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Gelfer Y, Cavanagh SE, Bridgens A, Ashby E, Bouchard M, Leo DG, Eastwood DM. The Core outcome Clubfoot (CoCo) study: relapse, with poorer clinical and quality of life outcomes, affects 37% of idiopathic clubfoot patients. Bone Joint J 2024; 106-B:735-743. [PMID: 38945546 DOI: 10.1302/0301-620x.106b7.bjj-2023-1258.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Aims There is a lack of high-quality research investigating outcomes of Ponseti-treated idiopathic clubfeet and correlation with relapse. This study assessed clinical and quality of life (QoL) outcomes using a standardized core outcome set (COS), comparing children with and without relapse. Methods A total of 11 international centres participated in this institutional review board-approved observational study. Data including demographics, information regarding presentation, treatment, and details of subsequent relapse and management were collected between 1 June 2022 and 30 June 2023 from consecutive clinic patients who had a minimum five-year follow-up. The clubfoot COS incorporating 31 parameters was used. A regression model assessed relationships between baseline variables and outcomes (clinical/QoL). Results Overall, 293 patients (432 feet) with a median age of 89 months (interquartile range 72 to 113) were included. The relapse rate was 37%, with repeated relapse in 14%. Treatment considered a standard part of the Ponseti journey (recasting, repeat tenotomy, and tibialis anterior tendon transfer) was performed in 35% of cases, with soft-tissue release and osteotomies in 5% and 2% of cases, respectively. Predictors of relapse included duration of follow-up, higher initial Pirani score, and poor Evertor muscle activity. Relapse was associated with poorer outcomes. Conclusion This is the first multicentre study using a standardized COS following clubfoot treatment. It distinguishes patients with and without relapse in terms of clinical outcomes and QoL, with poorer outcomes in the relapse group. This tool allows comparison of treatment methods and outcomes, facilitates information sharing, and sets family expectations. Predictors of relapse encourage us to create appropriate treatment pathways to reduce relapse and improve outcome.
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Affiliation(s)
- Yael Gelfer
- St George's University Hospitals NHS Foundation Trust, London, UK
- St George's University of London, London, UK
| | - Sean E Cavanagh
- St George's University Hospitals NHS Foundation Trust, London, UK
- St George's University of London, London, UK
| | - Anna Bridgens
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Maryse Bouchard
- The Hospital for Sick Children, Toronto, Canada
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Donato G Leo
- St George's University Hospitals NHS Foundation Trust, London, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Deborah M Eastwood
- Great Ormond Street Hospital, London, UK
- University College London, London, UK
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Hussain SA, Russell A, Cavanagh SE, Bridgens A, Gelfer Y. A 'Hub and Spoke' Shared Care initiative for CTEV Ponseti service. Bone Jt Open 2023; 4:865-872. [PMID: 37963491 PMCID: PMC10645486 DOI: 10.1302/2633-1462.411.bjo-2023-0076.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2023] Open
Abstract
Aims The Ponseti method is the gold standard treatment for congenital talipes equinovarus (CTEV), with the British Consensus Statement providing a benchmark for standard of care. Meeting these standards and providing expert care while maintaining geographical accessibility can pose a service delivery challenge. A novel 'Hub and Spoke' Shared Care model was initiated to deliver Ponseti treatment for CTEV, while addressing standard of care and resource allocation. The aim of this study was to assess feasibility and outcomes of the corrective phase of Ponseti service delivery using this model. Methods Patients with idiopathic CTEV were seen in their local hospitals ('Spokes') for initial diagnosis and casting, followed by referral to the tertiary hospital ('Hub') for tenotomy. Non-idiopathic CTEV was managed solely by the Hub. Primary and secondary outcomes were achieving primary correction, and complication rates resulting in early transfer to the Hub, respectively. Consecutive data were prospectively collected and compared between patients allocated to Hub or Spokes. Mann-Whitney U test, Wilcoxon signed-rank test, or chi-squared tests were used for analysis (alpha-priori = 0.05, two-tailed significance). Results Between 1 March 2020 and 31 March 2023, 92 patients (139 feet) were treated at the service (Hub 50%, n = 46; Spokes 50%, n = 46), of whom nine were non-idiopathic. All patients (n = 92), regardless of allocation, ultimately achieved primary correction, with idiopathic patients at the Hub requiring fewer casts than the Spokes (mean 4.0 (SD 1.4) vs 6.9 (SD 4.4); p < 0.001). Overall, 60.9% of Spokes' patients (n = 28/46) required transfer to the Hub due to complications (cast slips Hub n = 2; Spokes n = 17; p < 0.001). These patients ultimately achieved full correction at the Hub. Conclusion The Shared Care model was found to be feasible in terms of providing primary correction to all patients, with results comparable to other published services. Complication rates were higher at the Spokes, although these were correctable. Future research is needed to assess long-term outcomes, parents' satisfaction, and cost-effectiveness.
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Affiliation(s)
- Sabba A. Hussain
- Trauma and Orthopaedics Department, St George’s University Hospitals NHS Foundation Trust, London, UK
- St George’s University of London, London, UK
| | - Aisling Russell
- Paediatric Physiotherapy Department, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Sean E. Cavanagh
- Trauma and Orthopaedics Department, St George’s University Hospitals NHS Foundation Trust, London, UK
- St George’s University of London, London, UK
| | - Anna Bridgens
- Trauma and Orthopaedics Department, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Yael Gelfer
- Trauma and Orthopaedics Department, St George’s University Hospitals NHS Foundation Trust, London, UK
- St George’s University of London, London, UK
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3
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Mitchell PD, Abraham A, Carpenter C, Henman PD, Mavrotas J, McCaul J, Sanghrajka A, Theologis T. Consensus guidelines on the management of musculoskeletal infection affecting children in the UK. Bone Joint J 2023; 105-B:815-820. [PMID: 37399098 DOI: 10.1302/0301-620x.105b7.bjj-2022-1316.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
Aims The aim of this study was to determine the consensus best practice approach for the investigation and management of children (aged 0 to 15 years) in the UK with musculoskeletal infection (including septic arthritis, osteomyelitis, pyomyositis, tenosynovitis, fasciitis, and discitis). This consensus can then be used to ensure consistent, safe care for children in UK hospitals and those elsewhere with similar healthcare systems. Methods A Delphi approach was used to determine consensus in three core aspects of care: 1) assessment, investigation, and diagnosis; 2) treatment; and 3) service, pathways, and networks. A steering group of paediatric orthopaedic surgeons created statements which were then evaluated through a two-round Delphi survey sent to all members of the British Society for Children's Orthopaedic Surgery (BSCOS). Statements were only included ('consensus in') in the final agreed consensus if at least 75% of respondents scored the statement as critical for inclusion. Statements were discarded ('consensus out') if at least 75% of respondents scored them as not important for inclusion. Reporting these results followed the Appraisal Guidelines for Research and Evaluation. Results A total of 133 children's orthopaedic surgeons completed the first survey, and 109 the second. Out of 43 proposed statements included in the initial Delphi, 32 reached 'consensus in', 0 'consensus out', and 11 'no consensus'. These 11 statements were then reworded, amalgamated, or deleted before the second Delphi round of eight statements. All eight were accepted as 'consensus in', resulting in a total of 40 approved statements. Conclusion In the many aspects of medicine where relevant evidence is not available for clinicians to base their practice, a Delphi consensus can provide a strong body of opinion that acts as a benchmark for good quality clinical care. We would recommend clinicians managing children with musculoskeletal infection follow the guidance in the consensus statements in this article, to ensure care in all medical settings is consistent and safe.
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Affiliation(s)
| | | | - Clare Carpenter
- University Hospital of Wales Healthcare NHS Trust, Cardiff, UK
| | - Philip D Henman
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Jason Mavrotas
- Health Education England North West School of Surgery, Manchester, UK
| | - Janet McCaul
- Royal Hospital for Sick Children Yorkhill, Glasgow, UK
| | | | - Tim Theologis
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Murray IR, Makaram NS, LaPrade RF, Haddad FS. Consensus statements: when and how? Bone Joint J 2023; 105-B:343-346. [PMID: 36916987 DOI: 10.1302/0301-620x.105b4.bjj-2023-0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
The Bone & Joint Journal has published several consensus statements in recent years, many of which have positively influenced clinical practice and policy.1-13 However, even the most valued consensus statements have limitations, and all ultimately represent Level V evidence. Consensus studies add greatest value where higher-order evidence to aid decision making is ambiguous or lacking. In all settings, care must be taken to critically appraise standards of methodology, with particular attention to potential biases that may influence the conclusions which are drawn.
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Affiliation(s)
- Iain R Murray
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Navnit S Makaram
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Fares S Haddad
- University College London Hospitals NHS Foundation Trust, London, UK.,The Bone & Joint Journal , London, UK
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Haddad FS. 75 years young. Bone Joint J 2023; 105-B:341-342. [PMID: 36916978 DOI: 10.1302/0301-620x.105b4.bjj-2023-0225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Affiliation(s)
- Fares S Haddad
- University College London Hospitals, The Princess Grace Hospital, and The NIHR Biomedical Research Centre at UCLH, London, UK.,The Bone & Joint Journal , London, UK
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Aarvold A, Perry DC, Mavrotas J, Theologis T, Katchburian M. The management of developmental dysplasia of the hip in children aged under three months : a consensus study from the British Society for Children's Orthopaedic Surgery. Bone Joint J 2023; 105-B:209-214. [PMID: 36722054 PMCID: PMC9869707 DOI: 10.1302/0301-620x.105b2.bjj-2022-0893.r1] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
AIMS A national screening programme has existed in the UK for the diagnosis of developmental dysplasia of the hip (DDH) since 1969. However, every aspect of screening and treatment remains controversial. Screening programmes throughout the world vary enormously, and in the UK there is significant variation in screening practice and treatment pathways. We report the results of an attempt by the British Society for Children's Orthopaedic Surgery (BSCOS) to identify a nationwide consensus for the management of DDH in order to unify treatment and suggest an approach for screening. METHODS A Delphi consensus study was performed among the membership of BSCOS. Statements were generated by a steering group regarding aspects of the management of DDH in children aged under three months, namely screening and surveillance (15 questions), the technique of ultrasound scanning (eight questions), the initiation of treatment (19 questions), care during treatment with a splint (ten questions), and on quality, governance, and research (eight questions). A two-round Delphi process was used and a consensus document was produced at the final meeting of the steering group. RESULTS A total of 60 statements were graded by 128 clinicians in the first round and 132 in the second round. Consensus was reached on 30 out of 60 statements in the first round and an additional 12 in the seond. This was summarized in a consensus statement and distilled into a flowchart to guide clinical practice. CONCLUSION We identified agreement in an area of medicine that has a long history of controversy and varied practice. None of the areas of consensus are based on high-quality evidence. This document is thus a framework to guide clinical practice and on which high-quality clinical trials can be developed.Cite this article: Bone Joint J 2023;105-B(2):209-214.
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Affiliation(s)
- Alexander Aarvold
- Southampton Children’s Hospital, Southampton, UK,University of Southampton, Southampton, UK,Correspondence should be sent to Alexander Aarvold. E-mail:
| | - Daniel C. Perry
- NDORMS, University of Oxford, Oxford, UK,Institute Population Health, University of Liverpool, Liverpool, UK,Alder Hey Children’s Hospital, Liverpool, UK
| | - Jason Mavrotas
- St Helens and Knowsley Teaching Hospitals NHS Foundation Trust, Liverpool, UK
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Hopwood S, Khan F, Kemp J, Rehm A, Ashby E. Clubfoot: an overview and the latest UK guidelines. Br J Hosp Med (Lond) 2023; 84:1-7. [PMID: 36708340 DOI: 10.12968/hmed.2022.0380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Clubfoot is one of the most common congenital anomalies, affecting every 1 of 1000 live births in the UK. Historically, clubfeet have been managed with a variety of conservative and operative techniques. Over the last two decades, the Ponseti serial casting method has become the gold standard of treatment. In July 2021, the British Society of Children's Orthopaedic Surgery (Gelfer et al, 2022) published a consensus statement that outlines the optimal management for clubfoot. This article provides an overview of clubfoot and a summary of the latest management guidelines.
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Affiliation(s)
- Samuel Hopwood
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge, UK
| | | | - Jennifer Kemp
- Department of Paediatric Trauma and Orthopaedic Physiotherapy, Addenbrooke's Hospital, Cambridge, UK
| | - Andreas Rehm
- Department of Paediatric Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge, UK
| | - Elizabeth Ashby
- Department of Paediatric Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge, UK
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