A case control study to determine the association between Perthes' disease and the recalled use of tobacco during pregnancy, and biological markers of current tobacco smoke exposure.

AIMS: It is well established that there is a strong association between Perthes' disease and worsening socioeconomic deprivation. It has been suggested that the primary determinant driving this association is exposure to tobacco smoke. This study aimed to examine this hypothesis. PATIENTS AND METHODS: A hospital case-control study (n = 149/146) examined the association between tobacco smoke exposure and Perthes' disease, adjusting for area-level socioeconomic deprivation. Tobacco smoke exposure was assessed by parental questionnaire of smoking habits during pregnancy, and by quantitative assay of current exposure using the urinary cotinine-creatinine ratio, which is a widely used and validated measure of tobacco smoke exposure. RESULTS: The odds of Perthes' disease significantly increased with reported in utero exposure after adjustment for socioeconomic deprivation (maternal smoking odds ratio (OR) 2.06, 95% confidence interval (CI) 1.17 to 3.63; paternal smoking OR 2.09, 95% CI 1.26 to 3.46). The cotinine-creatinine ratio was significantly greater in cases, OR 1.63 (95% CI 1.09 to 2.43), suggesting a greater 'dose' of current tobacco exposure. CONCLUSION: An association exists between tobacco smoke exposure and Perthes' disease but we remain unable to disentangle the association with socioeconomic deprivation. Cite this article: Bone Joint J 2017;99-B:1102-8.

The lognormal age of onset distribution in Perthes' disease: an analysis from a large well-defined cohort.

AIMS: To explore the of age of onset distribution for Perthes' disease of the hip, with particular reference to gender, laterality and conformity to the lognormal distribution. PATIENTS AND METHODS: A total of 1082 patients were identified from the Liverpool Perthes' Disease Register between 1976 and 2010, of which 992 had the date of diagnosis recorded. In total, 682 patients came from the geographical area exclusively served by Alder Hey Hospital, of which 673 had a date of diagnosis. Age of onset curves were analysed, with respect to the predefined subgroups. RESULTS: The age of onset demonstrated a positive skew with a median of 5.8 years (interquartile range 4.6 to 7.5). Disease onset was a mean five months earlier in girls (p = 0.01) and one year earlier in those who went on to develop bilateral disease (p < 0.001). There was no difference in the age of onset between geographical districts with differing incidence rates. The entire dataset (n = 992) conformed to a lognormal distribution graphically and with the chi-squared test of normality (p = 0.10), but not using the Shapiro-Wilk test (p = 0.01). The distribution for the predefined geographical subgroup (n = 673) conformed well to a lognormal distribution (chi-squared p = 0.16, Shapiro-Wilk p = 0.08). Given the observed lognormal distribution it was assumed that Perthes' disease followed on incubation period consistent with a point-source disease exposure. The incubation period was further examined using Hirayama's method, which suggested that the disease exposure may act in the prenatal period. CONCLUSION: The age of onset in Perthes' disease conforms to a lognormal distribution, which allows comparisons with infectious disease epidemiology. Earlier onset in girls and those who develop bilateral disease may offer clues to understanding the aetiological determinants of the disease. The analysis suggests that an antenatal aetiological determinant may be responsible for disease. TAKE HOME MESSAGE: Perthes' disease age of onset conforms to a lognormal model, which is most typical of infectious diseases. The shape of the distribution suggests that an aetiological trigger in the pre-natal period may be an important determinant of disease. Cite this article: Bone Joint J 2016;98-B:710-14.

The effect of a dedicated Ponseti service on the outcome of idiopathic clubfoot treatment.

We report the effect of introducing a dedicated Ponseti service on the five-year treatment outcomes of children with idiopathic clubfoot. Between 2002 and 2004, 100 feet (66 children; 50 boys and 16 girls) were treated in a general paediatric orthopaedic clinic. Of these, 96 feet (96%) responded to initial casting, 85 requiring a tenotomy of the tendo-Achillis. Recurrent deformity occurred in 38 feet and was successfully treated in 22 by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior, The remaining 16 required an extensive surgical release. Between 2005 and 2006, 72 feet (53 children; 33 boys and 20 girls) were treated in a dedicated multidisciplinary Ponseti clinic. All responded to initial casting: 60 feet (83.3%) required a tenotomy of the tendo-Achillis. Recurrent deformity developed in 14, 11 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior. The other three required an extensive surgical release. Statistical analysis showed that children treated in the dedicated Ponseti clinic had a lower rate of recurrence (p = 0.068) and a lower rate of surgical release (p = 0.01) than those treated in the general clinic. This study shows that a dedicated Ponseti clinic, run by a well-trained multidisciplinary team, can improve the outcome of idiopathic clubfoot deformity.

The epidemiology of transient synovitis in Liverpool, UK.

BACKGROUND: The epidemiology of transient synovitis is poorly understood, and the aetiology is unknown, although a suggestion of a viral association predominates. PURPOSE: This population-based study investigated the epidemiology in order to formulate aetiological theories of pathogenesis. PATIENT AND METHODS: Cases in Merseyside were identified between 2004 and 2009. Incidence rates were determined and analysed by age, sex, season and region of residence. Socioeconomic deprivation scores were generated using the Index of Multiple Deprivation, allocated by postcode. Poisson confidence intervals were calculated and Poisson regression was used to check for trends. RESULTS: Two hundred and fifty-nine cases were identified over 5.5 years. The annual incidence was 25.1 (95 % CI 22.1-28.5) per 100,000 0-14 year-olds. Male to female ratio was 3.2:1 (p < 0.001). Mean age at presentation was 5.4 years (95 % CI 5.0-5.8), which demonstrated a near-normal distribution. No relationship was identified between seasonality and incidence (p = 0.64). A correlation was identified with socioeconomic deprivation in Merseyside: incidence rate ratio 1.16 (95 % CI 1.06-1.26, p < 0.001), although further analysis within the subregion of Liverpool did not confirm this finding (p = 0.35). CONCLUSIONS: The normal distribution for age at disease presentation suggests a specific disease entity. The absence of seasonality casts some doubt on the popular theory of a viral aetiology. The absence of a consistent socioeconomic gradient in both Merseyside and Liverpool challenges a previous suggestion of an association with Perthes' disease. This paper provides ecological evidence that may challenge existing aetiological theories, though transient synovitis remains an enigma.

Delayed surgery in displaced paediatric supracondylar fractures: a safe approach? Results from a large UK tertiary paediatric trauma centre.

BACKGROUND: Displaced paediatric supracondylar humeral fractures pose a significant risk of neurovascular injury and consequently have traditionally been treated as a surgical emergency. Recently, the need for emergency surgery has been questioned. We wished to analyse our experience at a large UK tertiary paediatric trauma centre. METHODS: A retrospective case note review was performed on patients with Gartland Grades 2 and 3 supracondylar fractures observed in a 2-year period from July 2008 to July 2010. We divided children into those treated before 12 h (early surgery) and after 12 h (delayed surgery). Analysis was undertaken using Fisher's exact test. RESULTS: Of the 137 patients, 115 were included in the study; median time-to-surgery was 15:30 (range 2:45-62:50); thirty-nine children were treated before 12 h and 76 patients after. In the early surgery group, three children (7.7%) developed a superficial pin-site infection, four children (10.3%) required open reduction, five children (12.8%) sustained an iatrogenic nerve injury, and two children (5%) required reoperation. In the delayed surgery group, one child (1.3%) had a superficial pin-site infection, four children (5.3%) required open reduction, seven children (9.2%) sustained an iatrogenic nerve injury, and two children (2.6%) reoperation. Bivariate analysis of our data using Fisher's exact t test revealed no statistically significant difference between early and delayed surgery groups with regard to infection rates (p = 0.1), iatrogenic nerve injury (p = 0.53) or need for open reduction (p = 0.44). CONCLUSION: Our results indicate that delayed surgery appears to offer a safe management approach in the treatment of displaced supracondylar fractures, but it is important that cases are carefully evaluated on an individual basis. These results indicate that patient transfer to a specialist paediatric centre, often with consequent surgical delay, is a safe management option and also negates the obligation to carry out these procedures at night.

Comorbidities in Perthes' disease: a case control study using the General Practice Research database.

Perthes' disease is an osteonecrosis of the juvenile hip, the aetiology of which is unknown. A number of comorbid associations have been suggested that may offer insights into aetiology, yet the strength and validity of these are unclear. This study explored such associations through a case control study using the United Kingdom General Practice Research database. Associations investigated were those previously suggested within the literature. A total of 619 cases of Perthes' disease were included, as were 2544 controls. The risk of Perthes' disease was significantly increased with the presence of congenital anomalies of the genitourinary and inguinal region, such as hypospadias (odds ratio (OR) 4.04 (95% confidence interval (CI) 1.41 to 11.58)), undescended testis (OR 1.83 (95% CI 1.12 to 3.00)) and inguinal herniae (OR 1.79 (95% CI 1.02 to 3.16)). Attention deficit hyperactivity disorder was not associated with Perthes' disease (OR 1.01 (95% CI 0.48 to 2.12)), although a generalised behavioural disorder was (OR 1.55 (95% CI 1.10 to 2.17)). Asthma significantly increased the risk of Perthes' disease (OR 1.44 (95% CI 1.17 to 1.76)), which remained after adjusting for oral/parenteral steroid use. Perthes' disease has a significant association with congenital genitourinary and inguinal anomalies, suggesting that intra-uterine factors may be critical to causation. Other comorbid associations may offer insight to support or refute theories of pathogenesis.

The use of CRP within a clinical prediction algorithm for the differentiation of septic arthritis and transient synovitis in children.

Clinical prediction algorithms are used to differentiate transient synovitis from septic arthritis. These algorithms typically include the erythrocyte sedimentation rate (ESR), although in clinical practice measurement of the C-reactive protein (CRP) has largely replaced the ESR. We evaluated the use of CRP in a predictive algorithm. The records of 311 children with an effusion of the hip, which was confirmed on ultrasound, were reviewed (mean age 5.3 years (0.2 to 15.1)). Of these, 269 resolved without intervention and without long-term sequelae and were considered to have had transient synovitis. The remaining 42 underwent arthrotomy because of suspicion of septic arthritis. Infection was confirmed in 29 (18 had micro-organisms isolated and 11 had a high synovial fluid white cell count). In the remaining 13 no evidence of infection was found and they were also considered to have had transient synovitis. In total 29 hips were categorised as septic arthritis and 282 as transient synovitis. The temperature, weight-bearing status, peripheral white blood cell count and CRP was reviewed in each patient. A CRP > 20 mg/l was the strongest independent risk factor for septic arthritis (odds ratio 81.9, p < 0.001). A multivariable prediction model revealed that only two determinants (weight-bearing status and CRP > 20 mg/l) were independent in differentiating septic arthritis from transient synovitis. Individuals with neither predictor had a < 1% probability of septic arthritis, but those with both had a 74% probability of septic arthritis. A two-variable algorithm can therefore quantify the risk of septic arthritis, and is an excellent negative predictor.

The association between clubfoot and developmental dysplasia of the hip.

The association between idiopathic congenital talipes equinovarus (CTEV) and developmental dysplasia of the hip is uncertain. We present an observational cohort study spanning 6.5 years of selective ultrasound screening of hips in clubfoot. From 119 babies with CTEV there were nine cases of hip dysplasia, in seven individuals. This suggests that 1 in 17 babies with CTEV will have underlying hip dysplasia. This study supports selective ultrasound screening of hips in infants with CTEV.

Correcting genu varum and genu valgum in children by guided growth: temporary hemiepiphysiodesis using tension band plates.

A total of 25 children (37 legs and 51 segments) with coronal plane deformities around the knee were treated with the extraperiosteal application of a flexible two-hole plate and screws. The mean age was 11.6 years (5.5 to 14.9), the median angle of deformity treated was 8.3 degrees and mean time for correction was 16.1 months (7 to 37.3). There was a mean rate of correction of 0.7 degrees per month in the femur (0.3 degrees to 1.5 degrees ), 0.5 degrees per month in the tibia (0.1 degrees to 0.9 degrees ) and 1.2 degrees per month (0.1 degrees to 2.2 degrees ) if femur and tibia were treated concurrently. Correction was faster if the child was under 10 years of age (p = 0.05). The patients were reviewed between six and 32 months after plate removal. One child had a rebound deformity but no permanent physeal tethers were encountered. The guided growth technique, as performed using a flexible titanium plate, is simple and safe for treating periarticular deformities of the leg.

Treatment of idiopathic club foot using the Ponseti method. Initial experience.

We report our initial experience of using the Ponseti method for the treatment of congenital idiopathic club foot. Between November 2002 and November 2004 we treated 100 feet in 66 children by this method. The standard protocol described by Ponseti was used except that, when necessary, percutaneous tenotomy of tendo Achillis were performed under general anaesthesia in the operating theatre and not under local anaesthesia in the out-patient department. The Pirani score was used for assessment and the mean follow-up time was 18 months (6 to 30). The results were also assessed in terms of the number of casts applied, the need for tenotomy of tendo Achillis and recurrence of the deformity. Tenotomy was required in 85 of the 100 feet. There was a failure to respond to the initial regimen in four feet which then required extensive soft-tissue release. Of the 96 feet which responded to initial casting, 31 (32%) had a recurrence, 16 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior. The remaining 15 required extensive soft-tissue release. Poor compliance with the foot-abduction orthoses (Denis Browne splint) was thought to be the main cause of failure in these patients.

Can CT determine the site of traumatic osteochondral defects in the paediatric knee?

Currently the ability of pre-operative CT imaging to determine the origin of traumatic osteochondral lesions (OCL) in the knee in children is yet to be established. The surgical approach to the knee will to some extent be determined by the origin of the lesion. It is important to directly determine the site of the lesion from pre-operative scanning both to facilitate surgery, to have a better cosmetic result for the patient and have a quicker rehabilitation period. In a tertiary referral centre, from May 2004 to April 2005, eight patients were diagnosed as having an OCL. The initial reporting was done by either a senior registrar or consultant paediatric radiologist. Those children that had an OCL underwent an arthroscopy or definitive open surgery. The exact site of the lesion was then determined and recorded in the operative notes. All the original pre-operative CT scans were given to a senior paediatric radiologist. The consultant on this occasion had no access to operative findings, or original CT reports. CTs reported by the paediatric radiology department are only able to correctly identify the site of origin of the OCL 50% of the time. Recent MR scanning techniques have improved the visualization of OCL. We authors therefore feel that in the future MRI should be used to assess the paediatric knee when an acute OCL is suspected.

Elastic stable intramedullary nail fixation for severely displaced fractures of the neck of the radius in children.

Several techniques are available for the treatment of displaced fractures of the neck of the radius in children. We report our experience in 14 children treated by indirect reduction and fixation using an elastic stable intramedullary nail. The patients were followed up for a mean of 28 months. One developed asymptomatic avascular necrosis. The rest had excellent results. One had a neuropraxia of the posterior interosseous nerve, which recovered within six weeks. We advocate elastic stable intramedullary nailing for the closed reduction and fixation of these fractures in children.

Osteochondritis dissecans of the knee in children. A comparison of MRI and arthroscopic findings.

The treatment of osteochondritis dissecans (OCD) in children and adolescents is determined by the stability of the lesion and the state of the overlying cartilage. MRI has been advocated as an accurate way of assessing and staging such lesions. Our aim was to determine if MRI scans accurately predicted the subsequent arthroscopic findings in adolescents with OCD of the knee. Some authors have suggested that a high signal line behind a fragment on the T2-weighted image indicates the presence of synovial fluid and is a sign of an unstable lesion. More recent reports have suggested that this high signal line is due to the presence of vascular granulation tissue and may represent a healing reaction. We were able to improve the accuracy of MRI for staging the OCD lesion from 45% to 85% by interpreting the high signal T2 line as a predictor of instability only when it was accompanied by a breach in the cartilage on the T1-weighted image. We conclude that MRI can be used to stage OCD lesions accurately and that a high signal line behind the OCD fragment does not always indicate instability. We recommend the use of an MRI classification system which correlates with the arthroscopic findings.

Simple treatment for torus fractures of the distal radius.

Torus (buckle) fractures of the distal radius are common in childhood. Based on the results of a postal questionnaire and a prospective, randomised trial, we describe a simple treatment for this injury, which saves both time and money. Over a six-month period, we randomised 201 consecutive patients with this injury to treatment with either a traditional forearm plaster-of-Paris cast or a 'Futura-type' wrist splint. All patients were treated for a period of three weeks, followed by clinical and radiological review. There was no difference in outcome between the two groups, and all patients had a good result. Only one patient did not tolerate the splint which was replaced by a cast. The questionnaire showed a marked variation in the way in which these injuries are treated with regard to the method and period of immobilisation, the number of follow-up visits and radiographs taken. We suggest that a 'Futura-type' wrist splint can be used to treat these fractures. The patient should be reviewed on the following day to confirm the diagnosis and to give appropriate advice. There is no evidence that further follow-up is required. This simple treatment has major benefits in terms of cost and reduction of the number of attendances.

Percutaneous Ethibloc injection in aneurysmal bone cysts.

OBJECTIVE: To investigate whether the injection of Ethibloc into aneurysmal bone cysts can be an effective treatment modality. DESIGN AND PATIENTS: Ethibloc is an alcoholic solution of zein (corn protein) which has thrombogenic and fibrogenic properties. Ten patients with aneurysmal bone cysts were treated with CT-guided percutaneous injection of Ethibloc into the cyst cavity. Ethibloc injection was the primary treatment in five patients. Four patients had recurrence following previous curettage and bone grafting and one patient had not responded to injection into the lesion of autologous iliac crest bone marrow aspirate. Three patients needed a second injection. The median follow-up was 27 (6-60) months. RESULTS AND CONCLUSION: Symptoms were relieved in all patients. At imaging, seven patients had resolution of the lesion and three had partial response at the most recent follow-up. Complications consisted of a local transitory inflammatory reaction in two patients and an aseptic abscess in one patient. This relatively simple, minimally invasive procedure makes an operation unnecessary by stopping the expansion of the cyst and inducing endosteal new bone formation. This technique may be used as the primary management of aneurysmal bone cysts excluding spinal lesions.

The persistently irritable joint in childhood an orthopaedic perspective.

Persistent joint or periarticular irritability and pain in children can have numerous explanations. This overview explores the diverse range of orthopaedic conditions, both acquired and congenital, that may lead to such a presentation.