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Bone & Joint Open
Vol. 3, Issue 2 | Pages 158 - 164
17 Feb 2022
Buddhdev P Vallim F Slattery D Balakumar J

Aims

Slipped upper femoral epiphysis (SUFE) has well documented biochemical and mechanical risk factors. Femoral and acetabular morphologies seem to be equally important. Acetabular retroversion has a low prevalence in asymptomatic adults. Hips with dysplasia, osteoarthritis, and Perthes’ disease, however, have higher rates, ranging from 18% to 48%. The aim of our study was to assess the prevalence of acetabular retroversion in patients presenting with SUFE using both validated radiological signs and tomographical measurements.

Methods

A retrospective review of all SUFE surgical cases presenting to the Royal Children’s Hospital, Melbourne, Australia, from 2012 to 2019 were evaluated. Preoperative plain radiographs were assessed for slip angle, validated radiological signs of retroversion, and standardized postoperative CT scans were used to assess cranial and mid-acetabular version.


Orthopaedic Proceedings
Vol. 103-B, Issue SUPP_2 | Pages 71 - 71
1 Mar 2021
Buddhdev P Vallim F Slattery D Balakumar J
Full Access

Abstract

Objective

To assess the prevalence of acetabular retroversion in patients presenting with Slipped Upper Femoral Epiphysis using both validated radiological signs and CT-angle measurements.

Methods

A retrospective review of all cases involving surgical management for acute SUFE presenting to the Royal Children's Hospital, Melbourne were assessed from 2012–2018. Pre-operative plain radiographs were assessed for slip angle, validated radiological signs of retroversion (post wall/crossover/ischial spine sign) and standardised post-operative CT Scans were used to assess cranial and mid-acetabular version.


Bone & Joint Open
Vol. 2, Issue 2 | Pages 86 - 92
10 Feb 2021
Ibrahim Y Huq S Shanmuganathan K Gille H Buddhdev P

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.


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_11 | Pages 16 - 16
1 Jun 2017
Esland J Johnson D Buddhdev P Norman-Taylor F
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Purpose

The aim of this study was to identify if perioperative outcomes were different in patients with cerebral palsy undergoing unilateral or bilateral hip reconstruction.

Method

All consecutive hip reconstructions for cerebral palsy performed by the senior author (FNT) within a tertiary-referral centre were identified between January 2012 and July 2016. Patients were stratified by age, gender, GMFCS and side of procedure. Length of surgery, pre- and post- operative haemoglobin, length of stay and immediate post-operative complications were measured.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_15 | Pages 14 - 14
1 Sep 2016
Buddhdev P Lepage R Fry N Shortland A
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Due to abnormal neuromuscular development, functional capability in children with cerebral palsy is often severely compromised. Single event multi-level surgery (SEMLS) is the gold standard surgical treatment for patients with cerebral palsy. It has been demonstrated to improve gait, however, how standing posture is affected is unknown.

The aim was to investigate the effect of SEMLS in patients with spastic cerebral palsy on walking and standing posture using 3D gait analysis.

Participants were identified from the One Small Step Gait Laboratory database. Standardised 3D-Gait analysis was performed within 2 years pre- and post-SEMLS. Gait abnormality was measured using the Gait Profile Score (GPS) index; standing abnormality was measured using the newly-developed Standing Profile Score (SPS) index. A control group (n=20) of age/sex-matched CP patients who did not undergo surgery were also assessed.

104 patients (73 boys, 31 girls) with spastic cerebral palsy underwent SEMLS with appropriate pre- and post-gait analyses (2000–2015). 91 patients had bilateral limb involvement, 14 had unilateral limb involvement. Average age at surgery was 10.38 years (range 4.85–15.60 years). A total of 341 procedures were performed, with hamstring and gastrocnemius lengthening representing approximately 65% of this.

There was a 20% mean improvement in walking (GPS reduced 2.4°, p<0.001) and standing (SPS reduced 3.4°, p<0.001) following SEMLS. No improvement was noted in the control group. Significant correlations were observed between the changes in SPS and GPS following surgery (r2, p<0.001). Patients with poorer pre-operative standing posture (SPS) reported the most significant improvement following surgery.

We confirmed improvement in walking following SEMLS using the Gait Profile Score (GPS). This is the first paper to report that standing posture is also improved following surgery using a novel index, the Standing Posture Score (SPS). SPS could be adopted as a tool to assess functional capability and predict post-operative changes.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_7 | Pages 58 - 58
1 May 2016
Buddhdev P Imbuldeniya A Lockey J Holloway I
Full Access

Introduction

Orthopaedic departments are increasingly put under pressure to improve services, cut waiting lists, increase efficiency and save money. It is in the interests of patients and NHS organisations to ensure that operating theatre resources are used to best effect to ensure they are cost effective, support the achievement of waiting time targets and contribute to a more positive patient experience.

Patients in the UK are expected to have undergone surgery once decided within 18 weeks. A good system of planning and scheduling in theatre enables more work, however is largely delegated to non-clinical managerial and administrative staff. After numerous cancellations of elective cases due to incomplete pre-operative work-up, unavailable equipment and patient DNAs, we decided to introduce a surgeon-led scheduling system.

Intervention

The surgeon-led scheduling diary involved surgeons offering patients a date for surgery in clinic. This allowed for appropriate organisation of theatre lists and surgical equipment, and pre-operative assessment.


The Bone & Joint Journal
Vol. 97-B, Issue 12 | Pages 1718 - 1725
1 Dec 2015
Vanhegan IS Cashman JP Buddhdev P Hashemi-Nejad A

Slipped upper femoral epiphysis (SUFE) is the most common hip disorder to affect adolescents. Controversy exists over the optimal treatment of severe slips, with a continuing debate between in situ fixation versus corrective surgery. We present our experience in a series of 57 patients presenting with severe unilateral SUFE (defined > 50°) managed with a subcapital cuneiform osteotomy.

Between 2001 and 2011, 57 patients (35 male, 22 female) with a mean age of 13.1 years (9.6 to 20.3, SD 2.3) were referred to our tertiary referral institution with a severe slip. The affected limb was rested in slings and springs before corrective surgery which was performed via an anterior Smith-Petersen approach. Radiographic analysis confirmed an improvement in mean head–shaft slip angle from 53.8o (standard deviation (sd) 3.2) pre-operatively to 9.1o (sd 3.1) post-operatively, with minimal associated femoral neck shortening. In total 50 (88%) patients were complication free at a mean follow-up of seven years (2.8 to 13.9 years, sd 3). Their mean Oxford hip score was 44 (37 to 48) and median visual analogue pain score was 0 out of 10 (interquartile range 0 to 4). A total of six patients (10.5%) developed avascular necrosis requiring further surgery and one (1.8%) patient developed chondrolysis but declined further intervention.

This is a technically demanding operation with variable outcomes reported in the literature. We have demonstrated good results in our tertiary centre.

Cite this article: Bone Joint J 2015;97-B:1718–25.


Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_9 | Pages 11 - 11
1 Aug 2015
Buddhdev P Fry N Shortland A
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Ambulating children with bilateral spastic cerebral palsy (BSCP) demonstrate atypical posture and gait due to abnormal muscle and skeletal growth when compared to typically–developing (TD) children. Normal postural alignment in standing facilitates many of the tasks of daily living because it allows a stable base of support without requiring significant muscular effort. Similarly, increasing gait abnormality is associated with poorer functional capacity. Our aims were to compare the standing posture of TD children and children with BSCP using the Standing Profile Score and identify if any abnormality in standing is correlated with abnormality in walking in children with BSCP using the Gait Profile Score index.

We retrospectively compared 44 typically-developing children to 74 age-matched children with BSCP (GMFCS I & II). We performed 3D Gait Analysis during long-standing (10seconds) and in gait after application of 16 retro-reflective markers on anatomical landmarks of the lower limb and pelvis. Analysis of all kinematics was performed for movements in the sagittal, coronal and axial planes. The Gait Profile score (GPS) is a validated index of overall gait pathology. The Standing Profile Score (SPS) was developed using the same calculations for GPS but during static trials.

A significant correlation was observed between the Standing Profile Score (SPS) and Gait Profile Score (GPS) in children with BSCP (p<0.001). Significant differences were exhibited in GPS between the two groups, across all parameters, except the pelvic obliquity (p<0.05). A significant positive correlation existed for hip rotation in both groups, however the correlations observed at hip flexion and ankle dorsiflexion were significantly greater in the BSCP group compare to the TD group (p<0.01).

We have shown that posture during gait (GPS) is predictable from standing posture (SPS) in patients with BSCP. This biomechanical relationship can aid surgical decision-making.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_1 | Pages 209 - 209
1 Jan 2013
Buddhdev P Mckenzie J Borgese A Davies N Waters T
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Introduction

Enhanced recovery programmes (ERP) have recently been adopted in the UK, enabling patients to recover quickly and return home sooner. Choice of anaesthetic is an important factor effecting post-operative outcome; studies show regional anaesthesia is more cost-effective, decreasing the incidence of venous thromboembolic events and reducing intra-operative blood loss, the need for transfusion and the length of hospital stay.

Objectives

The objective of this study was to compare the short-term outcome of patients enrolled in our ERP who underwent either general or spinal +/− epidural anaesthesia.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_1 | Pages 166 - 166
1 Jan 2013
Buddhdev P Basu D Davies N Waters T
Full Access

Introduction

Rivaroxiban is a direct inhibitor of factor Xa, a licensed oral thromboprophylactic agent that is increasingly being adopted for lower limb arthroplasty. Rivaroxiban has been NICE-approved for use in primary hip and knee arthroplasty following the RECORD 4 trials; proving it more effective in preventing venous thrombo-embolic (VTE) events compared to enoxaparin. Enhanced Recovery Programmes (ERP) are designed to enable patients to recover quickly and return home safely within a few days.

Methods

We prospectively studied 1223 patients (age- and sex-matched) who underwent lower-limb arthroplasty enrolled in our ERP between March 2010 and December 2011; 454 patients (Group 1) received enoxaparin, 769 patients (Group 2) received rivaroxiban. Patients wore thrombo-embolic stockings for six weeks post surgery. Patients were monitored for thrombo-embolic events and wound-related complications for 42 days post-operatively.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XL | Pages 24 - 24
1 Sep 2012
Buddhdev P Tudor F Davies N Waters T
Full Access

Introduction

Obesity is a direct contributor to degenerative joint disease, and as the prevalence of obesity increases globally it is likely that more overweight patients will present for hip replacement surgery. There are reports that overweight patients in the UK's National Health Service, typically with a Body Mass Index (BMI) over 30 (BMI 30–39 obese, BMI≥40 morbidly obese), are being denied operations on the premise that they are at risk of significant complications. Enhanced Recovery Programmes (ERP) are designed to enable patients to recover quickly and return home safely within a few days. The aim of this study was to compare the outcome of hip replacements in obese and non-obese patients enrolled in our ERP.

Methods

We prospectively studied 350 patients who underwent primary and revision total hip replacements and were treated through our ERP form March 2010 to January 2011. The mean age was 68 (range 23–92 years). 130 patients (37%) were considered obese with a BMI of >30. 11 patients (3%) were considered morbidly obese with a BMI >40. They were age & sex-matched with the non-obese patients. Outcomes measured included: Length of stay, wound complications (including surgical site infections), deep vein thrombosis and blood transfusion requirements. Data was collected to 42 days following discharge.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXIV | Pages 31 - 31
1 Jul 2012
Buddhdev P Davies N Waters T
Full Access

The need for hip and knee replacement surgery is increasing. Enhanced recovery programmes, where patients mobilise quickly and safely after surgery, have been adopted now in many hospitals. There are anecdotal reports of Primary Care Trusts raising thresholds for referral for surgery based on patients' Body Mass Index (BMI).

The aim of this study was to evaluate the early outcome of hip and knee arthroplasty in obese patients (BMI>30) enrolled in the enhanced recovery programme.

Between March 2010 and January 2011, 672 patients were enrolled in our enhanced recovery programme. 316 patients (47%) were classified as obese (BMI>30, range 30-39). There was no significant difference in the length of stay: 4.58 days in the obese patients and 4.44 days in the non-obese. There was also no difference in the rates of superficial infections or oozy wounds. Knee replacements was performed more commonly than hip replacements in the obese group

There was no significant difference in the early outcome of hip and knee replacement surgery in patients with a higher Body Mass Index when undergoing lower limb arthroplasty through the enhanced recovery programme. These patients should continue to be offered surgery when clinically indicated.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_I | Pages 132 - 133
1 Mar 2009
Hart A Tarrassoli P Patel C Buddhdev P Hester T Muirhead-Allwood S Skinner J
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Introduction: We have previously shown an association between whole blood metal particles from unilateral metal on metal (MOM) hip resurfacing and reduced CD8+ T cells (JBJS Br April 2006). There are no reported clinical effects of these findings. Certain patients maybe at high risk of developing clinical effects; one such group is patients with bilateral hip resurfacings. There are no published studies of bilateral hip resurfacings. Our aim was to investigate the association between whole blood metal ions and reduced CD8+ T cells in a follow up cohort of bilateral MOM hip resurfacings.

Method : Peripheral blood samples were analysed from patients with bilateral MOM hip resurfacings (n=25), unilateral hip resurfacings (n=34) and metal on polyethylene (MOP) hip arthroplasty (n=34). Samples were analysed for: lymphocyte subsets (FACS analysis); whole blood cobalt and chromium ion levels (using inductively-coupled mass spectrometry). Xrays revealed all hip components were well fixed.

Results : When compared to patients with standard MOP hip replacements there was a 30% reduction in both the bilateral and unilateral resurfacing groups’ level of CD8+ cells (T cytotoxic) (p=0.010). All other lymphocyte subgroups were not significantly different. There was evidence of a threshold effect of raised metal ions and reduced CD8+ T cells but no evidence of a dose-response relationship.

Conclusions : Bilateral MOM hip resurfacing is associated with a reduced CD8+ T cell count when compared to MOP hip arthroplasty. This association is not significantly different from the levels seen after unilateral MOM hip resurfacing.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_II | Pages 378 - 378
1 Jul 2008
Buddhdev P Hart A Tarassoli P Skinner J
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Background: Metal-on-metal bearing hip replacements release between three and nine times more cobalt and chromium ions than a metal on polyethylene bearing hip replacement. We do not fully understand the cause for the variability of ion levels after metal on metal hip replacement. The factors that determine an individual’s levels of metal ions include: firstly, patient factors (renal failure, patient weight, high activity); secondly, manufacture factors (head size (and fluid film lubrication), carbide density, surface finish) and lastly study factors (bilateral implants, time from operation). Biomechanical studies suggest that component position, in particular acetabular inclination, is important for wear rate but there is no published correlation from clinical studies.

Aim: To investigate the relationship between acetabular inclination angle and metal ion levels of patients with Birmingham Hip resurfacings.

Methods: Using standardised radiographs, we measured the inclination angle (using UTHSCSA image tool) of the acetabular components in thirty-one patients (mean age 54 years) who underwent unilateral Birmingham hip resurfacing (mean time post operation of 22 months). We also measured peripheral whole blood chromium and cobalt ion concentrations using inductively coupled mass spectrometry. All components were well fixed.

Results: There was a positive correlation between the inclination angle (range 28 degrees – 55 degrees) of the acetabular component and whole blood concentration of Cobalt (range 2.3 – 7 mcg/L), Chromium (range 0.56 – 4.3 mcg/L) and total metal ion levels (range 3.1 – 10.3 mcg/L). This finding was statistically significant, with a Pearson correlation coefficient of 0.46 (95% CI 0.13-0.70) and a p-value of 0.00398.

Conclusion: Acetabular inclination angle is likely to be a factor in determining an individual’s metal ion levels in patients with metal on metal resurfacing. We also iden-tified a threshold level of 50 degrees inclination, after which the metal ion levels rise dramatically. We describe the possible biomechanical mechanisms to explain these results. We recommend surgeons implant the metal socket at an inclination angle of less than 50 degrees.