were done on the 1. st. or 2. nd. post-operative day. Results. Out of 100 patients aged from 49 to 92 years old (mean age of 69 years), 39 were male and 48 underwent a right KA. The mean LOS was 4.73 days with a standard deviation (SD) of 3.07 days. The mean drop of Hb was 2.04 g/dl (15.5%) with a SD of 0.89 g/dl (6.2%). The mean drop of Hct was 0.096 (16.7%) with a SD of 0.325 (10.0%). Only 2 patients had developed symptoms of anaemia and were transfused with 2 units of red blood cells each. Ultrasound scan was used to investigate patients with possible Deep Venous Thrombosis (DVT). Indications were calf pain and swelling of the lower limb. 10 patients were investigated, out of which in only 3 patients the diagnosis of DVT was confirmed, whereas in 2 patients DVT could not be excluded because of obesity. Conclusions. We believe that the use of two standardised intravenous bolus doses of 500 mg of Tranexamic Acid reduces peri-operative blood loss, reducing the need for transfusion, without increasing the risk of thromboembolic complications

Background: Aetiology of venous thromboembolism is multifactorial and thromboprophylaxis includes mechanical and chemical agents. There is no clear consensus on the choice of chemical agent in elective total hip arthroplasty (THA), although National Institute of Clinical Excellence (NICE) recommends low molecular weight heparin or fondaparinux to all patients. Aim: The aim of our study was to define the efficacy and safety of various chemical agents currently used for venous throboprophylaxis – namely aspirin, warfarin and low molecular weight heparin in primary THA. Methods: We retrospectively reviewed 905 consecutive patients with primary THA during an 18 month period. Medical notes were reviewed to record demographic data, inpatient and outpatient thromboprophylactic agents, total hospital stay, readmission, incidence of DVT, pulmonary embolism and death following surgery. Post-operative mobility, transfusion requirements and complications were noted. Suspected thromboembolic events were investigated with venous Doppler ultrasound scanning and CTPA. Results: 417 (46%) patients received aspirin, 253 received enoxaparin, 190 patients had low dose warfarin and 45 patients had none or multiple agents for inpatient thromboprophylaxis. 615 patients had cemented and 290 patients received uncemented total hip arthroplasty. Patients predominantly received aspirin (61%) as outpatient prophylactic agent. 41 patients were investigated for a suspected thromboembolic event. 2 patients had DVT and 2 patients had PE. There were 3 deaths within 6 weeks, one each due to PE, sepsis and unknown cause. All 4 patients with thromboembolism were on enoxaparin for prophylaxis. Conclusion: In our study aspirin was the preferred choice for thromboprophylaxis following total hip arthroplasty. We found that aspirin was most effective with no complications and enoxaparin was least effective. We advise the use of aspirin as the first choice drug for thromboprophylaxis as reiterated by some recent studies

INTRODUCTION:. Previous modalities such as static x-rays, MRI scans, CT scans and fluoroscopy have been used to diagnosis both soft-tissue clinical conditions and bone abnormalities. Each of these diagnostic tools has definite strengths, but each has significant weaknesses. The objective of this study is to introduce two new diagnostic, ultrasound and sound/vibration sensing, techniques that could be utilized by orthopaedic surgeons to diagnose injuries, defects and other clinical conditions that may not be detected using the previous mentioned modalities. METHODS:. A new technique has been developed using ultrasound to create three-dimensional (3D) bones and soft-tissues at the articulating surfaces and ligaments and muscles across the articulating joints (Figure 1). Using an ultrasound scan, radio frequency (RF) data is captured and prepared for processing. A statistical signal model is then used for bone detection and bone echo selection. Noise is then removed from the signal to derive the true signal required for further analysis. This process allows for a contour to be derived for the rigid body of questions, leading to a 3D recovery of the bone. Further signal processing is conducted to recover the cartilage and other soft-tissues surrounding the region of interest. A sound sensor has also been developed that allows for the capture of raw signals separated into vibration and sound (Figure 2). A filtering process is utilized to remove the noise and then further analysis allows for the true signal to be analyzed, correlating vibrational signals and sound to specific clinical conditions. RESULTS:. Numerous tests have been conducted using this ultrasound technique to create 3D bones compared more traditional techniques, MRI and CT Scans. These tests have shown repeatedly that 3D bones can be created with an error less than 1.0 mm. Soft-tissues at the joint of question are also created with a high accuracy. Sound signals have been analyzed and correlated to specific knee and hip clinical pathology as well as complications after Total Joint Arthroplasty. Sounds such as squeaking, knocking, grinding, clicking and even a rusty door hinge have been recovered during weight-bearing activities. DISCUSSION:. Both CT scans and x-rays emit radiation, and static CT scans and MRI scans are conducted under non weight-bearing conditions. These two new orthopaedic diagnostic techniques, ultrasound and sound, allow a surgeon to make clinical diagnoses while the patient is performing weight-bearing, dynamic activities, while not being subjected to harmful radiation. Sound analyses allow for support of the ultrasound and physical exam that can lead to enhanced diagnostics that are not possible using only a visual based analysis. Early results are promising for both of these new diagnostic techniques. This study revealed that weight-bearing, dynamic diagnoses can be made by an orthopaedic surgeon and could have distinct advantages compared to traditional techniques

The factors involved in the mechanism leading to traumatic posterior dislocation of the hip are examined. In 47 adult patients who had previously suffered such a dislocation, ultrasound scans were used to measure femoral anteversion on both the affected and the uninjured side. In 36 normal adult volunteers, used as controls, similar measurements were made. Femoral anteversion on both the injured and uninjured side was significantly reduced in the patients compared with the volunteers. These findings are discussed in the light of previous work which indicates that medial rotation is a factor in the mechanism of posterior dislocation of the hip. It is suggested that reduced anteversion acts like medial rotation to make the hip more susceptible to posterior dislocation, and that the less the anteversion the more likely is the injury to be a dislocation rather than a fracture-dislocation. It is concluded that patients who suffer such dislocated hips belong at one extreme of the normal population, having either reduced femoral anteversion or even retroversion, and that this anatomical feature selects towards hip dislocation rather than to injury of the femoral shaft, knee or tibia during the appropriate type of accident

Introduction: Pain and mass lesions around hip resurfacing are reported with increasing frequency. The aetiology is unknown but reaction to metal wear debris and mechanical impingement have both been suggested. We are aware of a group of our patients with significant pain following resurfacing. We sought to correlate metal ion levels with X-ray findings and any local soft tissue reaction around the prosthesis. Methods: Patients with significant groin pain following hip resurfacing were identified from routine clinics. Blood was tested for cobalt and chromium levels using inductively coupled mass spectrometry in all patients. Cup abduction angle and femoral stem version were estimated from plain radiographs. Patients underwent ultrasound scan (USS) of the affected hip joint. Bilateral prostheses were excluded to avoid confounding. Results: 47 unilateral painful hip resurfacings (24 female) were identified. USS was performed in 42 patients and was abnormal in 25 (15 female). Abnormalities ranged from simple joint effusion with or without synovial thickening, through to cystic masses in the posterior joint and solid masses related to the ileopsoas tendon similar to the appearances previously described in pseudotumours. A two sample t-test demonstrated cobalt and chromium ion levels were significantly higher in patients with abnormalities on USS (p=0.038, p=0.05 respectively), patients with normal USS were more likely to have a retroverted femoral component (p=0.01). Discussion: We describe two groups of patients with a painful hip resurfacing: those with raised metal ions and local soft tissue reaction, and those with lower metal ions and no soft tissue reaction. The retroverted stems in the second group could cause an iatrogenic cam-type impingement. Metal ion levels are useful to guide further imaging. Raised levels should prompt investigation for a soft tissue abnormality with either USS or MRI, lower levels suggest investigation should look for mechanical impingement with imaging such as CT

Ultrasonography for rotator cuff disease is a cheap and non-invasive investigation. Our study investigates the tendon specific pathologies leading to misinterpretation of ultrasound findings and their implication for the surgical management. On hundred and five consecutive patients who had an ultrasound scan by a single musculoskeletal radiologist and then underwent shoulder arthroscopy by a single shoulder surgeon for rotator cuff pathologies were included. Surpraspinatus Tendon (SST): There was a sensitivity of 90%. The relatively low positive predictive value (76%) and specificity (42.5%) were influenced by a high number of false positives. This was a mixed group of 23 cases, in which ultrasonography had described either a full-thickness (FTT) or partial-thickness (PTT) tear when arthroscopy did not show any evidence for a cuff tear. Seven of these cases were described as FTT with dimensions less than 1 cm and in ten cases the radiologist described a “possible sub-centimetre tear”. Subscapularis Tendon (SSC): There was a specificity of 100%. The poor negative predictive value (78%) and sensitivity (26%) were caused by a high number of false negatives. Further analysis of the 20 “false negative” patients showed four FTT and sixteen PTT. All partial thickness tears involved the superior fibres of the subscapularis tendon. Our results confirm that USG is a reliable investigation in larger full thickness tears, particularly of the superior rotator cuff (SST). The reliability is significantly reduced in sub-centimetre tears and partial thickness tears, particularly of the subscapularis tendon. Associated tendon pathologies like intra-tendinous calcifications and intra-substance tears make an accurate diagnosis even more difficult and add to the tendency to ‘over-diagnose’ tears of the rotator cuff with use of ultrasonography. The shoulder surgeon should be aware of the potential misinterpretation of ultrasonography findings and be prepared to adjust the surgical procedure accordingly

Universal neonatal screening of developmental dysplasia of the hip (DDH) remains controversial and a few centres have adapted this practice in the United Kingdom. Our institute has established a DDH screening programme over the last 19 years. The following shows our result after a recent change in our screening programme protocol. All infants born in Coventry are screened for DDH by a clinical examination and ultrasound scan (USS). 5,084 babies were born over a 12-months period. Normal examination and USS were detected in over 90% of the cases. Abnormality detected through either clinical examination or USS was referred to a special orthopaedic/USS clinic. However, in the majority of the cases, subsequent assessments were normal and only 23 babies required treatment. In these cases, the majority had not shown any signs of clinical abnormality. However, serial USS had shown persistent abnormality of at least Graf grade II or higher. The average time from birth to a treatment with a Pavlik Harness was 35 days and the average duration of a treatment was 48 days. Apart from one case, all the babies were treated successfully. The unsuccessful cases had a Graf grade IV at the presentation and had shown no sign of improvement on sequential USS. No complications were noted. While the sensitivity of detecting DDH through clinical examination remains poor, USS has become an essential tool in our screening programme. Many initial abnormalities are secondary to hip immaturity and they tend to resolve. Those with clinical instability and persistent USS Graf grade II or higher should be treated with early Pavlik Harness. Early detection has led to better results than late diagnosis, and in addition to this, the overall number of operations required could be reduced. Yet, the need for a major surgical intervention has been all but eliminated

The position of the gastrocnemius tendon relative to the calcaneus and fibular head distance may be different in children with cerebral palsy (CP) when compared to normal children. However, no such data is available. Usually, palpation of the muscle bellies or previous experience of the operating surgeon is employed to place the surgical incision. Inaccurate localisation may cause incorrect incision and a risk of iatrogenic damage to the vital structures (i.e. sural nerve). The aim of our study is to compare gastrocnemius muscle length in-vivo between paretic and unaffected children and suggest a formula to localise muscle-tendon junction. Ten children with di/hemiplegia (seven females and three males; mean age 8y 7mo, range 2–14y) were recruited. None of them had received any conventional medical treatment. An equal number of age/sex matched, typically developing children (mean age 9y 1mo, range 4–14y) were recruited. Participants lay prone on an examination plinth with their feet hanging from its edge. Sagittal-plane ultrasound scanning of the gastrocnemius muscle at rest was performed to measure the length of gastrocnemius bellies. We also measured the heights, lower leg lengths, thigh lengths and leg lengths. At similar age, the lower leg lengths in CP patients were shorter than normal children. Similarly, gastrocnemius medial (GM) muscles were shorter in CP children when compared to similar aged normal children. In CP children, the GM muscle and lower leg ratio ranges between 35 to 50% with an average ratio of 45%. When compared to leg length, the ratio is 22%. Using these figures we created a formula that may be used clinically to identify the tendon for open or endoscopic lengthening and also to make simple and accurate localisation of GM-tendon junction for surgical access. This minimizes the risk of iatrogenic neurovascular injuries and decreases the length of the surgical incision

Universal neonatal screening of developmental dysplasia of the hip (DDH) remains controversial and a few centres have adapted this practice in the United Kingdom. Our institute has established a DDH screening programme for many years. The following shows our result after a recent hospital relocation and changes to the screening programme. All infants born in Coventry are screened for DDH by a clinical examination and ultrasound scan (USS). 5,084 babies were born over a 12-months period. Normal examination and USS were detected in over 90% of the cases. Abnormality detected through either clinical examination or USS was referred to a special orthopaedic/USS clinic. However, in the majority of the cases, subsequent assessments were normal and only 23 babies required treatments. In these cases, the majority had not shown any signs of clinical abnormality. However, serial USS had shown persistent abnormality of at least Graf grade II or higher. The average time from birth to a treatment with a Pavlik Harness was 35 days and the average duration of a treatment was 48 days. Those with Graf III or higher at initial presentation, but spontaneous reduced without treatment were follow-up to one year. The acetabular index in these cases was normal. Apart from one case, all the babies were treated successfully. The unsuccessful cases had a Graf grade IV at the presentation and had shown no sign of improvement on sequential USS. While the sensitivity of detecting DDH through clinical examination remains poor, USS has become an essential tool in our screening programme. Many initial abnormalities are secondary to hip immaturity and they tend to resolve. Those with clinical instability and persistent USS Graf grade II or higher should be treated with early Pavlik Harness. Early detection has led to better results than late diagnosis, and in addition to this, the overall number of operations required could be reduced

Introduction: Rat-bite fever is an uncommon illness caused by Streptobacillus moniliformis or Spirillum minor. We present an unusual case of rat bite fever involving a left cemented total hip replacement after a rodent bite. Case report: A 38-year-old lady, presented with poly arthralgia, who had Total Hip replacement for arthritis secondary to developmental dysplasia of Hip(one year ago), presented with signs & symptoms suggestive of infective joint pathology. Examination revealed painful restricted joint movements. Initial blood tests revealed very high ESR, c-reactive proteins with leucocytosis. Blood cultures were negative. X-rays revealed dislocation of Total hip replacement Ultrasound scan and CT scan revealed a large collection of fluid in the Left Total Hip Replacement. Aspirate from the affected joints revealed gram negative bacilli, Streptobacillus moniliformis. The joints were all washed out arthroscopically. She was put on intravenous antibiotics and continued for six weeks. The inflammatory markers normalised after six weeks. Follow up x-rays of the left hip prosthesis do reveal some signs of osteolysis and surveillance is ongoing. Discussion: Prosthetic replacements are now commonplace, with large number of patients keeping pets. Septic arthritis following the rat bite has been reported. As far as we can tell from the available literature that it has not been reported in a joint prosthesis. The long- term outcome is unknown. The possibility of low grade infection involving the joint prosthesis and the association of this organism with endocarditis is a cause for concern

Purpose of study: We report the results of a prospective case series of 10 patients who developed tumour-like masses following resurfacing arthroplasty. Method: Ten subjects were referred to the tumour service at the Nuffield Orthopaedic Centre with symptomatic masses around the hip, all had previously received a resurfacing arthroplasty. We report the clinical, radiographic and histologic features of these cases. Results: MRI and ultrasound scanning was preformed, which demonstrated masses with solid and cystic components. Biopsy was performed and subsequent histological examination revealed a profound plasma-cell lymphocytic response associated with metal wear debris. There were no infections in this series. Three subjects required revision surgery. Conclusion: Over 50,000 resurfacing arthroplasties have been implanted worldwide over the past ten years. Although the early clinical results are encouraging little is known about the long term consequences of large head metal on metal bearing surfaces. Despite this, these devices are being widely marketed and are often implanted in younger patients. Resurfacing arthroplasties are associated with high serum and urine metal ion concentrations, metal particles have also been shown to migrate along the lymphatic system. In addition, there is now evidence that high local metal ion concentrations can induce haempoietic cancers. This study suggests that resurfacing arthoplasty can also induce a local hypersensitivity reaction in response to metal wear debris. It therefore raises new concerns regarding the long-term safety of this procedure

The standard plane imaging of Graf and the dynamic methods of Harcke are well established methods in assessing hip dysplasia but give limited information in the flexed-abducted treatment position used in the Pavlik harness. The femoral head may sit on the edge of the acetabulum in a flexed position and only reduce when the hips are abducted. This may mean that hips, which reduce when abducted in the Pavlik harness, appear subluxed when scanned in neutral abduction. Harness treatment may thereby be abandoned prematurely due to the failure to confirm reduction. This study identifies ultrasound landmarks on an anterior hip scan which could be used to confirm reduction of the hip in Pavlik Harness. Hips of a newborn piglet were scanned, imaged with magnetic resonance and x-rayed both before and after anatomical dissection. Radiographic markers delineated the position of the tri-radiate cartilage and potential ultrasound landmarks identified to help confirm hip reduction in the flexed-abducted position. Porcine imaging was then compared with that of a human newborn. The porcine model corresponded well to human imaging and we were able to establish a landmark, the “Ischial Limb”, which corresponds to the ossification front delineating the posterior ischial edge of the tri-radiate cartilage. This could clearly be seen on anterior hip ultrasound of both the porcine and human hip. This landmark can be used to confirm the hip is reduced by reference to the centre of the femoral head. We would recommend anterior hip scanning using the “Ischial Limb” as a reference point to confirm hip reduction in Pavlik harness. This simple method is a useful adjunct to conventional ultrasound scanning in the harness treatment of hip instability

This study was undertaken between May 1992 and April 2002 in a hospital where there was a targeted screening programme for Developmental Dysplasia of the Hip. All data was collected prospectively. 2,578 infants with clinically unstable or at risk hips underwent bilateral hip ultrasound examination. This was performed by the senior author. At risk hips were considered to be those where there was a history of breech presentation, foot deformity, oligohydramnios on prenatal maternal ultrasound scans or a strong family history of Developmental Dysplasia of the Hip. There were significant changes in the reasons for referral for targeted screening over the ten year period. In the first year of the study 1.5% of referrals were because of oligohydramnios. In the last year of the survey 16.5% of referrals were because of oligohydramnios. The number of referrals for screening because of oligohydramnios increased sixty fold between the first year and last year of the study period. The overall number of infants referred for targeted screening more than doubled between the first and the last year of the study period. Of the infants that were found to have unstable or dislocated hips, no infants had oligohydramnios as a risk factor. The number of referrals for targeted ultrasound screening is increasing. In a targeted screening programme for Developmental Dysplasia of the Hip we suggest that oligohydramnios should not be used as a possible risk factor

The purpose of this study is to ascertain the efficacy of ultrasound in determining pathology prior to surgical intervention for rotator cuff tears, 88 patients were referred for surgery on clinical grounds. One Radiologist who is widely experienced in shoulder ultrasound scanned these patients within one month prior to their operation using up to date equipment. The patients were categorised into 2 groups: those with or those without a full thickness rotator cuff tear. The results were then verified using surgery as the ‘gold standard’. This enabled the researcher to calculate the diagnostic accuracy of the procedure. The findings show that in this Trust, ultrasound has a sensitivity of 95% in the detection of full thickness rotator cuff tears. The specificity is 87%, positive predictive value 87% and negative predictive value 95%. Knowledge of the cuff status prior to surgery aids in pre-operative patient counselling in terms of surgical procedure (arthroscopic or open surgery), rehabilitation and prognosis. This study demonstrates that expert practitioners can produce reliable results using ultrasound, which can then be used as the primary investigation for the detection of full thickness rotator cuff tears. More expensive procedures such as Magnetic Resonance imaging are now limited to those patients with equivocal ultrasound findings

We have followed the natural progress of newborn infants in whom ultrasound examination showed abnormalities in hips which appeared to be clinically normal. Over six years we saw 306 such children out of 9952 examined (31 per 1000 live births). The examination was repeated at two to three months and those who still showed an abnormality were followed up further. At four to five months a standard radiograph was obtained, and treatment began if this and another ultrasound scan were both abnormal. At this stage, 291 infants had normal hips. In the 15 infants with abnormal hips there was no pronounced deterioration, none developed a frank dislocation, and all became normal after treatment in an abduction splint. Newborn infants with abnormal and suspicious ultrasound findings who are normal on clinical examination do not need treatment from birth; most of these hips will settle spontaneously. Treatment can be postponed until the age of four to five months unless clinical instability develops or ultrasound shows dislocation. The criteria for treatment should be based on measurements by both ultrasound and radiography: both should show an abnormality before intervention is considered necessary