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Bone & Joint Open
Vol. 1, Issue 5 | Pages 121 - 130
13 May 2020
Crosby BT Behbahani A Olujohungbe O Cottam B Perry D

Objectives

This review aims to summarize the outcomes used to describe effectiveness of treatments for paediatric wrist fractures within existing literature.

Method

We searched the Cochrane Library, Scopus, and Ovid Medline for studies pertaining to paediatric wrist fractures. Three authors independently identified and reviewed eligible studies. This resulted in a list of outcome domains and outcomes measures used within clinical research. Outcomes were mapped onto domains defined by the COMET collaborative.


The Bone & Joint Journal
Vol. 101-B, Issue 10 | Pages 1179 - 1183
1 Oct 2019
Parsons N Carey-Smith R Dritsaki M Griffin X Metcalfe D Perry D Stengel D Costa M


Bone & Joint Research
Vol. 7, Issue 2 | Pages 148 - 156
1 Feb 2018
Pinheiro M Dobson CA Perry D Fagan MJ

Objectives

Legg–Calvé–Perthes’ disease (LCP) is an idiopathic osteonecrosis of the femoral head that is most common in children between four and eight years old. The factors that lead to the onset of LCP are still unclear; however, it is believed that interruption of the blood supply to the developing epiphysis is an important factor in the development of the condition.

Methods

Finite element analysis modelling of the blood supply to the juvenile epiphysis was investigated to understand under which circumstances the blood vessels supplying the femoral epiphysis could become obstructed. The identification of these conditions is likely to be important in understanding the biomechanics of LCP.


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_11 | Pages 13 - 13
1 Jun 2017
Dorman S Ayodele O Shelton J Bruce C Perry D George H
Full Access

Purpose

The decision to undertake prophylactic pinning to prevent contralateral slipped upper femoral epiphysis (SUFE) remains controversial; we hypothesised that the grade of initial SUFE could predict the grade of a second SUFE and risk of poor outcome.

Method

We retrospectively reviewed radiographs of all children who presented to Alder Hey with a new diagnosis of SUFE between 2007–2014. Of those who developed a contralateral SUFE, grade of first and second SUFE was determined radio-graphically using % slip and Southwick angle on frog lateral radiograph.


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_11 | Pages 14 - 14
1 Jun 2017
Luo W Kiran M Perry D
Full Access

Purpose

To assess the use of radiographic measurement compared to descriptive classification in the evaluation of Perthes' disease.

Method

Fifteen consultant Paediatric Orthopaedic surgeons, members of the BOSS Collaborative from different UK centres, were asked to rate a series of 100 healed AP radiographs of hips affected by Perthes' Disease from the Liverpool Perthes' Disease Register using the Stulberg' s grading. Two independent observers categorised roundness error using Digitimizer™ software. Kappa scores were used to determine the inter-observer concordance amongst the 15 observers for Stulberg classification. Lin concordance was used to determine roundness error assessment. The relationship between the two outcomes was explored statistically and graphically; considering the mean Stulberg grade recorded by the 15 observers as a continuous outcome.


The Bone & Joint Journal
Vol. 99-B, Issue 4 | Pages 419 - 420
1 Apr 2017
Costa ML Griffin XL Parsons N Dritsaki M Perry D


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_15 | Pages 20 - 20
1 Sep 2016
Metcalfe D Van Dijck S Parsons N Christensen K Perry D
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This study sought to determine the genetic contribution of Perthes' disease, using the world's largest twin-registry.

We extracted all twin pairs from the Danish Twin Registry (DTR) in which at least one individual had Perthes' Disease. The DTR captures every twin pair born alive in Denmark. Those with Perthes' disease were identified using health record linkage to the Danish Morbidity Record. Probandwise concordance was calculated to describe the likelihood that any given individual had LCPD if their co-twin was also diagnosed.

There were 81 twin pairs; 10 monozygotic (MZ), 51 dizygotic (DZ), and 20 unclassified (UZ). There was no association between birth weight and being the affected co-twin. Four pairs (two dizygotic and two unclassified) were concordant for LCPD, which is greater than would be expected assuming no familial aggregation. There were no concordant MZ twin pairs. The overall probandwise concordance was 0.09 (95% CI 0.01–0.18): 0.00 for the MZ, 0.08 (95% CI 0.00–0.18) for the DZ, and 0.18 (95% 0.00–0.40) for the UZ twin pairs.

This study found evidence of familial clustering in LCPD but did not demonstrate a genetic component. The absolute risk that a co-twin of an affected individual will develop LCPD is low, even in the case of MZ twin pairs.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_15 | Pages 19 - 19
1 Sep 2016
Perry D Metcalfe D Costa M
Full Access

The aim was to examine the descriptive epidemiology of Slipped Capital Femoral Epiphysis, with respect to geography and time.

We extracted all children with a diagnosis of Slipped Capital Femoral Epiphysis from the Clinical Practice Research Database between 1990 and 2014 (24 years). CPRD is the world's largest database of primary care, which encompasses 8% of the UK population. CPRD was linked to Hospital Episode Statistics, and a validation algorithm applied to maximise sensitivity and specificity of the cases finding methodology. Poisson confidence intervals were calculated, and poison regression used.

596 cases of SCFE were identified. The internal validation algorithm supported a SCFE diagnosis in 88% cases. The age and sex distribution of cases mirrored that in the literature, offering external validity to the cases identified. There was no significant change in the incidence of SCFE over the 24-year study period, with the overall incidence being 4.8 cases per 100,00 0–16 year olds. There was no significant geographic variation in SCFE within the UK. There was a positive association with rising socioeconomic deprivation (p<0.01). There was no seasonal variation in presentation.

This study found no evidence to support the common belief that SCFE incidence is increasing, and for the first time demonstrated an association with socioeconomic deprivation. The results are important for considering the feasibility of intervention studies, and offer insights into the disease aetiology.


The Bone & Joint Journal
Vol. 97-B, Issue 3 | Pages 412 - 419
1 Mar 2015
Walton RDM Martin E Wright D Garg NK Perry D Bass A Bruce C

We undertook a retrospective comparative study of all patients with an unstable slipped capital femoral epiphysis presenting to a single centre between 1998 and 2011. There were 45 patients (46 hips; mean age 12.6 years; 9 to 14); 16 hips underwent intracapsular cuneiform osteotomy and 30 underwent pinning in situ, with varying degrees of serendipitous reduction. No patient in the osteotomy group was lost to follow-up, which was undertaken at a mean of 28 months (11 to 48); four patients in the pinning in situ group were lost to follow-up, which occurred at a mean of 30 months (10 to 50). Avascular necrosis (AVN) occurred in four hips (25%) following osteotomy and in 11 (42%) following pinning in situ. AVN was not seen in five hips for which osteotomy was undertaken > 13 days after presentation. AVN occurred in four of ten (40%) hips undergoing emergency pinning in situ, compared with four of 15 (47%) undergoing non-emergency pinning. The rate of AVN was 67% (four of six) in those undergoing pinning on the second or third day after presentation.

Pinning in situ following complete reduction led to AVN in four out of five cases (80%). In comparison, pinning in situ following incomplete reduction led to AVN in 7 of 21 cases (33%). The rate of development of AVN was significantly higher following pinning in situ with complete reduction than following intracapsular osteotomy (p = 0.048). Complete reduction was more frequent in those treated by emergency pinning and was strongly associated with AVN (p = 0.005).

Non-emergency intracapsular osteotomy may have a protective effect on the epiphyseal vasculature and should be undertaken with a delay of at least two weeks. The place of emergency pinning in situ in these patients needs to be re-evaluated, possibly in favour of an emergency open procedure or delayed intracapsular osteotomy. Non-emergency pinning in situ should be undertaken after a delay of at least five days, with the greatest risk at two and three days after presentation. Intracapsular osteotomy should be undertaken after a delay of at least 14 days. In our experience, closed epiphyseal reduction is harmful.

Cite this article: Bone Joint J 2015;97-B:412–19.


The National Joint Registry (NJR) was set up by the Department of Health to collect information on all joint replacements. The NJR data is externally validated against nationally collated Hospital Episode Statistics (HES).

Errors associated with the use of HES data have been widely documented. We sought to explore the accuracy of the NJR data, for a single surgeon, against a prospectively collected personal logbook.

The NJR and logbook were compared over a 3-year period (01/07/2009 to 30/06/2012).

Total procedure recorded in the personal logbook was 684 and in the NJR was 681. TKR in personal log book was 304 and in NJR 316, revision knee's in personal logbook 45 and in NJR 36, THR 274 in personal logbook and 271 in NJR, revision hip procedures in personal logbook 64 and 58 in NJR.

Whilst the total number of procedures captured correlates closely (681 vs 684) there is more variation with the different individual procedures. This may be due to the addition of 11% of HES data used for this time period by the NJR as it is known to be inaccurate. This therefore demonstrates the importance of maintaining your own accurate records.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_6 | Pages 5 - 5
1 Feb 2013
Perry D Green D Bruce C Pope D Dangerfield P Platt M Hall A Jones H
Full Access

Objective

There is mounting evidence to suggest a vascular insult is responsible for Perthes' disease, and it is suggested that this may have long-term implications for the vascular health of affected individuals. This study sought to use ultrasound measures to investigate vascular structure and function in children affected by Perthes' disease.

Material and Methods

This case control study encompassed 149 cases and 146 controls, frequency matched for age and sex. Endothelial function was measured using the technique of flow-mediated dilatation of the brachial artery, and alterations in arterial flow were recorded in response to an ischaemic stimulus.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_6 | Pages 2 - 2
1 Feb 2013
Mayne A Perry D Stables G Dhotare S Bruce C
Full Access

Purposes of study

Evaluation of the pre-operative documentation of neurovascular status in children presenting with Gartland Grades 2 and 3 supracondylar fractures and the development of an Emergency Department Proforma.

Methods and results

A retrospective case-note review was performed on patients with Gartland Grade 2 and 3 supracondylar fractures observed in a two-year period from July 2008 – July 2010.

137 patients were included; sixteen patients (11.7%) sustained a Gartland Grade 2a fracture, sixty patients (43.8%) a Gartland Grade 2b fracture and sixty-one (44.5%) a Gartland Grade 3 fracture. Mean patient age at presentation was 5.59 years (range 12 months to 13 years). Nineteen patients (13.9%) had evidence of neurological deficit at presentation and thirteen patients (9.5%) presented with an absent radial pulse. Only twelve patients (8.8%) and nineteen patients (13.9%) respectively had a complete pre-operative neurological or vascular assessment documented. Regarding the individual nerves, fifty-nine (43.1%) patients had median nerve integrity documented, fifty-five (40.1%) ulnar nerve and forty-nine (35.8%) radial nerve integrity documented. Only eighteen patients (13.1%) had their anterior interosseous nerve function documented. Ten patients (7.3%) had post-operative neurological dysfunction, consisting of eight ulnar nerve injuries, and two radial nerve injuries.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_6 | Pages 9 - 9
1 Feb 2013
Singhal R Perry D Prasad S Davidson N Bruce C
Full Access

Background

The association between idiopathic scoliosis and intrinsic abnormalities of the spinal cord are well known. MRI is the most sensitive imaging modality available to diagnose an intraspinal anomaly. The use of a routine ‘screening MRI’ prior to scoliosis correction is controversial.

Purpose

This study sought to quantify the frequency of previously unidentified cord anomalies identified by a routine pre-operative MRI, in patients planned for surgical scoliosis correction.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_6 | Pages 1 - 1
1 Feb 2013
Perry D
Full Access

Introduction

2010 marked a century since Perthes' disease was first described, but the aetiology and mechanism remain unknown. Worldwide, the incidence of Perthes' disease varies widely, yet this may be through differences in study design, population denominators or case ascertainment. It is suggested that differential exposure to adverse socioeconomic circumstances may be a key precipitant, although this remains the subject of debate. This work draws on several epidemiological studies that have sought to develop the understanding of Perthes' disease by examining a case register from Merseyside, discharge data from Scotland and the world's largest community disease register. A systematic review was performed to ensure a robustness and homogeneity between published studies in order to allow meaningful comparisons.

Methods

Studies were based on data from the Merseyside Perthes' Disease Register (1976–2008), the UK General Practice Research Database (GPRD, 1990–2008) and hospital discharge data for Scotland (2000–2009). Temporal trends and geographic patterns were analysed and the relationship to deprivation investigated. A systematic review of the published literature was used to explore international variations in incidence up to December 2010 focusing upon the influence of race and latitude. Analyses were conducted using Poisson regression.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_6 | Pages 4 - 4
1 Feb 2013
Perry D Bruce C Pope D Dangerfield P Platt M Hall A
Full Access

Objective

The relationship between the index (2D) to ring finger (4D) is one of the most commonly studied anthropometric measures, which is believed to offer insight into early growth and the foetal environment. This study aimed to determine the relationship between the 2D:4D ratio and the risk of Perthes' disease in children.

Methods

The 2D:4D ratio was measured in 144 cases of Perthes' disease, and 144 controls. Cases and controls were frequency matched for age and sex. Measurements were recorded using a digital venier calliper on the palmar surface of the hand. Logistic regression was undertaken adjusting for age, with stratification for sex.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXIX | Pages 157 - 157
1 Sep 2012
Singhal R Perry D Khan F Cohen D Stevenson H James L Sampath J Bruce C
Full Access

Background

Establishing the diagnosis in a child presenting with an atraumatic limp can be difficult. Clinical prediction algorithms have been devised to distinguish septic arthritis (SA) from transient synovitis (TS). Within Europe measurement of the Erythrocyte Sedimentation Rate (ESR) has largely been replaced with assessment of C-Reactive Protein (CRP) as an acute phase protein. We produce a prediction algorithm to determine the significance of CRP in distinguishing between TS and SA.

Method

All children with a presentation of ‘atraumatic limp’ and a proven effusion on hip ultrasound between 2004 and 2009 were included. Patient demographics, details of the clinical presentation and laboratory investigations were documented to identify a response to each of the four variables (Weight bearing status, WCC >12,000 cells/m3, CRP >20mg/L and Temperature >38.5°C). SA was defined based upon culture and microscopy of the operative findings.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVI | Pages 11 - 11
1 Aug 2012
Singhal R Perry D Khan F Cohen D Stevenson H James L Sampath J Bruce C
Full Access

Background

Establishing the diagnosis in a child presenting with an atraumatic limp can be challenging. There is particular difficulty distinguishing septic arthritis (SA) from transient synovitis (TS) and consequently clinical prediction algorithms have been devised to differentiate the conditions using the presence of fever, raised erythrocyte sedimentation rate (ESR), raised white cell count (WCC) and inability to weight bear. Within Europe measurement of the ESR has largely been replaced with assessment of C-reactive protein (CRP) as an acute phase protein. We have evaluated the utility of including CRP in a clinical prediction algorithm to distinguish TS from SA.

Method

All children with a presentation of ‘atraumatic limp’ and a proven effusion on hip ultrasound between 2004 and 2009 were included. Patient demographics, details of the clinical presentation and laboratory investigations were documented to identify a response to each of four variables (Weight bearing status, WCC >12,000 cells/m3, CRP >20mg/L and Temperature >38.5 degrees C. The definition of SA was based upon microscopy and culture of the joint fluid collected at arthrotomy.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXV | Pages 6 - 6
1 Jul 2012
Singhal R Perry D Bruce C
Full Access

Purpose

To evaluate the efficacy of Kocher's criteria to differentiate between transient synovitis and septic arthritis in children.

Methods and results

All children with a presentation of ‘atraumatic limp’ and a proven effusion on hip ultrasound between 2004 and 2009 were included. Patient demographics, details of the clinical presentation and laboratory investigations were documented to identify a response to each of the four variables (Weight bearing status, WCC >12,000 cells/m3, CRP >20mg/L and Temperature >38.5°C). SA was defined based upon culture and microscopy of the operative findings. 311 hips were included within the study. Of these 282 were considered to have transient synovitis. 29 patients met criteria to be classified as SA based upon laboratory assessment of the synovial fluid. The introduction of CRP eliminated the need for a four variable model as the prediction for two variables (CRP and weight bearing status) was of similar efficacy. Treating individuals who were non-weight-bearing and a CRP >20mg/L as SA correctly classified 94.8% individuals, with a sensitivity of 75.9%, specificity of 96.8%, positive predictive value of 71.0%, and negative predictive value of 97.5%. CRP was a significant independent predictor of septic arthritis.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_I | Pages 23 - 23
1 Jan 2011
Perry D Unnikrishnan P George H Bassi R Bruce C
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Primary pyomyositis is increasing in incidence in the western world. Although a commonly encountered condition in the tropics it was not described in the USA until 1971 and the UK until 1998. The reason for the increasing incidence is not understood.

Typically pyomyositis affects the muscles around the hip and may present in a variety of ways to orthopaedic or general surgeons – occasionally leading to unnecessary operative intervention. We sought to identify the experience gained, of this condition, within a UK paediatric tertiary referral unit.

A retrospective review of cases of pyomyositis, from our institution, since 1998 was undertaken to identify demographics, presentation, diagnosis and management. Thirteen cases of pyomyositis were identified. Obturator internus was most commonly affected (n = 7). Trauma was implicated in three cases and group A staphylococcus was cultured in nine cases. Male:Female ratio ~ 3: 2. Initial working diagnosis at presentation was septic joint in eight cases, appendicitis in three cases and soft tissue abscess in two cases. Ten cases settled with antibiotics alone. One diagnostic retroperitoneal exploration was performed which may have been avoided with greater preoperative awareness of this condition. On reflection, all cases were identified by CT or MRI.

To our knowledge, this is the first UK series of pyomyositis, reflecting its increasing incidence in the western world. Its presentation is similar to other common paediatric surgical emergencies, yet its management is very different – often not requiring surgery. A greater awareness of this emerging condition is therefore essential to both general and orthopaedic surgeons in order to prevent misdiagnosis and unnecessary surgical intervention.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 544 - 544
1 Aug 2008
Cope MR Perry D Moorehead J Scott SJ
Full Access

Introduction: Sock application is a daily task that can pose a dislocation risk to implanted hips. The aim of this study was to measure hip flexion and rotation using three seated techniques of sock application. Namely:- 1. The leg crossed in a “figure of four” technique, 2. The lean forward technique, and 3. using a specialised sock applicator (Foxy Sock Aid).

Methods: The movement of 32 hips in 16 healthy male volunteers, aged 20–43, were assessed as socks were applied using the 3 techniques listed above. Hip flexion and axial rotation were measured with a “Polhemus Fastrak” magnetic tracking system. Data was recorded from magnetic sensors attached around the subjects femur and Iliac Spine. The sensors measurement accuracy was 0.15 degrees.

Results: All measurements started with the subjects sitting with their hips in approximately 90 degrees of flexion. The mean (SD) additional flexion required for each of the 3 techniques were:- Cross leg = 57.20 (13.7), Lean forward = 51.30 (17.7), and Sock applicator = 11.20 (7.2). Hence the sock applicator required 40.1 degrees less flexion (P< < 0.001) than the lean forward technique. The lean forward technique required 5.9 degrees less flexion (P=0.007) than the cross legged technique.

The mean (SD) peak rotations for each of the 3 techniques were:- Cross leg = 35.10 (9.8) external, Lean forward = 0.10 (3.8) internal, and Sock applicator = 0.80 (4.0) internal.

Discussion: The sock applicator, when used correctly, requires very little hip flexion. When patients stop using the sock applicator, they should be encourage to use the lean forward technique, as this requires little axial rotation.