Distribution and motor ability of children with cerebral palsy in Scotland: a registry analysis.

BACKGROUND AND AIMS: Cerebral palsy is the commonest long-term physical disability in children with a prevalence of between 1.77 and 2.11/1000 live births. In 2013, the Cerebral Palsy Integrated Pathway Scotland (CPIPS) surveillance programme was introduced in all 14 Health Boards in Scotland and provides a standardised musculoskeletal examination of the spine and lower limbs. The purpose of this study was to report the prevalence, subtypes, motor classification and motor ability of children with cerebral palsy in Scotland. METHODS AND RESULTS: The family/carer's postal address, the child's neurological classification, motor subtypes, Gross Motor Functional Classification (GMFCS) Level and Functional Mobility Scale of 1972 children at first registration in CPIPS 2013-2018 were analysed. Their mean age at first assessment was 7.6 years. There was an overall prevalence of cerebral palsy in Scotland of 2.02/1000. GMFCS levels and Functional Mobility Scale data and prevalence were reported by Health Board and were comparable to that reported elsewhere. CONCLUSION: For the first time, data are available on the motor abilities of the total population of children with cerebral palsy in Scotland. This information will be highly relevant to resource management of current and future motor needs of these children.

Metaphyseal Sleeves for Revision Total Knee Arthroplasty: Good Short-Term Outcomes.

Metaphyseal sleeve prostheses have shown promising results in the management of bone defects at revision TKA. We present a study of their use in aseptic revision TKA. Thirty-five revisions were included in 34 patients with wear or aseptic loosening indicated in 71% of cases. The majority of cases (63%) were AORI grade 2 or greater on the tibia or femur. Knee Society scores were excellent or good in 83% of patients with the same percentage having no or only mild pain. One patient suffered a sleeve-related complication with femoral condylar fractures three years postoperatively; these united with good outcomes. All radiographs were satisfactory; no patient required a further revision. We report good outcomes with the use of metaphyseal sleeves in revision TKA.

Open ankle fractures: who gets them and why?

Open ankle fractures present a significant clinical challenge. The management and outcome of these injuries has been extensively reported, but there have been no reports of the epidemiology and how this has changed over time. We report 178 adult patients with open ankle fractures presenting to our unit over a twenty-three year period. The study centre is the only hospital receiving adult orthopaedic trauma in the region and has a defined population. The incidence of open ankle fractures was 1.5/10(5)/year, representing 1.5 % of all ankle fractures. The mean age was 55 years (range 16-96), with the highest incidence occurring in women over the age of 90. The most common mechanism was a simple fall with only 26 % of cases due to a motor vehicle collision (MVC). 82 % of cases were isolated injuries. Social deprivation had no significant influence on the incidence, but there was a difference in the mechanism with the majority of injuries in the most deprived quintile caused by MVCs and significantly fewer due to simple falls (p = 0.047). Over the twenty-three years, there was a significant increase in the mean age from 44 to 64 years (p = 0.03). The overall incidence remained constant over the two decades. In common with many traumatic injuries, open ankle fractures are increasingly low-energy insufficiency fractures affecting elderly patients, particularly older women. This has implications for service planning and training as well as the surgical intervention in these patients.

Changing epidemiology of adult fractures in Scotland.

BACKGROUND: Fracture epidemiology in adults is changing but there is very little information about the rate of change or whether the change affects males and females equally. METHODS: We have compared fracture incidence in two similar populations 50-60 years apart. A study of fractures in Dundee, Scotland and Oxford, England, in 1954-1958, was compared with a similar cohort of fractures in Edinburgh, Scotland, in 2010-2011. Fracture incidence in patients >35 years was recorded in both time periods. RESULTS: The incidence of fractures increased by 50% between the two time periods, although the increase in males was only 5% compared with 85% in females. The spectrum of fractures has changed considerably, and there has been an increase in the incidence of both fragility and non-fragility fractures. Analysis showed an increased incidence of fall-related fractures in all age groups in both males and females. INTERPRETATION: There has been a substantial change in the incidence of fractures in the last 50-60 years. These have been caused by greater longevity and by considerable social and economic changes.

A Prospective, Randomized, Controlled, Two-Center, International Trial Comparing the Fibular Nail With Open Reduction and Internal Fixation for Unstable Ankle Fractures in Younger Patients.

OBJECTIVE: To compare the outcome of fibular nailing with plate fixation for unstable fractures of the ankle in a cohort of patients under the age of 65 years. SETTING: 2 international university trauma centers. PATIENTS/PARTICIPANTS: One hundred twenty-five patients who were 18-64 years of age with an acute unstable fracture of the ankle were included in the study. INTERVENTION: Patients were randomized to fixation with a fibular nail (n = 63) or plate (n = 62) and were reviewed at 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery. MAIN OUTCOME MEASUREMENTS: The primary outcome measure was the Olerud and Molander score at 1 year. Secondary outcomes were the rates of complications and reinterventions. RESULTS: There was no difference between the 2 groups with respect to the primary outcome measure [mean Olerud and Molander score 78.4 in the nail group vs. 80.2 in the plate group (P = 0.621)]. Wound infections occurred in 2 patients who were treated with a nail and 9 patients who were treated with a plate, but this did not reach statistical significance. No difference was seen in the overall rate of complications and reinterventions between groups [28.6% in the nail group vs. 29% in the plate group (P = 0.955)]. CONCLUSIONS: In younger patients with ankle fractures, no difference was found in the patient-reported outcome between fibular nail and plate fixation at 1 year after surgery. The fibular nail is an effective and safe option for the stabilization of ankle fractures in younger patients, although the benefits associated with reduced wound complications are not as apparent as for elderly patients. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Hip displacement in children with cerebral palsy.

AIMS: The migration percentage (MP) is one criterion used for surgery in dislocated or displaced hips in children with cerebral palsy (CP). The MP at which a displaced hip can no longer return to normal is unclear. The aim of this paper was to identify the point of no return of the MP through a large population-based study. METHODS: All children registered on the Cerebral Palsy Integrated Pathway Scotland surveillance programme undergo regular pelvic radiographs. Any child who had a MP measuring over 35% since the programme's inception in 2013, in at least one hip and at one timepoint, was identified. The national radiography database was then interrogated to identify all pelvic radiographs for each of these children from birth through to the date of analysis. A minimum of a further two available radiographs following the initial measurement of MP ≥ 35% was required for inclusion. RESULTS: A total of 239 children (346 hips) were identified as suitable for analysis at a mean of 6.5 years (2.0 to 14.8) follow-up. In all, 1,485 radiographs taken both prior to and after a hip had a MP ≥ 35% were examined and the MP measured to identify any progression of displacement. Interrogation of the data identified that hips with a MP up to 46% returned to a MP below 40% without intervention, and all hips with a MP equal to or greater than 46% displaced further and the MP did not return to the normal range. Statistical analysis showed the result to be 98% specific with this degree of certainty that hips reaching a MP ≥ 46% would not spontaneously regress. CONCLUSION: These findings are clinically relevant in showing that it may be reasonable to continue to monitor hips with a MP not exceeding 46%. This threshold will also guide referral for further management of a displacing hip. Cite this article: Bone Joint J 2021;103-B(2):411-414.

Hip displacement and dislocation in a total population of children with cerebral palsy in Scotland.

AIMS: The purpose of this study was to compare the prevalence of hip displacement and dislocation in a total population of children with cerebral palsy (CP) in Scotland before and after the initiation of a hip surveillance programme. PATIENTS: A total of 2,155 children with CP are registered in the Cerebral Palsy Integrated Pathway Scotland (CPIPS) surveillance programme, which began in 2013. Physical examination and hip radiological data are collected according to nationally agreed protocols. METHODS: Age, Gross Motor Function Classification System (GMFCS) level, subtype of CP, migration percentage (MP), and details of hip surgery were analyzed for all children aged between two and 16 years taken from a time of census in March 2019 and compared to the same data from the initial registration of children in the CPIPS. Displacement of the hip was defined as a MP of between 40% and 99%, and dislocation as a MP of 100%. RESULTS: A total of 1,646 children were available for analysis at the time of the census and 1,171 at their first registration in CPIPS. The distribution of age, sex, and GMFCS levels were similar in the two groups. The prevalence of displacement and dislocation of the hip before surveillance began were 10% (117/1,171) and 2.5% (29/1,171) respectively, and at the time of the census were 4.5% (74/1,646) and 1.3% (21/1,646), respectively. Dislocation was only seen in GMFCS levels IV and V and displacement seen in 90.5% (67/74) of these levels and 9.5% (7/74) in levels I to III. In total, 138 children had undergone hip surgery during the study period. The hip redisplaced after the initial surgery in 15 children; seven of these had undergone a second procedure and at the time of the census the hips in all seven had a MP < 40. CONCLUSION: Hip surveillance appears to be effective and has reduced the prevalence of hip displacement by over half and dislocation almost by half in these children. Cite this article: Bone Joint J 2020;102-B(3):383-387.

Optimizing Long-Term Outcomes and Avoiding Failure With the Fibula Intramedullary Nail.

OBJECTIVES: To identify risk factors for fixation failure, report patient outcomes, and advise on modifications to the surgical technique for fibula nail stabilization of unstable ankle fractures. DESIGN: Retrospective review. SETTING: Academic orthopaedic trauma unit. PATIENTS: All 342 patients were identified retrospectively from a prospectively collected single-center trauma database over a 9-year period. INTERVENTION: Unstable ankle fractures managed surgically with a fibula nail. MAIN OUTCOME MEASUREMENTS: The primary short-term outcome was failure, defined as any case that required revision surgery because of an inadequate mechanical construct. The mid-term outcomes included the Olerud-Molander Ankle Score and the Manchester-Oxford Foot Questionnaire. RESULTS: Twenty failures occurred (6%), of which 7 (2%) were due to device failure and 13 (4%) due to surgeon error. Of the surgeon errors, 8 consisted of inappropriate weight-bearing after syndesmotic diastasis, and 5 were due to inadequate fracture reduction or poor nail placement. Proximal locking screw (PLS) pull-out was the cause of all device failures. Positioning the PLS >20 mm above the plafond significantly increased failure risk (P = 0.003). At a mean follow-up of 5.1 years (range, 8 months-8 years) the median Olerud-Molander Ankle Score and Manchester-Oxford Foot Questionnaire were 80 (interquartile range, 45) and 10.94 (interquartile range, 44.00), respectively. Patient outcome was not negatively affected by the requirement for revision surgery. CONCLUSIONS: The fibula nail offers secure fixation and good patient-reported outcomes for unstable ankle fractures. Appropriate postoperative management and surgical technique, including careful placement of the PLS, is essential to minimize construct failure risk. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Open Finger Fractures: Incidence, Patterns of Injury and the Influence of Social Deprivation.

BACKGROUND: This study investigates the patterns and epidemiology of open finger fractures. There is little good data about these injuries. METHODS: Data were collected prospectively in a single trauma unit serving a well-defined population. RESULTS: Over a 15 year period 1090 open finger fractures were treated in 1014 patients. These made up the vast majority of open fractures treated in the trauma unit during this period. The incidence of open finger fractures was 14.0 per 100,000 patients per year. Deprivation did not influence the incidence of open finger fractures but did affect treatment choices for women. Most open finger fractures resulted from crush injuries or falls and required only simple operative treatments: debridement, lavage and early mobilization. CONCLUSIONS: Open finger fractures formed the majority of the workload of open fractures at our trauma centre but usually required simple treatments only. Social deprivation was not shown to influence the patterns or epidemiology of these injuries but did affect treatment choices for women.

Nonoperative management of displaced olecranon fractures in low-demand elderly patients.

BACKGROUND: The aim of this study was to document both the short and the long-term outcomes following primary nonoperative management of isolated displaced fractures of the olecranon. METHODS: We identified, from our prospective trauma database, all patients who had been managed nonoperatively for a displaced olecranon fracture over a thirteen-year period. Inclusion criteria included all isolated fractures of the olecranon with >2-mm displacement of the articular surface. The primary short-term outcome measure was the Broberg and Morrey Elbow Score. The primary long-term outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score. RESULTS: There were forty-three patients with a mean age of seventy-six years (range, forty to ninety-eight years) in the study cohort. A low-energy fall from a standing height accounted for 84% of all injuries, and one or more comorbidities were documented in thirty-eight patients (88%). At a mean of four months (range, 1.5 to ten months) following injury, the mean Broberg and Morrey score was 83 points (range, 48 to 100 points), with 72% of the patients having an excellent or good short-term outcome. No patient underwent surgery for a symptomatic nonunion. At a mean of six years (range, two to fifteen years) postinjury, the mean DASH score was 2.9 points (range, 0 to 33.9 points) and the mean Oxford Elbow Score was 47 points (range, 42 to 48 points); 91% (twenty-one) of twenty-three patients available for follow-up expressed satisfaction with the result of the procedure. CONCLUSIONS: We found satisfactory short-term and long-term outcomes following the nonoperative management of isolated displaced olecranon fractures in older, lower-demand patients.

The epidemiology of open fractures in adults. A 15-year review.

There is little information available about the epidemiology of open fractures. We examined 2386 open fractures over a 15-year period analysing the incidence and severity of the fractures. The majority of open fractures are low energy injuries with only 22.3% of open fractures being caused by road traffic accidents or falls from a height. The distribution curves of many open fractures are different to the overall fracture distribution curves with high-energy open fractures being commoner in younger males and low energy open fractures in older females. The mode of injury and the different demographic characteristics between isolated and multiple open fractures are also discussed.