Hip displacement is the second most common deformity in children with cerebral palsy (CP). A displaced, and particularly a dislocated hip, can have significantly adverse effects on an individual. Surgical intervention to correct progressive hip displacement or dislocation is recommended for children with CP. Success of surgical intervention is often described using radiological outcomes. There is evidence that surgical treatment for displaced or dislocated hips decreases pain and hip stiffness and improves radiological outcomes. However, there is no information in the literature regarding the impact of surgical treatment on the health related quality of life (HRQOL) in these children. The aim of our study was to examine the impact of surgical treatment of hip displacement or dislocation on HRQOL in children with CP.

This prospective longitudinal cohort study involved children attending a tertiary care hospital orthopaedic department. Children with CP between the ages of 4 and 18 years, with hip displacement/dislocation, defined as a Reimer's migration percentage (MP) of >40% on a pre-operative x-ray, and undergoing surgical reconstruction were eligible for inclusion. Quality of life was measured pre-operatively and post-operatively using the CPCHILD Questionnaire.

Twelve patients (one child was GMFCS level III, 4 were level IV, and 7 were level V), aged 4.0 to 17.3 years, were assessed pre-operatively and then again at least six months post-operatively. All underwent unilateral (5) or bilateral (7) reconstructive hip surgery. The migration percentage of hips undergoing reconstruction was reduced by an average of 52% (9–100%). The average change in CPCHILD score showed an increase of 6.4 points [95% CI: −1.4–14.2].

In this pilot study, no significant change was noted in HRQOL following reconstructive hip surgery, despite a marked reduction in Reimer's MP. However, only 4 of 12 parents reported that their child had daily pain pre-operatively. A larger sample size will be required to draw more accurate conclusions from these findings. There is an evident need for a multicentre study examining this issue in a larger patient population in order to determine the long-term impact of different hip interventions on quality of life in children with CP.

The objectives of this study are to ascertain primary caregivers' understanding of risks associated with home trampoline use; to educate caregivers in regard to documented literature based risks associated with home trampoline use; and to evaluate if this information will have any influence on their future regulation of home trampoline use for their children. One hundred primary caregivers of patients treated in the paediatric orthopaedic surgery outpatient clinic at London Health Sciences centre were surveyed. All caregivers in clinic were invited to participate. The only exclusion criteria was the inability to provide consent. Caregivers' baseline perceptions on the risks associated with home trampoline use were assessed using a questionnaire. Caregivers then received an information pamphlet outlining documented trampoline safety data. They were then sent the same questionnaire to complete within one week of reading the pamphlet. Using our research electronic database capture (Redcap), the results of the surveys were compiled and analysed using spss 22, paired t-test and repeated measures anova. A sample size of 55 was calculated to result in a power of 80%. Of primary caregivers surveyed, 36% owned a home trampoline, and only 5% had personal experiences with their child sustaining a trampoline injury. Pre-education, when caregivers were asked on a scale of one (not dangerous) to 10 (very dangerous) how dangerous they felt a trampoline was for their child, the average response was six. Post-education, this number changed to eight. Providing education to primary caregivers significantly changed their perceptions on all sections of the questionnaire, yet 47% of primary caregivers were willing to allow their child to use a trampoline at home despite their new understanding of trampoline injury and safety. Providing education to primary caregivers significantly changed their perceptions on all trampoline safety questions, indicating effective comprehension. Despite caregivers' understanding of the risks associated with home trampoline use, approximately half of the study population continue to permit this activity for their children. There is potential to reduce paediatric orthopaedic injuries associated with home trampoline use if safer trampoline related practices are implemented based on information provided

Acute Haematogenous Osteomyelitis (AHO) remains a cause of severe illness among children with the possibility of long-term consequences for growth and development. Previous research on sequelae from AHO rarely considers outcomes more than two years following treatment. This study aims to establish the quality of life of patients diagnosed with AHO in childhood up to 13 years after diagnosis, evaluating the impact on social, emotional, physical, and school function. Children treated for AHO between 2008–2018 at a tertiary referral centre in New Zealand were identified. PedsQL™ questionnaires were conducted via phone with either the child or primary caregiver and responses analysed. 40 patients met inclusion criteria, were contactable by phone, and consented to participate. The mean age was 7 years (range 0–15) and most were female (60%). Health related quality of life (HRQOL) was scored as a percentage with most participants scoring >80% (n=27). Those who do experience reduced quality of life following treatment for AHO were likely to complain of pain, stiffness, or anxiety. The impact of significant childhood illness on mental health was not adequately captured by the PedsQL™ but was highlighted in qualitative feedback. We conclude that the majority of children treated for AHO reported excellent health-related quality of life up to 13 years following treatment although an negative impact on mental health was reported using qualitative analysis. A refined scoring system is needed to assess the long-term impact of musculoskeletal infection

Child abuse is an essential discussion within society and poses many challenges. The international literature describes patient and family based risk factors and suspicious injuries. We have created a protocol for the identification and investigation of children with suspected non-accidental injuries. The paediatric orthopaedic ward experiences many children being delayed in the ward once fit for discharge. This study aimed to quanitify those delayed discharges and describe the demographics and risk factors for abuse within the local population. After obtaining ethics clearance, we conducted a retrospective review of records from the Teddy Bear Clinic, as well as admission records. The study examined demographic characteristics, family, injury characteristics and referral to Child Welfare. The delay of discharge from hospital was quantified and was compared to those characteristics. Records were collected from 1 January 2015 to 31 December 2021. Seventy-nine complete records were included. There were 40 males and 39 females with an average age of 20 months. 75.9% were under 36 months old. 94.1% of the cases sustained lower limb fractures. Fifty-two cases had a delayed discharge. The delay ranged from 1 to 233 days. There was an association between an age less than 36 months and delayed discharge. There were no significant correlations between caregiver characteristics and delayed discharge. The later the completion of investigations, the more likely there would be a delay. There was also a significant correlation between referral to Child Welfare and delayed discharge. Children under 36 months on this remain at highest risk for non-accidental injury. Delayed discharge was associated with age less than 36 months, upper limb fractures and referral to Child Welfare. Despite the delayed discharge, most children returned to the same home environments

Introduction. Several hexapod external fixator devices are used in the treatment of bone fracture and deformity corrections. One characteristic of all of them is the requirement for manual adjustment of the fixator struts. The purpose of this study was to introduce a novel robotic system that executes automatic adjustment of the struts. Materials and Methods. Ten patients were treated for various bone deformities using a hexapod external fixator with Auto Strut system, which implemented automatic adjustment of the fixator struts. Patients arrived at the clinic for follow during the correction period until the removal of the hardware. During each visit, the progress of the correction was assessed (clinically and radiographically) and reading of the strut scale numbers was performed. Results. All patients completed the treatment plan during the follow up period achieving all planned correction goals. Healing of the bone ranged between approximately one to seven months. Duration of distraction ranged between 10 and 90 days. The distraction index ranged between 8 and 15 days/cm. The length of distraction varied between 1 and 6 cm. The planned corrections were fully attained in all patients who completed the treatment (n=10). No device related adverse events were reported. One patient was not available for registration of struts length, one patient switched to manual struts due to personal preference.48 struts of eight patients were recorded, 94% of the final strut number readings presented a displacement of 0–1 mm, three struts (6%) had 2–3 mm displacement due to inter-observer reading errors. indicating high precision of the automatic adjustment. Conclusions. This study presents preliminary result, showing that Auto Strut can successfully replace the manual strut adjustment providing important advantages that benefit the patient, the caregiver and the surgeon

Septic Arthritis (SA) is considered a surgical urgency/ emergency by physicians around the world. As our understanding grows, and improved diagnostic algorithms are developed, it has become apparent that competing interests in terms of accurately diagnosing concurrent osteomyelitis may supercede rapid surgical intervention when the imaging is timely. Nevertheless, even in cases of isolated SA, many patients will require repeat surgery. We aimed to assess factors which could predict this. A multicenter retrospective redcap database was created involving 20 pediatric centers from the CORTICES study group with the goal of better understanding pediatric musculoskeletal infection (PMSKI). All patients who met inclusion for the database were considered, surgeons for each site determined through imaging and chart review which patients met the diagnosis of isolated SA. Patients with concomitant abscesses or osteomyelitis were expressly excluded. Appropriate non parametric statistics were used to assess univariate significance. Multivariable logistic regression was used to assess clinical factors associated with an increased likelihood of more than one surgery. Receiver characteristics operating curve (ROC) analysis was used to determine optimal cutoffs to discriminate between children who required more than one surgery compared to those who required only one surgery. A probability algorithm was developed for the number of clinical factors present and the likelihood requiring more than one surgery following SA diagnosis. “Four hundred and fifty-four patients with isolated SA were analyzed from 20 US hospitals. Patients were 5.4 +/− 4.8 years old at admission, and the cohort was 56% male. Of the 454 patients, 47 (10.4%) needed more than one surgery. Bivariate comparisons across surgery groups found significant differences in minimum platelet count (pplatelet, a patient has a 0.3% reduction in the odds of needing more than one surgery (OR=.997; p=0.04). For each additional ten units of CRP, a patient has a 0.1% increase in the odds of needing more than one surgery (OR=1.001; p<0.001). Our predictive algorithm found that children with both risk factors had a 64% chance of requiring multiple surgeries. Higher CRP values and lower platelet values indicate more severe disease in isolated SA with a greater likelihood of repeat surgery. Higher CRP and lower platelet counts may portend multiple surgeries and caregivers of children with isolated SA should be advised as such

Background. Total Knee Arthroplasty (TKA) provides patients with significant improvements in quality of life. Subjective patient reported outcome measures (PROMs) are traditionally used to measure preoperative functional status and postoperative outcomes. However, there are limitations to PROMs. In particular, they provide virtually no functional information in the first 3 weeks after surgery, which could be used to guide the patient's recovery. Newly available wearable electronic sensors make it possible to: 1) measure important functional outcomes following TKA; 2) guide the patient's physical therapy (PT); and 3) provide real-time functional and clinical information to the provider. Compliance with PT after TKA is a challenge. Patients cite time, transportation, and cost as deterrents to PT appointments. However, an intensive PT program is essential in TKA. Surface sensor devices may be able to increase PT compliance by guiding patients through exercises at home. Additionally, these devices can transmit PT progress in real-time to the providers, allowing them to monitor and assist the patient's recovery. Our study investigates the feasibility of using a surface sensor device (TracPatch™) on patients following TKA. We sought to answer the following questions: 1) Will patients tolerate the device; 2) Will patients comply with device instructions; 3) Will patients be able to use the smart phone application; 4) Will the device collect, transmit, and store data as it was designed? We believe these fundamental questions must be answered as we enter the era of personal sensor-measured functional outcomes. Methods. 20 patients undergoing primary, unilateral TKA were enrolled in this IRB approved study. At the pre-surgical visit, patients were given instructions for the device and smart phone application. Each patient used the device in the week prior to surgery, and data was collected. The device was again applied in the operating room. For 3 weeks post-operatively, the device collected functional data, along with WOMAC, OKS, KSS, PROMIS, and VAS pain scores. A satisfaction survey was collected on the device. Results. The study results emphasize the importance of clear device instructions. Using the sensor and phone application prior to surgery was very helpful. The device was surprisingly well tolerated. Older patients were able to use the device without significant difficulty. Virtually all patients found the device helpful and, often fun. Physical therapists felt that the devices helped personalize the therapy program. The functional information from the device was much more helpful in guiding care in the first 3 weeks following surgery than PROM scores. Conclusion. It is anticipated that sensor devices of the kind tested in this study will have a major impact on the care of TKA patients. The purpose of this study was not to measure that impact. Our goal was to examine the factors that optimize the use of these devices. It is critical that clear device instructions be given to patients. Office procedures must be established to monitor use of the devices. If protocols are established for their use, surface sensors have the potential to provide invaluable information to TKA patients and caregivers

Introduction. Non accidental injury is an under diagnosed problem worldwide. It is for this reason that all healthcare workers should be equipped in making the diagnosis and be aware of their obligation according to the Children's Act. Purpose. The aim of the study was to determine if child abuse is adequately diagnosed at our institution and to identify areas of weakness in our current management protocol. Methods. Records of all children admitted under the age of 3 years with fractures from January to December 2010 were reviewed. The radiographs were retrospectively classified as likely child abuse or not according to the fracture pattern, by consensus between an orthopaedic surgeon and a radiologist. The x-ray findings were then correlated with the clinical notes, to determine if appropriate management had been instituted in each case. University ethics approval was obtained to undertake the study. Results. Included in the study are 53 children; it was found that 28 (52%) of these had fractures that could be regarded as being suspicious of a non accidental injury that warranted further investigation. The clinical notes revealed that of the patients at risk, 28 (100%) were referred to a social worker for further investigation and a skeletal survey was only performed in 11 (39%). Only one skeletal survey showed another fracture in a healing stage. Two patients were removed from their primary homes or caregiver. Conclusion. Our results suggest that non accidental injury according to fracture pattern is under diagnosed and investigated at our institution. Heightened awareness of child abuse is imperative and emphasis must be placed on appropriate investigation and referral where suspicion exists. NO DISCLOSURES

Aims

The evidence base within trauma and orthopaedics has traditionally favoured quantitative research methodologies. Qualitative research can provide unique insights which illuminate patient experiences and perceptions of care. Qualitative methods reveal the subjective narratives of patients that are not captured by quantitative data, providing a more comprehensive understanding of patient-centred care. The aim of this study is to quantify the level of qualitative research within the orthopaedic literature.

Aims

The number of females within the speciality of trauma and orthopaedics (T&O) is increasing. The aim of this study was to identify: 1) current attitudes and behaviours of UK female T&O surgeons towards pregnancy; 2) any barriers faced towards pregnancy with a career in T&O surgery; and 3) areas for improvement.

Background and Aims:. In 2009 a combined clinic was formed by the orthopaedic Surgeons and Developmental Paediatricians in our hospital. The aim was to help improve the assessment and management of patients with Cerebral Palsy. Included in the assessment team, are the paediatric orthopaedic surgeons, the developmental paediatricians, physiotherapists and occupational therapists. Our aim was to audit the patients presenting to this clinic over a 15 month period to look at the demographic data, clinical severity and decisions taken for these patients. Methods:. We looked at patients seen in the clinic from January 2013 to March 2014. We recorded the age, gender and primary caregiver. We also recorded the reason for referral. Clinically we wanted to know the type and distribution of the CP, GMFCS score, attainment of milestones and type of schooling. We recorded underlying aetiologies and HIV status of the patients. Finally the access the patients had to physiotherapy and Occupational therapy. Results:. We saw 41 patients in total with 18 males and 23 females. The ages ranged from 5 months to 9 years (mean 4.9 years). 36 of 41 (88%) had spastic CP, 2 (5%) dystonic, 1 (2%) mixed and 2 (5%) were not recorded. Diplegic and hemiplegic predominated with 15 (37%) and 14 (34%) respectively, there were 6 (15%) quadriplegics, 1 double hemiplegic and 5 were not recorded. 13 (31%) of patients had birth asphyxia as an aetiology, 13 (31%) had brain anomalies, 9 (22%) were premature babies, the remaining 16% comprised HIV, post natal sepsis and injury. 38 (93%) were cared for by at least one parent and the remaining 3 (7%) were cared for by a grandparent. 39 (95%) had access to physiotherapy and 30 (73%) had access to occupational therapy. 21 (51%) had no access to appropriate schooling. 9 (22%) were known to be HIV positive. The recommended orthopaedic interventions were continued physiotherapy for 17 (41%) and botox in 22(54%). Discussion:. The combined clinic has highlighted the diverse nature of cerebral palsy and the challenges facing our patients. It is an invaluable tool in the goal directed management of complex cases

Purpose. The incidence of hip displacement in children with cerebral palsy is approximately 30% in large population based studies. The purpose of this study was to report the long-term effect of hip surgery on the incidence of hip displacement using a newly validated Cerebral Palsy (CP) hip classification. Method. Retrospectively, a sub-group of 100 children who underwent surgery for hip displacement were identified from a large-population based cohort of children born with CP between January 1990 and December 1992. These children were followed to skeletal maturity and closure of their tri-radiate cartilage. All patients returned at maturity for clinical and radiographic examination, while caregivers completed the disease specific quality of life assessments. Patients were grouped according to motor disorder, topographical distribution and GMFCS. Radiographs were independently graded according to CP hip classification scheme to ensure reliability. Surgical Failures were defined as CP Grade > IV. Results. Ninety-seven children and 194 hips were available for final review. According to GMFCS, greater than half the children were GMFCS IV and V (67/94, 67%), 12 were II and 18 were III. Fifteen hips were dislocated or had salvage surgery for dislocation (15/194, 7.7%) at time of skeletal maturity. The majority of hips were graded Grade II and III (149/194, 76.8%). A total of 39 (39/194, 20%) hips were classified as surgical failure with 95% (37/39) hips occurring in GMFCS IV and V children. Conclusion. Using the CP hip classification scheme, the natural history and outcome of 100 children with CP at skeletal maturity have been described. Despite hip surveillance and surgical intervention GMFCS IV and V children are at the greatest risk for surgical failure at skeletal maturity. In this study, the majority of failures were associated with either no hip surveillance and/or index surgery at a non-specialist centre. In contrast, hip surveillance and index surgery at a specialist tertiary centre was associated with a very high probability of a successful outcome. This is the first population based cohort study of children with cerebral palsy followed from index surgery to skeletal maturity for hip displacement. Surgical success rates for the treatment of hip displacement in children with cerebral palsy have not previously been reported. This information will aid surgeons in the treatment of hip displacement in children with cerebral palsy

Aims

Sickle cell disease (SCD) is an autosomal recessive inherited condition that presents with a number of clinical manifestations that include musculoskeletal manifestations (MM). MM may present differently in different individuals and settings and the predictors are not well known. Herein, we aimed at determining the predictors of MM in patients with SCD at the University Teaching Hospital, Lusaka, Zambia.

Construction of a functional skeleton is accomplished through co-ordination of the developmental processes of chondrogenesis, osteogenesis, and synovial joint formation. Infants whose movement in utero is reduced or restricted and who subsequently suffer from joint dysplasia (including joint contractures) and thin hypo-mineralised bones, demonstrate that embryonic movement is crucial for appropriate skeletogenesis. This has been confirmed in mouse, chick, and zebrafish animal models, where reduced or eliminated movement consistently yields similar malformations and which provide the possibility of experimentation to uncover the precise disturbances and the mechanisms by which movement impacts molecular regulation. Molecular genetic studies have shown the important roles played by cell communication signalling pathways, namely Wnt, Hedgehog, and transforming growth factor-beta/bone morphogenetic protein. These pathways regulate cell behaviours such as proliferation and differentiation to control maturation of the skeletal elements, and are affected when movement is altered. Cell contacts to the extra-cellular matrix as well as the cytoskeleton offer a means of mechanotransduction which could integrate mechanical cues with genetic regulation. Indeed, expression of cytoskeletal genes has been shown to be affected by immobilisation. In addition to furthering our understanding of a fundamental aspect of cell control and differentiation during development, research in this area is applicable to the engineering of stable skeletal tissues from stem cells, which relies on an understanding of developmental mechanisms including genetic and physical criteria. A deeper understanding of how movement affects skeletogenesis therefore has broader implications for regenerative therapeutics for injury or disease, as well as for optimisation of physical therapy regimes for individuals affected by skeletal abnormalities.

Cite this article: Bone Joint Res 2015;4:105–116