Virtual physiotherapy has been provided to hundreds of patients at the Holland Centre during the COVID pandemic. As we plan for virtual care to be one part of our care delivery we want to evaluate it and ensure the care delivery is safe and effective.

The objectives of this project was two-fold: 1) to examine the outcome of virtual physiotherapy and/ or a hybrid of virtual and in-person care in patients who received post-operative treatment following total knee replacement at the Holland Centre, 2) to explore the challenges of virtual care participation in the joint replacement population.

Patients who received either virtual care or a combination of in-person and virtual care (hybrid model) based on the patients’ needs were included. Patient-related outcomes were the Patient Specific Functional Scale (PSFS) and pain scale. Flexion and extension range of motion were measured before and after treatment. A modified Primary Care Patient Experience Virtual Care Survey was used to examine barriers for virtual care.

Sixty patients, mean age 68(8), ranging between 45-83 years, 34(57%) females, who received either virtual care or a combination of in-person and virtual care based on the patients’ needs were included. Patients showed improvement in the PSFS and pain scores (p<0.0001). Flexion (p<0.0001) and extension (p=0.02) improved at a statistically significant level. A separate sample (N=54) (age range 50-85 years) completed the patient experience survey.

A well-designed post-operative virtual physiotherapy program, initially implemented to maintain continuity of care during the pandemic, continues to be an important part of our model of care as we normalize our activities. Clear understanding of barriers to virtual care and mitigation strategies will help us create virtual care standards, meet our patient needs, optimize our care delivery and potentially increase the use of virtual rehab in the future.

Introduction

Joint preserving procedures have gained popularity in an attempt to delay arthroplasty in young, dysplastic hips. Excellent results can be achieved with peri-acetabular osteotomy (PAO) in congruent non-arthritic hips. The role of salvage procedures such as the Shelf acetabuloplasty remains undefined. This study aims to determine the long-term survival and functional outcome following Shelf acetabuloplasty and to identify factors that influence outcome.

The purpose of the study was to identify risk factors that are associated with re-displacement of the hip after surgical reconstruction in cerebral palsy.

Retrospective review of children with cerebral palsy who had hip reconstruction with proximal femoral varus derotation osteotomy (VDRO) and Dega-type pelvic osteotomy, between 2005–2012, at a UK and European institution, was performed. Patient demographics, GMFCS, clinical and radiological outcome were assessed as well as the presence of pelvic obliquity and significant scoliosis (Cobb angle > 10 degrees). Redisplacement was defined as Reimer's Migration Index (MI) >30% at final follow-up. Logistic regression analysis was used to assess which factors were predictive of redisplacement and adjusted for clustered variables (α = 0.05).

Eighty hips were identified in 61 patients. The mean age at surgery was 8.8 years (± 3.3). Mean MI pre-op was 68% (± 23%) and post-op was 8% (± 12%). At a mean follow-up, of 3.2 years (± 2.0), 23 hips had a MI >30%. Of these; five were symptomatic, and one had required a salvage procedure. Metalwork removal was undertaken in 14 hips. Logistic regression demonstrated that the pre-operative MI and the percentage of acute correction were significant predictors of re-displacement. If the pre-operative MI was greater than 65 percent, the odds ratio (OR) for redisplacement was 5.99 (p = 0.04). If correction of the MI was less than 90% of the pre-operative MI, the OR for re-displacement was 4.6 (p = 0.03). Age at the time of surgery, GMFCS, pelvic obliquity and scoliosis were not predictive of re-displacement.

These results, firstly, highlight the importance of hip surveillance in children with cerebral palsy to allow timely intervention to ensure adequate radiological outcomes. Secondly, as in developmental hip dysplasia, full concentric reduction is essential to reduce the risk of re-displacement, with its associated clinical consequences.

Purpose

We describe a novel method to encourage children to weight-bear after frame surgery using a whoopee cushion; the objective of this study is to assess the amount of force taken though a limb using this method.

Purpose

The purpose of this study was to assess the accuracy of three-dimensional camera technology when monitoring deformity correction by an Ilizarov frame and to compare it to manual measurements.

Purpose of study

To assess the risk of early re—dislocation following closed reduction (CR) of the hip for idiopathic developmental dysplasia of the hip (DDH).

We developed the Oxford ankle foot questionnaire to assess the disability associated with foot and ankle problems in children aged from five to 16 years. A survey of 158 children and their parents was carried out to determine the content, scaling, reliability and validity of the instrument. Scores from the questionnaire can be calculated to measure the effect of foot or ankle problems on three domains of children’s lives: physical, school and play, and emotional. Scores for each domain were shown to be internally consistent, stable, and to vary little whether reported by child or parent. Satisfactory face, content and construct validity were demonstrated. The questionnaire is appropriate for children with a range of conditions and can provide clinically useful information to supplement other assessment methods. We are currently carrying out further work to assess the responsiveness of questionnaire scores to change over time and with treatment.

The management of pathological fractures in children remains controversial. The indications for surgical treatment are unclear and the need for histological diagnosis before or after definitive treatment is not clearly defined.

We reviewed retrospectively the records of all patients under the age of 16 years who presented over the past 7 years with a fracture as the first manifestation of bone pathology. There were 26 patients (19 boys and 7 girls) of an average age of 12 years and 2 months (range 4.1–15.8 years).

There were 9 cases of fracture through a simple bone cyst, 6 in the humerus and 3 in the femur. In all cases the fracture was treated conservatively initially. Subsequent management included needle biopsy in all, followed by bone marrow injection under the same anaesthetic. The patients suffered a refracture and were treated with flexible intra-medullary nail fixation.

There were 5 cases of fibrous dysplasia, of which 2 in the femur, 2 in the tibia and one in the proximal radius. Histological diagnosis was obtained in all cases prior to definitive treatment. This included a locked intra-medullary nail in one patient and flexible nailing in another two. The remaining two patients are still under observation.

There were 2 patients with giant cell tumour, 3 patients with aneurysmal bone cyst and one patient with chondroblastoma. Histological diagnosis preceded treatment with curettage and grafting in all these cases. There were 6 patients with malignant primary bone tumour, 1 adamantinoma, 2 osteosarcoma, and 3 with Ewings Sarcoma.

The 3 patients with Ewing’s sarcoma involved the femur. One had extensive local disease and early intra-medullary nailing was performed for palliative reasons. The second patient was treated conservatively initially. Definitive surgery was performed after fracture healing and included segmental resection and vascularised fibular graft. The third patient was initially treated elsewhere. She was thought to have a benign lesion and internal fixation with a screw/plate device was performed. Histology from intra-operative specimens confirmed Ewing’s sarcoma. Definitive surgery required extensive resection and prosthetic replacement.

The 2 patients with osteosarcoma had fracture of proximal humerus and distal femur. The former was treated by forequarter amputation as there was tumour involvement of brachial plexus and remains AWND at 7 years. The latter had resection and EPR of the distal femur.

One patient with adamantinoma underwent segmental resection and reconstruction with VFFG

We recommend that primary fixation of pathological fractures should be avoided until histological diagnosis is obtained. However, if radiographic appearances are reassuringly benign, biopsy can be delayed until conservative fracture management is completed. Definitive treatment of benign lesions with protective intramedullary nailing or curettage and grafting can follow frozen section under the same anaesthetic.

Aims: To assess the value of hip arthrography in planning definitive treatment for children with DDH and Perthes’ disease.

Background: It is sometimes unclear whether children with DDH and Perthes’ disease need an operation. Surgeons are guided by the clinical symptoms and signs together with the radiographic appearances of the affected hip. In our Unit children on whom an operation is considered undergo an examination under anaesthetic (EUA) and a hip arthrogram. This prospective study was developed to assess whether treatment was modified by the arthrogram.

Methods: All patients who underwent an EUA and hip arthrogram for DDH or Perthes’ disease over a 10 month period were entered into this prospective study. Prior to arthrography a Consultant Children’s Orthopaedic Surgeon formulated a treatment plan. A standard arthrogram was performed which included anteroposterior, frog lateral, Von Rosen and oblique views. Traction axial loading views were taken to assess stability. Following EUA and arthrogram the Consultant Surgeon formulated a definitive treatment plan. Three Children’s Consultants were then invited subsequently to review the preoperative and arthrographic appearances blindly to monitor reproducibility. Twenty-one patients with DDH and 19 with Perthes’ disease were entered into the study.

Results: In the DDH group of patients the treatment plan was modified in 12 of the 21 patients as a consequence of the arthrogram. Six of the 19 patients (31.6 %) of the Perthes’ affected patients had their treatment modified. When it was felt likely prior to EUA a conservative treatment was indicated. The correlation of intra-observer Consultant agreement was high but inter-observer Consultant agreement was moderate only. In both groups of patients the range of hip motion was significantly greater under anaesthesia.

Conclusion: Static and dynamic arthrography helps decision making in patients with DDH and Perthes’ disease.

Introduction: Traditionally, the degree of correction for derotational femoral osteotomies in cerebral palsy has been based on clinical or radiographic measures. Recently, three dimensional gait analysis has been used to plan and evaluate orthopaedic surgery. Our aim was to assess the outcome of derotation osteotomies, where the degree of rotation at surgery was guided by transverse plane kinematics (aiming at reducing peak hip rotations to normal limits).

Method: Pre and post-operative gait analyses were reviewed in a group of these patients (16 legs) and compared with a similar group of 8 patients (16 legs) who had soft tissue procedures only.

Results: Improvement following derotation osteotomy occurred in all but one case; 11/16 osteotomies resulted in peak internal rotation within one standard deviation (SD) of peak normal internal rotation (normal range −6° to +11°), the other 4 were within 1.4 SDs.

Discussion: Objective improvement in hip rotation during gait was measured in 15/16 subjects undergoing dero-tation osteotomy based on gait analysis. There was no rotational change overall in patients who had soft tissue procedures only. Average dynamic correction of internal rotation during gait was slightly less than intra-operative correction, possibly due to tensioning of spastic muscles.

Seventy-eight children, with 79 femoral fractures, treated with titanium elastic intramedullary nails were reviewed for complications.

Insertion site symptoms (41), malunion (8), refracture (2), transient neurological deficit (2), superficial wound infection (2), and reoperation prior to union (10).

Malunion/loss of reduction was increased with mismatched nails (p=0.02) and comminution (p=0.02). Insertion site symptoms were increased with nail ends that were bent (p=0.02), or > 10mm prominent (p=0.002). Nails remain implanted in 25 children without problems.

Nail ends should lie against the femur to avoid insertion site symptoms. Nails of different diameters should not be implanted. Comminuted fractures require close monitoring.