The aim of this study is to use a defined population of patients with meningococcal septicaemia to calculate the incidence of orthopaedic complications.

Medical records and radiographs were analyzed retrospectively for all patients admitted to the Paediatric Intensive Care Unit (PICU) of the Bristol Royal Hospital for Children from 01/01/2001 to 31/12/2012 with meningococcal septicaemia.

Of the 130 patients with meningococcal septicaemia alive at discharge, 10 developed orthopaedic sequelae, representing an overall incidence in this patient population of 7.7%.

9 patients required an amputation, mostly in the lower limb, 16/22 (72.7%). 48 growth plate abnormalities were identified in 8 patients. 39 (81.3%) The most commonly affected was the distal tibia (38.5%). 10 ankles were identified as having a varus malalignment. 6 patients had documented leg length discrepancy

Using a clearly defined denominator this study has identified an incidence of orthopaedic sequelae following meningococcal septicaemia of 7.7%.

The National Institute for Clinical Excellence (NICE) suggested that the incidence of growth disturbance is approximately 3%.

This study highlights the underestimation of orthopaedic complications following meningococcal septicaemia. Close follow up of at risk patients should be considered to reduce the potential impact of these debilitating injuries.

Background:

Paley et al has developed the multiplier method for predicting leg length. It is a tool that is used clinically to predict leg length discrepancy. The method is also a way of comparing different populations, to identify differences in growth trajectory. This has been done by identifying the differing multipliers for girls and boys. However it has not been used to identify trends in populations separated by time. Tanner showed that in the first half of the twentieth century girls went from an average age of menarche of 15 in 1900, to 13 in 1970, how this has affected growth trajectory over the last 50 years has not been studied.

Introduction:

Paley et al has developed a multiplier method for calculating both leg length and total height. In the development of this algorithm, they evaluated the effect of factors including bone age and sex. They established that sex had a significant impact, but adjusting for bone age did not improve accuracy. Bone age and menarche have been shown to improve other height prediction models.

Predictions of lower limb growth are based upon historical data, collected from patients who had coexistent poliomyelitis. By utilising standardised longitudinal prospective European data, our objective was to generate superior estimates for the age and rate at which lower limb skeletal maturity is reached; thus improving the timing of epiphysiodesis, for the management of leg length discrepancy.

The Avon Longitudinal Study of Parents and Children of the 90s (ALSPAC) is a longitudinal cohort study of children recruited antenatally 2. Using a previously validated Multiplier Method, a sequence of leg length multipliers were calculated for each child.

15,458 individuals were recruited to the ALSPAC study; and of those whose growth was measured, 52% were boys and 48% girls, each with an average of eight recording episodes. 25,828 leg length multiplier (LLM) values were calculated with final recordings taken at a mean age of 15.5 years.

From this data, the age at which girls reach skeletal maturity (LLM=1) is 11 months later than previously calculated and for boys nearly 9 months earlier. With nearly 4000 more children recruited in this cohort than preceding studies, this study brings increased power to future leg length calculations.

Paley et al developed a mathematical model to predict height, using age, sex and current height. His predictions were based on growth charts from epidemiological databases, and then validated using 52 children. We looked at a recent large, local database, to assess whether the height multiplier is a reliable tool that can be used in clinical practice.

The Avon Longitudinal Study of Parents and Children of the 90s (ALSPAC) is a population based cohort study of 14, 000 contemporary British families. 5363 children had final height measured with an average of 10.5 additional height measurements. The height multiplier equation was defined as height at specific age divided by height at skeletal maturity.

No significant difference was observed between the mean results from Paley et al and the ALSPAC data. There was a significant range of results in the ALSPAC data, with a standard deviation of the multiplier of 0.08 for ages 7–15.

This large population study shows no significant difference between the historical databases Paley used and the more current European databases. The large range of results shown by the ALSPAC cast doubt on the clinical usefulness of individual results.

Background:

There are multiple risk factors regarding the outcome of open tibia fractures treated with surgical fixation. In this study we have looked at delay to debridement and HIV infection as risk factors in the outcome of open tibia fractures.

Meningococcal infection is the most common infective cause of death in children and causes significant morbidity in survivors.

Patients admitted to the Paediatric Intensive Care Unit (PICU) of the Bristol Royal Hospital for Children from 01/01/2001 to 31/12/2012 with a primary diagnosis of meningococcal septicaemia were reviewed.

A total of 10 (7.7%) of 130 patients developed orthopaedic complications. Those affected were significantly younger (p < 0.05), remained on PICU for longer (p < 0.001) and boys had a greater risk of developing orthopaedic complications (risk ratio: 3.1; 95% CI: 0.69–14.14). 9 patients required an amputation, 16/22 (72.7%) in the lower limb. Patient requiring amputation had multiple limb involvement. 48 growth plate abnormalities were identified in 8 patients, 39 (81.3%) in the lower limb, most commonly in the distal tibia.

This study has identified a high incidence of musculoskeletal morbidity. Close surveillance of these patients is recommended to identify growth arrest before the onset of clinically significant deformity. It identifies a defined population of patients with meningococcal septicaemia using admission to PICU as an entry criterion allowing accurate determination of the incidence and characteristics of the skeletal consequences of this condition.

We compared early post-operative rates of wound infection in HIV-positive and -negative patients presenting with open tibial fractures managed with surgical fixation.

The wounds of 84 patients (85 fractures), 28 of whom were HIV positive and 56 were HIV negative, were assessed for signs of infection using the ASEPIS wound score. There were 19 women and 65 men with a mean age of 34.8 years. A total of 57 fractures (17 HIV-positive, 40 HIV-negative) treated with external fixation were also assessed using the Checkett score for pin-site infection. The remaining 28 fractures were treated with internal fixation. No significant difference in early post-operative wound infection between the two groups of patients was found (10.7% (n = 3) vs 19.6% (n = 11); relative risk (RR) 0.55 (95% confidence interval (CI) 0.17 to 1.8); p = 0.32). There was also no significant difference in pin-site infection rates (17.6% (n = 3) vs 12.5% (n = 5); RR 1.62 (95% CI 0.44 to 6.07); p = 0.47).

The study does not support the hypothesis that HIV significantly increases the rate of early wound or pin-site infection in open tibial fractures. We would therefore suggest that a patient’s HIV status should not alter the management of open tibial fractures in patients who have a CD4 count > 350 cells/μl.

Cite this article: Bone Joint J 2013;95-B:1703–7.

Background

In 2011 Aird et al published their results of the effects of HIV on early wound healing in open fractures treated with internal and external fixation. The study was conducted between May 2008 and March 2009 and performed in semi-rural area of KwaZulu-Natal, South Africa. These results suggested that HIV is not a contraindication to internal or external fixation of open fractures, as HIV is not a significant risk factor for acute wound implant infection. We present a longer term follow up of this same cohort of patients from the original study.

This study addresses the evolution of the orthopaedic management of patients with hypophosphatemic rickets, with the aim of providing skeletal mature aligned lower limbs, with minimal surgical insult.

The use of patient reported outcome measures (PROMs) of function is increasing in popularity. Self reported outcome instruments are used to measure change in health status over time allowing for the collection of accurate and relevant data on the quality of healthcare services. With recent changes outlined by the government, it will become increasingly important for surgeons to be able to demonstrate, with quantitative data, positive benefit of the surgery they perform. This study demonstrates the effectiveness of, and issues involved with setting up a PROMs database in a busy orthopaedic unit.

We have previously shown that a high proportion of our orthopaedic patients have access to the Internet. Suitable patients were identified at foot and ankle clinics or from surgical lists, and the well validated Foot and Ankle Ability Measure (FAAM) regional scoring system was used. The FAAM is a self-reported, region specific, instrument consisting of 21-item activities of daily living (ADL) subscale and an eight-item sports subscale. This was completed pre-operatively and also online at six-months post operatively, using limesurvey, a free online survey with internet/email based responses.

The software was simple to use and took about 4 hours to develop. 77% of the patient cohort for the period of study had email access and the majority of patients without email were happy to have the questionnaire completed over the phone. This took approximately ten minutes per survey. Patients who did not conduct the study prior to their admission were able to fill it in on the ward using a laptop.

This project has demonstrated that the initiation and continuation of a PROMs data collection system is feasible in a busy orthopaedic unit, producing reliable data which will enable us to monitor and improve standards of clinical practice. We discuss the issues involved with its introduction and usage.

Surgical training in the UK since the Second World War has developed into a world class education programme. However, with the dramatic increase in the number of doctors and surgeons, combined with the improvement in access to health care, pathologies are now being treated earlier, and trainee exposure to advanced pathology has consequentially reduced. Not all countries are as privileged as the UK to have 3 doctors per 1000 head of population; South Africa has approximately 1/3rd of this number, Cambodia 1/10^th, and Malawi 1/100^th. Many of these countries have difficulty filling posts for medical professionals within their own hospitals.

The publication of the CRISP report and Lord Crisp's subsequent book ‘Turning the world upside down’ in 2010, highlighted, and tried to produce evidence of the mutual benefit of international health links to both the developed and the developing countries. It cited the bilateral transfer of skills and ideas, development of management skills, and improved workforce morale as beneficial effects of such links. The Department for International Development has prioritised the formation of these international partnerships. The Tropical Health Education Trust has been given the task of distributing grant funds. There are over 100 currently established and funded different health links across the UK. Some local links already exist such as the Gloucester NHS Trust Kambia, Sierra Leone link which focuses on maternal health, NHS South Centrals leadership programme which has a broader remit and works in conjunction with the ministries of health in certain areas of Tanzania and Cambodia and UHB/BRI link with Mbarara, Uganda in obstetrics, child health, ophthalmology.

Over the last 4 years, a series of South West Trainees have spent 1 year working in hospitals in Malawi and South Africa. The positive feedback that they have given, the dramatic increase in the surgical exposure as documented in their log books, and the number of high quality research projects that they have published as a result, has led to the programme director looking favourably on future requests.

We feel it would be mutually beneficial to formalise these links, with a regular stream of surgeons from this region spending time in these hospitals. Benefits for the recipient hospital would be a dependable and regular supply of staff, who could be incorporated into more long scale programmes, aimed at improving regional health care. Benefits to the donor institution and surgeon would be streamlined application process, simpler living logistics, car house etc, continuity of research projects, and the possibility to apply for funding for local research staff.

Introduction

HIV is known to affect many of the processes involved in fracture healing. Recent work has suggested that CD4 cells may act as suppressor in the regulation of fracture healing. There are no clinical studies looking at fracture healing in patients with open fractures in these patients.

Background: The importance of HIV in trauma has been poorly investigated. There’re few reports in the literature on the effects of HIV on fracture healing, those that there are involve small numbers. Many surgeons have concerns about both internal and external fixation in these patients.

Some of the most recent published studies have suggested a 4 fold increase in infection rates in internal fixation of open fractures (small series 39 patients, 12 of whom HIV positive)

In our hospital we have prospectively reviewed the outcomes of our open fractures treated by internal fixation, to see if HIV is a significant risk factor for wound infection and non union.

Methods: All patients undergoing internal fixation for open fractures were entered into a database. Patients were managed along predesigned protocols, under the care of one consultant to try and standardise care. Patients were followed up in a dedicated clinic. 96% 2 month follow up and 84% 3 month follow up was obtained

Results: Over a 9 month period 102 open fractures were treated with internal fixation. 23% of patients were HIV positive and 14% declined to be tested. CD4 counts ranged from 131–862, mean of 387. The superficial wound infection rate was 13% in HIV positive patients and 15% in HIV negative patients. Sub group analysis suggested that HIV positive patients with low CD4 counts and grade 1 injuries were significantly more likely to develop wound infections (50%) than controls (12%), p value=0.02. Grade 1 injuries were not managed with urgent debridement, under hospital guidelines, and had an average delay to theatre of 4 days. Rates of non union were 4% and 2% in the HIV positive/negative groups respectively.

Conclusions: This series is the largest prospective study in the literature. Our data suggests that:

The risks of acute infection in open fractures fixed by internal fixation in HIV positive individuals may not be as high as some previous studies have suggested;

Discussion: We feel that the current dogma of denying such patients internal fixation, is no longer appropriate. Although this study does not provide a direct comparison between differing Methods: of fixation, it provides the strongest evidence available in the literature, that internal fixation should be considered as a treatment option in these patients. We are currently awaiting the result of long term follow up looking at rates of delayed sepsis in these patients.

There are 33 million people worldwide currently infected with human immunodeficiency virus (HIV). This complex disease affects many of the processes involved in wound and fracture healing, and there is little evidence available to guide the management of open fractures in these patients. Fears of acute and delayed infection often inhibit the use of fixation, which may be the most effective way of achieving union.

This study compared fixation of open fractures in HIV-positive and -negative patients in South Africa, a country with very high rates of both HIV and high-energy trauma. A total of 133 patients (33 HIV-positive) with 135 open fractures fulfilled the inclusion criteria. This cohort is three times larger than in any similar previously published study.

The results suggest that HIV is not a contraindication to internal or external fixation of open fractures in this population, as HIV is not a significant risk factor for acute wound/implant infection. However, subgroup analysis of grade I open fractures in patients with advanced HIV and a low CD4 count (< 350) showed an increased risk of infection; we suggest that grade I open fractures in patients with advanced HIV should be treated by early debridement followed by fixation at an appropriate time.

Background: Blount’s original paper in 1937 described a case series of 28 patients with “Tibia Vara”. Since then various authors have attempted to describe in more detail the tibial and femoral deformities seen in this disease. It is still a poorly understood condition. This study describes the femoral rotational deformity that can occur in Blount’s disease.

Methods: Over a 2 year period, all patients with Blount’s disease seen in the Orthopaedic department of a regional hospital in South Africa were entered into a database. They underwent a review of their notes, a clinical rotational profile of their lower limbs and a CT scan of the femoral head/neck and distal femur. From this database we performed a cross sectional study. We then compared our results both to previously published controls for hip rotation and anteversion angles and with respect to the rotational profile, to a small cohort of 32 “normal” local children.

Results: A statistically significant increase in femoral anteversion in the affected legs was noted, with on average the femurs in Blount’s disease being 26 degrees more anteverted than previously published controls. A significant decrease in external rotation were also noted.

Conclusions: Our results suggest that the marked intoeing seen in many cases of Blount’s disease may be caused by internal femoral version, in addition to the well recognized internal tibial version. This study highlights the following issues:

A rotational profile should be part of the routine clinical assessment of all Blount’s cases.