Evidence based treatment for developmental dysplasia of the hip in children under 6 months of age. Systematic review and exploratory analysis.

INTRODUCTION: Developmental dysplasia of the hip (DDH) is a common paediatric orthopaedic condition that attracts a substantive amount of controversy. The treatments vary because of the wide spectrum of the condition and the age of children at presentation. Although conservative and surgical treatments exist; it is widely accepted that conservative treatment is the first line of treatment in the first 6 months of life. Several devices have been proposed as the treatment of choice; however, to the best of our knowledge these have not been critically appraised. Therefore, we conducted this review. METHODS: A modified Cochrane method was followed with a preplanned detailed research protocol that was developed to guide all aspects of the review. Treatment failure of the devices was chosen as the primary outcome. Secondary outcomes included femoral nerve palsy (FNP), avascular necrosis of the femoral head (AVN), residual dysplasia, skin problems, failure of subsequent surgical treatment, compliance and tolerance issues. Results are reported according to the PRISMA guidelines. RESULTS: A total of 30 studies were included in the review comparing 5 devices (The Pavlik harness, the Von Rosen splint, the Tubingen brace, the Frejka pillow, and the Aberdeen splint). The devices were compared in terms of success rate, AVN rate and residual dysplasia. The von Rosen splint has been shown to be superior to other devices in term of success rates and residual dysplasia (Χ2: P < 0.05). CONCLUSION: The review findings should be interpreted with caution as there are substantive flaws in the literature and a randomized control trail is warranted to confirm the best device to treat DDH. This is feasible given the magnitude of the problem, the clear diagnostic criteria and the treatment options.

Moon (or Eid) Crescent Sign of the Femoral Head.

Avascular necrosis (AVN) of the femoral head following slipped capital femoral epiphysis (SCFE) is a serious complication that often leads to a permanent disability. Radiological findings of AVN may take up to two years to become apparent. This means painful waiting for children, parents, and treating teams. We would like to describe a new radiological sign that we noted in four patients. The sign has been named as the crescent moon sign or eid crescent sign. It may become visible as early as six weeks following surgery, and it carries a good prognosis that the femoral head is viable and will not develop AVN. Two out of the four patients were treated in our hospital by Ganz surgical dislocation. The other two patients had been featured in other publications, but the significance of the moon crescent signs, which were present, was not recognized or appreciated. All four patients did not develop AVN. A relatively similar radiological sign has been described in talus bone fractures (Hawkins' sign). Like SCFE, talus bone fractures have a high AVN rate. Both, the crescent moon sign and Hawkins' sign carry a good prognosis and indicate that the bone blood supply is restored.

Intramedullary Percutaneous Fixation of Extra-Articular Proximal and Middle Phalanx Fractures.

Multiple methods have been described for treating unstable proximal and middle phalangeal fractures. Irrespective of using an open or closed technique of fixation, stiffness and extensor lag at the proximal/distal interphalangeal joint almost always occur. This issue can be avoided by allowing the patients to mobilize the fingers out of plaster or splint as early as possible from the day of surgery. We describe a technique of intramedullary percutaneous fixation of extra-articular proximal and middle phalanx fractures allowing immediate mobilization of fingers, concurrent stabilization with progressive healing and thus preventing such complications.

Radius-only intramedullary nailing for both-bones diaphyseal forearm fractures in children.

Both-bones diaphyseal forearm fractures are common injuries in the paediatric age group and are potentially unstable. Both-bones intramedullary nailing for these fractures is a minimally invasive procedure that maintains alignment, and promotes rapid bony healing. Good results have also been shown with single-bone fixation. We report our experience in treating these common injuries with radius-only intramedullary nailing in 29 children. The clinical notes and radiographs were reviewed retrospectively. There were 9 girls and 20 boys; the mean age at the time of operation was 9 years (range: 5 to 17 years). Closed reduction was achieved in 21 patients, while eight patients required open reduction. Mean duration of follow-up was 6.8 months (range: 4 to 12 months). All fractures achieved clinical and radiological union at 6-8 weeks. Radius-only intramedullary nailing is a sufficient and effective option in treating both bones paediatric forearm displaced unstable type AO 22-A3 fractures, with excellent functional outcome and union rates.

Latex-free gloves: safer for whom?

Increasing latex hypersensitivity among patients and health care workers has prompted the development of latex-free surgical gloves. Latex-free gloves must perform equally as the existing latex standard. We analyzed perforation rates in a clinical trial comparing latex and a latex-free alternative during primary hip and knee arthroplasty. The overall latex glove perforation rate was 8.4% compared with 21.6% for the latex-free alternative (chi(2) P < .001). The operation perforation rate for latex gloves was 34.4% compared with 80% for latex-free gloves (chi(2) P < .001). We suggest that the latex-free glove tested cannot provide a reliable barrier between the surgeon and the patient. As such, we question the safety of these gloves and the standards sets by the regulators.

The role of peri-operative cell salvage in instrumented anterior correction of thoracolumbar scoliosis: a case-controlled study.

Anterior scoliosis surgery is associated with potentially high blood loss, usually requiring allogenic transfusion either intra- or post-operatively. Blood loss in this type of surgery has been shown to correlate with surgical and anaesthetic techniques. In our centre the development of specific anaesthetic techniques as well as the routine use of cell salvage has dramatically reduced the rates of allogenic blood transfusion. Specific indications for the use of the cell saver in anterior scoliosis surgery have not been well defined. Previous studies have commented on the benefit from re-infusion of salvaged autologous blood for orthopaedic patients in general, whilst others have shown a negligible advantage specifically in anterior thoraco-lumbar fusion surgery. We carried out a retrospective study of 137 consecutive patients, all of whom underwent instrumented anterior scoliosis correction between March 1999 and September 2004. A study group consisting of 104 patients in whom a cell saver was used was compared with a control group consisting of 33 patients who underwent anterior instrumentation without cell saver. There was no significant difference in the mean ages, extent of surgery and male to female ratio between groups. In the control group 39.4% of patients required allogenic blood transfusion, versus 6.7% in the study group; the difference is statistically significant (p < 0.0001). A significant difference was also noted in post-operative haemoglobin values. The mean post-operative haemoglobin was 9.6 g/dl in the control group, versus 10.2 g/dl in the study group (p = 0.007). Our experience confirms that re-infusion of salvaged autologous blood in anterior scoliosis surgery has a role in the minimisation of postoperative anaemia and allogenic transfusion requirements in this type of surgery.

Non-accidental burns in children--are we neglecting neglect?

Although many studies have described burn abuse in detail, burns that have occurred as a result of neglect have been studied to a much lesser degree. A retrospective study of 440 hospitalised paediatric burns patients during 2000-2002 inclusive was performed. A multidisciplinary team investigation of suspicious cases was used. This included a home assessment. There were 41 cases of neglect (9.3%) and 395 cases of accidental burning (89.8%). Parental drug abuse, single parent families, delay to presentation and a lack of first aid were statistically more prevalent in the "neglect" group than in the "accidental" group. Children in the "neglect" group were also statistically more likely to have deeper burns and require skin grafting. 82.9% of children whose burns were deemed to be due to neglect had a previous entry on the child protection register. 48.8% were transferred into foster care. This study shows that burning by neglect is far more prevalent than abuse. We advocate a multidisciplinary investigation coupled with the use of home assessments to aid diagnosis. It may be possible to target preventative strategies on the children with the above risk factors.