Clinical prediction algorithms are used to differentiate transient synovitis from septic arthritis. These algorithms typically include the erythrocyte sedimentation rate (ESR), although in clinical practice measurement of the C-reactive protein (CRP) has largely replaced the ESR. We evaluated the use of CRP in a predictive algorithm.

The records of 311 children with an effusion of the hip, which was confirmed on ultrasound, were reviewed (mean age 5.3 years (0.2 to 15.1)). Of these, 269 resolved without intervention and without long-term sequelae and were considered to have had transient synovitis. The remaining 42 underwent arthrotomy because of suspicion of septic arthritis. Infection was confirmed in 29 (18 had micro-organisms isolated and 11 had a high synovial fluid white cell count). In the remaining 13 no evidence of infection was found and they were also considered to have had transient synovitis. In total 29 hips were categorised as septic arthritis and 282 as transient synovitis. The temperature, weight-bearing status, peripheral white blood cell count and CRP was reviewed in each patient.

A CRP > 20 mg/l was the strongest independent risk factor for septic arthritis (odds ratio 81.9, p < 0.001). A multivariable prediction model revealed that only two determinants (weight-bearing status and CRP > 20 mg/l) were independent in differentiating septic arthritis from transient synovitis. Individuals with neither predictor had a < 1% probability of septic arthritis, but those with both had a 74% probability of septic arthritis. A two-variable algorithm can therefore quantify the risk of septic arthritis, and is an excellent negative predictor.

The association between idiopathic congenital talipes equinovarus (CTEV) and developmental dysplasia of the hip is uncertain. We present an observational cohort study spanning 6.5 years of selective ultrasound screening of hips in clubfoot. From 119 babies with CTEV there were nine cases of hip dysplasia, in seven individuals. This suggests that 1 in 17 babies with CTEV will have underlying hip dysplasia.

This study supports selective ultrasound screening of hips in infants with CTEV.

Purpose of Study: To present the clinical features, investigations, histopathology, differential diagnosis and treatment options for lipoblastoma, based on a series of six encountered in our paediatric orthopaedic practice.

Method: The records of six children with lipoblastoma who attended Alder Hey Hospital between 2000 and 2006 were reviewed. Mean age was 17 months and mean follow up was 26 months.

Results: The youngest was a six month old infant with a swelling on his right instep. The second patient, a three year old girl, presented with a limp and swelling in her foot. The third patient was an 18 month old boy with a swelling on the dorsum of his left forearm. The fourth patient had a swelling of his left thigh and two patients had swellings in their backs. Each was investigated by MRI (1), CT (1) or US (4) and surgical excision planned accordingly. There were no post operative complications. None has shown recurrence during follow-up.

Conclusions: All patients were originally thought to have simple lipomata or soft tissue swellings. This is primarily because lipoblastoma is a rare tumour, yet lipoblastoma is the most likely diagnosis of a fatty lump in a child aged less than two. Differential diagnoses include myxoid liposarcoma, well-differentiated liposarcoma, spindle cell lipoma, typical lipoma and soft tissue sarcoma.

Lipoblastomata need thorough imaging. Cytogenetic evaluation of tumour cells often reveals chromosomal anomalies, such as abnormalities of the long arm of chromosome 8 leading to rearrangement of the PLAG1 gene. Biopsy of the lesion is recommended for accurate diagnosis, as clinical and radiological diagnoses can be misleading.

Lipoblastomata tend to spread locally and may recur after incomplete resection; metastatic potential has not been reported. Complete surgical resection is mandatory to prevent recurrence.

We determined the rate of contamination of donated femoral heads at primary hip arthroplasty within a single region between July 1992 and July 2001. We established the null hypothesis that culture results played no role in predicting early failure of the joint because of infection.

The rate of contamination was 9%. A positive culture, at the time of retrieval, was found in 367 of 4045 femoral heads. Coagulase-negative staphylococcus was isolated in 77% of the positive cases. At a minimum follow-up of one year, there was no statistically significant difference in the rate of complications or of revision of age-matched patients whose femoral heads had a positive culture compared with those whose femoral heads were sterile.

Our findings confirm that culture of the femoral head plays no part in determining future failure of joint replacement in the donor.

Background: Femoral heads donated at primary arthroplasty are screened microbiologically. Contaminated femoral heads are either discarded or irradiated in an effort to protect recipients from the risk of transmitted infection.

Aims:

Determine the contamination rate of donated femoral heads at primary arthroplasty within the Trent Region between July 1992 and July 2001.

Method: We reviewed the culture results of all femoral heads donated to the Leicester Bone Bank. All patients with a contaminated femoral head that were operated upon in the Leicestershire region were then compared to a control group of patients with no contamination of their femoral heads. The two groups of patients were then cross-referenced against the data in the Trent Arthroplasty Audit Group database. Hospital records of all patients who had a complication or re-operation were also reviewed to determine their outcome

Results: A contamination rate of 9% was present with 365 of 4043 femoral heads culturing positive at the time of retrieval. Coagulase negative Staphylococcus was isolated in 75% of the cases. At a minimum of one year follow up, there was no statistically significant difference in the complication or revision rate of age matched patients whose femoral heads cultured positive compared to those whose heads were sterile.

Conclusion: The allograft contamination rate is similar to other published series with coagulase negative staphylococcus being the most prevalent contaminant. The available evidence confirms what has been anecdotal in the past. Femoral head culture results play no role in determining future joint failure in the donor

This study seeks to determine the additional cost involved in the management of patients requiring operative fixation of their fractured ankle but whose operation is delayed more than 24 hours.

87 consecutive patients presenting acutely with a fractured ankle that required an operation during a single year were included in the study. All patients with ankle fractures referred from other centres, open fractures and ankle fractures whose non-operative management had failed were excluded from the study. 79 patients presented within 24 hours of their injury and so were eligible for early operative intervention. Of these, 74 presented within 6 hours of injury. Only 47 (60%) of the patients were operated on within 24 hours of their injury. Similarly, 11 (61%) of the 18 patients with trimalleolar fractures were operated on within 24 hours. Patients whose operations were delayed spent an average 4. 4 days more as an inpatient. This was statistically significant (p< 0. 0001, Wilcoxon signed rank test). The postoperative stay of patients having delayed operations was also statistically more than those undergoing early operation, (p< 0. 0001). The cost of the additional stay was calculated at £225/day/patient and equalled £39, 600 for the 40 patients whose operations were delayed.

We believe that the operative management of ankle fractures should be given special consideration. These injuries are such that they offer an initial limited window of opportunity for operative intervention (within 24 hours of injury). If this opportunity is missed, then the patient’s operation may have to be delayed for clinical reasons. In our study, only 60% of patients underwent early operative fixation of their fracture; a figure that can surely be improved upon. Therefore, we conclude that significant savings could be accrued by hospitals adopting protocols to fast-track pre-operative interventions to achieve early operation (within 24 hours) unless contraindicated.