Aims. The aim of this study was to determine the consensus best practice approach for the investigation and management of children (aged 0 to 15 years) in the UK with musculoskeletal infection (including septic arthritis, osteomyelitis, pyomyositis, tenosynovitis, fasciitis, and discitis). This consensus can then be used to ensure consistent, safe care for children in UK hospitals and those elsewhere with similar healthcare systems. Methods. A Delphi approach was used to determine consensus in three core aspects of care: 1) assessment, investigation, and diagnosis; 2) treatment; and 3) service, pathways, and networks. A steering group of paediatric orthopaedic surgeons created statements which were then evaluated through a two-round Delphi survey sent to all members of the British Society for Children’s Orthopaedic Surgery (BSCOS). Statements were only included (‘consensus in’) in the final agreed consensus if at least 75% of respondents scored the statement as critical for inclusion. Statements were discarded (‘consensus out’) if at least 75% of respondents scored them as not important for inclusion. Reporting these results followed the Appraisal Guidelines for Research and Evaluation. Results. A total of 133 children’s orthopaedic surgeons completed the first survey, and 109 the second. Out of 43 proposed statements included in the initial Delphi, 32 reached ‘consensus in’, 0 ‘consensus out’, and 11 ‘no consensus’. These 11 statements were then reworded, amalgamated, or deleted before the second Delphi round of eight statements. All eight were accepted as ‘consensus in’, resulting in a total of 40 approved statements. Conclusion. In the many aspects of medicine where relevant evidence is not available for clinicians to base their practice, a Delphi consensus can provide a strong body of opinion that acts as a benchmark for good quality clinical care. We would recommend clinicians managing children with musculoskeletal infection follow the guidance in the consensus statements in this article, to ensure care in all medical settings is consistent and safe. Cite this article: Bone Joint J 2023;105-B(7):815–820

Aims. This study aimed to evaluate the relationship between hip shape and mid-term function in Perthes’ disease. It also explored whether the modified three-group Stulberg classification can offer similar prognostic information to the five-group system. Methods. A total of 136 individuals aged 12 years or older who had Perthes’ disease in childhood completed the Patient-Reported Outcomes Measurement Information System (PROMIS) Mobility score (function), Nonarthritic Hip Score (NAHS) (function), EuroQol five-dimension five-level questionnaire (EQ-5D-5L) score (quality of life), and the numeric rating scale for pain (NRS). The Stulberg class of the participants’ hip radiographs were evaluated by three fellowship-trained paediatric orthopaedic surgeons. Hip shape and Stulberg class were compared to PROM scores. Results. A spherical hip was associated with the highest function and quality of life, and lowest pain. Conversely, aspherical hips exhibited the lowest functional scores and highest pain. The association between worsening Stulberg class (i.e. greater deviation from sphericity) and worse outcome persisted after adjustment for age and sex in relation to PROMIS (predicted mean difference -1.77 (95% confidence interval (CI) -2.70 to -0.83)), NAHS (-5.68 (95% CI -8.45 to -2.90)), and NRS (0.61 (95% CI 0.14 to 1.08)), but not EQ-5D-5L (-0.03 (95% CI -0.72 to 0.11)). Conclusion. Patient-reported outcomes identify lower function, quality of life, and higher pain in aspherical hips. The magnitude of symptoms deteriorated with time. Hip sphericity (i.e. the modified three-group classification of spherical, oval, and aspherical) appeared to offer similar levels of detail to the five-group Stulberg classification. Cite this article: Bone Joint J 2023;105-B(6):711–716

Aims

The aim of this study was to identify the information topics that should be addressed according to the parents of children with developmental dysplasia of the hip (DDH) in the diagnostic and treatment phase during the first year of life. Second, we explored parental recommendations to further optimize the information provision in DDH care.

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.

Aims

The aim of this study was to gain an agreement on the management of idiopathic congenital talipes equinovarus (CTEV) up to walking age in order to provide a benchmark for practitioners and guide consistent, high-quality care for children with CTEV.

In 2017, the British Society for Children’s Orthopaedic Surgery engaged the profession and all relevant stakeholders in two formal research prioritization processes. In this editorial, we describe the impact of this prioritization on funding, and how research in children’s orthopaedics, which was until very recently a largely unfunded and under-investigated area, is now flourishing. Establishing research priorities was a crucial step in this process.

Cite this article: Bone Joint J 2024;106-B(5):422–424.

The April 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: Can you treat type IIA supracondylar humerus fractures conservatively?; Bone bruising and anterior cruciate ligament injury in paediatrics; Participation and motor abilities after treatment with the Ponseti method; Does fellowship training help with paediatric supracondylar fractures?; Supracondylar elbow fracture management (Supra Man): a national trainee collaborative evaluation of practice; Magnetically controlled growing rods in early-onset scoliosis; Weightbearing restrictions and weight gain in children with Perthes’ disease?; Injuries and child abuse increase during the pandemic over 12,942 emergency admissions.

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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.

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The aim of this study was to gain a consensus for best practice of the assessment and management of children with idiopathic toe walking (ITW) in order to provide a benchmark for practitioners and guide the best consistent care.

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The aim of this study was to explore clinicians’ experience of a paediatric randomized controlled trial (RCT) comparing surgical reduction with non-surgical casting for displaced distal radius fractures.

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The aim of this study is to develop a core set of outcome domains that should be considered and reported in all future trials of childhood limb fractures.

Avascular necrosis (AVN) of the femoral head is a devastating complication of slipped capital femoral epiphysis (SCFE). The reported prevalence of AVN following unstable SCFE has ranged between fifteen and forty-seven per cent in the literature. The explanation for this discrepancy is not clear. The inter-observer and intra-observer agreement between Orthopaedic surgeons for the radiographic diagnosis of AVN following SCFE has not been reported. It is the objective of this study to estimate these parameters between two experienced pediatric Orthopaedic surgeons for the radiographic diagnosis of AVN following SCFE. A retrospective review of all one hundred and three cases of SCFE treated at a Canadian pediatric referral center between 1995 and 2005 was performed. Of these, eight were diagnosed, by the treating surgeon, with AVN. Each of these eight children and a random sample of fifteen of the remaining children, who were not diagnosed with AVN, were included in this study. The most recent anteroposterior and lateral radiographs were digitised and presented to two experienced pediatric orthopaedic surgeons in a blinded, random order. Each surgeon reviewed the radiographs independently and recorded which radiographs they believed to be consistent with AVN. The surgeons were told that each patient had SCFE and that some developed AVN, however neither the classification of the slip, nor the proportion who developed AVN were divulged. Each observer repeated this process two weeks after the initial review in order to determine intra-observer agreement. The kappa value was determined to assess inter-observer and intra-observer agreement. The first observer recorded eight cases of AVN at the initial and seven cases at the second observation time. The intra-observer agreement was 0.9. The second observer recorded six cases of AVN at the initial and five cases at the second observation time. The intra-observer agreement was 0.88. The inter-observer agreement was determined at the first observation time and was 0.79. On the basis of the results of this study, both the inter-observer and intra-observer agreement for the radiographic diagnosis of AVN following SCFE, amongst experienced pediatric Orthopaedic surgeons, was very high. It is unlikely that the reported discrepancy in prevalence of AVN following SCFE is due to a lack of inter-observer agreement, on the basis of the findings of this study. The inter-observer agreement between less experienced observers requires further study to determine if this may be the source of the variability in the reported prevalence of AVN following SCFE

Introduction. Derotation osteotomies are commonly performed in paediatric orthopaedic and limb reconstruction practice. The purpose of this study was to determine whether the use of a digital inclinometer significantly improves the accuracy in attaining the desired correction. Materials & Methods. We designed an electronic survey regarding derotation femoral osteotomy (DFO) including methods of intra-operative angular correction assessment and acceptable margins of error for correction. This was distributed to 28 paediatric orthopaedic surgeons in our region. A DFO model was created, using an anatomic sawbone with foam covering. 8 orthopaedic surgeons each performed two 30-degree DFOs, one using K-wires and visual estimation (VE), and the other using a Digital Inclinometer (DI). Two radiologists reported pre and post procedure rotational profile CT scans to assess the achieved rotational correction. Results. There was a 68% response rate to the survey. The most popular methods of estimating intra-operative correction were reported to be K-wires and rotation marks on bone. The majority of respondents reported that a 6–10 degree margin of error was acceptable for a 30-degree derotation. This was therefore set as the upper limit for acceptable error margin in the simulation study. The mean error in rotation in the VE group of simulated DFO was 19.7 degrees, with error>5 degrees and error>10 degrees in 7 (88%) and 6 (75%) cases respectively. Mean error in DI group was 3.1 degrees, with error>5 degrees in 1 case (13%). Conclusions. Our results show that the compared to conventional techniques, the use of an inclinometer significantly improves the accuracy of femoral de-rotation and significantly reduces the incidence of unacceptable errors in correction. We would suggest that digital inclinometers be used to assess intra-operative correction during derotation osteotomies

Introduction. Activity scales are used throughout orthopaedics as a component of PROMs. Tegner Activity Scale is commonly used and is validated in various knee injuries in adults. It has a reading age of 18 years presenting an understanding problem for children. An alternative is HSS-PediFABS, but this looks at specific skills like running, cutting, pivoting rather than sporting level. Our aim was to determine if children understood TAS and whether their answers compared to how their parents scored them and determine if our suggested sporting levels were more appropriate for them. Method. We created a study form to compare levels given by children and their parent. We added our own suggested levels, with a reading age of 9, created by a discussion group of paediatric orthopaedic surgeons. Following ethics approval, a sample size was determined via power calculation. All patients over 7 and their parents presenting to the orthopaedic clinic at SCH over a 4-month period were asked to fill out the TAS, baseline questions and rank the new suggested sporting levels. Results. 51 patients and their parents were recruited, with a mean age of 13 (±0.31, 8–17). 35% female. The mean TAS score for children rating themselves was 7.04 (±0.32, 2–10) vs 6.43 (±0.37, 0–10) for parents rating the child (p=0.31). The average weekly activity time rated by children was 6.72 hours (±0.84, 0–30) vs 7.48 (±1.02, 0–36) rated by the parent (p=0.68). Our suggested levels for paediatric patients were ordered correctly by both groups (mode score). The mean new activity level for children was 4.9 (±0.24, 2–9) vs 4.81 (±0.26, 1–8) by their parent(p=0.79). The mean score difference for TAS was 1.42 vs 1.2 in the new score (p=0.38). Conclusion. Paediatric patients had difficulty understanding the TAS and there was poor agreement of activity levels between patients and parents

Introduction: School screening for scoliosis aims to reduce the need for surgery by detecting curve changes in children at an early stage when bracing may be effective in halting the progression of the deformity. Although the effectiveness of the current screening techniques has not been established yet, AAOS and SRS continue to support school screening.. The major criticism focuses on the cost-ineffectiveness of the process, as too many students are unjustifiably referred to specialists. Moreover, examiner’s skills and experience are important factors in screening outcome. An ongoing, large-scale study of school screening is conducted in public schools at the northern part of Israel comparing the screening performance of a Scoliometer and a new, hand-held computerized device (SpineScan). SpineScan was designed to automatically measure the “angle of trunk inclination” (ATI), and is less dependent on examiner’s level of medical training. Furthermore, this tool enables also fast assessment of the kyphosis angle. Methods: In a first phase of the study, 1000 children aged 10 to 14 years were screened. Each child underwent “blinded” examinations by two examiners with different skills (a pediatric orthopaedic surgeon and a physiotherapist), each of whom using a different tool (a Scoliometer and SpineScan, respectively). Screening was performed in examination positions specific for true scoliosis (standing and sitting forward bending) and ATI measurements were compared. Children with an ATI =or > 7º measured with either tool at both positions were referred to undergo a standard full spine X-ray in standing position, on which an experienced pediatric orthopaedic surgeon measured the Cobb angles. Curves = or > 10º were considered true positive findings for scoliosis. Statistical analysis included specificity, sensitivity and predictive value estimates of both methods. Results: Referral rate for Scoliometer was 2.5% and for SpineScan 1.9%. SpineScan reached 80% sensitivity vs. 70% of the Scoliometer. Moreover, SpineScan achieved higher PPV values than the Scoliometer (80% vs. 54% respectively). Discussion: These results imply that efficient and cost effective screening can be performed by minimally skilled examiner using SpineScan

Guiding growth by harnessing the ability of growing bone to undergo plastic deformation is one of the oldest orthopaedic principles. Correction of deformity remains a major part of the workload for paediatric orthopaedic surgeons and recently, along with developments in limb reconstruction and computer-directed frame correction, there has been renewed interest in surgical methods of physeal manipulation or ‘guided growth’. Manipulating natural bone growth to correct a deformity is appealing, as it allows gradual correction by non- or minimally invasive methods. This paper reviews the techniques employed for guided growth in current orthopaedic practice, including the basic science and recent advances underlying mechanical physeal manipulation of both healthy and pathological physes

We have tested the reliability of a recently reported classification system of hip morphology in adolescents with cerebral palsy in whom the triradiate cartilage was closed. The classification is a six-grade ordinal scale, based on the measurement of the migration percentage and an assessment of Shenton’s arch, deformity of the femoral head, acetabular deformity and pelvic obliquity. Four paediatric orthopaedic surgeons and four physiotherapists received training in the use of the classification which they applied to the assessment of 42 hip radiographs, read on two separate occasions. The inter- and intra-observer reliability was assessed using the intraclass correlation coefficient and found to be excellent, with it ranging from 0.88 to 0.94. The classification in our study was shown to be valid (based on migration percentage), and reliable. As a result we believe that it can now be used in studies describing the natural history of hip displacement in cerebral palsy, in outcome studies and in communication between clinicians

The Gartland extension-type supracondylar humerus fracture is the most common elbow fracture in the paediatric population. Depending on fracture classification, treatment options range from nonoperative treatment such as taping, splinting or casting to operative treatments such as closed reduction and percutaneous pinning or open reduction. Classification variability between surgeons is a potential contributing factor to existing controversy over nonoperative versus operative treatment for Type II supracondylar fractures. The purpose of this study was to investigate levels of agreement in classification of extension-type supracondylar humerus fractures using the Gartland classification system. A retrospective chart review was conducted on patients aged 2–12 years who had sustained an extension-type supracondylar fracture and received either operative or nonoperative treatment at a tertiary children's hospital. De-identified baseline anteroposterior (AP) and lateral plain elbow radiographs were provided along with a brief summary of the modified Gartland classification system to surgeons across Canada, United States, Australia, United Kingdom and India. Each surgeon was blinded to patient treatment and asked to classify the fractures as Type I, IIA, IIB or III according to the classification system provided. A total of 21 paediatric orthopaedic surgeons completed one round of classification, of these, 15 completed a second round using the same radiographs in a reshuffled order. Kappa values using pre-determined weighted kappa coefficients were calculated to assess interobserver and intraobserver levels of agreement. In total, 60 sets of baseline elbow radiographs were provided to survey respondents. Interobserver agreement for classification based on the Gartland criteria between surgeons was a mean of 0.68, 95% CI [0.67, 0.69] (0.61–0.80 considered substantial agreement). Intraobserver agreement was a mean of 0.80 [0.75, 0.84]. (0.61–0.80 substantial agreement, 0.81–1 almost perfect agreement). Radiographic classification of extension-type supracondylar humerus fractures at baseline demonstrated substantial agreement both between and within surgeon raters. Levels of agreement are substantial enough to suggest that classification variability is not a major contributing factor to variability in treatment between surgeons for Type II supracondylar fractures. Further research is needed to compare patient outcomes between nonoperative and operative treatment for these fractures, so as to establish consensus and a standardized treatment protocol for optimal patient care across centres