1
|
Singh A, Wade RG, Metcalfe D, Perry DC. Does This Infant Have a Dislocated Hip?: The Rational Clinical Examination Systematic Review. JAMA 2024; 331:1576-1585. [PMID: 38619828 DOI: 10.1001/jama.2024.2404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
Importance Delayed diagnosis of a dislocated hip in infants can lead to complex childhood surgery, interruption to family life, and premature osteoarthritis. Objective To evaluate the diagnostic accuracy of clinical examination in identifying dislocated hips in infants. Data Sources Systematic search of CINAHL, Embase, MEDLINE, and the Cochrane Library from the inception of each database until October 31, 2023. Study Selection The 9 included studies reported the diagnostic accuracy of the clinical examination (index test) in infants aged 3 months or younger and a diagnostic hip ultrasound (reference test). The Graf method of ultrasound assessment was used to classify hip abnormalities. Data Extraction and Synthesis The Rational Clinical Examination scale was used to assign levels of evidence and the Quality Assessment of Diagnostic Accuracy Studies tool was used to assess bias. Data were extracted using the individual hip as the unit of analysis; the data were pooled when the clinical examinations were evaluated by 3 or more of the included studies. Main Outcomes and Measures Sensitivity, specificity, and likelihood ratios (LRs) of identifying a dislocated hip were calculated. Results Among infants screened with a clinical examination and a diagnostic ultrasound in 5 studies, the prevalence of a dislocated hip (n = 37 859 hips) was 0.94% (95% CI, 0.28%-2.0%). There were 8 studies (n = 44 827 hips) that evaluated use of the Barlow maneuver and the Ortolani maneuver (dislocate and relocate an unstable hip); the maneuvers had a sensitivity of 46% (95% CI, 26%-67%), a specificity of 99.1% (95% CI, 97.9%-99.6%), a positive LR of 52 (95% CI, 21-127), and a negative LR of 0.55 (95% CI, 0.37-0.82). There were 3 studies (n = 22 472 hips) that evaluated limited hip abduction and had a sensitivity of 13% (95% CI, 3.3%-37%), a specificity of 97% (95% CI, 87%-99%), a positive LR of 3.6 (95% CI, 0.72-18), and a negative LR of 0.91 (95% CI, 0.76-1.1). One study (n = 13 096 hips) evaluated a clicking sound and had a sensitivity of 13% (95% CI, 6.4%-21%), a specificity of 92% (95% CI, 92%-93%), a positive LR of 1.6 (95% CI, 0.91-2.8), and a negative LR of 0.95 (95% CI, 0.88-1.0). Conclusions and Relevance In studies in which all infant hips were screened for developmental dysplasia of the hip, the prevalence of a dislocated hip was 0.94%. A positive LR for the Barlow and Ortolani maneuvers was the finding most associated with an increased likelihood of a dislocated hip. Limited hip abduction or a clicking sound had no clear diagnostic utility.
Collapse
Affiliation(s)
- Abhinav Singh
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, England
| | - Ryckie George Wade
- Academic Department of Plastic and Reconstructive Surgery, University of Leeds, Leeds, England
| | - David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, England
| | - Daniel C Perry
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, England
- Department of Child Health, Alder Hey Children's Hospital, University of Liverpool, Liverpool, England
| |
Collapse
|
2
|
Burt JEA, AlKandari N, Campbell DM, MacLean JGB. Who performs neonatal hip assessment: is there a cause for concern? BMJ Paediatr Open 2024; 8:e002490. [PMID: 38663937 PMCID: PMC11043736 DOI: 10.1136/bmjpo-2023-002490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 04/05/2024] [Indexed: 04/28/2024] Open
Abstract
OBJECTIVE The UK falls behind other European countries in the early detection of developmental dysplasia of the hip (DDH) and screening strategies differ for early detection. Clinical detection of DDH is challenging and recognised to be dependent on examiner experience. No studies exist assessing the number of personnel currently involved in such assessments.Our objective was to review the current screening procedure by studying a cohort of newborn babies in one teaching hospital and assess the number of health professionals involved in neonatal hip assessment and the number of examinations undertaken during one period by each individual. METHODS This was a retrospective observational study assessing all babies born consecutively over a 14-week period in 2020. Record of each initial baby check was obtained from BadgerNet. Follow-up data on ultrasound or orthopaedic outpatient referrals were obtained from clinical records. RESULTS 1037 babies were examined by 65 individual examiners representing 9 different healthcare professional groups. The range of examinations conducted per examiner was 1-97 with a median of 5.5 examinations per person. 49% of individuals examined 5 or less babies across the 14 weeks, with 18% only performing 1 examination. Of the six babies (0.48%) treated for DDH, one was picked up on neonatal assessment. CONCLUSION In a system where so many examiners are involved in neonatal hip assessment, the experience is limited for most examiners. Currently high rates of late presentation of DDH are observed locally, which are in accordance with published national experience. The potential association merits further investigation.
Collapse
Affiliation(s)
- Justine E A Burt
- The Department of Trauma and Orthopaedics, Ninewells Hospital, Dundee, UK
| | - Nourah AlKandari
- The Department of Trauma and Orthopaedics, Ninewells Hospital, Dundee, UK
| | - Donald M Campbell
- The Department of Trauma and Orthopaedics, Ninewells Hospital, Dundee, UK
| | - James G B MacLean
- The Department of Trauma and Orthopaedics, Ninewells Hospital and Medical School, Dundee, UK
| |
Collapse
|
3
|
Nicholson A, Dunne K, Taaffe S, Sheikh Y, Murphy J. Developmental dysplasia of the hip in infants and children. BMJ 2023; 383:e074507. [PMID: 37996104 DOI: 10.1136/bmj-2022-074507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Affiliation(s)
| | | | - Sarah Taaffe
- Irish College of General Practitioners, Dublin, Ireland
| | - Yusra Sheikh
- Department of Paediatric Radiology, Children's Health Ireland at Temple Street, Dublin, Ireland
| | - John Murphy
- Department of Neonatology, National Maternity Hospital, Dublin, Ireland
| |
Collapse
|
4
|
Nicholson A, Dunne K, Taaffe S, Sheikh Y, Murphy J. Developmental dysplasia of the hip in infants and children. BMJ 2023; 383:e074507. [PMID: 37996106 DOI: 10.1136/bmj-2023-074507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Affiliation(s)
| | | | - Sarah Taaffe
- Irish College of General Practitioners, Dublin, Ireland
| | - Yusra Sheikh
- Department of Paediatric Radiology, Children's Health Ireland at Temple Street, Dublin, Ireland
| | - John Murphy
- Department of Neonatology, National Maternity Hospital, Dublin, Ireland
| |
Collapse
|
5
|
Kuitunen I, Uimonen MM, Haapanen M, Sund R, Helenius I, Ponkilainen VT. Incidence of Neonatal Developmental Dysplasia of the Hip and Late Detection Rates Based on Screening Strategy: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e2227638. [PMID: 35980635 PMCID: PMC9389349 DOI: 10.1001/jamanetworkopen.2022.27638] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Universal ultrasonographic screening for developmental dysplasia of the hip (DDH) has gained increasing popularity despite the lack of benefit in terms of reducing the rates of late-detected cases (age ≥12 weeks) in randomized clinical trials. OBJECTIVE To report the reported incidence of DDH in the English scientific literature and compare rates of late-detected cases in settings with different DDH screening strategies. DATA SOURCES PubMed, Scopus, and Web of Science databases were searched on November 25 and 27, 2021. No time filters were used in the search. STUDY SELECTION All observational studies reporting the incidence of early-detected or late-detected (age ≥12 weeks) DDH were included. Non-English reports were excluded if the abstract did not include enough information to be included for analysis. DATA EXTRACTION AND SYNTHESIS The number of newborns screened and the detection rates were extracted. Meta-analysis calculated the pooled incidence of DDH per 1000 newborns with 95% CIs using a random- or fixed-effects model. This study is reported according to the PRISMA and MOOSE guidelines. MAIN OUTCOMES AND MEASURES The main outcome measures were early detection, early treatment, late detection, and operative treatment incidences. RESULTS A total of 1899 studies were identified, 203 full texts were assessed, and 76 studies with 16 901 079 infants were included in final analyses. The early detection rate was 8.4 (95% CI, 4.8-14.8) infants with DDH per 1000 newborns with clinical screening, 4.4 (95% CI, 2.4-8.0) infants with DDH per 1000 newborns with selective ultrasonographic screening, and 23.0 (95% CI, 15.7-33.4) infants with DDH per 1000 newborns with universal ultrasonographic screening. Rates for nonoperative treatment were 5.5 (95% CI, 2.1-14) treatments per 1000 newborns with clinical screening, 3.1 (95% CI, 2.0-4.8) treatments per 1000 newborns with selective ultrasonographic screening, and 9.8 (95% CI, 6.7-14.4) treatments per 1000 newborns with universal ultrasonographic screening. The incidence of late-detected DDH was 0.5 (95% CI, 0.2-1.5) infants with DDH per 1000 newborns with clinical screening, 0.6 (95% CI, 0.3-1.3) infants with DDH per 1000 newborns with selective ultrasonographic screening, and 0.2 (95% CI, 0.0-0.8) infants with DDH per 1000 newborns with universal ultrasonographic screening. The corresponding incidences of operative treatment were 0.2 (95% CI, 0.0-0.9) operations per 1000 newborns with clinical screening, 0.5 (95% CI, 0.4-0.7) operations per 1000 newborns with selective ultrasonographic screening, and 0.4 (95% CI, 0.2-0.7) operations per 1000 newborns with universal ultrasonographic screening. CONCLUSIONS AND RELEVANCE This meta-analysis found that early detection rates and nonoperative treatments were higher with universal screening. The late detection and operative treatment rates with universal screening were similar to those among selectively and clinically screened newborns. Based on these results, universal screening may cause initial overtreatment without reducing the rates of late detection and operative treatment.
Collapse
Affiliation(s)
- Ilari Kuitunen
- Institute of Clinical Medicine, Department of Pediatrics, University of Eastern Finland, Kuopio, Finland
- Department of Pediatrics and Neonatology, Mikkeli Central Hospital, Mikkeli, Finland
| | - Mikko M. Uimonen
- Department of Surgery, Central Finland Hospital Nova, Jyväskylä, Finland
| | - Marjut Haapanen
- Institute of Clinical Medicine, Department of Pediatrics, University of Eastern Finland, Kuopio, Finland
| | - Reijo Sund
- Kuopio Musculoskeletal Research Unit, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Ilkka Helenius
- Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Paediatric Orthopedics, Helsinki University Hospital, New Children’s Hospital, Helsinki, Finland
| | | |
Collapse
|
6
|
Pinto D, Aroojis A, Shah H, Patwardhan S, Venkatadass K, Sahu C, Schaeffer E, Mulpuri K. Demographic and Practice Variability Amongst Indian Centres in a Multicentre Prospective Observational Study on Developmental Dysplasia of the Hip. Indian J Orthop 2021; 55:1559-1567. [PMID: 35003542 PMCID: PMC8688623 DOI: 10.1007/s43465-021-00516-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 09/04/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Since 2017, five Indian centres have enrolled into the International Hip Dysplasia Registry for prospective collection of data on Developmental Dysplasia of Hip (DDH). AIMS To assess how baseline patient characteristics and initial treatment modalities differ across these five centres. METHODS Registry data collected over 3 years were analyzed. Children with DDH that had radiograph-based diagnoses were included. RESULTS Collectively, there were 234 hips (181 patients), of which 218 had undergone surgery. Overall, median age at presentation was 25.3 months (IQR 16.8-46.0); female/male ratio was 2.6:1 (range 1.46-4.75:1); with 42%, 29%, and 29% unilateral left, bilateral and unilateral right hip dislocations respectively. Most were IHDI grade III and IV dislocations (94%). Closed reduction was performed at all but one centre, at median 15.3 months (IQR 9.6-21.1). Open reduction (OR) as a stand-alone procedure was performed at all centres, at median 20.8 months (IQR 15.4-24.9). Combination of OR with a single osteotomy, femoral (FO) or acetabular (AO), was performed at all centres at median 29.7 months (IQR 22.1-43.5). However, for the same age group, three centres exclusively performed FO, whereas the other two exclusively performed AO. The combination of OR with both FO and AO was used at all centres, at median 53.4 months (IQR 42.1-70.8). CONCLUSIONS The preliminary findings of this multi-centre study indicate similar patient demographics and diagnoses, but important differences in treatment regimens across the five Indian centres. Comparison of treatment regimens, using the 'centre' as a predictive variable, should allow us to identify protocols that give superior outcomes.
Collapse
Affiliation(s)
- Deepika Pinto
- grid.414135.60000 0001 0430 6611Department of Paediatric Orthopaedics, Bai Jerbai Wadia Hospital for Children, Mumbai, India
| | - Alaric Aroojis
- grid.414135.60000 0001 0430 6611Department of Paediatric Orthopaedics, Bai Jerbai Wadia Hospital for Children, Acharya Donde Marg, Parel, Mumbai, Maharashtra 400012 India
| | - Hitesh Shah
- grid.465547.10000 0004 1765 924XDepartment of Orthopaedics, Kasturba Medical College, Manipal, India
| | - Sandeep Patwardhan
- grid.489159.80000 0004 1767 0852Department of Orthopaedics, Sancheti Institute, Pune, India
| | - K. Venkatadass
- grid.415287.d0000 0004 1799 7521Department of Orthopaedics, Ganga Medical Centre, Coimbatore, India
| | - Chittaranjan Sahu
- Department of Orthopaedics, Balaji Institute of Surgery, Research and Rehabilitation, Tirupati, India
| | - Emily Schaeffer
- grid.414137.40000 0001 0684 7788Department of Orthopaedic Surgery, BC Children’s Hospital, Vancouver, BC Canada
| | - Kishore Mulpuri
- grid.414137.40000 0001 0684 7788Department of Orthopaedic Surgery, BC Children’s Hospital, Vancouver, BC Canada
| |
Collapse
|
7
|
Davies R, Talbot C, Paton R. Evaluation of primary care 6- to 8-week hip check for diagnosis of developmental dysplasia of the hip: a 15-year observational cohort study. Br J Gen Pract 2020; 70:e230-e235. [PMID: 32094221 PMCID: PMC7041638 DOI: 10.3399/bjgp20x708269] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 08/27/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The current 6- to 8-week Newborn and Infant Physical Examination (NIPE) clinical assessment is a current standard hip-screening test in the community (England) to detect developmental dysplasia of the hip (DDH). AIM To assess the value of the primary care 6- to 8-week clinical hip examination for the diagnosis of DDH. DESIGN AND SETTING A single-centre 15-year observational cohort study at a district general hospital between 1 January 1996 and 31 December 2010. METHOD Those referred by the GP or community practitioner with suspected instability or abnormality of the hip joint (DDH), were clinically and sonographically examined in a specialist hip-screening clinic. Modified Graf Type III and IV, and radiological irreducible hip dislocation were considered to be 'pathological' hips. Screening failures were defined as those who had not been identified by this primary care screening assessment (but had irreducible hip dislocation). Secondary univariate and multivariable analyses were performed to determine which clinical findings are predictive of instability. RESULTS Over the study period, there were 70 071 infants who underwent the 6- to 8-week clinical hip assessment. In the specialist hip-screening clinic, six (from the 170 referred) were diagnosed with pathological DDH. The sensitivity, specificity, positive predictive value, and negative predictive value for the 6- to 8-week clinical hip assessment were 16.7%, 99.8%, 3.5%, and 100.0%, respectively. A multivariable model showed a positive Ortolani manoeuvre to be the sole independent predictor of instability at 6 to 8 weeks. CONCLUSION This 15-year study highlights the limitations of a hip check at 6 to 8 weeks. These findings support the reassessment of the national guidelines for this aspect of the NIPE DDH screening programme.
Collapse
Affiliation(s)
- Ronnie Davies
- Department of Trauma and Orthopaedics, Royal Manchester Infirmary, Manchester
| | - Christopher Talbot
- Department of Paediatric Trauma and Orthopaedics, Alder Hey Childrens NHS Foundation Trust, Liverpool
| | - Robin Paton
- Department of Trauma and Orthopaedics, Royal Blackburn Hospital, Blackburn; honorary professor, School of Medicine, University Central Lancashire, Preston
| |
Collapse
|
8
|
Wenger D, Düppe H, Nilsson JÅ, Tiderius CJ. Incidence of Late-Diagnosed Hip Dislocation After Universal Clinical Screening in Sweden. JAMA Netw Open 2019; 2:e1914779. [PMID: 31702798 PMCID: PMC6902841 DOI: 10.1001/jamanetworkopen.2019.14779] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
IMPORTANCE Developmental dysplasia of the hip, including late-diagnosed hip dislocation, is the leading cause of hip arthroplasties in young adults. Early treatment is essential for a good prognosis. Before the institution of a national screening program, a minimum of 0.9 per 1000 Swedish children were affected. OBJECTIVES To evaluate the incidence of late-diagnosed hip dislocation among children who undergo clinical screening as neonates and to study antenatal and perinatal risk factors for late-diagnosed hip dislocation. DESIGN, SETTING, AND PARTICIPANTS This nested case-control study included children born in Sweden from January 1, 2000, through December 31, 2009. All maternity wards, maternal health units, and orthopedic departments in Sweden participated. Children with a late-diagnosed hip dislocation were matched by sex and birth year to randomly selected controls in a 1:10 ratio. Potential risk factors in pregnant women and newborns were recorded, and cases of hip dislocation were registered. Observation time ranged from 8 to 18 years, with the last data analysis in January 2019. EXPOSURES Clinical hip examinations neonatally and at 6 to 8 weeks, 6 months, and 10 to 12 months. MAIN OUTCOMES AND MEASURES Hip dislocation diagnosed more than 14 days after birth, age at diagnosis, and severity of dislocation. RESULTS Among 1 013 589 live births (521 728 [51.5%] boys), 126 children (0.12 [95% CI, 0.10-0.15] per 1000 live births) had a late-diagnosed hip dislocation at a median age of 31.4 weeks (interquartile range, 16.1-67.1 weeks; 95% CI, 27.4-44.1 weeks). The incidence of late-diagnosed hip dislocation was 9 times higher among girls (113 of 491 861; 0.23 [95% CI, 0.19-0.28] per 1000 live births) than among boys (13 of 521 728; 0.02 [95% CI, 0.01-0.04] per 1000 live births). Twenty-one children (0.02 per 1000 live births) had high (severe) dislocations. Breech delivery (adjusted odds ratio, 3.07; 95% CI, 1.34-7.02), short body length at birth (adjusted odds ratio, 0.86; 95% CI, 0.76-0.98, per additional 1 cm), and being large for gestational age (adjusted odds ratio, 3.59; 95% CI, 1.30-9.95) were independent risk factors. Maternal smoking at the first visit to the maternal health care center was less common among children with hip dislocation (adjusted odds ratio, 0.16; 95% CI, 0.04-0.70). CONCLUSIONS AND RELEVANCE Compared with historical data, the incidence of late-diagnosed hip dislocation in Swedish-born children appears to have decreased substantially since the screening program was initiated, as have the age at detection and disease severity. Similar screening programs should also be possible to institute in upper-middle- and lower-middle-income countries.
Collapse
Affiliation(s)
- Daniel Wenger
- Lund University, Lund, Sweden
- Department of Orthopedics, Skåne University Hospital, Malmö, Sweden
| | - Henrik Düppe
- Lund University, Lund, Sweden
- Department of Orthopedics, Skåne University Hospital, Lund, Sweden
| | - Jan-Åke Nilsson
- Lund University, Lund, Sweden
- Department of Rheumatology, Skåne University Hospital, Lund, Sweden
| | - Carl Johan Tiderius
- Lund University, Lund, Sweden
- Department of Orthopedics, Skåne University Hospital, Lund, Sweden
| |
Collapse
|
9
|
Reidy M, Collins C, MacLean JGB, Campbell D. Examining the effectiveness of examination at 6-8 weeks for developmental dysplasia: testing the safety net. Arch Dis Child 2019; 104:953-955. [PMID: 30518519 DOI: 10.1136/archdischild-2018-316520] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 11/18/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The 'GP check' at 6-8 weeks forms part of the selective surveillance system for developmental dysplasia of the hip (DDH) in the UK. It is imperative to pick up DDH within the first months of life to allow for non-invasive treatment and the avoidance of surgery. We aim to investigate the effectiveness of hip examination at 6-8 weeks. METHODS This is a longitudinal observational study including all infants born in our region in the 5 years following 2006. Early presentation was defined as diagnosis within 14 weeks of birth and late presentation after 14 weeks. Treatment records for early and late DDH as well as referrals for ultrasound (US) following examination at 6-8 weeks were analysed. Attendance of the examination at 6-8 weeks in those patients who went on to present with a late DDH was also analysed. RESULTS 23 112 live births occurred during the study period. There were 141 confirmed cases of DDH. 400 referrals for US were received following examination at 6-8 weeks; 6 of these had a positive finding of DDH. 27 patients presented after 14 weeks and were classified as late presentations. 25 of these patients had attended examination at 6-8 weeks and no abnormality had been identified. CONCLUSIONS The sensitivity of examination at 6-8 weeks was only 19.4%, its specificity was 98% and it had a positive predictive value of 1.5%. For many years the check at 6-8 weeks has been thought of as a means to identify those children not identified as neonates; however, we found that four out of five children with DDH were not identified by the check at 6-8 weeks. Unfortunately, we conclude that the presumed safety net of the examination in its current form is not reliable.
Collapse
Affiliation(s)
- Mike Reidy
- Trauma and Orthopaedic Department, Ninewells Hospital, Dundee, UK
| | - Caitlin Collins
- Trauma and Orthopaedic Department, Ninewells Hospital, Dundee, UK
| | | | - Donald Campbell
- Trauma and Orthopaedic Department, Ninewells Hospital, Dundee, UK
| |
Collapse
|