Identification of the paediatric orthopaedic patient at high risk of venous thromboembolism (VTE) can allow a targeted approach to thromboprophylaxis. There is currently no national consensus on the correct method of risk assessment in this patient group. The Royal National Orthopaedic Hospital has developed a guideline using the evidence available to allow stratification of risk for the paediatric orthopaedic patient. A list of departments offering specialist paediatric orthopaedic surgery was obtained from the member list of the British Society of Paediatric Orthopaedic Surgeons (BSCOS). These hospitals were contacted via telephone interview to determine if they have a specific guideline or risk assessment proforma for paediatric VTE risk. A total of 74 hospitals were identified with a specialist paediatric orthopaedic practice in the United Kingdom. A response rate was gained from 100% of these hospitals. Only 3/74 of these hospitals had a guideline or protocol in place for the formal assessment of VTE risk in the paediatric patient (Royal National Orthopaedic Hospital, Stanmore; Sheffield Children's Hospital; Barts & the London NHS Trust). All three hospitals were able to provide details of their guideline. Both the RNOH and Barts & the London commented that their guideline was based on that of the Sheffield group, with adaptations for their own requirements. The majority of hospitals in the UK with a paediatric orthopaedic interest do not have guidance available for the management of VTE risk. Presented here is the outcome of using the limited evidence available, in combination with expert opinion, to develop a guideline suitable for the requirements of a paediatric unit in an orthopaedic hospital. This may be of benefit to other units producing their own guidelines, producing thought and discussion as to the specific requirements of paediatric patients undergoing orthopaedic procedures

Purpose. Clinical coding is used to record information from patient admissions in the form of coded data used for monitoring the provision of health services and trends, research, audit and NHS financial planning. Method. A sample of 105 cases admitted to Southampton General paediatric orthopaedic department from 2006-9 was used. 31 admissions were grouped using HRG4 and the remaining 74 using HRG3.5. Accuracy of coding was calculated by establishing correct discharge coding and comparing them with coding records. The correct codes were run through HRG 3.5 and 4 payment groupers and their outcomes were compared financially to the HRG codes these admissions were actually grouped under. Results. There were 800 interventions which should have been coded over 148 patient episodes. Of these 442 (55%) were not coded, 189 (24%) were coded inappropriately and 169 (21%) were coded correctly. The HRG3.5 group was coded 18% correctly, the HRG4 29% correctly. However, 70% of the HRG4 and 49% of the HRG 3.5 group were inaccurately grouped. The resulting deficit was a £54,352 (HRG4-£36,711, HRG3.5-£17,641) an average of £507 per patient stay. A conservative estimate of 150 ward admissions monthly means a projected loss of £912,600 per annum. The fractured radius and ulna group (one of the most common causes of admission) suffered greatest financial losses. Additional losses come from paediatric/orthopaedic top-ups (63% and 14% respectively) as only one can be applied to each HRG. Conclusion. The implementation of HRG4 means accuracy is crucial as smaller inaccuracies result in bigger costing discrepancies than with HRG 3.5. Financial losses are larger with paediatric orthopaedics from inadequate top-ups. This system of Payment by Estimates not Results is only acceptable if financial underestimates are balanced with financial overestimates. These results strongly suggest this is not happening

Aim. Assess the incidence of Vitamin D deficiency from a cohort of new referrals to a general Paediatric Orthopaedic outpatient clinic and evaluate the relationship between Vitamin D deficiency and the diagnosis of radiological or biochemical nutritional rickets. Methods. We performed a retrospective case note and biochemistry database review of all new patients seen in an elective Paediatric Orthopaedic clinic in the year 2010, who had Vitamin D levels measured. Radiographs were reviewed by the senior author to determine the presence or absence of radiological rickets. Biochemical rickets was diagnosed if there was deficient Vitamin D (< 20 mcg/ml) and raised PTH. Results. We identified 115 children with a mean age of 10.95 years (95% CI 10.24 to 11.68). There were 63 females, 52 males and 51 were of Asian ethnicity. The mean vitamin D level was 18.27mcg/ml (95% CI 16.13 to 20.41). One hundred and three patients (88%) were found to have sub-optimum vitamin D levels. Although, males and those of Asian origin were more likely to be deficient, this was not statistically significant. Winter/Springtime blood sampling was statistically more likely to show Vitamin D deficiency than in Summer/Autumn. Three Asian female children (2.61%) had radiological rickets. The association between low Vitamin D levels (< 20) and radiological or biochemical rickets had poor positive predictive values PPV. Conclusion. Suboptimal Vitamin D levels are common in children presenting with vague limb or back pain, suggesting ‘growing pains’ might reflect deficiency. Vitamin D levels cannot be used as a screening test for the diagnosis of radiological or biochemical ‘rickets’ due to its poor Positive Predictive Value. Further research into Vitamin D requirement is necessary, particularly in relation to growth and age, as growth is not linear and Vitamin D requirement is likely to vary accordingly

Aim. The use of intraoperative cell salvage as a tool for reducing allogenic transfusion has been demonstrated in pelvic osteotomies. The aims of this audit were to identify any problems or complications with cell salvage, reduction in allogenic transfusion and identify procedures that would benefit. Methods. The use of cell salvage and allogenic transfusions were prospectively recorded over a 27-month period for all those who had major non spinal surgery looking at whether cell-salvage reduced allogenic transfusions and where cell salvage was used it was matched to procedure, diagnosis and age with cases where it was not used over the same time period. Results. Cell salvage was used in 61 cases. For these, average blood loss was 624mls and re-transfused volume 176mls (range=0-888mls). There were no complications. 4 problems occurred, 2 where suction became desterilised and 2 with insufficient sample to process. Of those that were matched, 3/55 cases required allogenic transfusion versus 11/55 that did not have cell salvage (p=0.03). Sub group analysis according to procedure did not reach significance. Excluding those with osteogenesis imperfecta, no isolated femoral osteotomy required allogenic transfusion (total number=48). Conclusion. Overall its use has reduced the number of children receiving allogenic blood and negates the need to cross match preoperatively. Group and save sample is probably sufficient for most major paediatric orthopaedic surgery with cell salvage. The specific indications for cell salvage have not been identified by this study, though useful in OI

Introduction. Albania is one of the poorest countries in Western European with a GDP per capita standing at 26 percent of the EU average in 2010. Whilst there is government-funded universal free provision of healthcare, it is accepted that delivery is patchy, not accessible to all and lacking expertise for more complex paediatric orthopaedic conditions. With the sponsorship of a UK-based charity, we have set up and completed 5 visits to Albania (3 assessment and 2 operative) to provide additional expertise for paediatric orthopaedic disorders running parallel to and utilising currently available local services. We present the results of this treatment and training programme to date. Patients and methods. Between 2008 and 2011, we assessed 204 children and adolescents with paediatric orthopaedic disorders in Tirana and Durres on 3 separate visits. Of these, 28 were listed for surgical procedures whilst the rest were treated non-operatively. Of the listed patients, 14 patients underwent surgical intervention (total of 18 procedures). Results. The most common diagnoses were developmental dysplasia of the hip, club feet, cerebral palsy and scoliosis. Most patients were treated non-operatively with advice and/or reassurance. Of those listed for surgery, the reasons for cancellation included problems with access to the treating hospital and failure to establish patient contact on the day of admission. Of the operated patients, the procedures performed, the perioperative challenges and significant complications (2/18) will be discussed. Conclusion. Although it is viable to establish parallel service delivery of paediatric orthopaedic surgical services in countries such as Albania, the perioperative and social challenges must be considered

Purpose This was an observational study to determine the prevalence of 25-hydroxyvitamin D (25[OH]D deficiency in our paediatric orthopaedic patient population. Methods We have measured serum 25(OH)D levels in 44 paediatric patients who presented with bone pain. None of these patients had a pre-existing diagnosis of 25(OH)D deficiency. The age of patients ranged from 11 months to 16.5 years. There were 23 female and 21 male patients. The range of diagnoses included hip pain/irritable hip (4), Blount's disease (4), developmental hip dysplasia (7), genu valgum (3), Legg Calve Perthes’ disease (6), slipped capital femoral epiphysis (11), knee pain (3), other (6). Those found to be 25(OH)D deficient underwent further biochemical investigation and were referred for paediatric endocrinology review with a view to vitamin D supplementation. Results We found 9 patients (20%) with serum 25(OH)D levels of <20ng/mL indicating 25(OH)D deficiency. 17 patients (39%) had serum 25(OH)D levels in the range 20-30ng/mL indicating possible deficiency. The remaining 18 patients (41%) had a normal level of 25(OH)D. There was no association between low serum 25(OH)D level and any specific diagnosis, nor with gender or age of patient. There was, however, a statistically significant difference between the serum 25(OH)D level in those patients with unexplained joint pain (mean 22.5ng/mL) and those with other diagnoses (mean 30.7ng/ml) (P<0.05). Conclusion Our results are consistent with other recent prevalence studies showing a concerning level of 25(OH)D deficiency among the paediatric population, and may suggest an increasing burden of disease in the coming years arising from the problem

Aims. Management of displaced paediatric supracondylar elbow fractures remains widely debated and actual practice is unclear. This national trainee collaboration aimed to evaluate surgical and postoperative management of these injuries across the UK. Methods. This study was led by the South West Orthopaedic Research Division (SWORD) and performed by the Supra Man Collaborative. Displaced paediatric supracondylar elbow fractures undergoing surgery between 1 January 2019 and 31 December 2019 were retrospectively identified and their anonymized data were collected via Research Electronic Data Capture (REDCap). Results. A total of 972 patients were identified across 41 hospitals. Mean age at injury was 6.3 years (1 to 15), 504 were male (52%), 583 involved the left side (60%), and 538 were Gartland type 3 fractures (55%). Median time from injury to theatre was 16 hours (interquartile range (IQR) 6.6 to 22), 300 patients (31%) underwent surgery on the day of injury, and 91 (9%) underwent surgery between 10:00 pm and 8:00 am. Overall, 910 patients (94%) had Kirschner (K)-wire) fixation and these were left percutaneous in 869 (95%), while 62 patients (6%) had manipulation under anaesthetic (MUA) and casting. Crossed K-wire configuration was used as fixation in 544 cases (59.5%). Overall, 208 of the fixation cases (61%) performed or supervised by a paediatric orthopaedic consultant underwent lateral-only fixation, whereas 153 (27%) of the fixation cases performed or supervised by a non-paediatric orthopaedic consultant used lateral-only fixation. In total, 129 percutaneous wires (16%) were removed in theatre. Of the 341 percutaneous wire fixations performed or supervised by a paediatric orthopaedic consultant, 11 (3%) underwent wire removal in theatre, whereas 118 (22%) of the 528 percutaneous wire fixation cases performed or supervised by a non-paediatric orthopaedic consultant underwent wire removal in theatre. Four MUA patients (6%) and seven K-wire fixation patients (0.8%) required revision surgery within 30 days for displacement. Conclusion. The treatment of supracondylar elbow fractures in children varies across the UK. Patient cases where a paediatric orthopaedic consultant was involved had an increased tendency for lateral only K-wire fixation and for wire removal in clinic. Low rates of displacement requiring revision surgery were identified in all fixation configurations. Cite this article: Bone Joint J 2023;105-B(1):82–87

Aims. The health-related quality of life (HRQoL) of paediatric patients with orthopaedic conditions and spinal deformity is important, but existing generic tools have their shortcomings. We aim to evaluate the use of Paediatric Quality of Life Inventory (PedsQL) 4.0 generic core scales in the paediatric population with specific comparisons between those with spinal and limb pathologies, and to explore the feasibility of using PedsQL for studying scoliosis patients’ HRQoL. Methods. Paediatric patients attending a speciality outpatient clinic were recruited through consecutive sampling. Two groups of patients were included: idiopathic scoliosis, and paediatric orthopaedic upper and lower limb condition without scoliosis. Patients were asked to complete PedsQL 4.0 generic core scales, Youth version of 5-level EuroQol-5-dimension questionnaire, and Refined Scoliosis Research Society 22-item (SRS-22r) questionnaire. Statistical analyses included scores comparison between scoliosis and limb pathology patients using independent-samples t-test, and correlation tests of PedsQL and SRS-22r. Results. A total of 566 paediatric patients were recruited: 357 (63.0%) having idiopathic scoliosis, and 209 (37.0%) with limb conditions. Patients with limb pathology had lower functioning scale, summary, and total scores of PedsQL than scoliosis patients (p < 0.05 to p < 0.001). No floor or ceiling effects (< 15%) were detected for PedsQL Psychosocial Health Summary and total scores in both groups. PedsQL was sensitive in differentiating patients with/without problems in their daily lives (p < 0.05 to p < 0.01). PedsQL summary and total scores correlated with SRS-22r total score. Conclusion. PedsQL is an effective HRQoL measure for both paediatric orthopaedic groups with minimal ceiling and floor effects, and is capable of detecting worse HRQoL in patients with limb pathology. The multidimensional PedsQL is sensitive in differentiating among those with daily life problems, especially for scoliosis patients. Cite this article: Bone Joint J 2020;102-B(7):890–898

We present a review of our Specialist Physiotherapy clinic for normal physiological variations of the lower limb (SPNV) clinics, demonstrating them to be clinically effective and cost effective. Children with normal variation of rotational profile and limb angulation present much anxiety to parents and primary care. Providing consultation: to eliminate significant pathology and reassure families, is an important service that a Paediatric Orthopaedic department provides. In our tertiary referral department we have a Specialist Physiotherapy led clinics into which primary care practitioners refer children with whom there are concerns about lower limb development variation. The (SPNV) Clinic was first set up by a Consultant and Senior Physiotherapist in 1999. The aim of the clinic was to reduce the waiting times for incoming referrals but ensuring they are seen in an appropriate environment by an experienced health care professional. Clinics are run by Senior Specialist Physiotherapists, alongside Consultant clinics who are available for advice and direction. This provides security for the physios, the Trust and the patient. Over 15 years there have been more than 4000 patient visits to this clinic. Over 80% were new patient visits. 70% of these visits were discharged in one or two reviews. 97.4% of new referrals were discharged without subsequent review by an orthopaedic surgeon. The most common conditions reviewed were Genu valgum (25%), Genu Varum (16%), intoeing (17%) and flexible flat feet (11%). The clinic has proven to be cost effective as well in drawing in up to £500,000 revenue into the trust in a single year. The department has been approached by other trusts to assist in the implementation of similar clinics. We present this review of the patients, as a template for supporting the work of Paediatric Orthopaedic Departments. This service has facilitated the streamlining of our Consultant Paediatric Orthopaedic clinics

The purpose of the study was to investigate the incidence of surgical site infection following elective paediatric orthopaedic surgery. A pro forma adopted from a pilot study was filled out preoperatively for each elective operation performed during the study period. Each patient was then followed up for six weeks postoperatively to record any SSI that developed. Data collected included patient demographics, type of operation, grade of Surgeon, type of procedure, wound length, skin preparations, use of tourniquet, any antibiotic prophylaxis and length of operation. This study collated data on 334 operations with 410 procedural sites over a six month period. Infection were recorded in 19 sites equivalent to a SSI rate of 4.63%. None of the patients developed long-term complications. The mean age of the participants in the study was 11 years (range 0.5 to 17 years), 57% were males and 43% were females. The infection were detected between 1 and 38 days after surgery. The outcome was not compromised in any of the patients as none of them required long-term treatment. Statistical analysis was undertaken. The study proves that the surgical site infection after elective paediatric orthopaedic surgery is low and serve as a bases for consenting patients for surgery

Aims. Accurate skeletal age and final adult height prediction methods in paediatric orthopaedics are crucial for determining optimal timing of growth-guiding interventions and minimizing complications in treatments of various conditions. This study aimed to evaluate the accuracy of final adult height predictions using the central peak height (CPH) method with long leg X-rays and four different multiplier tables. Methods. This study included 31 patients who underwent temporary hemiepiphysiodesis for varus or valgus deformity of the leg between 2014 and 2020. The skeletal age at surgical intervention was evaluated using the CPH method with long leg radiographs. The true final adult height (FH. TRUE. ) was determined when the growth plates were closed. The final height prediction accuracy of four different multiplier tables (1. Bayley and Pinneau; 2. Paley et al; 3. Sanders – Greulich and Pyle (SGP); and 4. Sanders – peak height velocity (PHV)) was then compared using either skeletal age or chronological age. Results. All final adult height predictions overestimated the FH. TRUE. , with the SGP multiplier table having the lowest overestimation and lowest absolute deviation when using both chronological age and skeletal age. There were no significant differences in final height prediction accuracy between using skeletal age and chronological age with PHV (p = 0.652) or SGP multiplier tables (p = 0.969). Adult height predictions with chronological age and SGP (r = 0.769; p ≤ 0.001), as well as chronological age and PHV (r = 0.822; p ≤ 0.001), showed higher correlations with FH. TRUE. than predictions with skeletal age and SGP (r = 0.657; p ≤ 0.001) or skeletal age and PHV (r = 0.707; p ≤ 0.001). Conclusion. There was no significant improvement in adult height prediction accuracy when using the CPH method compared to chronological age alone. The study concludes that there is no advantage in routinely using the CPH method for skeletal age determination over the simple use of chronological age. The findings highlight the need for more accurate methods to predict final adult height in contemporary patient populations. Cite this article: Bone Jt Open 2023;4(10):750–757

Aims. This observational study examines the effect of the COVID-19 pandemic upon the paediatric trauma burden of a district general hospital. We aim to compare the nature and volume of the paediatric trauma during the first 2020 UK lockdown period with the same period in 2019. Methods. Prospective data was collected from 23 March 2020 to 14 June 2020 and compared with retrospective data collected from 23 March 2019 to 14 June 2019. Patient demographics, mechanism of injury, nature of the injury, and details of any surgery were tabulated and statistically analyzed using the independent-samples t-test for normally distributed data and the Mann-Whitney-U test for non-parametric data. Additionally, patients were contacted by telephone to further explore the mechanism of injury where required, to gain some qualitative insight into the risk factors for injury. Results. The 2020 lockdown resulted in 30% fewer paediatric trauma presentations (441 vs 306), but no significant change in the number of patients requiring surgery (47 vs 51; p = 0.686). Trampolining injuries increased in absolute numbers by 168% (p < 0.001), almost four times more common when considered as percentage of all injuries observed in 2020 vs 2019. There was a decrease in high energy trauma from road traffic accidents and falls from height (21.5% decrease, p < 0.001). Despite a shift towards more conservative treatment options, trampolining injuries continued to require surgery in similar proportions (19.4 vs 20%; p = 0.708). Qualitative investigation revealed that the most common risk factor for trampolining injury was concurrent usage, especially with an older child. Conclusion. COVID-19 lockdown has resulted in a decrease in paediatric orthopaedic presentations and high energy trauma. However, due to a marked increase in home trampolining injuries, and their unchanged requirement for surgery, there has been no change in the requirement for surgery during the lockdown period. As home exercise becomes more prevalent, a duty of public health falls upon clinicians to advise parents against trampoline usage. Cite this article: Bone Jt Open 2021;2(2):86–92

We report the effect of introducing a dedicated Ponseti service on the five-year treatment outcomes of children with idiopathic clubfoot. Between 2002 and 2004, 100 feet (66 children; 50 boys and 16 girls) were treated in a general paediatric orthopaedic clinic. Of these, 96 feet (96%) responded to initial casting, 85 requiring a tenotomy of the tendo-Achillis. Recurrent deformity occurred in 38 feet and was successfully treated in 22 by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior, The remaining 16 required an extensive surgical release. . Between 2005 and 2006, 72 feet (53 children; 33 boys and 20 girls) were treated in a dedicated multidisciplinary Ponseti clinic. All responded to initial casting: 60 feet (83.3%) required a tenotomy of the tendo-Achillis. Recurrent deformity developed in 14, 11 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior. The other three required an extensive surgical release. . Statistical analysis showed that children treated in the dedicated Ponseti clinic had a lower rate of recurrence (p = 0.068) and a lower rate of surgical release (p = 0.01) than those treated in the general clinic. This study shows that a dedicated Ponseti clinic, run by a well-trained multidisciplinary team, can improve the outcome of idiopathic clubfoot deformity. Cite this article: Bone Joint J 2014;96-B:1424–6

Originally used for correction of angular malalignment, 2 hole plate epiphyseodesis has recently gained popularity in paediatric orthopaedic practice for the correction of leg length discrepancy. In this study we aim to assess the efficiency of guided growth plates in correcting leg length discrepancy. Thirty-three children treated for leg length discrepancy with guided growth plates (“8-Plate”, Orthofix, Inc and “I-Plate”, Orthopediatrics) in a tertiary referral centre were retrospectively analysed. Medial and Lateral plates were inserted for symmetrical growth reduction and patients were followed up with clinical and radiological assessment. Thirty patients had distal femoral epiphyseodesis and three had proximal tibial epiphyseodesis. Leg lengths and individual bone lengths were measured from pre and post – operative radiographs. The angle between the screws was measured from radiographs taken intra operatively and at the time of final follow up to assess screw divergence with growth. Efficiency was calculated as the ratio of growth inhibition achieved to the projected discrepancy at maturity if left untreated. At a mean follow up of 17 months (4–30 m) leg length discrepancy improved from a mean of 30 mm (50–15mm) to 13 mm (2.5–39mm) (p < 0.01). The angle between screws increased from 6 degrees to 26 degrees over the follow up period. Efficiency was found to be 66%. There were 5 patients with angular deformity who needed plate removal and 2 patients developed superficial infection that responded to oral antibiotics. Epiphyseodesis using guided growth plates is an effective way to correct leg length discrepancy as it is a reversible procedure. Patients undergoing this treatment should be kept under close follow up to prevent development of angular malalignment. Inserting the screws in a divergent fashion at the outset may increase the effectiveness of this procedure

Aim. With the link between obesity and Slipped Upper Femoral Epiphysis (SUFE) well established and a rising number of paediatric orthopaedic patients presenting with vitamin D deficiency, the aim of our study was to establish the incidence of vitamin D deficiency in SUFE patients and whether low vitamin D levels increases the time to proximal femoral physeal fusion post surgical fixation. Method. All paediatric patients presenting to the orthopaedic department at University Hospital Southampton with a SUFE and tested for vitamin D between June 2007 to present day and who were subsequently found to have low levels of vitamin D, were eligible for inclusion in the study. A deficient level of vitamin D (25-(OH)D) was determined as < 52 nmols/L and insufficiency between 52–72 nmols/L. Levels > 72 nmols/L were considered to be normal. The normal time for 50% of physeal fusion on anteroposterior radiograph quoted in the literature is 9 months. Results. This study includes a cohort of 28 patients and 45 hips. All of these patients were treated with pinning insitu. Eighty six per cent were found to be vitamin D deficient. The mean physeal closure for these patients post fixation, including those yet to fuse and which have exceeded 12 months, was 23 months (range 9–64 months). Conclusion. This study has shown a correlation between vitamin D deficiency and prolonged physeal closure in SUFE patients. With an increasing prevalence of vitamin D deficiency, it is recommended that all patients presenting with a SUFE, be tested for low vitamin D levels, so that early treatment with supplementation can be initiated

Aim. This pilot study aimed to identify the important symptomatic, functional and psychosocial aspects of hip disorders from the perspective of adolescent patients and their families in order to begin developing a patient-focused instrument (Bridging Adolescent Self-Reported Hip – BASH - score). Methods. This was a qualitative patient-centred study at a tertiary paediatric orthopaedic centre involving 50 adolescents aged 13–17 years, composed of five groups of 10 adolescents with slipped capital femoral epiphysis (SCFE), hip dysplasia (DDH), labral tears undergoing arthroscopic treatment, lower limb trauma and a miscellaneous group with conditions including Perthes' disease. A control group of 100 adolescents were also interviewed from a local school. Adolescent and separate concurrent parent groups underwent an ‘open’ phase face-to-face or telephone interview (theme development). This involved agreeing or disagreeing with statements, and open exploration of ideas related to the ‘day in the life’ of an adolescent with hip problems in order to generate and specify themes. This was followed by ranking and finally, scoring and testing. Results. All focus groups consistently and successfully generated themes related to hip problems and the majority of adolescents and parents were able to easily localise their issues to the hip. The ranking activity enabled the final definition of three key themes: a) physical symptoms, b) limitations and restrictions on life activities and situations and c) emotional experiences and self-consciousness which formed the basis of scoring and testing and the test version of the BASH score for adolescents. Scaling was developed with a total of 20 items rated on a five-point scale based on the frequency of effect from 0 (always) to 5 (never) providing a maximum score of 100. Conclusion. The BASH score is the first patient-reported outcome score for adolescent hip disorders developed with adolescents for adolescents

Aim:. An assessment of the relationship between pathological Developmental Dysplasia of the Hip (DDH) and Congenital Talipes Equinovarus (CTEV). Introduction:. Traditional UK guidelines consider abnormalities of the foot to be a risk factor for DDH. 1,2. Currently, there is controversy whether congenital foot abnormalities are true risk factors for pathological DDH. 3,4. There is a relationship between CTCV and hip dysplasia though the relationship between CTEV and pathological DDH is less clear. 5. In a previous 11 year prospective longitudinal study no case of Graf Types III, IV or irreducible hip dislocation were associated with CTEV. 5. Subsequent correspondence and case histories have challenged this view. 6. Methods:. In order to clarify this issue, a 20-year prospective longitudinal observational study was undertaken. All cases of fixed CTEV (Harold & Walker types 1 to 3) referred to the sub-regional Paediatric Orthopaedic clinic at the Royal Blackburn Hospital were evaluated, the feet and hips clinically assessed (Ortolani & Barlow manoeuvres) and the hips ultra-sounded by the senior author (RWP). Modified Graf and Harcke hip ultrasound classification systems were employed. Graf Type III, IV and irreducible hip dislocation were considered pathological. Results:. The incidence of CTEV was 1.46 per 1000 live births (nationally quoted incidence of 1 to 2 per 1000 live births. 7. ). There was one case of Graf Type III dysplasia with no cases of clinical hip instability. Currently, the clinical significance of this type of dysplasia is uncertain. There were no cases of Graf Type IV dislocations or radiological irreducible hip dislocation. Conclusion:. Fixed CTEV should not be considered as a risk factor for pathological DDH and routine sonographic hip screening of CTEV should not be advocated. This is supportive evidence for the current English NIPE guidelines in which the only risk factors screened are family history and breech presentation. Level of evidence: II

This study aimed to determine the major diagnoses and needs of children in Rwanda with musculoskeletal conditions to enable the Rwandan government to begin to plan orthopaedic and rehabilitation services. BACKGROUND. When faced with developing orthopaedic services for children in Sub-Saharan Africa, there is little objective evidence-based data on the magnitude and type of services needed. Rwanda is a small country that is in the process of developing orthopaedic and rehabilitation services, and its Ministry of Health supported a survey that would provide information necessary for planning such services. METHODS. A national survey of musculoskeletal impairment (MSI) prevalence was undertaken. Of a population of 8.4 million, 8368 people were enumerated. Four thousand one hundred thirty-four were aged 16 years or less. Cases who failed a screening test for MSI were examined, allocated a diagnostic category, and assessed as to treatment needed. RESULTS. Of 4134 people aged 16 years or less who were enumerated, 3526 (85%) were screened and 91 had MSI, giving a prevalence of MSI among children of 2.58% (95% confidence interval; 2.06-3.10). Twenty-three percent of MSIs were a result of congenital deformity, 14% neurologic conditions, 12% trauma, 3% infection, and 46% other acquired pathology. Of the MSIs, 56.7% were mild, 37.8% moderate, and 5.6% severe. Extrapolated treatment needs suggest that 2% of Rwandan children (approximately 80,000) need orthopaedic physical therapy, 1.2% (50,000) need orthopaedic surgery, and approximately 10,000 need orthopaedic appliances. CONCLUSIONS. These results will be of use in planning future paediatric orthopaedic services in Rwanda, and for comparative studies in other low-income countries

Aim. To compare outcomes for children treated for idiopathic clubfeet with the Ponseti regimen before (2002–2004) and after (2005–2006) implementation of a dedicated Ponseti service. Method. A retrospective analysis of outcomes for all patients with idiopathic clubfeet treated in the 2 years before and after implementation of a dedicated Ponseti service was undertaken. Results were statistically analysed using Fisher's exact t-test. Results. In the original cohort treated between 2002–2004, with an ad-hoc service where children were treated in general paediatric orthopaedic clinics by a number of different consultants, 100 feet in 66 children were treated. 96 feet (96%) responded to initial casting. 85 feet (85%) required tendo-achilles tenotomy. 31 feet had a recurrence within the first 2 years (16 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior, the remaining 15 requiring extensive soft tissue release). Between 2005–2006, with a dedicated Ponseti service, 72 feet in 53 children were treated. 72 (100%) responded to initial casting. 60 feet (83.3%) required tendo-achilles tenotomy. Relapse of the initial deformity occurred within 2 years in 11 feet – 4 children required repeat serial casting, 3 feet required tendon of tibialis anterior transfer, 3 required repeat tenotomy of tendo-achilles and one foot required extensive soft tissue release. Conclusion. Our results have shown that a dedicated Ponseti service leads to improved outcomes in the treatment of idiopathic clubfeet. We have shown a statistically significant reduction of recurrence (p=0.02) and extensive soft tissue release (0.002) in those children treated in a specialist service compared to an earlier ad hoc treatment programme

Reimers’ hip migration percentage is commonly used to document the extent of subluxation of the hip in children with spasticity. In this study, two measurers, with six months paediatric orthopaedic experience, measured the migration percentage on 44 pelvic radiographs of children with cerebral palsy, aged between two and eight years. Unknown to the measurers, each radiograph was duplicated, giving 22 non-identical radiographs (44 hips) which were measured twice at time 0 and twice six weeks later. The intra-measurer, intra-sessional absolute differences between the first and second measurements ranged from 0% to 23%, with median values of 2.5% to 3.6%. The intra-sessional median absolute differences were not statistically different between the two measurers and measuring sessions (p = 0.42, Kruskal-Wallis test). The inter-sessional absolute differences for measurements made by the same measurers ranged from 0% to 18% with a median absolute difference of 1.7% to 3.2%. Overall, only 5% of the intra-measurer measurement differences, within and between sessions, were above 13%. Repeated measurements by one measurer over time must, therefore, vary by more than 13% in order to be 95% confident of a true change. The inter-measurer error was higher with median absolute differences between the two measurers’ measurements of the same hip of 3.25% to 5% (0% to 26%) and a 95. th. upper confidence interval of 21% to 23%. Averaging the four separate measurements over the two sessions reduced the inter-measurer error to a median absolute difference of 2.8%, but did not improve the 95. th. upper confidence interval, which measured 22.4%. Such inter-measurer errors may be clinically unacceptable