Attaining a British consensus statement on managing idiopathic congenital talipes equinovarus (CTEV) through a Delphi process: a study protocol

INTRODUCTION

Idiopathic congenital talipes equinovarus (CTEV) is the most common congenital limb deformity. Non-operative intervention using the Ponseti method has shown to be superior to soft tissue release and has become the gold standard for first-line treatment. However, numerous deviations from the Ponseti protocol are still reported following incomplete correction or deformity relapse. Significant variation in treatment protocols and management is evident in the literature. Reducing geographical treatment variation has been identified as one of The James Lind Alliance priorities in children's orthopaedics. For this reason, the British Society of Children's Orthopaedic Surgery (BSCOS) commissioned a consensus document to form a benchmark for practitioners and ensure consistent high quality care for children with CTEV.

METHODS AND ANALYSIS

The consensus will follow an established Delphi approach aiming at gaining an agreement on the items to be included in the consensus statement for the management of primary idiopathic CTEV up to walking age. The process will include the following steps: (1) establishing a steering group, (2) steering group meetings, (3) a two-round Delphi survey aimed at BSCOS members, (4) final consensus meeting and (5) dissemination of the consensus statement. Degree of agreement for each item will be predetermined. Descriptive statistics will be used for analysis of the Delphi survey results.

ETHICS AND DISSEMINATION

No patient involvement is required for this project. Informed consent will be assumed from participants taking part in the Delphi survey. Study findings will be published in an open access journal and presented at relevant national and international conferences. Charities and associations will be engaged to promote awareness of the consensus statement.

Surgical Outcomes of Single-Level Bilateral Selective Dorsal Rhizotomy for Spastic Diplegia in 150 Consecutive Patients

OBJECTIVES

Selective dorsal rhizotomy (SDR) is used to improve spasticity, gait, and pain in children with spastic diplegia. There is growing evidence supporting its long-term benefits in terms of functional outcomes, independence, and quality of life. There is, however, little contemporary work describing the surgical morbidity of this irreversible procedure. The purpose of this study is to evaluate the surgical outcomes and complications of SDR at a single United Kingdom center.

METHODS

Demographics, surgical, postoperative, and follow-up data for all patients undergoing SDR between 2011 and 2016 were collected from medical records.

RESULTS

Preoperative Gross Motor Function Classification System levels in 150 consecutive patients were II (35%), III (65%), and IV (1%). Median age was 6 years and 58% were male patients. There were no deaths, cerebrospinal fluid leaks, returns to theater, or readmissions within 30 days. There were no new motor or sphincter deficits. Postoperative neuropathic pain was reported by 5.3% and sensory symptoms by 8.7%. Other complications included: postoperative nausea and vomiting (19.3%), superficial wound infection (3.3%), urinary retention (1.3%), headache (6.7%), and urine or chest infection (4.7%). Follow-up data were available for all patients (93% to 12 months, 72% to 24 months). Persistent neuropathic symptoms were reported in 6.5% at 24 months.

CONCLUSIONS

SDR using a single-level approach is a safe procedure with low surgical morbidity. This study complements the growing evidence base in support of SDR for spastic diplegia and should help inform decisions when considering treatment options.

The medial approach for the treatment of children with developmental dysplasia of the hip

The medial approach for the treatment of children with developmental dysplasia of the hip (DDH) in whom closed reduction has failed requires minimal access with negligible blood loss. In the United Kingdom, there is a preference for these children to be treated using an anterolateral approach after the appearance of the ossific nucleus. In this study we compared these two protocols, primarily for the risk of osteonecrosis. Data were gathered prospectively for protocols involving the medial approach (26 hips in 22 children) and the anterolateral approach (22 hips in 21 children) in children aged < 24 months at the time of surgery. Osteonecrosis of the femoral head was assessed with validated scores. The acetabular index (AI) and centre-edge angle (CEA) were also measured. The mean age of the children at the time of surgery was 11 months (3 to 24) for the medial approach group and 18 months (12 to 24) for the anterolateral group, and the combined mean follow-up was 70 months (26 to 228). Osteonecrosis of the femoral head was evident or asphericity predicted in three of 26 hips (12%) in the medial approach group and four of 22 (18%) in the anterolateral group (p = 0.52). The mean improvement in AI was 8.8° (4° to 12°) and 7.9° (6° to 10°), respectively, at two years post-operatively (p = 0.18). There was no significant difference in CEA values of affected hips between the two groups. Children treated using an early medial approach did not have a higher risk of developing osteonecrosis at early to mid-term follow-up than those treated using a delayed anterolateral approach. The rates of acetabular remodelling were similar for both protocols.

A year's trauma admissions and the effect of the weather

PURPOSE OF THE STUDY

To study the admissions to a busy trauma unit on a day-by-day basis over a 1 year period, and to look for any correlation with local weather variation or temporal factors (day of the week, weekends/school holidays, etc.).

METHOD

Admissions data for the Trauma Unit at the Leicester Royal Infirmary was collected from an administrative database and ward records for the calendar year of 1998. Admissions were split into four groups: all admissions, adult admissions, admissions for proximal femoral fractures (neck of femur (NOF)) and paediatric admissions. Weather information for the local area was obtained from the Meteorological Office. Details of school holidays were obtained from the local Education Department. The above variables were examined using Poisson regression analysis for their potential importance in explaining day-to-day variation in admission rates for the four groups.

RESULTS

For adult and NOF admissions, none of the weather factors appeared to explain variation in incidence, only day of the week appears to be important, with the earlier part of the week yielding a highly statistically significant increase in the relative incidence of trauma admissions. For both paediatric and total admissions, a number of factors appear important, including maximum and minimum temperatures, hours of sunshine, day of the week and month of the year. Daily rainfall, significant weather and whether the day was a school day or school holiday did not appear to be important on univariate analysis.

CONCLUSION

Trauma admissions are related to both weather and temporal factors. This may have implications both in terms of prevention and in planning of care provision in trauma units.

Inter- and intra-measurer error in the measurement of Reimers' hip migration percentage

Reimers' hip migration percentage is commonly used to document the extent of subluxation of the hip in children with spasticity. In this study, two measurers, with six months paediatric orthopaedic experience, measured the migration percentage on 44 pelvic radiographs of children with cerebral palsy, aged between two and eight years. Unknown to the measurers, each radiograph was duplicated, giving 22 non-identical radiographs (44 hips) which were measured twice at time 0 and twice six weeks later. The intra-measurer, intra-sessional absolute differences between the first and second measurements ranged from 0% to 23%, with median values of 2.5% to 3.6%. The intra-sessional median absolute differences were not statistically different between the two measurers and measuring sessions (p = 0.42, Kruskal-Wallis test). The inter-sessional absolute differences for measurements made by the same measurers ranged from 0% to 18% with a median absolute difference of 1.7% to 3.2%. Overall, only 5% of the intra-measurer measurement differences, within and between sessions, were above 13%. Repeated measurements by one measurer over time must, therefore, vary by more than 13% in order to be 95% confident of a true change. The inter-measurer error was higher with median absolute differences between the two measurers' measurements of the same hip of 3.25% to 5% (0% to 26%) and a 95th upper confidence interval of 21% to 23%. Averaging the four separate measurements over the two sessions reduced the inter-measurer error to a median absolute difference of 2.8%, but did not improve the 95th upper confidence interval, which measured 22.4%. Such inter-measurer errors may be clinically unacceptable.

Follow-up after carpal tunnel decompression - general practitioner surgery or hand clinic? A randomized prospective study

We prospectively randomized 100 patients following carpal tunnel decompression who were having a 2-week postoperative assessment and removal of stitches to either their local general practitioner (GP) or the hospital outpatient department. All patients were seen at hospital 6 weeks postoperatively for a final assessment. The waiting time for assessment and suture removal was shorter at the GP surgery than in the outpatient department (mean 13 min and 28 min respectively) but significantly more patients were diagnosed as having wound infections (14% and 0% respectively); most were given antibiotics, perhaps unnecessarily.

False aneurysm of an intercostal artery after thoracoscopic sympathectomy

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