Developmental Dysplasia of the Hip (DDH) is the most common orthopaedic disorder in newborns. Whilst the Pavlik harness is one of the most frequently used treatments for DDH, there is immense variability in treatment parameters reported in the literature and in clinical practice, leading to difficulties in standardising teaching and comparing outcomes. In the absence of definitive quantitative evidence for the optimal Pavlik harness management strategy in DDH, we addressed this problem by scientifically obtaining international expert-based consensus on the same.

An initial list of items relevant to Pavlik harness treatment was derived by systematic review of the literature according to PRISMA criteria and reviewed by two expert clinicians in DDH management. Delphi methodology was used to guide serial rounds of surveying and feedback to content matter experts from the International Hip Dysplasia Institute (IHDI), a collaborative group of paediatric orthopaedic surgeons with expertise in the management of DDH. Rounds of surveying continued in the same manner until consensus was reached.

Importance ratings were derived from each round of surveying by calculating median score responses on the 5-point Likert scale for each item. Items requiring clarification or those with a median score of below 4 (“agree”) were modified as needed prior to each subsequent round. Consensus was considered reached when 90% or more of the items had an interquartile range (IQR) of ≤ 1. This value indicates low sample deviation and is accepted as having achieved consensus. This was followed by a corroboration of face validity to derive the final set of management principles.

The literature search and expert review identified an initial list of 66 items in 8 categories relevant to Pavlik harness management. Four rounds of structured surveying were required to reach consensus. Following a final round of face validity, a definitive list of 33 items in 8 categories met consensus by the experts. These items were tabulated and presented as “General Principles of Pavlik Harness Treatment for DDH” and “Pavlik Harness Treatment by Severity of Hip Dysplasia”. Furthermore, highly contentious items were identified as important future areas of study and will be discussed.

We have developed a comprehensive set of principles derived by expert consensus to assist clinicians, and for use as a teaching resource, in the non-operative management of DDH using the Pavlik harness. We have gained consensus on both the general principles of Pavlik harness treatment as well as the detailed treatment of hip subtypes seen across the spectrum of pathology of DDH. Furthermore, this study has also served to generate a list of the most controversial areas in the non-operative management of DDH which should be considered high priority for future study to further refine and optimise the outcomes of children with developmental hip dysplasia.

The purpose of this study was to determine whether the reasons for delay to surgery are secondary to health system constraints or patient factors. This study explored factors that contribute to patients' delay to surgery as well as how patients perceive the delay in surgery to have affected their treatment and care.

Semi-structured qualitative interviews were conducted with 30 patients aged 18 to 50 years old who had undergone arthroscopic ACL reconstruction. Qualitative data analysis was performed in accordance with the Straus and Corbin theory to derive codes, categories and themes.

Patient interviews revealed three overarching themes regarding delay to ACL reconstruction surgery: access to care, finances and work, and personal advocacy. Elements of those factors were shown to influence the timing of ACL reconstruction surgery. Less common factors included choice of imaging study (i.e., ultrasound), geography, and family commitments.

Patients' perceptions of delay in access to care was overwhelming due to the wait time for MRI. Several patients also described significant self-advocacy required to navigate the healthcare system, suggesting that some level of medical literacy may be necessary to gain timely access to surgery. Once patients had seen the surgeon, few patients described untimely delay to surgery, suggesting that OR resources are adequate. Recommendations to decrease delays to ACL reconstruction surgery include better access to MRI and broader education of non-surgical healthcare providers to help navigate access to surgery.

There has been a widespread adoption of training programs or “boot-camps” targeting new surgical residents prior to entrance to the hospital environment. A plethora of studies have shown positive reactions to implementations of “boot camps”. Reaction surveys, however, lack the ability to provide a deeper level of understanding into how and why “boot camps” are seen as effective. The purpose of this study was to develop a rich perspective on the role “boot camps” are perceived to play in resident education.

A constructivist approach to qualitative grounded theory methodology, employing iterative semi-structured, in-person, interviews was used to explore the construct of a “boot camp” through the eyes of key stakeholders, including junior surgical residents (n=10), senior surgical residents (n=5), and faculty members (n=5) at a major academic centre. Interviews were coded and analysed thematically using NVIVO software. Three members of the research team coded data independently and compared themes until consensus was reached. A method of constant comparative analysis was utilised throughout the iterative process. Emerging themes were revisited with stakeholders as a measure of rigor. Axial coding of themes was used to discover the overlying purposes embedded in the “boot camp” construct.

The overarching themes resonating from participants were ‘anxiety reduction’, ‘cognitive unloading’ and ‘practical logistics’. Resident anxiety was ameliorated through subthemes of ‘social inclusion’, ‘group formation’, ‘confidence building’ and ‘formalisation of expectations’. A resident commented “the nuances of how things work is more stressful than the actual job.” Residents bonded together to create personal and group identities, “forming the identity of who we are as a group”, that shaped ongoing learning throughout training, “right from the beginning we would be able to call on each other.” Junior residents found themselves cognitively unloaded for higher level learning through ‘expectation setting’ and ‘formalised basic skills’; “I knew how the equipment was going to fit together, it allowed me to focus more on what was happening from the operative perspective.” Stakeholders highlighted the importance of positioning “boot camp” at the beginning of residency training, as it directly influenced the point of transition. This highlights the strength of the “boot camp” construct at targeting the challenges associated with discrete moments of transition in the advancement in practice.

While surgical preparatory “boot camps” were initially born out of a competency-based framework focused on technical skill development, our findings demonstrate that the benefits outweigh simple improvement in technical ability. The formation of a learner group identity has downstream effects on resident perceptions of anxiety and confidence, while priming for higher-level learning. “Boot camp” then, is re-imagined as an experience of social professional enculturation.

To provide a comprehensive radiographic, clinical, and functional description of the shoulder in Apert Syndrome.

A cohort of nine Apert Syndrome patients (ages nine to twenty-seven) followed at a tertiary care facility was included in this prospective study. Patients were clinically assessed with physical examination and completion of two validated functional assessment tools, the Shoulder Pain and Disability Index (SPADI) and AAOS Paediatrics Questionnaire (PODCI). Radiographs were obtained of both shoulders and a standardised protocol MRI was performed on the dominant shoulder of all participants.

All patients had some degree of functional impairment attributable to their shoulder pathology. Physical examination consistently revealed reduced forward flex-ion and abduction. Radiographic findings were similar to previous reports, with pervasive osseous dysplasia of the shoulder joint. Medial humeral head hypoplasia was seen in eight out of nine patients and greater tuberosity overgrowth in seven out of nine patients. MR imaging of the shoulder, not previously performed in a cohort of Apert patients, allowed better delineation of abnormalities seen radiographically such as a central glenoid cleft, seen in eight out of nine patients. It also revealed a new finding of inferior glenoid inclination (seven out of nine patients), which has not been described in the literature. Very few soft tissue or degenerative abnormalities were demonstrated.

The findings of this study confirm that patients with Apert Syndrome are functionally impaired by their shoulder pathology, which may have a similar clinical impact as the more well-described hand and foot anomalies. The global functioning of patients with Apert syndrome is equivalent to patients with juvenile rheumatoid arthritis. The shoulder range of motion in Apert patients is decreased, most significantly in flexion and abduction. Radiographs confirmed previous imaging findings of glenohumeral dysplasia. The novel MRI component demonstrated consistent inferior glenoid inclination, which may be a significant factor in their shoulder impairment. MR imaging revealed no significant soft tissue or degenerative abnormalities to account for their clinical disability. These findings have potential relevance in the surgical and clinical management of these patients.

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.