Treatment for hip displacement in children and youth with cerebral palsy (CP) is dependent upon when the problem is detected. Hip surveillance aims to identify hip displacement early through systematic screening and, together with timely orthopaedic intervention, can eliminate the need for salvage hip procedures. Here we report the impact on surgical practice of 1) hip surveillance program advocacy and knowledge translation efforts and 2) initial population-based program implementation.

A retrospective review was completed of all children with CP undergoing surgery for hip displacement at a provincial tertiary pediatric hospital in the years 2004 to 2018. Date and type of surgery, age at surgery, Gross Motor Function Classification System (GMFCS) level, and pre-operative migration percentages (MP) were collected. Surgeries were categorized as soft-tissue release, reconstructive, and salvage procedures. Results were collected for three time periods: historical (September 2004- June 2010), hip surveillance advocacy and knowledge translation (July 2010- August 2015), and post provincial hip surveillance program implementation (September 2015 – December 2018).

A total of 261 surgeries on 321 hips were reviewed. The rate of salvage procedures dropped from 29% (24) of surgeries performed in the historical period to 12% (14) during the period that included targeted hip surveillance knowledge translation and development of provincial guidelines. Since implementation of the surveillance program, salvage procedures have accounted for 7% (4) of interventions performed; all of these were in patients new to the province or existing patients. During the three study periods, reconstructive surgeries accounted for 64%, 81%, and 80% of the interventions performed. The mean initial MP at time of reconstructive surgery has decreased from 66% (SD 20%) in the historical time period to 57% (SD 25%) and 57% (SD 22%) in the subsequent time periods. There were a greater number of children at GMFCS levels III and IV in the two more recent time periods suggesting surveillance may assist in identifying children at these levels of impairment. The rate of soft-tissue surgeries was low during all time periods with the number trending higher since program implementation (7%, 7%, 10%).

Knowledge translation and use of standardized surveillance guidelines can have a significant impact on the prevalence of salvage hip surgeries. Centers should utilize existing surveillance guidelines and educate key stakeholders about the importance of hip surveillance in the absence of a formal hip surveillance program.

Developmental dysplasia of the hip (DDH) is the most common paediatric hip condition and is a major cause of hip replacement or osteoarthritis in young adults. Due to potential impact on quality of life, every child is checked at birth for unstable hips. Should instability be detected, or the infant has other DDH risk factors, they are referred for an ultrasound exam and orthopaedic surgeon consultation.

Since the implementation of a DDH screening program at our institution, the Radiology Department has seen a dramatic increase in hip ultrasounds performed. While helping prevent the complications of missed DDH diagnoses, this program has placed strain on radiology resources, and often families must attend multiple appointments before receiving a diagnosis and beginning treatment. To mitigate this, we have implemented a pilot point-of-care DDH clinic, where an ultrasound technician performs hip ultrasound exams using a portable ultrasound in the orthopaedic clinic in conjunction with surgeon consultation. The aim of this clinic is to enable diagnosis and treatment in one appointment, reduce referral-to-treatment delays, wait times, and decrease costs and travel time for families while also alleviating strain on radiology resources.

A point-of-care DDH test clinic was implemented in the Orthopaedic Department at our institution. Patients referred with suspected/confirmed DDH attended a single orthopaedic clinic appointment. An ultrasound technician was present to perform scans in conjunction with the orthopaedic surgeon's clinical assessment. Surveys were distributed at the end of the appointment to collect feedback on the family's satisfaction with the program, as well as other pertinent demographic information (i.e. occupation, geographic location, travel time to hospital).

To date, 40 patients have attended the pilot clinic. Families spent an average 61.3 minutes (range 15–420 minutes) traveling to the hospital for an appointment (122.6 minutes round-trip). This program reduced the number of hospital visits for DDH screening from three (initial consultation, radiology, follow-up) to one per patient, saving an average 245.2 minutes of travel time to/from the hospital per family. Appointment time averaged 35.9 minutes and families rated their satisfaction with appointment length an average of 9.6/10 (35/40 families rated satisfaction 10/10, 1 = very unsatisfied, 10 = very satisfied). Additionally, 33/40 families were also asked to rate their satisfaction with check-in/check-out processes (average 9.4/10), ultrasound screening (average 9.9/10), and time with specialist (average 9.9/10). Satisfaction scores did not differ based on variables such as survey taker's gender, occupation, or geographic location.

The pilot point-of-care ultrasound DDH clinic has considerably reduced the number of clinic visits and travel time for families, reduced aggregate clinic wait times, and has resulted in high family satisfaction. This specialized clinic may have potential to free up hospital staff time and resources, possibly decreasing wait times in other clinical areas, ultimately improving quality of care for patients and families across our institution.

Aims

Though the pathogenesis of Legg-Calve-Perthes disease (LCPD) is unknown, repetitive microtrauma resulting in deformity has been postulated. The purpose of this study is to trial a novel upright MRI scanner, to determine whether any deformation occurs in femoral heads affected by LCPD with weightbearing.

Avascular necrosis (AVN) of the femoral head is a potentially devastating complication of treatment for developmental dysplasia of the hip (DDH). AVN most commonly occurs following operative management by closed (CR) or open reduction (OR). This occurrence has frequently been examined in single centre, retrospective studies, however, little high-level evidence exists to provide insight on potential risk factors. The purpose of this observational, prospective multi-centre study was to identify predictors of AVN following operatively-managed DDH.

A multi-centre, prospective database of infants diagnosed with DDH from 0–18 months was analyzed for patients treated by CR and/or OR. At minimum one year follow-up, the incidence of AVN (Salter criteria) was determined from AP pelvis radiographs via blinded assessment and consensus discussion between three senior paediatric orthopaedic surgeons. Patient demographics, clinical exam findings and radiographic data were assessed for potential predictors of AVN.

A total of 139 hips in 125 patients (102 female, 23 male) underwent CR/OR at a median age of 10.4 months (range 0.7–27.9). AVN was identified in 37 cases (26.6% incidence) at a median 23 months post-surgery. Univariate logistic regression analysis comparing AVN and no AVN groups identified sex, age at diagnosis, age at surgery, pre-surgery IHDI grade and time between diagnosis and surgery as potential predictive factors. Specifically, male sex (OR 2.21 [0.87,5.72]), IHDI grade IV, and older age at diagnosis (7.4 vs. 9.5 months) and surgery (10.2 vs. 13.6 months) were associated with development of AVN. Likewise, increased time between diagnosis and surgery (2.9 vs. 5.5 months) was also associated with a higher incidence. No association was found with surgery type (CR vs. OR), pre-surgery acetabular index or surgical hip.

Development of AVN occurred in 26.6% of hips undergoing CR or OR at a median 23 months post-surgery. Male sex, older age at diagnosis and surgery, dislocation severity and increased time between diagnosis and surgery were associated with AVN. Longer-term follow-up and larger numbers will be required to confirm these findings. Early outcomes from this prospective patient cohort suggest that AVN is an important complication of operative management for DDH, and appears to occur at a comparable rate whether the reduction is performed open or closed. Male patients may be more susceptible to developing AVN and merits further exploration. Potential predictive factors of older age and length of time between diagnosis and surgery emphasize the importance of early detection and treatment to minimize complications and optimize outcomes.

The Gartland extension-type supracondylar humerus fracture is the most common elbow fracture in the paediatric population. Depending on fracture classification, treatment options range from nonoperative treatment such as taping, splinting or casting to operative treatments such as closed reduction and percutaneous pinning or open reduction. Classification variability between surgeons is a potential contributing factor to existing controversy over nonoperative versus operative treatment for Type II supracondylar fractures. The purpose of this study was to investigate levels of agreement in classification of extension-type supracondylar humerus fractures using the Gartland classification system.

A retrospective chart review was conducted on patients aged 2–12 years who had sustained an extension-type supracondylar fracture and received either operative or nonoperative treatment at a tertiary children's hospital. De-identified baseline anteroposterior (AP) and lateral plain elbow radiographs were provided along with a brief summary of the modified Gartland classification system to surgeons across Canada, United States, Australia, United Kingdom and India. Each surgeon was blinded to patient treatment and asked to classify the fractures as Type I, IIA, IIB or III according to the classification system provided. A total of 21 paediatric orthopaedic surgeons completed one round of classification, of these, 15 completed a second round using the same radiographs in a reshuffled order. Kappa values using pre-determined weighted kappa coefficients were calculated to assess interobserver and intraobserver levels of agreement.

In total, 60 sets of baseline elbow radiographs were provided to survey respondents. Interobserver agreement for classification based on the Gartland criteria between surgeons was a mean of 0.68, 95% CI [0.67, 0.69] (0.61–0.80 considered substantial agreement). Intraobserver agreement was a mean of 0.80 [0.75, 0.84]. (0.61–0.80 substantial agreement, 0.81–1 almost perfect agreement).

Radiographic classification of extension-type supracondylar humerus fractures at baseline demonstrated substantial agreement both between and within surgeon raters. Levels of agreement are substantial enough to suggest that classification variability is not a major contributing factor to variability in treatment between surgeons for Type II supracondylar fractures. Further research is needed to compare patient outcomes between nonoperative and operative treatment for these fractures, so as to establish consensus and a standardized treatment protocol for optimal patient care across centres.

Paediatric femoral fractures are a common result of significant trauma, and always require intervention. Hip spica casting, traction, and surgical fixation can all be used to treat these fractures. This variety in treatment options leads to a vast potential for variability in management decisions among surgeons and has prevented effective comparative studies to show which treatment methods provide optimal outcomes for patients. The purpose of this study was to identify practice variability in management and follow-up and assess patient outcomes to aid in the development of a comprehensive, prospective, evidence-based pathway for the management of paediatric femoral fractures.

A retrospective chart review was performed of all patients treated surgically for isolated femoral fractures during a six year period at a single tertiary care paediatric centre. Patients were identified from a surgical database and were included if there was no pre-existing pathology and no history of previous femoral fracture. Demographic data, operative details, post-operative management, and clinical outcomes were collected. Radiographic images and reports were analyzed to determine fracture classification and imaging parameters. Variability in treatment among eight surgeons was assessed, including number of follow-up appointments and length of follow-up. Patient demographics and follow up measures were summarised for each surgeon and between surgeon variability was assessed with linear models.

In total, 138 femoral fractures in 134 patients (101 male, 33 female) were included in analysis. Of these patients, 55 had right femoral fractures, 76 left, and three bilateral (one bilateral patient had three distinct femoral fractures). Of 138 total fractures, 131 were of the diaphysis of the femur. 14 patients sought initial surgical treatment at our institution but received follow-up management elsewhere. Across all patients, median follow-up time was 32.8 weeks (0–201.4) with a median of three follow-up visits (0–26) in that period. Mean number of follow-up clinic visits ranged from 3 to 4.8 among surgeons, and mean length of follow-up ranged from 31.8 to 62.3 weeks.

No significant differences in follow-up between surgeons were found, but small sample sizes are a likely contributing factor. Summary statistics show large ranges in most variables and differences in patient demographics between surgeon groups. The large ranges in follow-up time and visit number suggest a lack of consensus on optimal management for paediatric femoral fractures. Further prospective study examining long-term functional and quality of life outcomes will be required to identify and develop optimized management guidelines.

Systematic reviews (SR) can provide physicians with effective means to further strengthen their practice and identify gaps in clinical knowledge. The focus of any SR is to identify the current state of evidence for a given treatment or condition, with the hopes of providing the best interventional methods physicians can base their practice on. In paediatric orthopaedics, high-level studies are lacking, thus potentially limiting the effectiveness of SRs in the field. There isn't one specific way to qualify research on its effectiveness, but there has been gradual enhancement in finding ways to identify a successful and reproducible study. The purpose of this study was to evaluate the quality of paediatric orthopaedic SRs, and highlight aspects of these SRs that have contributed to improved outcomes.

A literature review was performed in EMBASE, MEDLINE and Cochrane databases to identify pre-existing systematic reviews that have been published in five well-known orthopaedic journals between 2007 and 2017. SRs were included if the study population was between 0 and 18 years of age. Selected articles had an AMSTAR checklist applied in order to score the studies on their quality and methodology. Articles were independently reviewed by two reviewers to determine the extent of AMSTAR guidelines fulfillment.

A total of 40 SRs were identified and reviewed, 20 of which partially or completely fulfilled AMSTAR guidelines. There was no disagreement between reviewers as to which of the analyzed articles have successfully reflected the checklist.

Only 20/40 SRs analyzed at least partially fulfilled AMSTAR guidelines. One of the weaknesses identified in the reviewed papers so far is the lack of justification for the chosen study designs for SRs and what strategy was used to decide on the exclusion of articles. There needs to be clear-cut criteria that mark studies to be included and excluded in a comprehensive systematic review. Further improvements are required to ensure that full details on the involvement of papers and the success rates regarding each interventional method are included in order to strengthen the quality of SRs across the paediatric orthopaedic literature.

Fractures through the physis account for 18–30% of all paediatric fractures, leading to growth arrest in 5.5% of cases. We have limited knowledge to predict which physeal fractures result in growth arrest and subsequent deformity or limb length discrepancy. The purpose of this study is to identify factors associated with physeal growth arrest to improve patient outcomes.

This prospective cohort study was designed to develop a clinical prediction model for growth arrest after physeal injury. Patients < 1 8 years old presenting within four weeks of injury were enrolled if they had open physes and sustained a physeal fracture of the humerus, radius, ulna, femur, tibia or fibula. Patients with prior history of same-site fracture or a condition known to alter bone growth or healing were excluded. Demographic data, potential prognostic indicators and radiographic data were collected at baseline, one and two years post-injury.

A total of 167 patients had at least one year of follow-up. Average age at injury was 10.4 years, 95% CI [9.8,10.94]. Reduction was required in 51% of cases. Right-sided (52.5%) and distal (90.1%) fractures were most common. After initial reduction 52.5% of fractures had some form of residual angulation and/or displacement (38.5% had both). At one year follow-up, 34 patients (21.1%) had evidence of a bony bridge on plain radiograph, 10 (6.2%) had residual angulation (average 12.6°) and three had residual displacement. Initial angulation (average 22.4°) and displacement (average 5.8mm) were seen in 16/34 patients with bony bridge (48.5%), with 10 (30.3%) both angulated and displaced. Salter-Harris type II fractures were most common across all patients (70.4%) and in those with bony bridges (57.6%). At one year, 44 (27.3%) patients had evidence of closing/closed physes.

At one year follow-up, there was evidence of a bony bridge across the physis in 21.1% of patients on plain film, and residual angulation and/or displacement in 8.1%. Initial angulation and/or displacement was present in 64.7% of patients showing possible evidence of growth arrest. The incidence of growth arrest in this patient population appears higher than past literature reports. However, plain film is an unreliable modality for assessing physeal bars and the true incidence may be lower. A number of patients were approaching skeletal maturity at time of injury and any growth arrest is likely to have less clinical significance in these cases. Further prospective long-term follow-up is required to determine the true incidence and impact of growth arrest.

Children with cerebral palsy (CP) have an increased risk of progressive hip displacement. While the cause of hip displacement remains unclear, spasticity and muscle imbalance around the hip are felt to be a major factor. There is strong evidence demonstrating that a selective dorsal rhizotomy (SDR) reduces spasticity. However, the impact of this decreased spasticity on hip displacement is unknown. Past studies, which are small and lack long-term follow-up, do not provide a clear indication of the effect of SDR on hip displacement. The purpose of this study was to determine the influence of SDR on hip displacement in children with CP a minimum of five years post-SDR.

A retrospective chart review was completed. Participants were selected from a consecutive series of children who had an SDR before January 1, 2013 at one tertiary care facility to ensure a minimum five year follow-up. Pre-operative and minimum five year post-SDR AP pelvis radiographs were required for inclusion. Hip displacement was evaluated using change in MP between radiographs completed pre-SDR and minimum five years post-SDR, or until orthopaedic hip surgery.

In total, 77 participants (45 males, 32 females) at GMFCS levels of I (1), II (11), III (22), IV (35) and V (8) were included in the review. Mean age at time of SDR was 5 years (2.8– 11.6yrs). Pre-SDR mean MP of the 154 hips was 29% (0–100%). Post-SDR, 67 (43.5%) hips in 35 children had soft tissue, reconstructive, or salvage hip procedures at an average of 4.9 years (0.5–13.8yrs) post-SDR and an average MP of 46% (11–100%). In addition, seven hips (5%) had a MP ≥ 40% (40–100%) at most recent radiographic review that averaged 11 years (5.6–18.6yrs). Overall, the total number of subjects with hip displacement measuring MP >40% or who had a surgical hip intervention, by GMFCS level, was: 0 (0%) at level I, 0 (0%) at level II, 20 (45%) at level III, 22 (59%) at level IV, and 5 (81%) at level V.

The incidence of hip displacement in children with CP post-SDR did not substantially differ from the overall incidence reported in the literature when evaluated by GMFCS level. This study is the largest long-term follow-up study investigating the effect of hip displacement post-SDR. Results suggest that SDR does not impact hip displacement in CP, however, further prospective study will be required to strengthen the evidence in this regard.

Dynamic 2D sonography of the infant hip is a commonly used clinical procedure for developmental dysplasia of the hip (DDH) screening. It however has been found to be unreliable with some studies reporting associated misdiagnosis rates of up to 29%. In a recent systematic review, Charlton et al. examined dynamic ultrasound (US) screening for hip instability in the first six weeks after birth and found current best practices for such early screening techniques to be divergent between international institutions in terms of clinical scanning protocols. Such protocols include: the appropriate scanning plane and US probe position (e.g. coronal, transverse, lateral, anterior), DDH diagnostic metrics (e.g. femoral head coverage, alpha angle), appropriate patient age when scanning, and follow up procedures. To improve reliability of diagnosis and to help in standardizing diagnosis across different raters and health-centers, we propose an automated method for dynamically assessing hip instability using 3D US.

38 infant hips from 19 patients were scanned with B-mode 3D US by a paediatric orthopaedic surgeon and two technologists from the radiology department at a paediatric tertiary care centre. To quantify hip assessment, we proposed the use of femoral head coverage variability (ΔFHC3D) within 3D US volumes collected during a sequence of US scans (one at rest, and another with posterior stress applied to the joint as maneuvered during a dynamic assessment). We used phase symmetry image features to localize the ilium's vertical cortex and a random forest classifier to identify the location of the femoral head.

The proposed ΔFHC3D provided good repeatability with an average test-retest ICC measure of 0.70 (95% confidence interval: 0.35 to 0.87, F(21,21) = 7.738, p<.001). The mean difference of ΔFHC3D measurements was 0.61% with a SD of 4.05%.

Since the observed changes in ΔFHC3D start near 0% and range up to about 18% from stable to mildly unstable hips in this cohort, the mean difference and standard deviation of ΔFHC3D measurements observed suggest that the proposed metric and technique likely have sufficient resolution and repeatability to quantify differences in hip laxity. The long-term significance of this approach to evaluating dynamic assessments may lie in increasing early diagnostic accuracy in order to prevent dysplasia remaining undetected prior to manifesting itself in early adulthood joint disease.

Although physical and ultrasound (US)-based screening for congenital deformities of the hip (developmental dysplasia of the hip, or DDH) is routinely performed in most countries, one of the most commonly performed manoeuvres done under ultrasound observation - dynamic assessment - has been shown to be relatively unreliable and is associated with significant misdiagnosis rates, on the order of 29%.

Our overall research objective is to develop a quantitative method of assessing hip instability, which we hope will standardise diagnosis across different raters and health-centres, and may perhaps improve reliability of diagnosis. To quantify dynamic assessment, we propose to use the variability in femoral head coverage (FHC) measurements within multiple US scans collected during a dynamic assessment. In every US scan, we use our recently-developed automatic FHC measuring tool which leverages phase symmetry features to approximate vertical cortex of ilium and a random forest classifier to identify approximate location of the femoral head. Having estimated FHC in each scan, we estimate the change in FHC across all the US scans during a dynamic assessment and compare this change with variability of FHC found in previous studies.

Our findings - in a dynamic assessment on an infant done by an orthopaedic surgeon, the femoral centre moved by up to 19% of its diameter during distraction, from 55% FHC to 74% FHC. This variability is similar to the variability of FHC in static US scans reported in previous studies, so the variability in FHC readings we found are not indicative of any subluxation or dislocation of the infant's femoral head. Our clinician's qualitative assessment concluded the hip to be normal and not indicative of instability. This suggests that our technique likely has sufficient resolution and repeatability to quantify differences in laxity between stable and unstable hips, although this presumption will have to be confirmed in a subsequent study with additional subjects. The long-term significance of this approach to evaluating dynamic assessments may lie in increasing early diagnostic sensitivity in order to prevent dysplasia remaining undetected prior to manifesting itself in early adulthood joint disease.

Hip displacement is the second most common deformity in children with cerebral palsy (CP). A displaced, and particularly a dislocated hip, can have significantly adverse effects on an individual. Surgical intervention to correct progressive hip displacement or dislocation is recommended for children with CP. Success of surgical intervention is often described using radiological outcomes. There is evidence that surgical treatment for displaced or dislocated hips decreases pain and hip stiffness and improves radiological outcomes. However, there is no information in the literature regarding the impact of surgical treatment on the health related quality of life (HRQOL) in these children. The aim of our study was to examine the impact of surgical treatment of hip displacement or dislocation on HRQOL in children with CP.

This prospective longitudinal cohort study involved children attending a tertiary care hospital orthopaedic department. Children with CP between the ages of 4 and 18 years, with hip displacement/dislocation, defined as a Reimer's migration percentage (MP) of >40% on a pre-operative x-ray, and undergoing surgical reconstruction were eligible for inclusion. Quality of life was measured pre-operatively and post-operatively using the CPCHILD Questionnaire.

Twelve patients (one child was GMFCS level III, 4 were level IV, and 7 were level V), aged 4.0 to 17.3 years, were assessed pre-operatively and then again at least six months post-operatively. All underwent unilateral (5) or bilateral (7) reconstructive hip surgery. The migration percentage of hips undergoing reconstruction was reduced by an average of 52% (9–100%). The average change in CPCHILD score showed an increase of 6.4 points [95% CI: −1.4–14.2].

In this pilot study, no significant change was noted in HRQOL following reconstructive hip surgery, despite a marked reduction in Reimer's MP. However, only 4 of 12 parents reported that their child had daily pain pre-operatively. A larger sample size will be required to draw more accurate conclusions from these findings. There is an evident need for a multicentre study examining this issue in a larger patient population in order to determine the long-term impact of different hip interventions on quality of life in children with CP.

Ultrasound (US) is the standard imaging modality used to screen for developmental dysplasia of the hip in infants. Currently, radiologists or orthopaedic surgeons review scan images and judge them to be adequate or inadequate for interpretation. If considered adequate, diagnostic dysplasia metrics are determined; however, there is no standardised method for this process. There is significant inter-observer variability in this manual process which can affect misdiagnosis rates. To eliminate this subjectivity, we developed an automatic method to identify adequate US images and extract dysplasia metrics. The purpose of this study was to validate the efficacy of this automatic method by comparing results with observer-determined dysplasia metrics on a set of US images.

A total of 693 US images from scans of 35 infants were analysed. Trained clinicians at a single institution labeled each image as adequate or inadequate, and subsequently measured alpha and beta angles on adequate images to diagnose dysplasia. We trained our image classifier on random sets of 415 images and used it to assess the remaining 278 images. Alpha and beta angles were automatically estimated on all adequate images. We compared the manual and automatic methods for discrepancies in adequacy determination, metric variability and incidences of missed early diagnosis or over-treatment.

There was excellent agreement between the automatic and manual methods in image adequacy classification (Kappa coefficient = 0.912). On each adequate US image, alpha and beta angle measurements were compared, producing mixed levels of agreement between methods. Mean discrepancies of 1.78°±4.72° and 8.91°±6.437° were seen for alpha and beta angles, respectively. Standard deviations of the angle measures across multiple images from a single patient scan were significantly reduced by the automatic method for both alpha (p<0.05) and beta (p<0.01) angles. Additionally, the automatic method classified three hips (two patients) as Graf type II and two hips (two patients) as type III, while the manual method classified them as type I and II, respectively. Both cases flagged as type III patients by the automatic system subsequently failed Pavlik harness treatment and were booked for surgery.

The automatic method produced excellent agreement with radiologists in scan adequacy classification and significantly reduced measurement variability. Good agreement between methods was found in Graf classification. In instances of disagreement, subsequent clinical findings seemed to support the classification of the automatic method. This proposed method presents an alternative automatic, near-real-time analysis for US images that may potentially significantly improve dysplasia metric reliability and reduce missed early diagnoses without increasing over-treatment.

Closed reduction and percutaneous pinning has become the most common technique for the treatment of Type III displaced supracondylar humerus fractures in children. The purpose of this study was to evaluate whether the loss of reduction in lateral K wiring is non-inferior to crossed K wiring in this procedure.

A prospective randomised non-inferiority trial was conducted. Patients aged three to seven presenting to the Emergency Department with a diagnosis of Type III supracondylar humerus fracture were eligible for inclusion in the study. Consenting patients were block randomised into one of two groups based on wire configuration (lateral or crossed K wires). Surgical technique and post-operative management were standardised between the two groups. The primary outcome was loss of reduction, measured by the change in Baumann's angle immediately post –operation compared to that at the time of K wire removal at three weeks. Secondary outcome data collected included Flynn's elbow score, the humero-capitellar angle, and evidence of iatrogenic ulnar nerve injury. Data was analysed using a t-test for independent means.

A total of 52 patients were enrolled at baseline with 23 allocated to the lateral pinning group (44%) and 29 to the cross pinning group (56%). Six patients (5 crossed, 1 lateral) received a third wire and one patient (crossed) did not return for x-rays at pin removal and were therefore excluded from analysis. A total of 45 patients were subsequently analysed (22 lateral and 23 crossed). The mean change in Baumann's angle was 1.05 degrees, 95% CI [-0.29, 2.38] for the lateral group and 0.13 degrees, 95% CI [-1.30, 1.56] for the crossed group. There was no significant difference between the groups in change in Baumann's Angle at the time of pin removal (p = 0.18). Two patients in the crossed group developed post-operative iatrogenic ulnar nerve injuries, while none were reported in the lateral group.

Preliminary analysis shows that loss of reduction in Baumann's angle with lateral K wires is not inferior to crossed K wires in the management of Type III supracondylar humerus fractures in children. The results of this study suggest that orthopaedic surgeons who currently use crossed K wires could consider switching to lateral K wires in order to reduce the risk of iatrogenic ulnar nerve injuries without significantly compromising reduction.

Laterality and bilaterality have been reported as prognostic variables in DDH outcomes. However, there is little clarity across the literature on the reporting of laterality in developmental dysplasia of the hip (DDH) due to the variability in severity of the condition. It is widely accepted that the left hip is most frequently affected; however, the true incidence of unilateral left, unilateral right and bilateral cases can be hard to quantify and compare across studies. The purpose of this study was to examine laterality accounting for graded severity in a multicentre, international prospective observational study of infants with hip dysplasia in order to demonstrate the complexity of this issue.

A multicentre, prospective database of infants diagnosed with DDH between the ages of 0 and 18 months was analysed from 2010 to April 2015. Patients less than six months were enrolled in the study if at least one hip was frankly dislocated. Patients between 6 and 18 months were enrolled if they had any form of hip dysplasia. Each hip was classified as reduced, dysplastic, dislocatable/subluxable, dislocated reducible or dislocated irreducible. Baseline diagnosis was used to classify patients into a graded laterality category accounting for hip status within the DDH spectrum.

A total of 496 patients were included in the analysis; 328 were <6 months old at diagnosis and 168 were between 6 and 18 months old. Of these patients, 421 had at least one frankly dislocated hip. Unilateral left hip dislocations were most common, with 223 patients, followed by unilateral right and bilateral dislocations with 106 and 92 respectively. Stratifying these patients based on status of the contralateral hip, 54 unilateral left and 31 unilateral right dislocated patients also had a dysplastic or unstable contralateral hip. There were significantly fewer bilateral patients in the 6–18 month group (p=0.0005). When classifying laterality by affected hip, bilaterality became the predominant finding, comprising 42% of all patients.

The distribution of unilateral left, unilateral right and bilateral cases was greatly impacted by the method of classification. Distinct patterns were seen when considering dislocated hips only, or when considering both dislocated and dysplastic/unstable hips. Findings from this multicentre prospective study demonstrate the necessity to account for the graded severity in hip status when reporting DDH laterality. In order to accurately compare laterality across studies, a standardised, comprehensive classification should be established, as contralateral hip status may impact prognosis and treatment outcomes.

A commonly misunderstood principle in medical literature is statistical significance. Often, statistically non-significant or negative results are thought to be evidence for equivalence; mistakenly validating treatment modalities and putting patients at risk. This study examines the prevalence of misinterpretation of negative results of superiority trials in orthopaedic literature and outlines the need for a non-inferiority or equivalence research design.

Four orthopaedic journals – Journal of Paediatric Orthopaedics A, Journal of Bone and Joint Surgery American Volume, Journal of Arthroplasty and Journal of Shoulder and Elbow Surgery – were hand searched to identify all randomised control trials (RCTs) published within the time periods 2002–2003, 2007–2008 and 2012–2013. The identified RCTs were read and classified by study methodology, results obtained, and interpretation of results.

A total of 237 RCTs were identified. When analysing the primary outcomes, 117 (49.4%) studies yielded negative results and 120 (50.8%) yielded positive results. Out of the 237 articles, 231 (97.5%) used superiority methodology and 6 (2.5%) used non-inferiority or equivalence methodology. Of the 231 studies that used superiority methodology, 115 (49.8%) obtained negative results; and 45 (39.1%) of those misinterpreted the negative results for equivalence. While no statistical differences were seen, there was an upward trend in utilising non-inferiority and equivalence methodologies over time.

Given the frequency of misinterpreted negative results, there is an evident need for a more appropriate research methodology that shows equivalence of treatment methods. A non-inferiority or equivalence study design can address orthopaedic clinical dilemmas more suitably when trying to show one treatment is no worse or is equal to another treatment. Regarding orthopaedic treatment modalities as equivalent when studies show negative statistical results can be detrimental to patients and their clinical outcomes. A non-inferiority methodology can be used to accurately depict no difference between treatment methods rather than attempting to show one treatment method as superior.

This pilot study aims to investigate the utility and feasibility of a unique upright MR scan for imaging hips affected by Legg-Calve-Perthes Disease (LCPD) with patient standing up, in comparison to the standard supine scans.

Protocol development using this unique upright MRI included healthy adult and child volunteers. Optimum patient positioning in a comparable way between supine to standing was assessed. The balance between shorter scan time (to what a child can tolerate) and longer scan time (for better image acquisition). The study protocol has begun in 2 children with LCPD. Patient recruitment continues.

Early results indicate a dynamic deformity of the femoral head in early stage LCP disease. Femoral epiphysis height decreased on standing (7.8 to 6.8mm), width increased on standing (16.6 to 20.9mm) and lateral extrusion increased (3.5 to 4.1mm). Overall epiphyseal shape changed from trapezoidal (LCP femoral head when supine) to flattened triangular (LCP femoral head when standing). Differences were thus demonstrated in all parameters of bony epiphyseal height, width, extrusion and shape of a femoral head with LCP Disease when the child stood and loaded the affected hip.

Satisfactory image acquisition was possible with Coronal T1 GFE sequences, with both hips in the Field of View. 2.5min scans were performed with the child standing first, then supine. Hip position was comparable when standing and supine. Longer scans were not tolerated by younger children, more so those with LCP disease.

To our knowledge this is the first reported use of standing MRI in LCPD. A dynamic deformity has been demonstrated, with flattening, widening and worsened lateral extrusion when the child is standing compared to supine. This proof of concept investigation demonstrates the feasibility of upright MRI scanning and may demonstrate previously undetected deformity.

Ultrasound (US) imaging is recommended for early detection of Developmental Dysplasia of the Hip (DDH) to guide decisions about possible surgical treatment. However, a number of studies have raised concerns over the efficacy of US in early diagnosis. The main limitation of US-based diagnosis is sub-standard reliability of the primary dysplasia metric measurements: namely, the alpha and beta angles. In this study, we have proposed a novel and automatic method to extract dysplasia metrics from 2D US, which we hope will improve the overall reliability of US-based DDH measurements by removing error due to subjective measurements. We hypothesise that improvements in reliability of dysplasia metric measurements will reduce the chances of missed early-diagnosis, and therefore reduce the need for later complex surgical treatments.

We evaluated performance of the algorithm on 4 infants diagnosed with US scans for DDH. The typical runtime of our algorithm is less than 1 second for an US image. We found a 6° bias between manual and automatic measurements, with automatic measurements tending to be lower in value; the standard deviation in the discrepancy values was also relatively high at 7°. This suggests that there is considerable variability in the angle estimation process, which is typically done manually, which supports our contention that further work needs to be done to establish an accurate and repeatable measurement technique. Further, we found agreements in the Graf-classification types in six out of seven sessions. For the one patient where there was a discrepancy in classification, later US sessions suggest the manual technique possibly missed the opportunity for early detection, in contrast to the automatic method which classified the patient as having evidence of dysplasia. Thus, such an automatic method may improve the reliability of current US-based DDH diagnosis techniques. The primary limitation of this study is that we have done strictly an intra-image discrepancy analysis and have not compared the results with what could be considered a ‘gold standard’ reference. In future work, we plan to assess these indices on 3D images of the hip and assess the accuracy of proposed 2D and 3D-based automatic index calculation techniques against a 3D reference model.

Perthes disease is a childhood disorder often resulting in femoral head deformity. Categorical/dichotomous outcomes of deformity are typical clinically, however quantitative, continuous measures, such as Sphericity Deviation Score (SDS), are critical for studying interventions. SDS uses radiographs in two planes to quantify femoral head deformity. Limitations of SDS may include non-orthogonal planes and lost details due to projections. We applied this method in 3D, with specific objectives to: 1. Develop SDS-like sphericity measures from 3D data 2. Obtain 2D and 3D sphericity for normal and Perthes hips 3. Compare slice-based (3D) and projection-based (2D) sphericity CT images of 16 normal (8 subjects) and 5 Perthes hips (4 subjects) were segmented to create 3D hip models. Ethics board approval was obtained for this study. SDS consists of roundness error (RE) in two planes and ellipsoid deformation (ED) between planes. We implemented a modified SDS which was applied to (a) orthogonal projections simulating radiographs (sagittal/coronal; 2D-mSDS), and (b) largest radii slices (sagittal/coronal; 3D-mSDS). Mean 2D-mSDS was higher for Perthes (27.2 (SD 11.4)) than normal (11.9 (SD 4.1)). Mean 3D-mSDS showed similar trends, but was higher than 2D (Perthes 33.6 (SD 5.3), normals 17.0 (SD 3.1)). Unlike 2D-mSDS, 3D-mSDS showed no overlap between groups. For Perthes hips, 2D-mSDS was consistent with SDS. For normal hips, 2D-mSDS was higher than expected (similar to Stulberg II). Projection-based (2D) measures may produce lower mSDS due to spatial averaging. Slice-based (3D) measures may better distinguish between normal and Perthes shapes, which may better differentiate effectiveness of treatments.

Purpose: The wait for surgical treatment of scoliosis is long in some countries, especially in those with publicly funded health care systems. Long wait times may have serious consequences if the deformity increases during the wait period. This study was undertaken to determine the surgeon’s perspective of the type and magnitude of surgery required with specific emphasis on peri – and post-operative measures, for patients with scoliosis on prolonged waitlist times (> 6 months) for surgery.

Method: Radiographs from 11 patients who had a Cobb angle of at least 50 degrees and had waited 6 or more months for scoliosis surgery selected from the scoliosis database. All patients had antero-posterior (AP), AP bending, and lateral radiographs taken when the primary curve magnitude was 50 degrees and at the time of pre-operative planning. 22 radiographic sets and a questionnaire were sent to three different surgeons. The surgeons were blinded to the fact that these sets contained films of the same patients at two different time points. The questionnaire requested information with regard to the type of surgery and instrumentation they would use, other peri-operative measures, and time taken to return to normal activities.

Results: The mean curve progression in the 11 patients was 25 degrees over the time on the waitlist, from an average of 50 degrees to 75 degrees. The type of surgery the surgeon would likely perform changed from posterior instrumentation and fusion with a screw construct in all patients to anterior release and posterior instrumentation and fusion with a screw construct in 8 of the 11 patients, in at least one surgeon’s opinion. The mean estimated operative time increased by 2 hours. The mean estimated length of stay at the hospital increased by 1 day, and the estimated level of difficulty of surgery increased from 3/10 to 5/10.

Conclusion: From a surgeon’s perspective, waits of 6 months or more for scoliosis surgery are unacceptable as they lead to the need for a second anterior procedure that probably would have not been necessary had the operation occurred earlier. It also leads to increased operative time, blood loss, length of stay, and difficulty of surgery. This, in turn, increases unwarranted risks and costs.

Purpose: Pinch strength has been shown to be a predictor of the ability to grip objects and perform functional hand-related tasks. As the sole flexor of the thumb IP joint, the flexor pollicus longus (FPL) muscle has previously been shown to play an essential role in directing thumb tip force as well as contribute to overall pinch strength. The relative contribution of FPL to pinch strength is unknown however. As the FPL may be affected in several acute and chronic conditions, determining the contribution of FPL to pinch strength may be useful in planning as well as evaluating treatment options. The purpose of this study was to estimate the contribution of FPL to pinch strength in-vivo using an EMG-guided, selective motor blockade, test-retest protocol.

Method: 11 healthy volunteers were recruited to participate in the study. All participants completed a brief questionnaire regarding prior hand injuries and subsequently underwent a physical examination to assess baseline hand function. Baseline pinch strength was recorded using three different pinch techniques: key pinch, 3-point chuck grasp, and tip pinch. Participants then underwent EMG-guided lidocaine blockade of the FPL muscle. Motor evoked potentials as well as skin potentials were used to confirm adequate FPL blockade. The physical exam was repeated as were pinch strength measurements. Post block splinting was necessary to stabilize the thumb IP joint. Grip strength, in addition to clinical examination, was utilized pre and post block to assess for inadvertent blockade of other muscle groups or nerves. A final clinical evaluation was conducted at study completion to note any complications or adverse effects.

Results: All three types of pinch strength showed a significant difference between pre and post measurements (p< 0.01). The mean differences pre and post were 9.7N,6.4N, and 5.2N in key, 3-point chuck, and tip pinch respectively (p< 0.01). The relative contribution of FPL for each pinch type was 53.2%,39.5%, and 44.3%. EMG, motor evoked potentials, and skin potentials confirmed adequate paralysis of the FPL. Physical examination did reveal decreased sensation in median and radial nerve distributions in some individuals, however the effect on observed motor function was negligible. Grip strength decreased by only 4N post blockade confirming no clinically significant median nerve motor blockade. The protocol was well tolerated and no serious complications were noted.

Conclusion: Using an in-vivo model we were able to estimate the contribution of FPL to overall pinch strength. In our study, FPL’s contribution to pinch strength was estimated to be 9.7N,6.4N, and 5.2N in key, 3-point chuck, and tip pinch respectively (p< 0.01). The relative contribution of FPL for each pinch type was 53.2%, 39.5%, and 44.3%. Inherent limitations in study design may have tended to overestimate the contribution of FPL to pinch. This information may be useful in planning and evaluating treatments for acute and chronic conditions affecting FPL function.

Purpose: Upper cervical spine stabilization in children can be challenging due to anatomic abnormalities such as incomplete posterior elements, vertebral artery variability and small patient size. Several techniques have been described for stabilization of the upper cervical spine, each with its own advantages and disadvantages. Since the introduction of the technique by Harms, many authors have shown C1 lateral mass screws to be safe and effective in the stabilization of the upper cervical spine in adults. No large series of paediatric C1 lateral mass screw fixation has been reported in the literature. The purpose of this study was to describe the indications, technique, and outcomes of C1 lateral mass screw fixation in a consecutive series of 11 paediatric patients.

Method: A database generated retrospective review of all patients who underwent C1 lateral mass screw fixation as part of an upper cervical spine stabilization construct was performed. In all patients the C2 dorsal root ganglion was sacrificed. Patient demographics and clinical outcomes were obtained through chart review. Radiographs immediately post-operatively, at six-weeks, three-months, and final follow-up were reviewed.

Results: Eleven consecutive paediatric patients underwent bilateral C1 lateral mass screw fixation for a variety of conditions including C1-C2 instability, deformity, congenital malformation, trauma, as well as revision surgery. The average age was 10 years (range 4 to 16 years) with a mean follow-up of 11 months (range 6 – 18 months). There were no iatrogenic vertebral artery, hypoglossal nerve or spinal cord injuries. All 11 patients had solid fusion clinically and radiographically, with no loss of fixation. The C2 dorsal root ganglion was sacrificed in all patients with resulting minor occipital parasthaesia that progressively diminished in severity.

Conclusion: This is the largest series of consecutive patients reported in the literature to date showing that the technique is safe and effective, with acceptable morbidity when applied to the paediatric population. We believe that C1 lateral mass screws offer significant advantages over traditional fixation techniques when the C1 vertebra is to be included in an upper cervical instrumented construct.

Purpose: Non-steroidal anti-inflammatory drugs (NSAIDs) are powerful analgesics, frequently used for post-operative pain control. However, concerns regarding the potential deleterious effects of NSAIDs on bone healing have compelled many physicians to avoid NSAIDs in patients with fractures, osteotomies, and fusions. The purpose of this study was to systematically review and meta-analyze the best clinical evidence regarding the effects of NSAIDs on bone healing.

Method: We performed a literature search for studies of fracture, osteotomy or fusion patients with NSAID exposure, and non-union as an outcome. Data on study design, patient characteristics and risk estimates were extracted. Pooled effect estimates were calculated. Study inclusion results were checked for evidence of publication bias. Metaregressions were performed to assess the impact of age, smoking, and study quality on reported risk of non-union.

Results: Seven spine fusion and four long-bone fracture studies were included. A significant association between lower quality studies and higher reported odds ratios for non-union was identified. When only higher quality studies were considered, seven spine fusion studies were analyzed, and no statistically significant association between NSAID exposure and non-union was identified (OR=2.2, 95%CI:0.8, 6.3). No statistically significant association was found in sub-analysis of patients exposed to high dose IV/IM ketorolac (OR=2.0, 95%CI:0.4, 11.1), low dose IV/IM ketorolac (OR=1.2 95%CI:0.3, 4.5), or standard oral NSAIDs (OR=7.1, 95%CI:0.1, 520). In sub-analysis of the four most clinically relevant studies of adult spine fusion patients with well defined peri-operative NSAID exposure, no statistically significant association was found between NSAID exposure and risk of non-union (OR=0.8 95%CI:0.4, 1.4).

Conclusion: Studies on NSAID exposure in long-bone healing settings were of lesser quality than studies in the spine fusion setting. Within the spine literature we could not demonstrate any increased risk of non-union with NSAID exposure. Randomized controlled trials (and meta-analyses of such trials) on the impact of standard NSAID and COX-2 inhibitor exposure in spine and long-bone fracture, fusion and osteotomy populations are warranted to confirm or refute the findings of this meta-analysis of observational studies.

Purpose: Tourniquet cuff pressures in paediatric patients are commonly set at standard pressures. Recent evidence on adult subjects has shown that safer and more effective cuff pressures can be achieved by measuring limb occlusion pressure (LOP) and using a wide, contour cuff. There is little evidence validating these techniques in children. The primary objective of this study was to evaluate if a difference in tourniquet cuff pressure can be achieved in a paediatric population using a wide contour cuff in conjunction with measured LOP when compared to a standard cuff and pressure.

Method: Subjects aged 10 to 17 years that underwent anterior cruciate ligament repair were included and ran-domised into either the control group or the experimental ‘LOP’ group using variable block randomisation. The tourniquet cuff was inflated to 300 mmHg in the control group or to the recommended tourniquet pressure based on LOP measurement in the LOP group. The surgeon was blinded to cuff selection, application and pressure throughout the surgical procedure. Immediately following the surgical procedure, the surgeon rated the quality of the bloodless field on a visual analogue scale (VAS). This study was powered as an effectiveness trial and intention to treat analysis was used.

Results: Following a planned interim analysis at midpoint, complete data was recorded for 11 patients (control group) and 10 patients (LOP group). The quality of the surgical field was not different between groups (p= 0.053). There was a statistically significant difference in mean cuff pressure between the control group (300 mmHg) and the LOP group (151 mmHg) (p < 0.001). We ran the same analysis comparing the LOP data to hypothetical control data of 250 mmHg and our results remained statistically significant (p < 0.001).

Conclusion: The use of an automatic LOP measurement with the use wide contour cuffs can significantly reduce average tourniquet cuff pressures in paediatric patients compared to typical practice of 300 mmHg or 250 mmHg without compromising the quality of the surgical field.

Purpose: The lateral pillar classification for Perthes disease described by Herring in 1992 has gained wide acceptance as a method of predicting outcome and planning treatment. Our purpose was to determine the reproducibility of Herring’s lateral pillar classification using visual estimation and by direct measurement and determine if the Herring’s grading alters as the child passes through the stage of fragmentation in Perthes’ disease.

Method: One hundred AP and frog lateral radiographs of children with unilateral Perthes’ disease in the stage of fragmentation were classified according to the Herrings classification by two investigators utilizing a visual and measurement technique. The change in Herring’s grading with progression of disease was evaluated in 86 patients with sequential radiographs in the stage of fragmentation.

Results: The level of intra-observer agreement by the measurement technique was excellent for both AP and lateral radiographs (Kappa = 0.92 and 0.98) as compared to the visual method for which the agreement was moderate (Kappa = 0.65 and 0.5). The inter-observer reproducibility was moderate by the visual method for both AP and lateral radiographs (Kappa = 0.51 and 0.43). The level of agreement for the measurement method was good for the AP radiographs (Kappa = 0.66) and was only moderate for the frog lateral radiographs (Kappa = 0.53). Of the total 86 cases that had sequential radiographs in the stage of fragmentation, 33 showed change in Herring’s grading. Among these 33 cases, 25 showed a change in the extent of epiphyseal collapse in the AP radiographs alone whereas 8 cases showed a change in lateral radiographs. Upgrading of Herring’s grade from A to B was seen in 11 cases and from B to C in 14 cases as observed in the AP radiographs. The clinical variables and radiological variables did not show any association with progression of Herring’s grade.

Conclusion: The measurement technique of assessing Herring’s classification is much more reliable than the originally described visual method. However, the Herring’s grade changes with the evolution of the disease even during the process of fragmentation and must be used with caution when predicting prognosis.

Supracondylar fractures of the humerus in children are among the most common paediatric fractures, and yet present one of the greatest technical challenges for management. Traditionally treated as surgical urgencies, recent literature calls that belief into question. The purpose of this study was to determine the influence of the elapsed time from injury to surgery of Gartland Type III supracondylar fractures on operative time and quality of reduction.

A retrospective review of all Gartland Type III supra-condylar factures treated by closed reduction and percutaneous pinning at our hospital between January 2003 and April 2006 was performed. Subjects in this consecutive series underwent a formal chart review to extract necessary data. The intra-operative fluroscopic images were utilised to assess the quality of reduction. All images were analyzed by three independent blinded reviewers on two separate occasions. Parameters measured on the AP images included: Baumann’s Angle, Humerocapitellar angle, Gordon Index, Griffet Index one and two.

Of the one hundred and forty-one charts reviewed, twenty-nine were excluded for various criteria. Of the remaining sample (N=112), sixty-one patients were treated in less than eight hours (Group one), and fifty-one treated after eighthours (Group two). There were sixty-one girls and fifty-one boys, with a mean age of six yrs. There were no cases of compartment syndrome. No subjects required conversion from closed to open reduction. The mean time from injury to surgery was six hundred and seventy minutes (min = 128, max = 3117). The mean for Group one was three hundred and forty-one minutes and one thousand and sixty-five minutes for Group two. The mean operative time was 33.29 minutes, (min=ten, max =eighty-two). The mean operative time in Group one was 33.13 minutes and 33.38 minutes in Group two. Two t-tailed t-test demonstrates no significant difference between the two groups. Radiographic analysis revealed the following means: Baumann’s angle (m = 70.26), humero-capitellar angle (m= 36.19), Gordon Index (m=33.78), Griffet Index 1 (m=0.88) and Griffet Index 2 (m=2.55). Comparison of the radiographic parameters and indices demonstrated no significant difference between the two groups.

This study demonstrates delaying surgery beyond eight hours led to no difference in operative time or quality of reduction. Previous studies have demonstrated no difference in rate of compartment syndrome, presence of complications or need for open reduction between these two groups. Our findings combined with previous retrospective studies support the need for further prospective study and support the surgeon’s clinical judgment in determining the urgency of surgical intervention in this patient population.

The promotion and practice of evidence-based medicine necessitates a critical evaluation of medical literature including the “gold standard” of randomised clinical trials. Recent studies have examined the quality of randomised clinical trials in various surgical specialties, but no study has focused on pediatric orthopedics. The purpose of this study was to assess and describe the quality of randomised clinical trials published in the last ten years in journals with high clinical impact in pediatric orthopaedics.

All of the randomised clinical trials in pediatric orthopedics published in five well-recognised journals between 1995–2005 were reviewed using the Detsky Quality Assessment Scale.

The mean percentage score on the Detsky Scale was 53% (95% CI: 46%–60%). Only seven (19%) of the articles satisfied the threshold for a satisfactory level of methodologic quality (Detsky > 75%).

The majority of randomised clinical trials in pediatric orthopedics that are published in well-recognised, peer-reviewed journals demonstrate substantial deficiencies in methodologic quality. Particular areas of weakness include inadequate rigor and reporting of randomization methods, use of inappropriate or poorly-described outcome measures, inadequate description of inclusion and exclusion criteria and inappropriate statistical analysis. Further efforts are necessary to improve the conduct and reporting of clinical trials in this field in order to avoid inadvertent misinformation of the clinical community.

Slipped capital femoral epiphysis (SCFE) is the most common pediatric hip disorder. The most devastating complication is development of avascular necrosis of the femoral head. In order to reduce the potential for this complication occurring following delayed contralateral SCFE, there has been consideration in the literature of prophylactic pinning of the contralateral hip. The objective of this study was to determine the cost-effectiveness of this treatment strategy.

The outcome probabilities and utilities utilised in a decision analysis of prophylactic pinning of the contralateral hip in SCFE, reported by Kocher et al, were used in this study. Costing data, reported in 2005 Canadian dollars, was obtained from our institution. Using this data, an economic evaluation was performed. The time horizon was four years, so as to follow the adolescents to skeletal maturity. Discounting was performed at 3% per year. Sensitivity analyses were conducted to determine the effect of variation of the outcome probabilities and utilities.

In all analyses, prophylactic pinning resulted in cost savings but lower utility, compared to the currently accepted strategy of observation of the contralateral hip. The results were most sensitive to an increase in the probability of a delayed contralateral SCFE to 27%. Using the base case analysis, the incremental cost-effectiveness ratio was $7856.12 per utility gained. Using the most sensitive probability of a delayed contralateral SCFE of 27%, the incremental cost-effectiveness ratio was $27,252.92 per utility gained.

The results of this study demonstrated overall cost savings with prophylactic treatment, however the utility was lower than the standard treatment of observation. For both the base case and sensitivity analysis, the incremental cost-effectiveness ratio was less than the accepted threshold of $50,000 per quality adjusted life year gained. It should be noted that the use of a four year time horizon excluded consideration of the costs related to total hip arthroplasty for the sequelae of AVN. A prospective, randomised controlled trial, with an accompanying economic evaluation, is required to definitively answer the question of the cost-effectiveness of this treatment. On the basis of this cost-effectiveness analysis, prophylactic pinning of the contralateral hip in SCFE cannot be recommended. A prospective, randomised controlled trial, with an accompanying economic evaluation, is required to definitively answer the question of the cost-effectiveness of this treatment.

Avascular necrosis (AVN) of the femoral head is a devastating complication of slipped capital femoral epiphysis (SCFE). The reported prevalence of AVN following unstable SCFE has ranged between fifteen and forty-seven per cent in the literature. The explanation for this discrepancy is not clear. The inter-observer and intra-observer agreement between Orthopaedic surgeons for the radiographic diagnosis of AVN following SCFE has not been reported. It is the objective of this study to estimate these parameters between two experienced pediatric Orthopaedic surgeons for the radiographic diagnosis of AVN following SCFE.

A retrospective review of all one hundred and three cases of SCFE treated at a Canadian pediatric referral center between 1995 and 2005 was performed. Of these, eight were diagnosed, by the treating surgeon, with AVN. Each of these eight children and a random sample of fifteen of the remaining children, who were not diagnosed with AVN, were included in this study. The most recent anteroposterior and lateral radiographs were digitised and presented to two experienced pediatric orthopaedic surgeons in a blinded, random order. Each surgeon reviewed the radiographs independently and recorded which radiographs they believed to be consistent with AVN. The surgeons were told that each patient had SCFE and that some developed AVN, however neither the classification of the slip, nor the proportion who developed AVN were divulged. Each observer repeated this process two weeks after the initial review in order to determine intra-observer agreement. The kappa value was determined to assess inter-observer and intra-observer agreement.

The first observer recorded eight cases of AVN at the initial and seven cases at the second observation time. The intra-observer agreement was 0.9. The second observer recorded six cases of AVN at the initial and five cases at the second observation time. The intra-observer agreement was 0.88. The inter-observer agreement was determined at the first observation time and was 0.79.

On the basis of the results of this study, both the inter-observer and intra-observer agreement for the radiographic diagnosis of AVN following SCFE, amongst experienced pediatric Orthopaedic surgeons, was very high. It is unlikely that the reported discrepancy in prevalence of AVN following SCFE is due to a lack of inter-observer agreement, on the basis of the findings of this study. The inter-observer agreement between less experienced observers requires further study to determine if this may be the source of the variability in the reported prevalence of AVN following SCFE.

Supracondylar humeral fractures are the most common elbow injury in children, usually sustained from a fall on the outstretched hand. Iatrogenic ulnarnerve injury is not uncommon following cross K wiring. NNH is the number of cases needed to treat in order to have one adverse outcome. A systemic review was undertaken to calculate relative risks, risk difference and number needed to harm following management of supracon-dylar fractures with cross or lateral K wires. It was found that there was one iatrogenic ulnar nerve injury for every twenty-seven cases that were managed with crossed K wires.

The aim of this study was to calculate the number of cross K wiring of supracondylar fractures of the humerus that would need to be performed for one iatrogenic ulnar nerve injury to occur.

Iatrogenic ulnarnerve injury is not uncommon following cross K wiring of supracondylar fractures of the humerus.

To date there are no clinical trials showing the benefit of cross K wiring over lateral K wiring in the management of supracondylar fractures of the humerus in children. If it can be confirmed that lateral K wiring is as effective as crossed K wiring, iatrogenic ulnar nerve injury can be avoided.

A systematic review of iatrogenic ulnar nerve injuries following management of supracondylar fractures was conducted. The databases MEDLINE 1966 – present, EMBASE 1980 – present, CINAHL 1982 – present, CDSR, and DARE were searched along with a meticulous search of the Journal of Paediatric Orthopaedics from 1998 to 2004. Of the two hundred and forty-eight papers identified, only thirty-six met the inclusion criteria. The papers where both lateral crossed K wires were used as treatment were identified for calculating relative rates, risk difference and number needed to harm.

NNH was 7.69. When a sensitivity analysis removing two studies that had five subjects or fewer and a 100% ulnar nerve injury rate was peformed, the NNH was 27.7. In other words, there was one iatrogenic ulnar nerve injury for every twenty-seven cases that were managed with crossed K wires.

Purpose: The purpose of this study was to assess the clinical, radiological, and functional outcomes following the treatment of a lumbar Chance fracture and to analyze the spectrum of associated abdominal injuries as seen in the Seat Belt Syndrome.

Methods: All patients diagnosed with L1 to L4 Chance fractures were included in this study. Patient data, injuries, treatment and complications were collected from hospital charts. A review of all available spinal radiology was done to measure pre-treatment, post-treatment and follow-up kyphosis angles. We have also described and calculated a Chance Fracture Deformity Index. Patients were seen in follow-up to assess for range of motion, tenderness and neurological status. A functional outcome questionnaire by the AAOS Pediatric Instruments was completed by the patients.

Results: Between December 1984 and February 2001, 27 patients aged 3 to 17 were treated for lumbar Chance fractures. The mean age at injury was 11.1 years. There were 17 females and 8 males. All injuries occurred as a result of a motor vehicle accident. Of the 25 patients, 17 were treated surgically. 12 patients had abdominal injuries. 3 cases involved abdominal arterial vascular trauma. Significant improvement in intra-vertebral kyphosis, segmental kyphosis, and vertebral kyphosis redmodelling (6.5 vs. 4 degrees) was noted in the operative group compared to the non-operative group. The disease specific AAOS Lumbar Spine Questionnaire scores were poor for pain and disability, 29.22, (26.41–31.98), but the SF-36 scores for both MCS and PCS were within the normal range, 47.79 (44.03–51.54) and 47.71 (42.59–52.82), respectively.

Conclusions: An abdominal and spinal CT must be taken when presented with a Chance fracture with abdominal symptoms. Injury type and kyphosis angle are the main factors that aid in treatment planning in paediatric lumbar chance fractures. A purely soft-tissue injury or a kyphosis angle greater than 20 requires surgical intervention.

Introduction and Aims: The anterior approach to dealing with complex spinal deformities around the cervical thoracic junction presents a surgical challenge. With the help of a cardiothoracic surgeon, a sternal splitting technique was utilised in five paediatric patients to resolve this difficulty and gain access to spinal deformities around the cervical thoracic junction.

Method: A longitudinal incision is made parallel to the sternocleido muscle and extended across the sternum for a median sternotomy. The sternocleido muscles are retracted to the lateral aspect of the incision. The carotid and jugular vein are dissected out. To continue with the dissection and exposure of the upper thoracic spine, a full sternotomy is done. The sternum is opened. The dissection of the right carotid is extended over the innominate artery, including the bifurcation of the right subclavian artery. The jugular vein is dissected out coming down to the superior vena cava. The innominate vein is isolated. The lower end of the anterior scalenus muscle is divided up.

Results: This technique was employed in five paediatric patients, aged three to 15 years, at the authors’ institution. Diagnoses included Klippel-Feil Syndrome, Proteus Syndrome, Larsen Syndrome and, Neurofibromatosis (two patients). All patients had severe cervical thoracic kyphosis requiring surgical instrumentation. This technique resulted in a range of access from C5 to T6 being granted. In one patient, a separate thorocotemy was performed in order to gain access to the lower thoracic spine.

Conclusion: This approach was invaluable in gaining access to the cervical thoracic junction to address complex spinal deformities. Access to the lower cervical and the upper thoracic spine is granted. No significant complications occurred. The aid of a cardiothoracic surgeon is advised.

Introduction and Aims: The aim of this paper is to review C1-C2 facet screw use in paediatric patients and to demonstrate that the technique plays an important role in patients with underlying anatomic abnormalities, which are common in children with cervical instability.

Method: A chart review was conducted of all patients managed with C1-C2 facet screws from January 1, 1996 until July 30, 2003 present in the case database. All radiographs were obtained and reviewed. Post-operative and follow-up films were assessed for acceptable screw position and evidence of fusion.

Results: C1-C2 facet screws were utilised in nine patients at British Columbia’s Children’s Hospital. The youngest patient treated was five years of age with a mean age for the group of 12. The group consisted of three Down syndrome patients and six with Os Odontoidium, two of which failed previous C1-C2 fusion. Two patients presented with an acute spinal cord injury. Pre-operative CT or MR imaging was used in all patients.

Screw placement was unacceptable in one case. Post-operative Halo immobilisation was used in seven patients. Post-operative complications included one wound infection and four halo pin infections requiring treatment. No patients have required surgery at a mean follow-up of four years. C1-C2 facet screws are an important adjunct in a paediatric spine practice. This technique has a great advantage in Down syndrome patients who have a high rate of pseudoarthosis because of: ligamentous laxity, non-compliance with immobilisation and a high incidence of congenital deformities such as os odontoidium and incomplete posterior arch of C1.

Conclusion: C1-C2 facet screws can be safely used in young children. The screws allow for fixation in the absence of an intact posterior arch. The technique has a great advantage in Down syndrome patients who have a high rate of pseudoarthosis due to congenital deformities, ligamentous laxity and non-compliance with immobilisation

Introduction and Aims: The aims of this study were to assess the clinical and functional outcomes following the treatment of a lumbar Chance fracture and to analyse the spectrum of associated abdominal injuries as seen in the Seat Belt Syndrome.

Method: All patients diagnosed with L1 to L4 Chance fractures at the British Columbia Children’s Hospital were included in this study. Patient data, injuries, treatment and complications were collected from hospital charts. A review of all available spinal radiology including pre-treatment, post-treatment and follow-up x-rays, CTs and MRIs was done to measure pre-treatment, post-treatment and follow-up kyphosis angles, as well as to help classify the Chance fracture. Patients were seen in follow-up to assess for range of motion, tenderness and neurological status. Furthermore, a functional outcome questionnaire by the American Academy of Orthopaedic Surgeons Pediatric Instruments was completed by the patients.

Results: Between December 1984 and February 2001, 27 patients aged three to 17 were treated for lumbar Chance fractures. The mean age at injury was 11.1 years. There were 18 females and nine males. All injuries occurred as a result of a motor vehicle accident. Nineteen were rear-seat passengers and eight were front-seat passengers. Of the 27 patients, 19 were treated surgically. Of these 19, nine were treated with either pedicle screws or laminar hooks and rods, four with intersegmental spinous process (ISP) wires alone, two with sublaminar wires and four with a combination of screws/hooks, rods and ISP wires. One patient had a post-operative urinary tract infection. Of the eight patients treated conservatively, four were treated with a hyperextension cast and four were treated with a hyperextension brace. Neurological impairment was seen in seven of the 19 surgical patients pre-operatively. Post-operatively impairment was impoved in two of the seven patients. One of the eight patients treated conservatively had neurological impairment which spontaneously resolved. A total of 13 patients underwent surgery for an associated abdominal injury. Three cases involved abdominal arterial vascular trauma and 12 involved small bowel injury.

Conclusion: An abdominal and spinal CT must be taken when presented with a Chance fracture with abdominal symptoms. Injury type and kyphosis angle are the main factors that aid in treatment planning in paediatric lumbar chance fractures. A purely soft-tissue injury or a kyphosis angle greater than 20 requires surgical intervention.

Introduction and Aims: The aims of this study were to compare the over-the-top and four-strand techniques of paediatric anterior cruciate ligament reconstruction. An age and sex-matched control study of these two different ACL reconstructive techniques was done to determine if there are differences in instability, functional outcomes and growth plate-related problems.

Method: Injuries, treatment and associated complications were collected from hospital charts. Pre-operative x-rays were used to determine growth plate status both at the distal femur and the proximal tibia. Pre-operative MRIs were studied to assess the position and nature of mid-substance ACL tear and any associated meniscal tear or pathology. Follow-up included examination as per International Knee Documentation Committee guidelines, including patient history and a clinical examination assessing the degree of anterior draw, presence and quality of a pivot shift test and pivot glide, and arthrometric measurements using the KT-1000 Arthrometer for anterior translational distance in millimetres. The Lysholm questionnaire was completed by all patients.

Results: Thirty-nine paediatric patients were reviewed for anterior cruciate ligament injuries requiring reconstruction at the authors’ institution. Data collected included background information on the injury, including mechanism and age at injury and surgical information including age at surgery, surgical procedure, and technique. Surgical follow-up information was also collected including wound problems, re-ruptures, or growth arrests. The mean age at injury was 14.3 years. The predominant mechanism of injury was twist and turn with 21 reports. The average age at surgery was 15.2 years, with 20 patients undergoing reconstruction of their ACL alone and 19 patients repair of their ACL and menisci. Fourteen patients were treated using the four-strand technique, while 25 patients were treated using the over-the-top method. We have an average follow-up of 1.9 years post-surgery. Three patients in the over-the-top group had wound infections. There were no known growth arrests or re-ruptures in this patient group based on this limited follow-up. Fifty-five percent of patients had meniscal involvement. Those with a meniscal tear were older than those without (14.5 years versus 11.5 years; p< 0.05).

Conclusion: Once rare, injuries of the anterior cruciate ligament in skeletally immature patients have become a common clinical presentation. It is important to have a documentation of the amount of pathologic laxity of the knee joint. Instrumented measurements can show the success of an ACL reconstruction in restoring the patient’s knee to normal joint kinetics.

Background: Current treatment for Perthes disease aims at preventing deformation of the femoral head during the active stage of the disease by obtaining containment of the femoral head. To effectively pre-empt femoral head deformation, one needs to know, when during the disease irreparable femoral head deformation occurs. This study was undertaken to attempt to clarify this.

Methods: Records and 2634 pairs of radiographs (AP and lateral) of 610 patients with Perthes’ disease were reviewed. The evolution of the disease was divided into seven stages (Stages Ia, Ib, IIa, IIb, IIIa, IIIb & IV) based on plain radiographic appearances. Intra-observer and inter-observer reproducibility of this new classification system was assessed. The duration of each stage of the disease was noted. The stage at which epiphyseal extrusion and widening of the metaphysis occurred and the stage at which metaphyseal and acetabular changes appeared were identified. The shape and the size of the femoral head, the extent of trochanteric overgrowth and the radius of the acetabulum were assessed in hips that had healed.

Results: The reproducibility of the new classification system of the evolution Of Perthes’ disease was good. The median duration of each stage varied between 95 and 326 days. Epiphyseal extrusion and metaphyseal widening was modest in Stages Ia, Ib and IIa but increased dramatically after Stage IIb. > 20% extrusion occurred in 70% of the hips by Stage IIIa. Metaphyseal changes were most frequently encountered in Stage IIb, while acetabular changes were most prevalent in Stage IIIa. At healing, only 24% of untreated patients had spherical femoral heads, while 52% had irregular femoral heads.

Conclusions: The new classification of the stages of evolution of Perthes’ disease helps to identify when crucial events occur during the course of the disease. The timing of epiphyseal extrusion, metaphyseal widening and the appearance of adverse metaphyseal and acetabular changes suggest that femoral head deformation occurs by Stage IIIa in untreated hips. Hence, if containment were to succeed, it should be achieved before this stage.

Aim: The neonatal screening procedure in South Australia has shown that the late diagnosis of developmental dysplasia of the hip (DDH) is rare with well conducted clinical screening. We studied the cases of late diagnosis of DDH to determine the epidemiological features and the out come of management with special reference to development of the femoral head and acetabulum.

Methods: Patients’ case records and radiographs with a delayed diagnosis of DDH, identified by the South Australian Birth Defects Register between 1988 and 1993, were reviewed. Epidemiological features, acetabular angles, size of femoral head, spherical index, CE angle and migration percentage were examined. The Severin’s grouping and Makey’s criteria were used to assess radiological and clinical outcomes. Late DDH was defined as DDH diagnosed after three months of age.

Results: The acetabular angles and percentage coverage improved rapidly -faster in younger children. The CE angle also improved rapidly. When treatment was started late (after one year) the improvement was slower and final out come was unpredictable. The femoral head continued to grow irrespective of age at reduction and became normal in most cases. In some patients Salter osteotomies stabilised the hips after open reductions and gave excellent results. The epidemiological features were compared with that of DDH diagnosed early in postnatal life.

Conclusions: Clinical screening and early detection is important in the outcome of DDH. Early treatment may give better results.

Background: Femoral varus osteotomy for Perthes’ disease aims at achieving Containment to prevent femoral head deformation. Theoretically, ontainment is most likely to succeed if it is achieved before the femoral head extrudes and is subjected to deforming stresses. It would follow that the timing of the procedure is an important factor in determining the outcome. This study was undertaken to verify this.

Methods: Records and radiographs of 610 patients with Perthes’ disease were analysed. The data of 302 patients who underwent femoral osteotomy were compared with those of non-operated patients. A new modification of the Elizabthtown classification of the stages of evolution of the disease with seven stages (Stages Ia, Ib, IIa, IIb, IIIa, IIIb & IV) was used to identify the timing of surgery and to monitor the progress of the disease following surgery. The results of treatment were assessed at healing by Mose’s criteria. Multivariate analysis was used to identify variables that influenced the shape and size of the femoral head at healing.

Results: 22 patients among 86 who were operated in Stage Ia or Ib by-passed the stage of fragmentation. The extent of metaphyseal widening was considerably less in operated children. At healing, spherical femoral heads were seen in 72% of operated hips as compared to 24% of non-operated hips. The variables that influenced the shape of the femoral head at healing were, metaphyseal width, sex, age at onset, epiphyseal extrusion and the stage at surgery. Patients who were operated before Stage IIb had significantly better results than those operated later.

Conclusions: The results of the study support the impression that the timing of containment is an important factor that influences the outcome in Perthes’ disease. The best results are obtained if containment is achieved before Stage IIb.

Aim: To determine that the aetiology of cord compression in mucopolysaccharidoses (MPS) type VI. To illustrate the variability of this complication of mucopolysaccharidoses even within families. To report the youngest MPS VI patient yet described with spinal cord compression and to present the technique and results of spinal stabilisation.

Method: The course, clinical findings and management of three patients with MPS VI and two with MPS IV were reviewed.

Results: The patients with MPS VI demonstrated that the pathogenesis of spinal cord compression in this condition is complex, with elements of joint instability, bony disease and soft tissue compression. Two of the patients with MPS VI are siblings: the younger sibling was 30 months old when she required surgery. She is the youngest reported patient with this complication of MPS VI. The patients with MPS IV are presented to illustrate similarities and differences in the pathogenesis of the same problem in the two disorders. Results of cervical spine stabilisation were found to be satisfactory.

Conclusions: In both MPS IV and MPS VI spinal cord compression may be multi-factorial. This complication of the mucopolysaccharidoses needs to be considered even when the patient is very young.

We studied the natural history of Perthes’ disease in 62 children in whom the onset of symptoms was in adolescence.

Three patterns of disease were noted, namely, late-onset pattern, segmental collapse, or destructive with failure of revascularisation. In the late-onset pattern, the disease followed the sequence of healing seen in younger children, but adequate epiphyseal remodelling did not occur. Consequently, the femoral head was never spherical after revascularisation. With segmental collapse, early and irreversible collapse of part of the epiphysis occurred with gross deformation of the femoral head. The destructive pattern was characterised by a failure of revascularisation and repair of the avascular epiphysis.

The radiological outcome was poor in all three patterns. The poorest clinical results were found in the destructive type which was frequently associated with incapacitating pain requiring arthrodesis or excision arthroplasty within three years of onset of the disease.