After open reduction for developmental dysplasia of the hip (DDH), a pelvic or femoral osteotomy may be required to maintain a stable concentric reduction. We report the clinical and radiological outcome in 82 children (95 hips) with DDH treated by open reduction through an anterior approach in which a test of stability was used to assess the need for a concomitant osteotomy. The mean age at the time of surgery was 28 months (9 to 79) and at the latest follow-up, 17 years (12 to 25). All patients have been followed up until closure of the triradiate cartilage with a mean period of 15 years (8 to 23). At the time of open reduction before closure of the joint capsule, the position of maximum stability was assessed. A hip which required flexion with abduction for stability was considered to need an innominate osteotomy. If only internal rotation and abduction were required, an upper femoral derotational and varus osteotomy was carried out. For a ‘double-diameter’ acetabulum with anterolateral deficiency, a Pemberton-type osteotomy was used. A hip which was stable in the neutral position required no concomitant osteotomy. Overall, 86% of the patients have had a satisfactory radiological outcome (Severin groups I and II) with an incidence of 7% of secondary procedures for persistent dysplasia including one hip which redislocated. The results were better (p = 0.04) in children under the age of two years. Increased leg length on the affected side was associated with poor acetabular development and recurrence of joint dysplasia (p = 0.01). The incidence of postoperative avascular necrosis was 7%. In a further 18%, premature physeal arrest was noted during the adolescent growth spurt (Kalamchi-MacEwen types II and III). Both of these complications were also associated with recurrence of joint dysplasia (p = 0.01). Studies with a shorter follow-up are therefore likely to underestimate the proportion of poor radiological results.
Aims. Paediatric triplane fractures and adult trimalleolar ankle fractures both arise from a supination external rotation injury. By relating the experience of adult to paediatric fractures, clarification has been sought on the sequence of injury, ligament involvement, and fracture pattern of triplane fractures. This study explores the similarities between triplane and trimalleolar fractures for each stage of the Lauge-Hansen classification, with the aim of
Aims. To identify a suite of the key physical, emotional, and social outcomes to be employed in clinical practice and research concerning Perthes' disease in children. Methods. The study follows the guidelines of the COMET-Initiative (Core Outcome Measures in Effectiveness Trials). A systematic review of the literature was performed to identify a list of outcomes reported in previous studies, which was supplemented by a qualitative study exploring the experiences of families affected by Perthes’ disease. Collectively, these outcomes formed the basis of a Delphi survey (two rounds), where 18 patients with Perthes’ disease, 46 parents, and 36 orthopaedic surgeons rated each outcome for importance. The International Perthes Study Group (IPSG) (Dallas, Texas, USA (October 2018)) discussed outcomes that failed to reach any consensus (either ‘in’ or ‘out’) before a final consensus meeting with representatives of surgeons, patients, and parents. Results. In total, 23 different outcome domains were identified from the systematic review, and a further ten from qualitative interviews. After round one of the Delphi survey, participants suggested five further outcome domains. A total of 38 outcomes were scored in round two of the Delphi. Among these, 16 outcomes were scored over the prespecified 70% threshold for importance (divided into six main categories: adverse events; life impact; resource use; pathophysiological manifestations; death; and technical considerations). Following the final consensus meeting, 14 outcomes were included in the final Core Outcome Set (COS). Conclusion. Core Outcome Sets (COSs) are important to improve standardization of outcomes in clinical research and to
The aim of this study was to produce clinical consensus recommendations about the non-surgical treatment of children with Perthes’ disease. The recommendations are intended to support clinical practice in a condition for which there is no robust evidence to guide optimal care. A two-round, modified Delphi study was conducted online. An advisory group of children’s orthopaedic specialists consisting of physiotherapists, surgeons, and clinical nurse specialists designed a survey. In the first round, participants also had the opportunity to suggest new statements. The survey included statements related to ‘Exercises’, ‘Physical activity’, ‘Education/information sharing’, ‘Input from other services’, and ‘Monitoring assessments’. The survey was shared with clinicians who regularly treat children with Perthes’ disease in the UK using clinically relevant specialist groups and social media. A predetermined threshold of ≥ 75% for consensus was used for recommendation, with a threshold of between 70% and 75% being considered as ‘points to consider’.Aims
Methods
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. A Delphi consensus study was performed among the membership of BSCOS. Statements were generated by a steering group regarding aspects of the management of DDH in children aged under three months, namely screening and surveillance (15 questions), the technique of ultrasound scanning (eight questions), the initiation of treatment (19 questions), care during treatment with a splint (ten questions), and on quality, governance, and research (eight questions). A two-round Delphi process was used and a consensus document was produced at the final meeting of the steering group.Aims
Methods
Given the possible radiation damage and inaccuracy of radiological investigations, particularly in children, ultrasound and superb microvascular imaging (SMI) may offer alternative methods of evaluating new bone formation when limb lengthening is undertaken in paediatric patients. The aim of this study was to assess the use of ultrasound combined with SMI in monitoring new bone formation during limb lengthening in children. In this retrospective cohort study, ultrasound and radiograph examinations were performed every two weeks in 30 paediatric patients undergoing limb lengthening. Ultrasound was used to monitor new bone formation. The number of vertical vessels and the blood flow resistance index were compared with those from plain radiographs.Aims
Methods
There is no consensus regarding optimum timing and frequency of ultrasound (US) for monitoring response to Pavlik harness (PH) treatment in developmental dysplasia of the hip (DDH). The purpose of our study was to determine if a limited-frequency hip US assessment had an adverse effect on treatment outcomes compared to traditional comprehensive US monitoring. This study was a single-centre noninferiority randomized controlled trial. Infants aged under six months whose hips were reduced and centred in the harness at initiation of treatment (stable dysplastic or subluxable), or initially decentred (subluxated or dislocated) but reduced and centred within four weeks of PH treatment, were randomized to our current standard US monitoring protocol (every clinic visit) or to a limited-frequency US protocol (US only at end of treatment). Groups were compared based on α angle and femoral head coverage at the end of PH treatment, acetabular indices, and International Hip Dysplasia Institute (IHDI) grade on one-year follow-up radiographs.Aims
Methods
Osteofibrous dysplasia (OFD) is a rare benign lesion predominantly affecting the tibia in children. Its potential link to adamantinoma has influenced management. This international case series reviews the presentation of OFD and management approaches to improve our understanding of OFD. A retrospective review at three paediatric tertiary centres identified 101 cases of tibial OFD in 99 patients. The clinical records, radiological images, and histology were analyzed.Aims
Methods
Aims. We report the use of the distal radius and ulna (DRU) classification
for the prediction of peak growth (PG) and growth cessation (GC)
in 777 patients with idiopathic scoliosis. We compare this classification
with other commonly used parameters of maturity. Patients and Methods. The following data were extracted from the patients’ records
and radiographs: chronological age, body height (BH), arm span (AS),
date of menarche, Risser sign, DRU grade and status of the phalangeal
and metacarpal physes. The mean rates of growth were recorded according
to each parameter of maturity. PG was defined as the summit of the curve
and GC as the plateau in deceleration of growth. The rates of growth
at PG and GC were used for analysis using receiver operating characteristic
(ROC) curves to determine the strength and cutoff values of the
parameters of growth. Results. The most specific grades for PG using the DRU classification
were radial grade 6 and ulnar grade 5, and for GC were radial grade
9 and ulnar grade 7. The DRU classification spanned both PG and
GC, enabling better prediction of these clinically relevant stages
than other methods. The rate of PG (≥ 0.7 cm/month) and GC (≤ 0.15
cm/month) was the same for girls and boys, in BH and AS measurements. Conclusion. This is the first study to note that the DRU classification can
predict both PG and GC, providing evidence that it may
Congenital Talipes Equinovarus (CTEV) is one
of the most common congenital limb deformities. We reviewed the records
of infants who had received treatment for structural CTEV between
1 January 2007 and 30 November 2012. This was cross-referenced with
the prenatal scans of mothers over a corresponding period of time.
We investigated the sensitivity, specificity, and positive and negative
predictive values of the fetal anomaly scan for the detection of CTEV
and explored whether the publication of Fetal Anomaly Screening
Programme guidelines in 2010 affected the rate of detection. During the study period there were 95 532 prenatal scans and
34 373 live births at our hospital. A total of 37 fetuses with findings
suggestive of CTEV were included in the study, of whom 30 were found
to have structural CTEV at birth. The sensitivity of screening for
CTEV was 71.4% and the positive predictive value was 81.1%. The negative
predictive value and specificity were more than 99.5%. There was
no significant difference between the rates of detection before
and after publication of the guidelines (p = 0.5). We conclude that a prenatal fetal anomaly ultrasound screening
diagnosis of CTEV has a good positive predictive value enabling
prenatal counselling. The change in screening guidance has not affected
the proportion of missed cases. This information will
Our aim was to determine whether abnormalities noted on MRI immediately after reduction for developmental dysplasia of the hip could predict the persistance of dysplasia and
This multicentre, retrospective study aimed to improve our knowledge
of primary pyogenic spinal infections in children by analyzing a
large consecutive case series. The medical records of children with such an infection, treated
at four tertiary institutions between 2004 and 2014, were analyzed
retrospectively. Epidemiological, clinical, paraclinical, radiological,
and microbiological data were evaluated. There were 103 children,
of whom 79 (76.7%) were aged between six months and four years.Aims
Patients and Methods
To compare the structural durability of hydroxyapatite-tricalcium
phosphate (HATCP) to autologous iliac crest bone graft in calcaneal
lengthening osteotomy (CLO) for pes planovalgus in childhood. We present the interim results of ten patients (HATCP, n = 6
and autograft, n = 5) with a mean age of 11.5 years (8.2 to 14.2)
from a randomised controlled non-inferiority trial with six months
follow-up. The primary outcome was the stability of the osteotomy
as measured by radiostereometric analysis. A non-inferiority margin
of ≤ 2 mm osteotomy compression was set.Aims
Patients and Methods
This study analysed the clinical and radiological outcome of
anatomical reduction of a moderate or severe stable slipped capital
femoral epiphysis (SCFE) treated by subcapital osteotomy (a modified
Dunn osteotomy) through the surgical approach described by Ganz. We prospectively studied 31 patients (32 hips; 16 females and
five males; mean age 14.3 years) with SCFE. On the Southwick classification,
ten were of moderate severity (head-shaft angle >
30° to 60°) and
22 were severe (head-shaft angle >
60°). Each underwent open reduction
and internal fixation using an intracapsular osteotomy through the
physeal growth plate after safe surgical hip dislocation. Unlike
the conventional procedure, 25 hips did not need an osteotomy of
the apophysis of the great trochanter and were managed using an
extended retinacular posterior flap. Aims
Patients and Methods
We present the long-term results of open surgery
for internal shoulder rotational deformity in brachial plexus birth palsy
(BPBP). From 1997 to 2005, 207 patients (107 females, 100 males, mean
age 6.2 (0.6 to 34)) were operated on with subscapularis elongation
and/or latissimus dorsi to infraspinatus transfer. Incongruent shoulder
joints were relocated. The early results of these patients has been
reported previously. We analysed 118 (64 females, 54 males, mean
age 15.1 (7.6 to 34)) of the original patient cohort at a mean of
10.4 years (7.0 to 15.1) post-operatively. A third of patients with
relocated joints had undergone secondary internal rotational osteotomy
of the humerus. A mixed effects models approach was used to evaluate the effects
of surgery on shoulder rotation, abduction, and the Mallet score.
Independent factors were time (pre-and post-surgery), gender, age,
joint category (congruent, relocated, relocated plus osteotomy)
and whether or not a transfer had been performed. Data from a previously published
short-term evaluation were reworked in order to obtain pre-operative
values. The mean improvement in external rotation from pre-surgery to
the long-term follow-up was 66.5° (95% confidence interval (CI)
61.5 to 71.6). The internal rotation had decreased by a mean of
22.6° (95% CI -18.7 to -26.5). The mean improvement in the three-grade
aggregate Mallet score was 3.1 (95% CI 2.7 to 3.4), from 8.7 (95%
CI 8.4 to 9.0) to 11.8 (11.5 to 12.1). Our results show that open subscapularis elongation achieves
good long-term results for patients with BPBP and an internal rotation
contracture, providing lasting joint congruency and resolution of
the trumpet sign, but with a moderate mean loss of internal rotation. Cite this article:
The traditional techniques involving an oblique
tunnel or triangular wedge resection to approach a central or mixed-type
physeal bar are hindered by poor visualisation of the bar. This
may be overcome by a complete transverse osteotomy at the metaphysis
near the growth plate or a direct vertical approach to the bar.
Ilizarov external fixation using small wires allows firm fixation
of the short physis-bearing fragment, and can also correct an associated angular
deformity and permit limb lengthening. We accurately approached and successfully excised ten central-
or mixed-type bars; six in the distal femur, two in the proximal
tibia and two in the distal tibia, without damaging the uninvolved
physis, and corrected the associated angular deformity and leg-length
discrepancy. Callus formation was slightly delayed because of periosteal
elevation and stretching during resection of the bar. The resultant
resection of the bar was satisfactory in seven patients and fair
in three as assessed using a by a modified Williamson–Staheli classification. Cite this article:
The accurate assessment of skeletal maturity
is essential in the management of orthopaedic conditions in the growing
child. In order to identify the time of peak height velocity (PHV)
in adolescents, two systems for assessing skeletal maturity have
been described recently; the calcaneal apophyseal ossification method
and the Sanders hand scores. The purpose of this study was to compare these methods in assessing
skeletal maturity relative to PHV. We studied the radiographs of
a historical group of 94 healthy children (49 females and 45 males),
who had been followed longitudinally between the ages of three and
18 years with serial radiographs and physical examination. Radiographs
of the foot and hand were undertaken in these children at least
annually between the ages of ten and 15 years. We reviewed 738 radiographs
of the foot and 694 radiographs of the hand. PHV was calculated
from measurements of height taken at the time of the radiographs. Prior to PHV we observed four of six stages of calcaneal apophyseal
ossification and two of eight Sanders stages. Calcaneal stage 3
and Sanders stage 2 was seen to occur about 0.9 years before PHV,
while calcaneal stage 4 and Sanders stage 3 occurred approximately
0.5 years after PHV. The stages of the calcaneal and Sanders systems can be used in
combination, offering better assessment of skeletal maturity with
respect to PHV than either system alone. Cite this article:
In this study we evaluated the results of midtarsal
release and open reduction for the treatment of children with convex
congenital foot (CCF) (vertical talus) and compared them with the
published results of peritalar release. Between 1977 and 2009, a
total of 22 children (31 feet) underwent this procedure. In 15 children
(48%) the CCF was isolated and in the remainder it was not (seven
with arthrogryposis, two with spinal dysraphism, one with a polymalformative
syndrome and six with an undefined neurological disorder). Pre-operatively, the mean tibiotalar angle was 150.2° (106° to
175°) and the mean calcaneal pitch angle was -19.3° (-72° to 4°).
The procedure included talonavicular and calcaneocuboid joint capsulotomies,
lengthening of tendons of tibialis anterior and the extensors of
the toes, allowing reduction of the midtarsal joints. Lengthening
of the Achilles tendon was necessary in 23 feet (74%). The mean follow-up was 11 years (2 to 21). The results, as assessed
by the Adelaar score, were good in 24 feet (77.4%), fair in six
(19.3%) and poor in one foot (3.3%), with no difference between
those with isolated CCF and those without. The mean American Orthopaedic
Foot and Ankle Society midfoot score was 89.9 (54 to 100) and 77.8
(36 to 93) for those with isolated CCF and those without, respectively.
At the final follow-up, the mean tibiotalar (120°; 90 to 152) and
calcaneal pitch angles (4°; -13 to 22) had improved significantly
(p <
0.0001). Dislocation of the talonavicular and calcaneocuboid
joints was completely reduced in 22 (70.9%) and 29 (93.6%) of feet,
respectively. Three children (five feet) underwent further surgery
at a mean of 8.5 years post-operatively, three with pes planovalgus
and two in whom the deformity had been undercorrected. No child
developed avascular necrosis of the talus. Midtarsal joint release and open reduction is a satisfactory
procedure, which may provide better results than peritalar release.
Complications include the development of pes planovalgus and persistent
dorsal subluxation of the talonavicular joint. Cite this article:
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. 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.
We investigated the predictive value of intra-operative
neurophysiological investigations in obstetric brachial plexus injuries.
Between January 2005 and June 2011 a total of 32 infants of 206
referred to our unit underwent exploration of the plexus, including
neurolysis. The findings from intra-operative electromyography,
sensory evoked potentials across the lesion and gross muscular response
to stimulation were evaluated. A total of 22 infants underwent neurolysis
alone and ten had microsurgical reconstruction. Of the former, one
was lost to follow-up, one had glenoplasty and three had subsequent
nerve reconstructions. Of the remaining 17 infants with neurolysis,
13 (76%) achieved a modified Mallet score >
13 at a mean age of
3.5 years (0.75 to 6.25). Subluxation or dislocation of the shoulder
is a major confounding factor. The positive predictive value and
sensitivity of the intra-operative EMG for C5 were 100% and 85.7%,
respectively, in infants without concurrent shoulder pathology.
The positive and negative predictive values, sensitivity and specificity
of the three investigations combined were 77%, 100%, 100% and 57%, respectively. In all, 20 infants underwent neurolysis alone for C6 and three
had reconstruction. All of the former and one of the latter achieved
biceps function of Raimondi grade 5. The positive and negative predictive
values, sensitivity and specificity of electromyography for C6 were
65%, 71%, 87% and 42%, respectively. Our method is effective in evaluating the prognosis of C5 lesion.
Neurolysis is preferred for C6 lesions. Cite this article:
