It is well established that there is a strong association between
Perthes’ disease and worsening socioeconomic deprivation. It has
been suggested that the primary determinant driving this association
is exposure to tobacco smoke. This study aimed to examine this hypothesis. A hospital case-control study (n = 149/146) examined the association
between tobacco smoke exposure and Perthes’ disease, adjusting for
area-level socioeconomic deprivation. Tobacco smoke exposure was
assessed by parental questionnaire of smoking habits during pregnancy,
and by quantitative assay of current exposure using the urinary
cotinine-creatinine ratio, which is a widely used and validated
measure of tobacco smoke exposure.Aims
Patients and Methods
To explore the of age of onset distribution for Perthes’ disease
of the hip, with particular reference to gender, laterality and
conformity to the lognormal distribution. A total of 1082 patients were identified from the Liverpool Perthes’
Disease Register between 1976 and 2010, of which 992 had the date
of diagnosis recorded. In total, 682 patients came from the geographical
area exclusively served by Alder Hey Hospital, of which 673 had
a date of diagnosis. Age of onset curves were analysed, with respect to
the predefined subgroups.Aims
Patients and Methods
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:
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. 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.Aim
Method
10 years after the introduction of the Ponseti casting regimen as standard treatment for idiopathic clubfoot at Alder Hey Children's Hospital, we reviewed the mid-term outcomes of the initial 2-year cohort (treated from 2002–2004) 100 feet were treated in 66 patients. 61 of the 100 feet have been prospectively reviewed on an annual/ bi-annual basis since successful correction, with outcomes of the remaining feet obtained by retrospective analysis.Aim
Method
Perthes’ disease is an osteonecrosis of the juvenile
hip, the aetiology of which is unknown. A number of comorbid associations
have been suggested that may offer insights into aetiology, yet
the strength and validity of these are unclear. This study explored
such associations through a case control study using the United
Kingdom General Practice Research database. Associations investigated
were those previously suggested within the literature. Perthes’ disease has a significant association with congenital
genitourinary and inguinal anomalies, suggesting that intra-uterine
factors may be critical to causation. Other comorbid associations
may offer insight to support or refute theories of pathogenesis.
Clinical prediction algorithms are used to differentiate
transient synovitis from septic arthritis. These algorithms typically
include the erythrocyte sedimentation rate (ESR), although in clinical practice
measurement of the C-reactive protein (CRP) has largely replaced
the ESR. We evaluated the use of CRP in a predictive algorithm. The records of 311 children with an effusion of the hip, which
was confirmed on ultrasound, were reviewed (mean age 5.3 years (0.2
to 15.1)). Of these, 269 resolved without intervention and without
long-term sequelae and were considered to have had transient synovitis.
The remaining 42 underwent arthrotomy because of suspicion of septic
arthritis. Infection was confirmed in 29 (18 had micro-organisms
isolated and 11 had a high synovial fluid white cell count). In
the remaining 13 no evidence of infection was found and they were
also considered to have had transient synovitis. In total 29 hips
were categorised as septic arthritis and 282 as transient synovitis.
The temperature, weight-bearing status, peripheral white blood cell
count and CRP was reviewed in each patient. A CRP >
20 mg/l was the strongest independent risk factor for
septic arthritis (odds ratio 81.9, p <
0.001). A multivariable
prediction model revealed that only two determinants (weight-bearing
status and CRP >
20 mg/l) were independent in differentiating septic
arthritis from transient synovitis. Individuals with neither predictor
had a <
1% probability of septic arthritis, but those with both
had a 74% probability of septic arthritis. A two-variable algorithm
can therefore quantify the risk of septic arthritis, and is an excellent
negative predictor.
The association between idiopathic congenital talipes equinovarus (CTEV) and developmental dysplasia of the hip is uncertain. We present an observational cohort study spanning 6.5 years of selective ultrasound screening of hips in clubfoot. From 119 babies with CTEV there were nine cases of hip dysplasia, in seven individuals. This suggests that 1 in 17 babies with CTEV will have underlying hip dysplasia. This study supports selective ultrasound screening of hips in infants with CTEV.
A total of 25 children (37 legs and 51 segments) with coronal plane deformities around the knee were treated with the extraperiosteal application of a flexible two-hole plate and screws. The mean age was 11.6 years (5.5 to 14.9), the median angle of deformity treated was 8.3° and mean time for correction was 16.1 months (7 to 37.3). There was a mean rate of correction of 0.7° per month in the femur (0.3° to 1.5°), 0.5° per month in the tibia (0.1° to 0.9°) and 1.2° per month (0.1° to 2.2°) if femur and tibia were treated concurrently. Correction was faster if the child was under 10 years of age (p = 0.05). The patients were reviewed between six and 32 months after plate removal. One child had a rebound deformity but no permanent physeal tethers were encountered. The guided growth technique, as performed using a flexible titanium plate, is simple and safe for treating periarticular deformities of the leg.
Lipoblastomata need thorough imaging. Cytogenetic evaluation of tumour cells often reveals chromosomal anomalies, such as abnormalities of the long arm of chromosome 8 leading to rearrangement of the PLAG1 gene. Biopsy of the lesion is recommended for accurate diagnosis, as clinical and radiological diagnoses can be misleading. Lipoblastomata tend to spread locally and may recur after incomplete resection; metastatic potential has not been reported. Complete surgical resection is mandatory to prevent recurrence.
We report our initial experience of using the Ponseti method for the treatment of congenital idiopathic club foot. Between November 2002 and November 2004 we treated 100 feet in 66 children by this method. The standard protocol described by Ponseti was used except that, when necessary, percutaneous tenotomy of tendo Achillis were performed under general anaesthesia in the operating theatre and not under local anaesthesia in the out-patient department. The Pirani score was used for assessment and the mean follow-up time was 18 months (6 to 30). The results were also assessed in terms of the number of casts applied, the need for tenotomy of tendo Achillis and recurrence of the deformity. Tenotomy was required in 85 of the 100 feet. There was a failure to respond to the initial regimen in four feet which then required extensive soft-tissue release. Of the 96 feet which responded to initial casting, 31 (32%) had a recurrence, 16 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior. The remaining 15 required extensive soft-tissue release. Poor compliance with the foot-abduction orthoses (Denis Browne splint) was thought to be the main cause of failure in these patients.
Several techniques are available for the treatment of displaced fractures of the neck of the radius in children. We report our experience in 14 children treated by indirect reduction and fixation using an elastic stable intramedullary nail. The patients were followed up for a mean of 28 months. One developed asymptomatic avascular necrosis. The rest had excellent results. One had a neuropraxia of the posterior interosseous nerve, which recovered within six weeks. We advocate elastic stable intramedullary nailing for the closed reduction and fixation of these fractures in children.
The mean age of surgery was approximately 12 with peaks at age 8 and 13 years. In the plate group, 70% to 80% were undertaken by the SpRs and in the nailing group, approximately 50% were undertaken by staff grades; 30% by Consultants and 20% by SpRs.
Compound fractures were approximately 10% in both groups. There were hyper-trophic scars in approximately 10% in the plate group and 3% in the nail group. There were 3 compartment syndromes in the plate group and 2 compartment syndromes in the nail group. In the plating groups, there was a higher rate of peri-prosthetic fracture, mal-union, hyper-trophic scarring, infection and neuro-vascular complications.
Low energy hip dislocation in children is an uncommon injury (0.335% of injuries ) which represents a true orthopaedic emergency. Case 1 ; A 6 year old girl attended hospital non-weightbearing with right thigh pain after slipping whilst attempting to kick a football. The leg was shortened and internally rotated with no neurovascular deficit. Radiographs revealed a posterior dislocation of the right hip. A closed reduction was undertaken in theatre within four hours. She was immobilised in a hip spica for 6 weeks. At six month review she was pain free and back to full activities. Radiographs showed no abnormality. Case 2 ; A 5 year old boy attended A+E non-weight-bearing with right lower leg and knee pain having done the splits playing football. Examination of knee and lower leg showed pain but nil else. Radiographs of the knee were normal. He was discharged with a diagnosis of possible ACL rupture. He re-attended 2 days later with immobility and increasing pain. Examination showed a 2cm leg length discrepancy. Radiographs revealed a posterior hip dislocation. He underwent a closed reduction in theatre. He progressed well under regular review until 5 months post-injury. He had increasing pain and decreasing range of movement. Radiographs showed trans-epiphyseal avascular necrosis. He therefore underwent a varus de-rotation osteotomy. One year on he has returned to full activities. He has a mild decreased range of movement. Radiographs show a flattened epiphysis and a united osteotomy. Hip dislocation requires less trauma in children due to ligamentous laxity and a soft pliable acetabulum. Overall 64% are low energy and 80% are posterior dislocations. Complications include AVN, arthritis, nerve palsy and recurrent dislocation. AVN is 20 times more common if reduction is after 6 hours. This report highlights the importance of thorough examination, accurate diagnosis and early treatment of paediatric hip dislocation.
This paper presents the results of forearm fractures in twenty children treated with flexible intramedullary nailing, over a period of 3 yrs. Forearm fractures in children are an extremely common injury and excellent results are obtained in the majority of cases by closed reduction and plaster immobilisation. If adequate reduction cannot be achieved or maintained by conservative means or if it fails, some form of internal fixation will be required. Flexible nails are an extremely effective way for addressing this problem. Twenty children had flexible intramedullary nailing done following forearm fractures over a 3-year period from 1997–2000 [failed reduction (10), unstable post MUA(3), slipped in plaster(6) and open fractures(1)]. There were 15 male and 5 female patients, the mean age being 10. 9. The nature of the injury were radial neck (3); proximal radius (1), galeazzi (1) and both bone fractures (15). Nine patients had closed nailing, while 11 required a mini open approach of which, 5 needed exposure only on one side. Patients were protected post surgery until signs of union were seen. The patients had regular clinical and radiological assessment and nails were removed on an average of 6–8 months, though in patients with radial neck fractures it was removed much earlier [4–5 weeks]. All patients went on to full bony union in excellent position, the average time to union being 5. 8 weeks. All but one patient regained full prono-supination, elbow and wrist motion, though none had any functional disability. There were a few minor complications especially following implant removal, including superficial wound infections (3), transient hypoasthesia in the distribution of the superficial radial nerve (2) and one patient in whom one nail had to be left behind as it could not be removed. There were no long-term sequelae. Several methods of internal fixation are available, and the very diversity of choice demonstrates the lack of an ideal solution. K-wires are not applicable at all levels and plates have the disadvantage that they require extensive exposure of the fracture site. Removal of the plates is just as, if not more, fraught with complications. Flexible nails can often be inserted closed, leave cosmetically more acceptable scars, provide excellent alignment of the fracture and can be removed easily without requiring any postoperative immobilisation. In our opinion it should be considered as the method of choice in treating forearm fractures in children, when some form of internal fixation is required.