Management of congenital talipes equinovarus using the Ponseti method: a systematic review

We present a systematic review of the results of the Ponseti method of management for congenital talipes equinovarus (CTEV). Our aims were to assess the method, the effects of modifications to the original method, and compare it with other similar methods of treatment. We found 308 relevant citations in the English literature up to 31 May 2010, of which 74 full-text articles met our inclusion criteria. Our results showed that the Ponseti method provides excellent results with an initial correction rate of around 90% in idiopathic feet. Non-compliance with bracing is the most common cause of relapse. The current best practice for the treatment of CTEV is the original Ponseti method, with minimal adjustments being hyperabduction of the foot in the final cast and the need for longer-term bracing up to four years. Larger comparative studies will be required if other methods are to be recommended.

Elastic intramedullary nailing of paediatric fractures of the forearm

We present the results of 90 consecutive children with displaced fractures of the forearm treated by elastic stable intramedullary nailing with a mean follow-up of 6.6 months (2.0 to 17.6). Eight (9%) had open fractures and 77 (86%) had sustained a fracture of both bones. The operations were performed by orthopaedic trainees in 78 patients (86%). All fractures healed at a mean of 2.9 months (1.1 to 8.7). There was one case of delayed union of an ulnar fracture. An excellent or good functional outcome was achieved in 76 patients (84%). There was no statistical difference detected when the grade of operating surgeon, age of the patient and the diaphyseal level of the fracture were correlated with the outcome. A limited open reduction was required in 40 fractures (44%).

Complications included seven cases of problematic wounds, two transient palsies of the superficial radial nerve and one case each of malunion and a post-operative compartment syndrome. At final follow-up, all children were pain-free and without limitation of sport and play activities.

Our findings indicate that the functional outcome following paediatric fractures of the forearm treated by elastic stable intramedullary nailing is good, without the need for anatomical restoration of the radial bow.

Orthopaedic aspects of paediatric non-accidental injury

Non-accidental injury (NAI) in children includes orthopaedic trauma throughout the skeleton. Fractures with soft-tissue injuries constitute the majority of manifestations of physical abuse in children. Fracture and injury patterns vary with age and development, and NAI is intrinsically related to the mobility of the child. No fracture in isolation is pathognomonic of NAI, but specific abuse-related injuries include multiple fractures, particularly at various stages of healing, metaphyseal corner and bucket-handle fractures and fractures of ribs. Isolated or multiple rib fractures, irrespective of location, have the highest specificity for NAI. Other fractures with a high specificity for abuse include those of the scapula, lateral end of the clavicle, vertebrae and complex skull fractures.

Injuries caused by NAI constitute a relatively small proportion of childhood fractures. They may be associated with significant physical and psychological morbidity, with wide- ranging effects from deviations in normal developmental progression to death.

Orthopaedic surgeons must systematically assess, recognise and act on the indicators for NAI in conjunction with the paediatric multidisciplinary team.

The inadequacy of musculoskeletal knowledge after foundation training in the United Kingdom

The aim of this study was to determine whether the foundation programme for junior doctors, implemented across the United Kingdom in 2005, provides adequate training in musculoskeletal medicine. We recruited 112 doctors on completion of their foundation programme and assessed them using the Freedman and Bernstein musculoskeletal examination tool. Only 8.9% passed the assessment. Those with exposure to orthopaedics, with a career interest in orthopaedics, and who felt that they had gained adequate exposure to musculoskeletal medicine obtained significantly higher scores. Those interested in general practice as a career obtained significantly lower scores. Only 15% had any exposure to orthopaedics during the foundation programme and only 13% felt they had adequate exposure to musculoskeletal medicine. The foundation programme currently provides inadequate training in musculoskeletal medicine. The quality and quantity of exposure to musculoskeletal medicine during the foundation programme must be improved.

The management of septic arthritis in children

We performed a systematic review of the optimal management of septic arthritis in children as recommended in the current English literature using MEDLINE, EMBASE, CINAHL, the Cochrane Library and reference lists of retrieved articles without date restrictions up to 31 January 2009. From 2236 citations, 227 relevant full-text articles were screened in detail; 154 papers fulfilled the inclusion criteria, from which conclusions were drawn on the management of infected joints in children.

Our review showed that no single investigation, including joint aspiration, is sufficiently reliable to diagnose conclusively joint infection. The roles of aspiration, arthrotomy and arthroscopy in treatment are not clear cut, and the ideal duration of antibiotic therapy is not yet fully defined. These issues are discussed. Further large-scale, multi-centre studies are needed to delineate the optimal management of paediatric septic arthritis.

Delaying treatment of supracondylar fractures in children

The aim of this retrospective multicentre study was to report the continued occurrence of compartment syndrome secondary to paediatric supracondylar humeral fractures in the period 1995 to 2005. The inclusion criteria were children with a closed, low-energy supracondylar fracture with no associated fractures or vascular compromise, who subsequently developed compartment syndrome. There were 11 patients (seven girls and four boys) identified from eight hospitals in three countries. Ten patients with severe elbow swelling documented at presentation had a mean delay before surgery of 22 hours (6 to 64). One patient without severe swelling documented at presentation suffered arterial entrapment following reduction, with a subsequent compartment syndrome requiring fasciotomy 25 hours after the index procedure.

This series is noteworthy, as all patients had low-energy injuries and presented with an intact radial pulse. Significant swelling at presentation and delay in fracture reduction may be important warning signs for the development of a compartment syndrome in children with supracondylar fractures of the humerus.

Patient expectations for hallux valgus surgery

PURPOSE

To determine preoperative patient expectations and their relative importance for hallux valgus surgery using a patient-derived questionnaire, and whether such expectations are influenced by age, gender, or occupation.

METHODS

Two patient-derived questionnaires were developed using open-ended interviews. The 19 most commonly stated expectations were included in the Patient Expectation Questionnaire: 2 related to improvement in appearance, 2 to pain reduction, and 15 to functional improvements in performing daily and recreational activities. The top 9 expectations were included in the Patient Priority Questionnaire for prioritising.

RESULTS

153 eligible patients aged 16 to 79 (mean, 47) years completed the questionnaires; 29 (19%) aged less than 40 years, 84 (55%) aged 40 to 60 years, and 40 (26%) aged more than 60 years. 86% were women and 81% were Caucasian. 62% were housewives or retired pensioners. Overall, the most important expectation was improved walking, followed by reduced pain over the bunion and wearing daily shoes. These expectations varied according to age and gender but not occupation.

CONCLUSION

Patient expectations differ from those of surgeons, and vary according to patient age and gender. Understanding preoperative patient expectations is crucial to achieve better clinical outcomes and satisfaction by selecting the most appropriate operation for each patient.

The deformity index as a predictor of final radiological outcome in Perthes’ disease

The deformity index is a new radiological measurement of the degree of deformity of the femoral head in unilateral Perthes’ disease. Its values represent a continuous outcome measure of deformity incorporating changes in femoral epiphyseal height and width compared with the unaffected side. The sphericity of the femoral head in 30 radiographs (ten normal and 20 from patients with Perthes’ disease) were rated blindly as normal, mild, moderate or severe by three observers. Further blinded measurements of the deformity index were made on two further occasions with intervals of one month.

There was good agreement between the deformity index score and the subjective grading of deformity. Intra- and interobserver agreement for the deformity index was high. The intraobserver intraclass correlation coefficient for each observer was 0.98, 0.99 and 0.97, respectively, while the interobserver intraclass correlation coefficient was 0.98 for the first and 0.97 for the second set of calculations.

We also reviewed retrospectively 96 radiographs of children with Perthes’ disease, who were part of a multicentre trial which followed them to skeletal maturity. We found that the deformity index at two years correlated well with the Stulberg grading at skeletal maturity. A deformity index value above 0.3 was associated with the development of an aspherical femoral head. Using a deformity index value of 0.3 to divide groups for risk gives a sensitivity of 80% and specificity of 81% for predicting a Stulberg grade of III or IV.

We conclude that the deformity index at two years is a valid and reliable radiological outcome measure in unilateral Perthes’ disease.

The anabolic and catabolic responses in bone repair

The literature on fracture repair has been reviewed. The traditional concepts of delayed and nonunion have been examined in terms of the phased and balanced anabolic and catabolic responses in bone repair. The role of medical manipulation of these inter-related responses in the fracture healing have been considered.

Adsorptive removal of tannin from aqueous solutions by cationic surfactant-modified bentonite clay

The removal of tannin from aqueous media by cationic surfactant-modified bentonite clay was studied in a batch system. The surfactant used was hexadecyltrimethylammonium chloride. Adsorbent characterizations were investigated using X-ray diffraction, infrared spectroscopy, surface area analysis, and potentiometric titration. The effects of pH, contact time, initial solute concentration, adsorbent dose, ionic strength, and temperature on the adsorption of tannin onto modified clay were investigated. The adsorbent exhibited higher tannin removal efficiency (>99.0%) from an initial concentration of 10.0 micromol/L at pH 3.0. Adsorption capacity decreased from 90.1 to 51.8% with an increase in temperature from 10 to 40 degrees C at an initial concentration of 25.0 micromol/L. The adsorption process was found to follow pseudo-first-order kinetics. Film diffusion was found to be the rate-limiting step. Tannin adsorption was found to decrease with increase in ionic strength. The tannin equilibrium adsorption data were fitted to Langmuir and Freundlich isotherm models, the former being found to provide the best fit of the experimental data. The maximum monolayer adsorption capacity for tannin was 69.80 micromol/g at 30 degrees C. Comparison of adsorption capacity of the modified clay with reported adsorbents in the literature was also presented. Adsorbed tannin on modified clay can be recovered by treatment with 0.1 M NaOH solution. Regeneration experiments were tried for four cycles and results indicate a capacity loss of <10.0%. From the results it can be concluded that the surfactant-modified clay could be a good adsorbent for treating tannin-contaminated waters.

Clinical outcome of nerve injuries associated with supracondylar fractures of the humerus in children: the experience of a specialist referral centre

Between 1998 and 2002, 37 neuropathies in 32 patients with a displaced supracondylar fracture of the humerus who were referred to a nerve injury unit were identified. There were 19 boys and 13 girls with a mean age of 7.9 years (3.6 to 11.3). A retrospective review of these injuries was performed. The ulnar nerve was injured in 19, the median nerve in ten and the radial nerve in eight cases. Fourteen neuropathies were noted at the initial presentation and 23 were diagnosed after treatment of the fracture. After referral, exploration of the nerve was planned for 13 patients. Surgery was later cancelled in three because of clinical recovery. Six patients underwent neurolysis alone. Excision of neuroma and nerve grafting were performed in four. At follow-up, 26 patients had an excellent, five a good and one a fair outcome.

Management of suspected scaphoid fractures in accident and emergency departments--time for new guidelines

INTRODUCTION

The objectives of this work were to assess the clinical knowledge of clinicians in the accident and emergency (A&E) departments in England & Wales and evaluate the current trend for the acute management of radiologically normal, but clinically suspected, fractures of the scaphoid.

SUBJECTS AND METHODS

We conducted a telephone survey on 146 A&E senior house officers (SHOs) in 50 different hospitals. This survey assessed the clinicians' experience, their clinical and radiological diagnostic methods, and their initial treatment of suspected scaphoid fractures.

RESULTS

The majority (55.8%) of SHOs performed only one clinical test to diagnose suspected scaphoid fractures. Overall, 41% were unable to cite the number of the radiographic views taken and only 10% of departments have direct access to further radiological investigation. There is wide variation in the early treatment of this injury, with the scaphoid cast used most commonly (46%). The majority of SHOs (89%) were unable to describe the features of immobilisation. The mean follow-up period was 10 days, and 53% of cases were followed-up by the senior staff in A&E. Of SHOs, 54% were not aware of any local guidelines for the management of suspected scaphoid fractures in their departments, and 92% were not aware of the existence of the 1992 British Association for Accident and Emergency Medicine (BAEM) guidelines.

CONCLUSIONS

The clinical knowledge and the management of suspected scaphoid fractures in A&E are unsatisfactory. We, therefore, suggest that the dissemination of up-to-date guidelines could help to educate clinicians to provide better care to the patients.

Impacted knife injury of the orbit, maxilla and oropharynx

Injuries in the maxillofacial region with knife in situ are not common. We report a rare case with knife impacted in the orbit, maxilla and soft palate. Removal was possible only by surgical intervention. Despite the deep penetration, the knife had not injured major structures and hence there was no untoward complication in the outcome.

Rotational osteotomies for congenital radioulnar synostosis

In five children, six forearms with a fixed pronation deformity secondary to congenital radioulnar synostosis were treated by a derotation osteotomy of the distal radius and the midshaft of the ulna.

There were three boys and two girls with a mean age of 4.9 years (3.5 to 8.25) who were followed up for a mean of 29 months (18 to 43). The position of the forearm was improved from a mean pronation deformity of 68° (40° to 80°) to a pre-planned position of 10° of supination in all cases. Bony union was achieved by 6.3 weeks with no loss of correction. There was one major complication involving a distal radial osteotomy which required exploration for a possible compartment syndrome.