Development and validation of a delayed presenting clubfoot score to predict the response to Ponseti casting for children aged 2-10.

The aim of the study was to develop a simple and reliable clinical scoring system for delayed presenting clubfeet and assess how this score predicts the response to Ponseti casting. We measured all elements of the Diméglio and the Pirani scoring systems. To determine which aspects were useful in assessing children with delayed presenting clubfeet, 4 assessors examined 42 feet (28 patients) between the ages of 2-10 years. Selected variables demonstrating good agreement were combined to make a novel score and were assessed prospectively on a separate consecutive cohort of children with clubfeet aged 2-10, comprising 100 clubfeet (64 patients). Inter-observer and intra-observer agreement was found to be greatest using the following clinically measured angles of the deformities. These were plantaris, adductus, varus, equinus of the ankle and rotation around the talar head in the frontal plane (PAVER). Measured angles of 1-20, 21-45 and > 45 degrees scored 1, 2 and 3 points, respectively. The PAVER score was derived from both the sum of points derived from measured angles and a multiplier according to age. The sum of the points was multiplied with 1, 1.5 or 2 for ages 2-4, 5-7 and 8-10, respectively. This demonstrated a good association with the total number of casts to achieve a full correction (tau = 0.71). A score greater than 18 out of 30 indicated a cast-resistant clubfoot. The score could be used clinically for prognosis and treatment, and for research purposes to compare the severity of clubfoot deformities.

A systematic review of long-term patient reported outcomes for the treatment of anterior cruciate ligament injuries in the skeletally immature.

PURPOSE: To systematically review the available literature regarding outcomes for the treatment of anterior cruciate ligament (ACL) injuries in the skeletally immature at skeletal maturity or more than five years after surgery. METHODS: A systematic search was performed of seven online databases for literature reporting patient reported outcomes for the treatment of ACL injuries in the skeletally immature. A systematic review of this literature was performed examining the outcomes and their association with skeletal immaturity and treatment techniques. RESULTS: A total of 18 articles reported the outcomes of 425 subjects. The mean age at surgery ranged from 10.3 to 15 years. Mean follow-up ranged from 36 to 163 months. Ten studies followed up subjects until skeletal maturity. Mean outcome scores were similar for extraphyseal (Lysholm 96.2 (95.7 to 97.4), Tegner 6.75, IKDC 95.4 (94 to 100)) and transphyseal surgery (Lysholm 94.3 (84.6-100), Tegner 7.6 (6 to 8.7), International Knee Documentation Committee (IKDC) 93.6 (84 to 99)). However, the lower range boundary for Lysholm and IKDC was worse for the transphyseal group. The results for non-surgical treatments were worse (Lysholm 63.2, Tegner 4.8, IKDC 87). No significant differences were found in the incidence of limb-length discrepancy (p = 0.32), coronal plane growth disturbance (p = 0.48), graft rupture (p = 0.88) and persistent symptomatic instability (p = 0.11) with transphyseal and extraphyseal surgical techniques. CONCLUSION: Both transphyseal and extraphyseal reconstructive techniques produced good patient reported outcomes, with no significant differences in the incidence of limb-length discrepancy, coronal plane growth disturbance, graft rupture and persistent symptomatic instability. They compare favourably with the repair techniques reviewed and the natural history of the condition. Further high-quality studies comparing the transphyseal and extraphyseal techniques are required. LEVEL OF EVIDENCE: Level IV.

Management of slipped capital femoral epiphysis: results of a survey of the members of the European Paediatric Orthopaedic Society.

AIM: To determine current practice recommendations for the treatment of slipped capital femoral epiphysis (SCFE) among members of the European Paediatric Orthopaedic Society (EPOS). MATERIALS AND METHODS: A questionnaire with 4 case vignettes of a 12-year-old boy presenting with a stable and unstable SCFE. Each, stable and unstable slips, was of mild (20° epiphyseal-shaft angle) and of severe (60° epiphyseal-shaft angle) degree was sent to all members of EPOS in 2009 in order to ascertain their views on the best management of SCFE. Specifically, respondents were asked about the role of reduction, methods of fixation, prophylactic fixation of the non-affected hip, postoperative management and their view on the anticipated need for secondary surgery. RESULTS: The response rate was 25% (72/287). The participating surgeons' average workload was 76% in paediatric orthopaedics, with mean 16 years of experience. Surgeons were most consistent in their advice for stable slips, where around 90% of the respondents did not recommend a reduction of the slip regardless of severity of slip. Seventy per cent of the respondents recommended the use of only one screw for fixation of a stable slip and for mild unstable slips. For severe unstable slips, 46% of surgeons recommended reduction only by positioning of the hip on the fracture table, 35% by manipulation and 11% advised open reduction. Responders were less consistent in their advice on the anticipated need for secondary osteotomies (in mild slips about 40% and about 60% in severe slips would advise an osteotomy) and on treatment of the contralateral hip (with 32% of surgeons recommending prophylactic fixation of the contralateral hip). CONCLUSION: Within members of EPOS, there is controversy on several aspects of the management of SCFE particularly on aspects of the treatment of unstable SCFE. SIGNIFICANCE: Members of EPOS predominantly use traditional means of treatment for patients with SCFE. In contrast, the more modern treatment concepts, such as open reduction via surgical dislocation, are rarely used.

Variability of simulants used in recreating stab events.

Forensic investigators commonly use simulants/backing materials to mount fabrics and/or garments on when recreating damage due to stab events. Such work may be conducted in support of an investigation to connect a particular knife to a stabbing event by comparing the severance morphology obtained in the laboratory to that observed in the incident. There does not appear to have been a comparison of the effect of simulant type on the morphology of severances in fabrics and simulants, nor on the variability of simulants. This work investigates three simulants (pork, gelatine, expanded polystyrene), two knife blades (carving, bread), and how severances in the simulants and an apparel fabric typically used to manufacture T-shirts (single jersey) were affected by (i) simulant type and (ii) blade type. Severances were formed using a laboratory impact apparatus to ensure a consistent impact velocity and hence impact energy independently of the other variables. The impact velocity was chosen so that the force measured was similar to that measured in human performance trials. Force-time and energy-time curves were analysed and severance morphology (y, z directions) investigated. Simulant type and knife type significantly affected the critical forensic measurements of severance length (y direction) in the fabric and 'skin' (Tuftane). The use of EPS resulted in the lowest variability in data, further the severances recorded in both the fabric and Tuftane more accurately reflected the dimensions of the impacting knives.

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.

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 children's 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.

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

The outcome of displaced hips treated by Somerville and Scott's 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.

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.

The false profile arthrogram in developmental dysplasia of the hip.

Arthrography is useful in the evaluation and treatment of developmental dysplasia of the hip. The authors describe the additional diagnostic value obtained from a "false profile" arthrogram. The "false profile" arthrogram allows assessment of anterior acetabulum cover, femoral neck anteversion and hip joint subluxation (instability), which may not be apparent on other views. (Hip International 2005; 15: 177-81).

Expanding role of local anaesthesia in vitreoretinal surgery.

PURPOSE: Local anaesthesia (LA) is increasingly common in vitreoretinal surgery. However, younger patients often have such surgery under general anaesthesia (GA). We reanalysed the anaesthetic practice for vitreoretinal surgery in our unit over a 19-month period. METHODS: A total of 1003 patients undergoing vitreoretinal surgery between August 2000 and February 2002 were studied. Type of surgery, patient pain score to anaesthesia and surgery, need for sedation and incidence of complications related to the local anaesthetic were recorded. Comparisons were made between this case series and previous data from our unit. RESULTS: In total, 920/1003 (91.7%) patients had LA. Total operations comprised 418 vitrectomies, 518 retinopexies with or without vitrectomy and 67 buckling procedures. More patients under the age of 35 years had LA than previously (60.2 vs 35.7%, P<0.001). In 920/920 (100%) of cases, LA was administered via intraconal injection, compared to 164/1221 (13.4%) of procedures previously. Significantly more patients under the age of 35 years required sedation (35.9%) than did older patients (19.2%). Overall, use of sedation was significantly increased since our previous study (20.2 vs 7.8%). Anaesthesia and surgery were well tolerated by patients. There were no cases of orbital haemorrhage or ocular perforation. Complications included bradycardia requiring atropine 1/920 (0.1%) and chemosis 88/920 (9.6%). CONCLUSIONS: LA is well tolerated and effective even in younger patients. Sedation may well be required in younger patients and for procedures involving scleral buckling. The main indication for GA was patient preference. Despite this, such patients accounted for only 5.2% of the total.

Kinetic anaesthesia for laser surgery.

PURPOSE: Local anaesthetic is widely used in ophthalmic surgery and more recently in vitreoretinal surgery. Akinesia is a useful effect of local anaesthetic blocks, but there are situations where some residual globe movements are of benefit. We looked to see whether reducing the volume of anaesthetic solution used in a block could retain some kinesia while achieving good analgesia. METHODS: We compared two groups of patients undergoing panretinal photocoagulation (PRP) with an indirect laser. The control group received 5 ml of anaesthetic solution in a single injection by a standard intraconal technique; a second group received a lower volume of solution by the same technique. We recorded the adequacy of anaesthesia and the amount of residual kinesia for the two groups. Differences between groups were analysed using the Student's t-test and chi(2) tests. RESULTS: The low-volume group received an average of 2.8 ml, compared to 5 ml in the control group. There was no significant difference in the adequacy of analgesia achieved, however 16/18 (89%: 95% confidence intervals (CI)=81.5-96.3%) of the low-volume group had good perioperative kinesia compared to just 3/21 (14%: 95% CI=6.6-21.9%) of the controls (P<0.001). CONCLUSIONS: We have shown that low-volume intraconal blocks retain some perioperative kinesia without compromising their analgesic effect.

Autoradiographic localization of (125)i[Tyr(14)] nociceptin/orphanin FQ binding sites in macaque primate CNS.

Nociceptin/orphanin FQ (N/OFQ) is a recently identified neuropeptide that has been implicated in a multitude of CNS functions. These include nociception, feeding, cognition, locomotion, stress and neuroendocrine control. The endogenous receptor for this ligand is the nociceptin/orphanin FQ peptide (NOP) receptor. The distribution of NOP in rodent has been widely reported by the use of in situ hybridization, immunohistochemistry and autoradiographic radioligand binding but less is known of its localization in higher species. We have therefore sought to optimize and determine the distribution of (125)I[Tyr(14)]N/OFQ binding sites in macaque primate brain and spinal cord. Highest levels of binding were observed in neocortical areas, hippocampus, amygdala, caudate nucleus and putamen, medial thalamic nuclei and superficial laminae of the superior colliculus. These novel data present for the first time, the distribution of N/OFQ receptors in non-human primate CNS and, by comparison with localization in the rat, reveal that species differences may exist in the distribution of this neuropeptide receptor. These data have important implications regarding the roles of N/OFQ across species and may have ramifications in the interpretation of preclinical pharmacological studies.

Audit of a policy of magnetic resonance imaging with diffusion-weighted imaging as first-line neuroimaging for in-patients with clinically suspected acute stroke.

AIM: To audit the feasibility and use of diffusion-weighted (DW) magnetic resonance imaging (MRI) as initial neuroimaging for in-patients with clinically suspected acute stroke. MATERIALS AND METHODS: In April 2000, MRI with DW and T2-weighted sequence was locally instituted as initial neuroimaging for patients with clinically suspected acute stroke. This retrospective study reviewed imaging performed for in-patients with suspected acute stroke over a 9-month period. Data were collected on image type, result and need for repeat imaging. RESULTS: During the study period, 124 patients had neuroimaging for suspected cerebrovascular accident, and 119 were MRI safe. Eighty-eight (73.9%) patients underwent DW MRI as first-line investigation. Five patients were not MRI safe and 31 had computed tomography (CT) as first-line imaging due to lack of available MRI capacity. Repeat neuroimaging was performed in 16 (12.9%) patients. Study times were comparable for both types of neuroimaging: a mean of 13 min for MRI and 11 min for CT. CONCLUSION: The audit standard was achieved in 88 (73.9%) patients. The use of DW MRI as a first-line investigation for patients with a clinical diagnosis of acute stroke is achievable in a district general hospital setting.

Synovial cyst of the pulp of the little finger--origin from the wrist joint.

Synovial cysts of the pulp of the little finger in three elderly patients were shown by arthrography to arise from leakage of synovial fluid from the wrist joint into the ulnar bursa and thence into the flexor synovial sheath in the digit. Distant as well as local sources of the contents of synovial cysts should be considered when the local anatomy permits communication between a degenerate joint and an adjacent tendon sheath.

Cloning, characterization and central nervous system distribution of receptor activity modifying proteins in the rat.

Calcitonin gene-related peptide (CGRP), adrenomedullin (ADM), amylin and calcitonin (CT) are structurally and functionally related neuropeptides. It has recently been shown that the molecular pharmacology of CGRP and ADM is determined by coexpression of one of three receptor activity-modifying proteins (RAMPs) with calcitonin receptor-like receptor (CRLR). Furthermore, RAMP proteins have also been shown to govern the pharmacology of the calcitonin receptor, which in association with RAMP1 or RAMP3, binds amylin with high affinity. In this study, we have cloned the rat RAMP family and characterized the pharmacology of rat CGRP and ADM receptors. Rat RAMP1, RAMP2 and RAMP3 shared 72%, 69% and 85% homology with their respective human homologues. As expected CRLR-RAMP1 coexpression conferred sensitivity to CGRP, whilst association of RAMP2 or RAMP3 with CRLR conferred high affinity ADM binding. Using specific oligonucleotides we have determined the expression of RAMP1, RAMP2 and RAMP3 mRNAs in the rat central nervous system by in situ hybridization. The localization of RAMP mRNAs was heterogeneous. RAMP1 mRNA was predominantly expressed in cortex, caudate putamen and olfactory tubercles; RAMP2 mRNA was most abundant in hypothalamus; and RAMP3 was restrictively expressed in thalamic nuclei. Interestingly, in specific brain areas only a single RAMP mRNA was often detected, suggesting mutual exclusivity in expression. These data allow predictions to be made of where each RAMP protein may heterodimerize with its partner G-protein-coupled receptor(s) at the cellular level and consequently advance current understanding of cellular sites of action of CGRP, ADM, amylin and CT. Furthermore, these localization data suggest that the RAMP family may associate and modify the behaviour of other, as yet unidentified neurotransmitter receptors.

A practical approach to the first iteration in the optimization of radiation dose and image quality in CT: estimates of the collective dose savings achieved.

CT is a diagnostic imaging modality giving higher patient dose in comparison with other radiological procedures. It contributed an estimated 20% to the collective effective dose to the UK population from medical X-rays in 1990, rising to an estimated 40% in 1999. Tremendous national effort has been expended in reducing patient doses from other radiological procedures with considerable success, but much of the collective dose reduction achieved has been offset by a corresponding increase in the collective dose from CT. Over a period of about 2 years, following the installation of a helical CT scanner, CT scan parameters in this hospital have been adjusted with the aim of working towards optimization of image quality and patient dose. A 33% reduction in annual collective effective dose has been achieved, from about 16.5 manSv to 11 manSv. However, despite this dose reduction, the annual collective effective dose to our sub-population is 2.8 times the value 9 years ago. The increase is almost entirely the result of an increased application of CT; 6149 examinations per annum in 1999 compared with 2210 in 1991. The crucial importance of reducing patient doses from this modality is discussed. Indicative effective doses and image noise values are presented for examination protocols approaching optimization.

Distribution of 5-ht(5A), 5-ht(5B), 5-ht(6) and 5-HT(7) receptor mRNAs in the rat brain.

The precise involvement of 5-ht(5A), 5-ht(5B), 5-ht(6) and 5-HT(7) receptors in the pleiotropic actions of 5-HT remain incompletely known. To gain insights into their physiological function(s), localization of mRNAs encoding these subtypes was carried out using in situ hybridization on rat brain sections. Localization was heterogeneous. For example, 5-ht(5A) mRNA was widely expressed while 5-ht(5B) mRNA was predominantly expressed in habenula, hippocampus and inferior olive. 5-ht(6) mRNA was abundant in olfactory tubercles and caudate putamen, and highest levels of 5-HT(7) mRNA were observed in multiple thalamic nuclei. These data suggest that these receptors may have distinct functional roles within the serotonergic system.