Radiological assessment of hip disease in children with cerebral palsy: development of a core measurement set

Aims

Hip disease is common in children with cerebral palsy (CP) and can decrease quality of life and function. Surveillance programmes exist to improve outcomes by treating hip disease at an early stage using radiological surveillance. However, studies and surveillance programmes report different radiological outcomes, making it difficult to compare. We aimed to identify the most important radiological measurements and develop a core measurement set (CMS) for clinical practice, research, and surveillance programmes.

Methods

A systematic review identified a list of measurements previously used in studies reporting radiological hip outcomes in children with CP. These measurements informed a two-round Delphi study, conducted among orthopaedic surgeons and specialist physiotherapists. Participants rated each measurement on a nine-point Likert scale ('not important' to 'critically important'). A consensus meeting was held to finalize the CMS.

Results

Overall, 14 distinct measurements were identified in the systematic review, with Reimer's migration percentage being the most frequently reported. These measurements were presented over the two rounds of the Delphi process, along with two additional measurements that were suggested by participants. Ultimately, two measurements, Reimer's migration percentage and femoral head-shaft angle, were included in the CMS.

Conclusion

This use of a minimum standardized set of measurements has the potential to encourage uniformity across hip surveillance programmes, and may streamline the development of tools, such as artificial intelligence systems to automate the analysis in surveillance programmes. This core set should be the minimum requirement in clinical studies, allowing clinicians to add to this as needed, which will facilitate comparisons to be drawn between studies and future meta-analyses.

Radiological hip shape and patient-reported outcome measures in healed Perthes' disease

Aims

This study aimed to evaluate the relationship between hip shape and mid-term function in Perthes' disease. It also explored whether the modified three-group Stulberg classification can offer similar prognostic information to the five-group system.

Methods

A total of 136 individuals aged 12 years or older who had Perthes' disease in childhood completed the Patient-Reported Outcomes Measurement Information System (PROMIS) Mobility score (function), Nonarthritic Hip Score (NAHS) (function), EuroQol five-dimension five-level questionnaire (EQ-5D-5L) score (quality of life), and the numeric rating scale for pain (NRS). The Stulberg class of the participants' hip radiographs were evaluated by three fellowship-trained paediatric orthopaedic surgeons. Hip shape and Stulberg class were compared to PROM scores.

Results

A spherical hip was associated with the highest function and quality of life, and lowest pain. Conversely, aspherical hips exhibited the lowest functional scores and highest pain. The association between worsening Stulberg class (i.e. greater deviation from sphericity) and worse outcome persisted after adjustment for age and sex in relation to PROMIS (predicted mean difference -1.77 (95% confidence interval (CI) -2.70 to -0.83)), NAHS (-5.68 (95% CI -8.45 to -2.90)), and NRS (0.61 (95% CI 0.14 to 1.08)), but not EQ-5D-5L (-0.03 (95% CI -0.72 to 0.11)).

Conclusion

Patient-reported outcomes identify lower function, quality of life, and higher pain in aspherical hips. The magnitude of symptoms deteriorated with time. Hip sphericity (i.e. the modified three-group classification of spherical, oval, and aspherical) appeared to offer similar levels of detail to the five-group Stulberg classification.

341 Alder Hey Experience of Paediatric Virtual Fracture Clinic During The COVID-19 Pandemic

Introduction

The SARS-CoV2/COVID-19 pandemic represented an unprecedented emergency prompting a drive to minimise non-essential patient contact and the need for a virtual fracture clinic (VFC); an uncommon practice in paediatric units. Management of paediatric fractures requires a greater degree of vigilance to safeguard children. The current climate has created social challenges that theoretically increase the risk of harm and exploitation to children. This study investigates VFC in the management of paediatric fractures to determine the efficiency of such a process and the risk of safeguarding.

Method

A protocol was devised in affiliation with BSCOS for the immediate management and streamlining of paediatric fractures into VFC. We retrospectively audited 235 VFC consults over a 1-month period. Patient sex was roughly evenly distributed, and age ranged from 9 months to 16 years (mean 8.4 years).

Results

42% of patients were recalled for a face-to-face (F2F) review (26% expedited), primarily for clinical assessment, plaster complaints and imaging requirements. 33% were discharged and 15% continued follow-up in VFC. All clavicle fractures were discharged. Forearm, hand, foot and elbow injuries were more likely to be discharged. Lower leg, upper arm and knee presentations more frequently required a F2F review. 2.3% of cases required safeguarding reviews.

Conclusions

Given the rapid transition to VFC without the use of triage we have determined a number of non-complex fractures safely managed and discharged via VFC. The low percentage of recall due to safeguarding concern highlights this may not be a barrier to the continuation of virtual care outside of the context of a pandemic.

1170 Outcome of Various Fixation Techniques for Talo-Navicular Arthrodesis

Aim

The talonavicular (TN) forms part of the medial joint complex, which is involved in maintaining stability during the gait cycle Arthrodesis can be used to manage a range of deformities and to treat degenerative and inflammatory changes of the joint. The most significant complication is non-union, but chronic pain due to complex regional pain syndrome, or progressive arthritic changes can also occur. The aim was to evaluate the outcome of different methods of fixation used for TN arthrodesis in adults within the trust.

Method

This was a quality improvement project, looking retrospectively at inpatient surgeries over a 6-year period. Inpatient notes, operative notes, clinic letters and imaging were analysed. Treatment methods included IOFIX devices, cannulated screws, staples, plates and screws, and combined staples and screws. The sample included a total of 57 patients (42 females and 15 males).

Results

IOFIX had a 93% fusion rate, and a 27% complication rate. Cannulated screws had a 79% fusion rate, and a 46% complication rate. Screws and staples had a 75% union rate, and a 13% complication rate. Only one sample used plates and screws, which resulted in union and no complications. Using staples alone had a 78% union rate and a 11% complication rate.

Conclusions

The greatest union rate was achieved with IOFIX devices, followed by cannulated screws. Greatest complication rate was with cannulated screws, and lowest with the combined use of staples and screws. Highest rate of revision surgery was with cannulated screws. Recommendations included a switch to IOFIX devices for TN arthrodesis.

Kingella kingae septic arthritis

AIMS

The aim of this study was to determine the extent to which patient demographics, clinical presentation, and blood parameters vary in Kingella kingae septic arthritis when compared with those of other organisms, and whether this difference needs to be considered when assessing children in whom a diagnosis of septic arthritis is suspected.

METHODS

A prospective case series was undertaken at a single UK paediatric institution between October 2012 and November 2018 of all patients referred with suspected septic arthritis. We recorded the clinical, biochemical, and microbiological findings in all patients.

RESULTS

A total of 160 patients underwent arthrotomy for a presumed septic arthritis. Of these, no organism was identified in 61 and only 25 of these were both culture- and polymerase chain reaction (PCR)-negative. A total of 36 patients did not undergo PCR analysis. Of the remaining 99 culture- and PCR-positive patients, K. kingae was the most commonly isolated organism (42%, n = 42). The knee (n = 21), shoulder (n = 9), and hip (n = 5) were the three most commonly affected joints. A total of 28 cases (66%) of K. kingae infection were detected only on PCR. The mean age of K. kingae-positive cases (16.1 months) was significantly lower than that of those whose septic arthitis was due to other organisms (49.4 months; p < 0.001). The mean CRP was significantly lower in the K. kingae group than in the other organism group (p < 0.001). The mean ESR/CRP ratio was significantly higher in K. kingae (2.84) than in other infections (1.55; p < 0.008). The mean ESR and ESR/CRP were not significantly different from those in the 'no organism identified' group.

CONCLUSION

K. kingae was the most commonly isolated organism from paediatric culture- and/or PCR-positive confirmed septic arthritis, with only one third of cases detected on routine cultures. It is important to develop and maintain a clinical suspicion for K. kingae infection in young patients presenting atypically. Routine PCR testing is recommended in these patients. Cite this article: Bone Joint J 2021;103-B(3):584-588.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Increasing smoking intensity is associated with increased disease activity in axial spondyloarthritis

A history of ever-smoking appears to be associated with a more severe disease phenotype in axial spondyloarthritis (axSpA). However, evidence is sparse for the effect of increased smoking exposure on disease outcomes or whether smoking reduction or cessation improves outcomes. The aim of this study was to explore whether a dose–response relationship exists between pack-years and disease activity and functional impairment in axSpA. Consecutive patients meeting ASAS criteria for axial SpA were recruited from a spondyloarthritis service. The associations between pack-years of smoking and: (1) disease activity (BASDAI/ASDAS), (2) spinal pain, (3) functional impairment (BASFI) and (4) inflammatory markers were explored using multivariable linear models, adjusted for age, gender and use of TNF inhibition (TNFi) therapy. Pack-years were categorised into four groups (<10, 11–20, 21–40, >40) and analysed with light smoking (<10) as reference. Two hundred and thirty-eight axSpA patients were recruited: 76% were male, mean age 46.4 years (SD ± 13.7), and 33% were treated with TNFi. One hundred and twelve patients reported history of ever-smoking with median pack-year 20 [IQR10-30]. Compared to light smokers, those with higher categories of smoking exposures had higher BASDAI (21–40 pack-years, β = 1.6 (95% CI 0.28, 2.95); >40, β = 2.6 (0.54, 3.56)), higher BASFI (21–40, β = 2.1 (0.42, 4.80); >40, β = 3.2 (0.76, 5.71)), and higher ASDAS (21–40, β = 0.82 (0.14, 1.51)). This cross-sectional study demonstrated that smoking is associated with increased axSpA severity markers in a dose–response manner. Particular effort should be made to restrict smoking exposure early before accruing a significant number of pack-years.

Bilateral Chest X-Ray Shadowing and Bilateral leg lesions - A case of Pulmonary Kaposi Sarcoma

We report a case of a 30 year old gentleman seen on the respiratory ward with no significant past medical history presenting with a three week history of worsening dyspnoea, productive cough, fever, bilateral leg swelling and bilateral leg swelling. Initial differential diagnosis included community-acquired pneumonia, cellulitis and deep vein thrombosis. After much investigation a diagnosis of AIDS-related kaposi's sarcoma with visceral manifestations was made.

Human mesenchymal stem cell response to poly(ε-caprolactone/poly(methyl methacrylate) demixed thin films

Advances in material sciences have enabled the fabrication of biomaterials which are able to provide the requisite cues to stimulate cells to behave in a specific way. Nanoscale surface topographies are well known to be able to positively influence cell-substrate interactions. This study reports on a novel series of poly(ε-caprolactone) PCL and poly(methyl methacrylate) demixed nanotopographic films as non-biological cell-stimulating cues. The topographic features observed ranged from nanoislands to nanopits. PMMA was observed to segregate to the air interface, while PCL preferred the substrate interface. Preliminary response of human mesenchymal stem cells to these surfaces indicated that the substrate with nanoisland topography has the potential to differentiate to osteogenic, chondrogenic and adipogenic lineages.

Advances in volume monitoring in dialysis patients

Estimating volume status in patients on chronic dialysis is of great clinical value. Both hypervolemia and hypovolemia are associated with serious short term and long term complications, and volume status is often difficult to assess due to multiple factors affecting intravascular and extravascular volume compartments, as well as variability between patients in baseline blood pressures and physical exams. Traditional methods such as estimated dry weight (EDW) and physical exams are often not accurate because of the subjective nature of these indicators and variability between patients' baselines. This can lead to inaccurate volume status estimation and the associated complications. Furthermore, the concept of estimated dry weight is often defined based on measurements of blood pressure which may not accurately reflect volume status. In this review we describe several methods of measuring volume status in dialysis patients that may be more accurate than traditional measurements of blood pressure and dry weight estimation. These methods include dilutional techniques, imaging of vascular structures, use of biomarkers, bioimpedance analysis and online monitoring of biochemical variables during dialysis itself. We also discuss the clinical applicability and comparisons between these methods including the benefits and drawbacks of these methods and areas for future research.