Andrew Wainwright

Surgical treatment of late developmental displacement of the hip. Results after 33 years.

The outcome of displaced hips treated by Somerville and Scotts method was assessed after more than 25 years. A total of 147 patients (191 displaced hips) was reviewed which represented an overall follow-up of 65.6%. The median age at the index operation was two years. During the first five years, 25 (13%) hips showed signs of avascular change. The late development of valgus angulation of the neck, after ten years, was seen in 69 (36%) hips. Further operations were frequently necessary. Moderate to severe osteoarthritis developed at a young age in 40% of the hips. Total hip replacement or arthrodesis was necessary in 27 (14%) hips at a mean age of 36.5 years. Risk factors identified were high dislocation, open reduction, and age at the original operation. Two groups of patients were compared according to outcome. All the radiographic indices were different between the two groups after ten years, but most were similar before. It takes a generation to establish the prognosis, although some early indicators may help to predict outcome.

The Oxford ankle foot questionnaire for children: SCALING, RELIABILITY AND VALIDITY

We developed the Oxford ankle foot questionnaire to assess the disability associated with foot and ankle problems in children aged from five to 16 years. A survey of 158 children and their parents was carried out to determine the content, scaling, reliability and validity of the instrument. Scores from the questionnaire can be calculated to measure the effect of foot or ankle problems on three domains of childrens lives: physical, school and play, and emotional. Scores for each domain were shown to be internally consistent, stable, and to vary little whether reported by child or parent. Satisfactory face, content and construct validity were demonstrated. The questionnaire is appropriate for children with a range of conditions and can provide clinically useful information to supplement other assessment methods. We are currently carrying out further work to assess the responsiveness of questionnaire scores to change over time and with treatment.

The outcome of patients with hinge abduction in severe Perthes disease treated by shelf acetabuloplasty.

Background: The management of patients with Perthes disease remains controversial. In children with hinge abduction and the potential for remodeling, we have performed a shelf acetabuloplasty, in an effort to contain the hip and allow remodeling. We report our medium-term results in a consecutive series of 27 children with severe Perthes disease and arthrographically proven hinge abduction. This is the first report in the English literature to look specifically at the results of treating patients with hinge abduction in severe Perthes disease by shelf acetabuloplasty. Methods: Twenty-seven consecutive children with unilateral Perthes disease and arthrographically proven hinge abduction were treated with a shelf acetabuloplasty. These patients have been prospectively reviewed with a clinical examination and radiographic assessment including Catterall, Salter Thompson, and Herrings lateral pillar classification. Radiological measurements included percentage acetabular cover, medial joint space, and femoral head size ratio. Results: The mean postoperative follow-up was 62 months (range, 26-125 months). All patients were Catterall grade III or IV and lateral pillar grade B or C and had arthrographically proven hinge abduction at the time of surgery. At final follow-up, 14 hips were Stulberg grades 1 and 2; 10 hips, grade 3; and 3 hips, grades 4 and 5. The medial joint space decreased from a preoperative ratio of 1.9 to 1.4 (P = 0.002), and the percentage acetabular cover increased from 81% preoperatively to 97% postoperatively (P < 0.001). Conclusion: These results suggest overall good outcomes from a group of patients with severe Perthes disease as measured by the Stulberg grading when compared with historical controls. We suggest that shelf acetabuloplasty is a straight forward surgical procedure with good medium-term results in patients with severe Perthes disease who have proven hinge abduction preoperatively. Level of Evidence: Level IV case series.

The use of minimally invasive techniques in multi-level surgery for children with cerebral palsy: PRELIMINARY RESULTS

This study compares the initial outcomes of minimally invasive techniques for single-event multi-level surgery with conventional single-event multi-level surgery. The minimally invasive techniques included derotation osteotomies using closed corticotomy and fixation with titanium elastic nails and percutaneous lengthening of muscles where possible. A prospective cohort study of two matched groups was undertaken. Ten children with diplegic cerebral palsy with a mean age of ten years six months (7.11 to 13.9) had multi-level minimally invasive surgery and were matched for ambulatory level and compared with ten children with a mean age of 11 years four months (7.9 to 14.4) who had conventional single-event multi-level surgery. Gait kinematics, the Gillette Gait Index, isometric muscle strength and gross motor function were assessed before and 12 months after operation. The minimally invasive group had significantly reduced operation time and blood loss with a significantly improved time to mobilisation. There were no complications intra-operatively or during hospitalisation in either group. There was significant improvement in gait kinematics and the Gillette Gait Index in both groups with no difference between them. There was a trend to improved muscle strength in the multi-level group. There was no significant difference in gross motor function between the groups. We consider that minimally invasive single-event multi-level surgery can be achieved safely and effectively with significant advantages over conventional techniques in children with diplegic cerebral palsy.

Developmental Dysplasia of the Hip

The term ‘developmental dysplasia of the hip’ (DDH) is preferable to the term ‘congenital dysplasia of the hip’ because it embraces a spectrum of disease, ranging from mild malformation of the acetabulum to irreducible hip dislocation. Cases have been reported in which examination of the child was normal at birth and later the hip was found to be unstable, i.e. subluxated or dislocated. DDH recognizes that instability and displacement may progress with growth.

The Oxford Ankle Foot Questionnaire for Children: Review of development and potential applications

There is increasing recognition of the credibility and utility of patient reported outcome measures, both in research and as routine quality indicators. This paper reviews the development of a questionnaire for children with foot or ankle problems and integrates the findings from three previously published studies in a cohesive way for the orthotic community. The Oxford Ankle Foot Questionnaire for Children was designed to evaluate the effectiveness of interventions. The development process was conducted in three phases. First the items were devised through focus groups with children affected by foot and ankle problems, and their parents. Second, test versions of child and parent questionnaires were evaluated to enable scales to be developed and tested for validity and reliability. Finally, findings from a prospective study assessing how scores changed over time and/or with treatment supported the longitudinal validity and responsiveness of the scales. The questionnaire offers an inexpensive and expedient means to evaluate the effectiveness of orthoses and other interventions used to treat childrens foot or ankle problems. The Oxford Ankle Foot Questionnaire for Children has broad utility both in routine clinical settings, or applied research to evaluate treatment programmes and interventions used in paediatric orthopaedics, trauma and rheumatology.

What is the early/mid-term survivorship and functional outcome after Bernese Periacetabular Osteotomy in a Pediatric Surgeon Practice?

BackgroundThe Bernese periacetabular osteotomy (PAO) is a recognized joint-preserving procedure. Achieving joint stability without creating impingement is important, but the orientation target that best balances these sometimes competing goals has not yet been clearly defined. Moreover, the learning curve of this challenging procedure has not been described.Questions/purposesThe purposes of this study were (1) to determine the 10-year survivorship and functional outcome after Bernese PAO in a single-surgeon series; (2) to review which patient, surgical, and radiographic factors might predict outcome after the procedure; and (3) to define the learning curve for target acetabular correction.MethodsThe first 68 PAOs performed for symptomatic hip dysplasia were retrospectively evaluated. None have been lost to followup with followup less than 2 years. Endpoints for the lost to followup (n = 2) are at the time of when last seen. During the study period, the same surgeon performed 562 pelvic osteotomies (including Salter, Pemberton, Dega and Chiari) and 64 shelf acetabuloplasties. Bernese PAO was used only for symptomatic dysplasia (center-edge angle < 25° and nonhorizontal acetabular roof) in developmentally mature hips without evidence of major joint incongruence or subluxation. Most patients were female (n = 49 [60 hips, 88%]); mean age at operation was 25 years (SD 7). Sixteen hips had previous hip procedures. The study’s mean followup was 8 years (range, 2–18 years). Patient-reported functional outcome was obtained using the WOMAC score (best-worst: 0–96). Radiographic parameters of dysplasia (acetabular index [AI], center-edge angle [CEA], congruency, Tönnis grade, and joint space) were evaluated from preoperative and postoperative radiographs using computer software.ResultsThe 10-year survival rate was 93% (95% confidence interval [CI], 82%–100%); four patients underwent further surgery to the hip in the study period. The mean WOMAC was 12 (range, 0–54). Factors that influenced survival included joint congruency (100% versus 78%; 95% CI, 61%–96%; p = 0.03) and acetabular orientation correction achieved (AIpostoperative < 15° [100% versus 65%; 95% CI, 43–88; p < 0.001] and CEApostoperative 20° to 40° [100% versus 71.9%; 52.8–100; p < 0.001]). Better WOMAC scores were seen if postoperative AI < 15° (7 versus 25, p = 0.005) and CEA between 20° and 40° (7 versus 23, p = 0.005) were achieved. The chances of obtaining acetabular correction within this range improved after the 20th procedure (30% versus 70%, p = 0.008).ConclusionsThis study reports excellent results after Bernese PAO in the hands of an experienced pediatric hip surgeon. We advocate cautious correction of the acetabular fragment. Future studies should concentrate on how to determine what the optimal target is and how to achieve it intraoperatively, minimizing the learning curve associated with it.Level of EvidenceLevel III, therapeutic study.

Rang retractors for sciatic notch exposure during pelvic osteotomy

We present simple but effective retractors used in pairs to expose the sciatic notch during Salter innominate osteotomy. We have found them to be useful for a wide range of procedures requiring similar exposure. We present them here in tribute to the memory of the designer Mercer Rang.

What is a good result after clubfoot treatment? A Delphi-based consensus on success by regional clubfoot trainers from across Africa.

Background Congenital talipes equino-varus (CTEV), also known as clubfoot, is one of the most common congenital musculoskeletal malformations. Despite this, considerable variation exists in the measurement of deformity correction and outcome evaluation. This study aims to determine the criteria for successful clubfoot correction using the Ponseti technique in low resource settings through Africa. Methods Using the Delphi method, 18 experienced clubfoot practitioners and trainers from ten countries in Africa ranked the importance of 22 criteria to define an ‘acceptable or good clubfoot correction’ at the end of bracing with the Ponseti technique. A 10cm visual analogue scale was used. They repeated the rating with the results of the mean scores and standard deviation of the first test provided. The consistency among trainers was determined with the intra-class correlation coefficient (ICC). From the original 22 criteria, ten criteria with a mean score >7 and SD <2 were identified and were rated through a second Delphi round by 17 different clubfoot treatment trainers from 11 countries in Africa. The final definition consisted of all statements that achieved strong agreement, a mean score of >9 and SD<1.5. Results The consensus definition of a successfully treated clubfoot includes: (1) a plantigrade foot, (2) the ability to wear a normal shoe, (3) no pain, and (4) the parent is satisfied. Participants demonstrated good consistency in rating these final criteria (ICC 0.88; 0.74,0.97). Conclusions The consistency of Ponseti technique trainers from Africa in rating criteria for a successful outcome of clubfoot management was good. The consensus definition includes basic physical assessment, footwear use, pain and parent satisfaction.