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.

Introduction

Carpal tunnel syndrome is the commonest peripheral nerve compression neuropathy. Carpal tunnel release (CTR) is a very successful operation. Failed CTR mainly presents as persistence of symptoms, recurrence and new symptoms. The commonest presentation is persistence of symptoms suggested to be due to inadequate release of transverse carpal ligament (TCL) [3], and ante brachial fascia (ABF) [2].

A delay in the diagnosis of paediatric acute and subacute haematogenous osteomyelitis can lead to potentially devastating morbidity. There are no definitive guidelines for diagnosis, and recommendations in the literature are generally based on expert opinions, case series and cohort studies.

All articles in the English literature on paediatric osteomyelitis were searched using MEDLINE, CINAHL, EMBASE, Google Scholar, the Cochrane Library and reference lists. A total of 1854 papers were identified, 132 of which were examined in detail. All aspects of osteomyelitis were investigated in order to formulate recommendations.

On admission 40% of children are afebrile. The tibia and femur are the most commonly affected long bones. Clinical examination, blood and radiological tests are only reliable for diagnosis in combination. Staphylococcus aureus is the most common organism detected, but isolation of Kingella kingae is increasing. Antibiotic treatment is usually sufficient to eradicate the infection, with a short course intravenously and early conversion to oral treatment. Surgery is indicated only in specific situations.

Most studies were retrospective and there is a need for large, multicentre, randomised, controlled trials to define protocols for diagnosis and treatment. Meanwhile, evidence-based algorithms are suggested for accurate and early diagnosis and effective treatment.

Purpose

To determine the impact of sonographic information on surgeons' diagnostic thinking and decision-making in the management of infants with clinically suspicious hip dysplasia.

Four experienced consultant surgeons examined 66 hips referred for possible hip dysplasia and reported for each hip (i) the confidence level (visual analogue scale 0-100) about the diagnosis of this hip, and (ii) how they would manage the hip. Each infant was referred to ultrasound and the same surgeon repeated the rating with the sonographic information available. We determined the efficiency in diagnostic thinking and calculated the mean gain in diagnostic confidence that was provided by the sonographic information. We also determined the therapeutic efficacy, ie the impact of ultrasound information on surgeons’ management plans.

The ultrasound led to a change in diagnosis in 34/66 (52%) hips. However, the management plan only changed in 21/66 (32%) hips. The mean gain in reported diagnostic confidence was 19.37 (95% CI = 17.27, 21.47). If the treatment plan did not change, there still was a gain in diagnostic confidence but this gain was small with a mean value of 8 (95% CI = 5.29, 10.70). However, if the ultrasound led to a change of the treatment plan, the mean gain in diagnostic confidence was much higher with 46 (95% CI = 30.53, 60.79). The difference was -37.67 (P < 0.0001). Ultrasound was most useful (mean gain >30) in hips demonstrating limited abduction or a positive Galeazzi sign.

The Achilles tendon is the strongest and largest tendon in the body. Rupture of this tendon usually occurs in the third and fourth decade and can be significantly debilitating. Repair of neglected ruptures of Achilles tendon pose a challenge to the orthopaedic surgeon due to the retraction and atrophy of the ends of the tendon. Various surgical procedures have been described which include VY plasty, fascia lata, peroneus brevis, plantaris tendon, flexor digitorum longus, flexor hallucis longus, allograft, and synthetic materials.

We carried out a prospective study to compare the results of peroneus brevis transfer with flexor hallucis longus transfer in the management of neglected ruptures of Achilles tendon. Forty-seven patients who had neglected ruptures of Achilles tendon were included in this study. They were randomly divided into two groups; the first group underwent peroneus brevis transfer (24 patients) and the second group had flexor hallucis longus transfer (23 patients). Patients were assessed using the Quigley's scoring system.

We conclude that Flexor hallucis longus transfer is better than peroneus brevis transfer as it is a long, durable tendon which is much stronger when compared to other tendon transfers. Flexor hallucis longus acts in the same axis as the Achilles tendon, is in the same gait phase and is in close proximity, making harvesting of the tendon easy.