The effect of adverse childhood experiences on chronic pain and major depression in adulthood: a systematic review and meta-analysis.

BACKGROUND: Adverse childhood experiences have been linked to increased multimorbidity, with physical and mental health consequences throughout life. Chronic pain is often associated with mood disorders, such as major depressive disorder (MDD); both have been linked to adverse childhood experiences. It is unclear how the effect of adverse childhood experiences on neural processing impacts on vulnerability to chronic pain, MDD, or both, and whether there are shared mechanisms. We aimed to assess evidence for central neural changes associated with adverse childhood experiences in subjects with chronic pain, MDD, or both using systematic review and meta-analysis. METHODS: Electronic databases were systematically searched for neuroimaging studies of adverse childhood experiences, with chronic pain, MDD, or both. Two independent reviewers screened title, abstracts, and full text, and assessed quality. After extraction of neuroimaging data, activation likelihood estimate meta-analysis was performed to identify significant brain regions associated with these comorbidities. RESULTS: Forty-nine of 2414 studies were eligible, of which 43 investigated adverse childhood experiences and MDD and six investigated adverse childhood experiences and chronic pain. None investigated adverse childhood experiences, chronic pain, and MDD together. Functional and structural brain abnormalities were identified in the superior frontal, lingual gyrus, hippocampus, insula, putamen, superior temporal, inferior temporal gyrus, and anterior cerebellum in patients with MDD exposed to adverse childhood experiences. In addition, brain function abnormalities were identified for patients with MDD or chronic pain and exposure to adverse childhood experiences in the cingulate gyrus, inferior parietal lobule, and precuneus in task-based functional MRI studies. CONCLUSIONS: We found that adverse childhood experiences exposure can result in different functional and structural brain alterations in adults with MDD or chronic pain compared with those without adverse childhood experiences. SYSTEMATIC REVIEW PROTOCOL: PROSPERO CRD42021233989.

A Scoping Review of the Recent Clinical Practice Regarding the Evaluation of Bone Mineral Density in Children and Adolescents with Neuromuscular Diseases.

Introduction: Neuromuscular Diseases (NMD) are associated with decreased bone strength due to altered muscle-bone interaction. However, the evaluation of bone quality remains a certain challenge in these patients. The purpose of this scoping review is to investigate the recent literature regarding the assessment of Bone Mineral Density (BMD) in this population. Methods: An electronic search of the PubMed and Scopus database was performed considering studies published in the English literature after 2007 that evaluated BMD in pediatric and adolescent patients with NMD. We excluded studies that evaluated patients > 20 years, studies not involving humans, and studies investigating bone mineral density in various pediatric conditions, but without specific data on NMD. Results: Overall, 19 studies were included that evaluated BMD in 1983 patients with NMD. Duchenne Muscular Dystrophy was the most widely studied disease (n = 11 studies). Dual energy X-ray absorptiometry (DEXA) was the most common diagnostic modality for BMD evaluation, while the most frequent site for BMD measurement was the lumbar spine (89.4%, n = 17 studies), followed by total body BMD (68.4%, n = 13 studies). Low BMD in children with NMD was demonstrated in all studies, especially after loss of ambulation. Moreover, a positive correlation between lower BMD and older age was shown. Conclusions: BMD evaluation in NMD remains a clinical challenge, as indicated by the high heterogeneity regarding the optimal site and technique for the evaluation of bone quality in these patients. Although DXA is currently the diagnostic modality of choice, a consensus regarding the optimal site for BMD measurement, and the adjustment method for its obtained measurements for parameters such as age and height is needed.

Persistently Raised Serum Titanium Levels After Spinal Instrumentation in Children.

STUDY DESIGN: Prospective study of patients undergoing elective spinal deformity surgery with repeated testing for circulating metal ions including preoperative levels acting as controls. OBJECTIVE: The aim was to determine if levels of particular circulating metal ions are maintained to two years postsurgery including different implant systems and rods. SUMMARY OF BACKGROUND DATA: Adults having hip replacements, especially metal-on-metal bearings, may develop high metal ion levels. Pediatric spinal implants are known to cause circulating metal ions, notably titanium, chromium, cobalt, and nickel. MATERIALS AND METHODS: Fifty-six children having spinal deformity surgery were studied with repeated testing for circulating metal ions, using high-resolution inductively coupled plasma mass spectrometry. Linear mixed-effects models adjusting for repeated measurements over time were used to analyze levels of titanium, cobalt, chromium, and nickel. RESULTS: Titanium levels showed a rapid increase by seven days and a peak at 30 days that was essentially maintained at the two-year assay. At two years, titanium levels were 5.14 times greater compared with the presurgery control level (P<0.0001). Cobalt levels were shown to gradually rise to a peak at 30 days and then slowly decline but remained 1.74 times above mean baseline level at two years (P=0.0004), with a declining trajectory. Chromium and nickel levels rose immediately postoperatively and then steadily declined to baseline by six months and remained at baseline at two years. The five implant systems tested had generally equivalent results. CONCLUSION: The persistent and rising levels of titanium, in a predominantly female population, is concerning. Titanium is known to cross the placental barrier and enter the circulation of the fetus in rodents and humans, and to accumulate in solid organs especially the liver, spleen, heart, and lymph nodes in humans. This potentially exposes the offspring of mothers with spinal implants to titanium, with potential teratogenic effects.

Failure to initiate trauma team activation for patients who meet the criteria in a level 1 paediatric trauma centre: which patients are missing out?

BACKGROUND: Trauma team activation (TTA) is paramount in the early hospital management of trauma patients. This study aimed to evaluate factors which contribute to failure to activate the Trauma team for management of paediatric trauma. METHODS: A retrospective cohort study of Emergency Department (ED) presentations at the paediatric major trauma hospital in Adelaide, South Australia was conducted over a 16-month period. Data from the hospital's trauma registry, individual case files and digital medical records were evaluated to determine factors that were associated with no TTA. RESULTS: During the study period, 617 trauma patients who met Level 1 or Level 2 TTA criteria attended the trauma centre. For 29 (4.7%) of these patients, there was no TTA. Predictors of no TTA included sustaining abdomen and/or pelvis injuries compared to limb injuries (unadjusted odds ratio [OR] = 10.59, 95% confidence interval [CI] 1.98-56.69, P = 0.006), sustaining non-accidental injury (NAI) versus an injury with vehicle involvement (OR = 30.13, 95% CI 6.43-141.21, P < 0.001), and arriving via emergency medical retrieval service compared to private vehicle (OR = 14.23, 95% CI 3.94-51.36, P < 0.001). No patients transferred directly to Paediatric Intensive Care Unit (PICU), or High Dependency Unit (HDU) received an appropriate TTA. CONCLUSION: Multiple factors were associated with no TTA in paediatric trauma patients. The results highlight that even in PICU and HDU admissions and transfer patients, vigilant clarification of mechanism of injury and potential for occult injuries should be undertaken to ensure appropriate TTA and improve patient outcome.

Bone Mineral Density Post a Spinal Cord Injury: A Review of the Current Literature Guidelines.

BACKGROUND: Spinal cord injury (SCI) causes rapid osteoporosis below the level of injury in a multi-factorial manner. This literature review focused on the early diagnosis of low bone mass (LBM) in SCI patients and aimed to summarize all the available recent data on the diagnosis and treatment of osteoporosis in this unique patient population.  Materials and Methods: Advanced literature research was conducted in the online PubMed database using the keywords 'bone mineral density, 'spinal cord injury, 'skeletal fragility', and 'osteoporotic fractures'. Out of the initial 430 articles, duplicates were removed and the remaining studies were assessed for eligibility. Two reviewers independently extracted data from each study and assessed variable reporting of outcome data. The exclusion criteria were: studies not measuring bone mineral density (BMD), studies comparing SCI to other diseases, animal studies, molecular studies, studies including children, and studies not written in English. The 83 remaining papers were divided into studies focusing on treatment and studies investigating LBM in SCI. Following this step, studies with small patient samples set at 20 patients with SCI for the treatment group and 30 patients for the diagnosis of the LBM group, were also excluded. RESULTS: In the remaining 32 studies, 18 focused on the diagnosis of LBM in SCI and 14 focused on the various treatment options to address this phenomenon. Most of these studies (n=13) used the dual-energy X-ray absorptiometry (DXA) method to evaluate bone mass while five studies preferred quantitative computed tomography (QCT) measurements and one evaluated LBM using calcaneal qualitative ultrasound. In the treatment group of studies, seven papers administered medication to address LBM and four clinical protocols used physiotherapy methods to reduce bone loss post-SCI while three studies combined medical treatment with physiotherapy. CONCLUSION: The unawareness of the unique mechanism through which bone is rapidly lost in the first months post-SCI led to initial scientific confusion. In this review, we summarize information to increase physicians' awareness of the dangers of 'silent' osteoporosis progression post-SCI. We have also provided information on the best timing to evaluate bone loss as well as treatment options that could prevent fragility fractures in this population.

Verbal fluency difficulties in aphasia: A combination of lexical and executive control deficits.

BACKGROUND: Verbal fluency tasks are routinely used in clinical assessment and research studies of aphasia. People with aphasia produce fewer items in verbal fluency tasks. It remains unclear if their output is limited solely by their lexical difficulties and/or has a basis in their executive control abilities. Recent research has illustrated that detailed characterization of verbal fluency performance using temporal characteristics of words retrieved, clustering and switching, and pause durations, along with separate measures of executive control stands to inform our understanding of the lexical and cognitive underpinnings of verbal fluency in aphasia. AIMS: To determine the locus of the verbal fluency difficulties in aphasia, we compared semantic and letter fluency trials between people with aphasia and healthy control participants using a wide range of variables to capture the performance between the two groups. The groups were also tested on separate measures of executive control to determine the relationship amongst these tasks and fluency performance. METHODS & PROCEDURES: Semantic (animal) and letter (F, A, S) fluency data for 60s trials were collected from 14 people with aphasia (PWA) and 24 healthy adult controls (HC). Variables, such as number of correct responses, clustering and switching analyses, were performed along with temporal measures of the retrieved words (response latencies) and pause durations. Participants performed executive control tasks to measure inhibitory control, mental-set shifting and memory span. OUTCOMES & RESULTS: Compared with HC, PWA produced fewer correct responses, showed greater difficulty with the letter fluency condition, were slower in getting started with the trials, showed slower retrieval times as noted in within- and between-cluster pause durations, and switched less often. Despite these retrieval difficulties, PWA showed a similar decline in the rate of recall to HC, and had similar cluster size. Executive control measures correlated primarily with the letter fluency variables: mostly for PWA and in one instance for HC. CONCLUSIONS & IMPLICATIONS: Poorer performance for PWA is a combination of difficulties in both the lexical and executive components of the verbal fluency task. Our findings highlight the importance of detailed characterization of fluency performance in deciphering the underlying mechanism of retrieval difficulties in aphasia, and illustrate the importance of using letter fluency trials to tap into executive control processes. WHAT THIS PAPER ADDS: What is already known on the subject PWA typically show impaired performance in verbal fluency tasks. It is debated whether this impaired performance is a result of their lexical difficulties or executive control difficulties, or a combination of both. This debate continues because previous studies have mostly used semantic fluency condition without including letter fluency condition; used a limited range of variables (e.g., number of correct responses); and not included separate executive control measures to explain the performance pattern in aphasia. This research addresses these outstanding issues to determine the specific contribution of lexical and executive control processes in verbal fluency in aphasia by including: both semantic and letter fluency conditions; a wide range of variables to identify the relative contribution of lexical and executive control mechanisms; and independent measures of executive control. What this paper adds to existing knowledge Using the multidimensional analysis approach for verbal fluency performance from both semantic and letter fluency conditions, this is the first study to systematically demonstrate that PWA had difficulties in both lexical and executive control components of the task. At the individual level, PWA had greater difficulty on the letter fluency condition compared with semantic fluency. We observed significant correlations between the executive control measures and verbal fluency measures primarily for the letter fluency condition. This research makes a significant contribution to our understanding of lexical and executive control aspects in word production in aphasia. What are the potential or actual clinical implications of this work? From a clinical perspective, this research highlights the importance of using a full range of verbal fluency and executive control measures to tap into the lexical as well as executive control abilities of PWA, and also the utility of using letter fluency to tap into the executive control processes in PWA.

Interobserver Reliability of Schatzker, AO Foundation-Orthopaedic Trauma Association, and Luo Classifications for Tibial Plateau Fractures: Does Three-Dimensional CT Improve Outcomes?

Objective To assess the interobserver agreement of the most widely used classification systems (Schatzker, AO Foundation-Orthopaedic Trauma Association (AO-OTA), and Luo) and investigate the impact of multiplane CT scans on their reliability. Methods Twelve raters (seven consultants and five senior trainees) were invited to classify 25 cases of tibial plateau fracture randomly selected out of a large database. Initially, they were asked to classify the fracture according to Schatzker, AO-OTA, and Luo based on plain anteroposterior (AP) X-ray and axial CT images. This procedure was applied for 25 cases consecutively. Next, the raters are given access to the multiplanar CT views of the same cases and were requested to reclassify each case. The interobserver agreement was calculated using the Fleiss kappa coefficient. Results An overall fair inter-rater agreement was observed for the Schatzker classification based on the plain AP X-ray (k=0.361) with a slight improvement after three-dimensional (3D) plane CT views (X-ray: k=0.361; 3D CT: k=0.364). For the AO-OTA classification, the relevant values were 0.204 and 0.231 based on plain X-ray and multiplanar CT, respectively. Finally, the Luo classification achieved the highest scores among the three classification systems (k=0.498), but its inter-rater agreement can still be characterized as moderate. No statistically significant improvement in the interobserver agreement was found for any classification even if only the consultants' subgroup was included in the data analysis. Conclusion All three classification systems failed to achieve a substantial agreement among the raters, with only a nonsignificant improvement after providing advanced imaging. This finding reflects the intrinsic weaknesses of the classification systems themselves rather than the disagreement on the fracture pattern due to unsatisfactory imaging.

An audit of computed tomography request practices for suspected cervical spine injury post-guideline change in a tertiary referral paediatric hospital.

BACKGROUND: Paediatric neck injuries are a common presenting complaint to emergency departments (EDs). Medical imaging can assist diagnosis, however previous research suggests computed tomography (CT) scan results do not alter management in this patient group and therefore expose children to unnecessary radiation. Following an audit by the hospital Trauma Service that identified unnecessary cervical spine CTs in patients at Women's and Children's Hospital (WCH), Adelaide, the Clinical Procedure for imaging and clearance of the cervical spine in conscious patients was modified to include CT scan only at the request of the orthopaedic service. The aim of this study was to evaluate whether a change in hospital guideline resulted in a change in practice and radiation exposure. METHODS: A retrospective review was performed for patients that presented to the WCH ED with a suspected cervical spine injury during two defined time periods pre- and post-guideline change. Mechanism of injury, imaging requested, radiation exposure and final diagnosis were compared. RESULTS: Three hundred seventy-nine patients were included, with 164 (43.3%) post-guideline changes. Radiograph use was similar between groups, 132/215 (61.4%) versus 101/164 (61.6%) (p = 0.97). CT scan use was lower post-guideline modification 19/215 (8.8%) versus 12/164 (7.3%), however was not statistically significant (p = 0.59), with an absolute reduction of 17%. CONCLUSION: Guideline modification at our hospital did not significantly reduce CT scan use or eliminate unnecessary CTs. Unnecessary CT scans followed lack of knowledge of and therefore compliance with guidelines. Individual hospitals should consider strategies to reduce unnecessary CTs, given the association with cancer risk in children.

Efficacy and safety of tranexamic acid in hip fracture surgery. How does dosage affect outcomes: A meta-analysis of randomized controlled trials.

AIM: The objective of this study was to assess the efficacy and safety of intravenous TXA administration in elderly patients undergoing hip fracture surgery focusing on the effect of various dosages. METHODS: A systematic search of PubMed, Embase and Cochrane Library was conducted until February 2021. Our primary outcome was peri­operative total blood loss, while secondary outcomes included transfusion rate, mean count of transfused RBC units and thromboembolic events' incidence. A subgroup analysis was performed with respect to TXA dosage. RESULTS: Out of 146 records identified, 10 randomized controlled studies met the selection criteria. Data synthesis revealed that TXA resulted in a significant reduction in total blood loss by 229.45 ml in favor of TXA; 95% CI: [189.5, 269.4] and transfusion rate by 40%, RR = 0.60; 95% CI: [0.47, 0.78]. No increase in thromboembolic events rate was observed (RR = 1.08, 95% CI: [0.68, 1.69]) Furthermore, sub-analysis with respect to TXA dosage showed no significant difference in total blood loss reduction between "single" and "multiple doses" studies (223 vs 233.5 ml, p = 0.85.), while a trend for lower complications rate was observed in patients receiving a single dose of ≤ 15 mg/kg. CONCLUSIONS: This meta-analysis provides strong evidence that TXA is a safe and effective agent to reduce perioperative blood loss in hip fracture surgery. When compared with higher dosages, a single dose of 15 mg/kg is associated with a non-significant reduction in adverse events, while achieving comparable outcomes.

Local Bone Grafting Is Sufficient for Instrumented Adolescent Idiopathic Scoliosis Surgery: A Preliminary Study.

BACKGROUND: Several options for grafting exist; iliac crest bone grafting, allografts, and bone substitutes. Local bone graft (LBG) offers high-quality bone graft and no commercial cost. The aim of this study was to assess the clinical and radiologic results of adolescent idiopathic scoliosis (AIS) surgery with posterior instrumentation and fusion (PIF) in patients using only LBG and to measure the quantities harvested. METHODS: A total of 218 AIS patients who underwent pedicle screw PIF surgery using only LBG with a minimum 1-year follow-up were reviewed. Bone was harvested during surgery from the excised facet joints, spinous processes (not from the end instrumented vertebrae) and decortication of laminae and transverse processes in the operative field. The harvested bone graft weight of 127 patients was recorded prospectively and then computed to graft weight per kilogram body weight (GWPK) and graft weight per motion segment (GWPMS). RESULTS: The median follow-up time was 24.7 months (12.1 to 133 mo) with 128 of the 218 patients having over 2 years follow-up. A total of 280 curves were fused. One hundred fifty-six of the patients had single curve instrumentation and 62 had double curve surgery. The median preoperative primary Cobb angle was 57.0 (31 to 100) degrees and postoperatively was 20.0 (0 to 66) degrees, indicating a median correction of 65.3% (17.5% to 100%). The median graft weight was 30 g (14 to 62 g), GWPK was 0.54 g/kg (0.24 to 1.29 g/kg) and GWPMS was 3.3 g/motion segments (2.3 to 10.0 g/kg). Twelve of 218 patients (5.5%) required subsequent surgery. Only 2 patients developed pseudarthrosis (0.91%), noting that modern segmental instrumentation warrants longer follow-up for increased confidence of complete fusion. CONCLUSIONS: LBG achieved successful fusion in over 99% of patients undergoing PIF for AIS. The described terms GWPK and GWPMS can be insightful for future studies. LBG offers a safe and low-cost solution for bone grafting in AIS surgery. LEVEL OF EVIDENCE: Level IV.

Clinical presentations of Kingella kingae musculoskeletal infections in South Australian children.

AIM: This study aimed to alert clinicians to the spectrum of presentations of Kingella kingae musculoskeletal infections. METHODS: Between August 2010 and March 2018, 55 children presented with positive K. kingae polymerase chain reaction on joint fluid, bone or deep soft tissue collections involving the limbs and subsequently underwent retrospective medical record, radiological and laboratory review. Demographics and clinical information are presented. RESULTS: Median age at presentation was 15.9 months (range 4.3 months-10.7 years) and 64% were male. Septic arthritis was the most common diagnosis (95%), median duration of symptoms was 4 days, 65% had a preceding infection (e.g. upper respiratory or gastrointestinal) and 22% re-presented to emergency departments after prior discharge. The lower limb was involved in 84%, with the knee being most affected (55%). If the lower limb was involved, 82% of previously weight-bearing children had a limp or were unable to weight bear. On presentation, median temperature was 36.7°C and inflammatory markers were mildly elevated. No blood cultures grew K. kingae. Five synovial fluid cultures were positive for K. kingae. Plain radiography showed effusion, soft tissue swelling or a lesion in 53% of patients. All 41 ultrasounds showed effusion, soft tissue swelling or synovial thickening. One patient with delayed diagnosis later presented with avascular necrosis of the femoral head. CONCLUSION: Kingella kingae is difficult to diagnose due to non-specific symptoms, absence of fevers and often unremarkable blood tests. Despite generally having good long-term outcomes, our case of avascular necrosis suggests accurate diagnosis and treatment are important.

The coronal aorto-mesenteric orientation theory for post-operative nausea and vomiting following scoliosis surgery in children: a pilot study.

BACKGROUND: Post-operative nausea and vomiting (PONV) is often encountered following corrective scoliosis surgery in children, frequently attributed to high-dose opiate administration. PONV is a frequent cause of prolonged hospital stay. Mechanisms related to transient partial duodenal compression by narrow angulation of the superior mesenteric artery (SMA) and aorta following scoliosis surgery are poorly understood and might be implicated in PONV. This study investigates relationships between biomechanical anatomic variations of the SMA and aorta, and its relationship with clinically significant PONV following scoliosis surgery in children. METHODS: Children undergoing elective spinal arthrodesis for adolescent idiopathic scoliosis were assessed by preoperative abdominal ultrasound and spinal X-ray prior to surgery. Post-operative assessment of clinically significant PONV is compared to preoperative imaging and clinical variables. RESULTS: Thirteen patients (11 female and two male), with a mean age of 14 years and 1 month were included. Five patients (38.5%) developed clinically significant PONV. A significant association was observed between the coronal aorto-mesenteric orientation and PONV (P = 0.035). Of the five patients who developed PONV, two had direct coronal angulation of the SMA, one had left angulation and two had right angulation. Patients with significant PONV had narrower aorto-mesenteric distances which approached significance (P = 0.06). No other preoperative variable reached significance. CONCLUSION: Patients with coronal aorto-mesenteric orientation preoperatively appear at greater risk of developing significant PONV following scoliosis surgery, independent of opiate requirements, prompting consideration of transient partial duodenal obstruction as an important factor in the mechanisms of PONV. A coronal aorto-mesenteric orientation theory (CAMOT) is proposed to explain this biomechanical vascular 'scissor'.

Disruption of paediatric orthopaedic hospital services due to the COVID-19 pandemic in a region with minimal COVID-19 illness.

PURPOSE: This study was designed to evaluate the impact of the COVID-19 pandemic on paediatric orthopaedic services in a paediatric tertiary hospital in South Australia. METHODS: A retrospective audit was conducted of orthopaedic activity at a major paediatric tertiary hospital with a Level 1 paediatric trauma centre, where no patients were admitted with COVID-19 illness. Orthopaedic Emergency Department (ED) presentations, outpatient clinics and hospital admissions for the period between 16 March 2020 to 26 April 2020 were studied and compared with the same period in 2019 (18 March 2019 to 28 April 2019). Chi-square tests were performed with p < 0.05 indicating statistical significance. RESULTS: In total, 621 patients presented to the ED with orthopaedic complaints during the pandemic (versus 997 in 2019). However, there was minimal change in the number of ED presentations requiring admission (110 in 2020 versus 116 in 2019). Among patients discharged directly from ED, 27.3% received hospital outpatient referral (versus 39.1% in 2019), with the remaining patients referred to community health services or discharged directly.There was a 509.8% increase in telehealth (video and phone) outpatient consultations compared to 2019 and a 60.6% decline in face-to-face appointments. There was a total of 144 orthopaedic admissions (elective and emergency) compared to 184 in 2019. Admissions for children under seven remained unchanged (32.5% reduction in children aged seven and above). CONCLUSION: Despite an overall decline in all paediatric orthopaedic hospital activity, the number of emergency admissions for musculoskeletal conditions did not change. Elective surgery numbers for children aged under seven were also unchanged. Appropriate planning and hospital resources allocation are necessary to meet this service requirement in future pandemics.Level of evidence IV.

Clubfoot deformity in the Solomon Islands: Melanesian versus Polynesian ethnicity, a retrospective cohort study.

PURPOSE: Congenital talipes equinovarus (CTEV) has a high incidence in the South Pacific, with New Zealand Maori and Polynesian rates of up to seven per 1000 live births, at least five times higher than the Caucasian population. A genetic component is suggested to explain this, however, there is little information regarding the difference of incidence between Polynesian and Melanesian ethnicity in the South Pacific. Our aim was to investigate the effects of ethnicity on the incidence of CTEV in the Solomon Islands, specifically comparing Melanesian and Polynesian ethnicity. METHODS: Between 2011 and 2017, data was collected in the Solomon Islands from over 40 clinics upon introduction of the Ponseti programme for treatment of CTEV. Records were kept using the validated Global Clubfoot Initiative data form. Ethnicity was documented, including family history. RESULTS: In total, 138 children presented during this period, with 215 affected feet reviewed and treated. In all, 74% of children had solely Melanesian parents and 6% Polynesian. Using the general population ethnic breakdown of 95.3% Melanesian and 3.1% Polynesian, the odds of CTEV in children of Melanesian parents were 0.41 times lower compared with the odds in children of Polynesian parents. CONCLUSION: The results indicate that in the Solomon Islands, CTEV in Melanesian children was less than half as likely to occur in Polynesian children. Our findings also support the theories of minimal Polynesian genetic material persisting in the Solomon Islands and a different genetic risk of CTEV between Polynesians and Melanesians. LEVEL OF EVIDENCE: III.

Chromium Metal Ion Release During Instrumented Spinal Surgery in Children: The Effects of Electrosurgery.

STUDY DESIGN: Prospective 2-year study with operative sampling and in-vitro analysis of chromium ions following spinal surgery in children. OBJECTIVES: To measure metal ion levels at preoperative, intraoperative, and postoperative times to determine patterns of metal ion release during instrumented spinal surgery. SUMMARY OF BACKGROUND DATA: Raised serum metal ion levels are reported following instrumented spinal fusion in adolescent idiopathic scoliosis. The authors noted raised chromium levels in patients receiving implants that did not contain chromium. This prompted further work to establish the source. The electrosurgery tips used were discovered to contain 17% chromium. METHODS: Chromium, cobalt, and titanium levels were measured before, during, and after surgery in serum and local intraoperative fluid samples in 11 children undergoing posterior instrumentation for scoliosis. Administered drugs, cell-saver fluids, and intraoperative fluids, both local and intravenous, were investigated to exclude these as sources of chromium ions. An in-vitro study was also performed to elucidate sources of intraoperative chromium ions. RESULTS: High chromium levels were detected in all samples from the wound irrigation fluid prior to insertion of metal implants. Immediate postoperative chromium serum ion levels were also elevated and returned to baseline by day 30. In-vitro sampling of fluids from test models using electrosurgery revealed high levels of chromium ions CONCLUSION.: This finding of high chromium metal ion concentrations in intraoperative and early postoperative samples provides evidence of chromium release during the dissection phase of spinal surgery. This challenges existing beliefs that metal ion release occurs solely due to implants and now implicates the electrosurgery electrode tips as a source of raised chromium ion levels. Thorough irrigation of the operative site after the dissection phase of surgery to both dilute and reduce the intraoperative chromium ion load is suggested. Alternative electrosurgery electrode tips or other methods to coagulate during surgery could be considered. LEVEL OF EVIDENCE: 2.

An integrated multidisciplinary team approach to the management of vascular anomalies: challenges and benefits.

BACKGROUND: Vascular anomalies comprise highly variable pathophysiology and commonly pose diagnostic and management dilemmas. Consequently, patients often benefit from input from multiple specialists. This study describes the inception of a multidisciplinary team (MDT) Vascular Anomaly Clinic (VAC) in a tertiary paediatric centre, and the subsequent experience managing this complex patient group. METHODS: This was a retrospective study of paediatric patients (< 18 years old) attending an MDT VAC from its inception in October 2012 until November 2019. Patient demographics, presentation, diagnosis and management were reviewed. RESULTS: One hundred and thirty-three paediatric patients were seen over 7 years with a median age of 9.8 years. Vascular malformations were the most common diagnosis (88%), with venous malformations predominating (27%). The most common symptoms were pain (46%) and swelling (34%). Patients often required ≥ 2 investigations, with Doppler ultrasound (86%) and magnetic-resonance imaging (61%) being most common. Management included surgery (27%), sclerotherapy (26%), compression garments (23%), analgesia (12%), laser (15%), embolisation (5%) and sirolimus (3%). CONCLUSIONS: The complex nature of vascular anomalies and high proportion of patients requiring multi-specialty management justified the establishment of an MDT VAC in our centre. Our experience demonstrates the success of an efficient one-stop MDT environment in the management of these challenging conditions. LEVEL OF EVIDENCE: IV.

Central Mirror Foot: Treatment and Review of the Literature.

Mirror foot is a rare abnormality which presents as a preaxial, postaxial, or central polydactyly of the foot. The latter is encountered infrequently. We describe the case of a central mirror foot. Our patient had eight digits of a central ray pattern type with fully developed metatarsal, proximal, middle, and distal phalanges, as well as a medial toe syndactyly. He had no tarsal bone duplications. He was treated by central ray resection via double V-shaped incisions on the dorsal and plantar aspects of the foot, while preserving the medial and lateral rays. The results were satisfactory. We describe the technique and attempt a review of the literature.

Do Children With Spinal Deformity Who Have Metal Implants and Frequent Exposure to X-Rays Increase Their Risk of Cancer?

STUDY DESIGN: Spinal surgery cohort. OBJECTIVE: The authors assess the risk of cancer in children who have undergone frequent radiographs and have metal implants for the treatment of spinal deformity. SUMMARY OF BACKGROUND DATA: Concerns have been raised regarding the cancer risk to children exposed to repeated radiological examinations as part of routine surveillance to monitor progression of spinal deformity. Additionally, there are reports of increased cancer risk in adults having joint replacement with metal implants causing raised metal ion levels in the blood. METHODS: A large number of consecutive children undergoing instrumented spinal surgery since 1979 were examined for their development of malignancy. High quality data on all invasive cancers from the South Australian Cancer Registry and deaths were linked to the spinal surgery cohort with the calculation of standardized incidence ratios (SIRs) using the Quinquinquennium method. RESULTS: The study cohort was formed by 865 children. The average follow-up time from date of surgery to either death or censoring date was 18 years with a maximum of 36 years. A total of 15,921 person years were examined. There was no increased rate of cancer in these patients. For the total cohort, the SIR was 1.00 (95% confidence interval [CI] 0.50-1.79). For females the SIR was 0.83 (95% CI 0.33-1.70) and for males the SIR was 1.33 (95% CI 0.36-3.40). The male SIR reflected an expected cancer incidence of three cases, when four cases were observed, and was not statistically significant. CONCLUSION: This study has found that radiation exposure and possible exposure to circulating metal ions as a result of routine instrumented spine surgery in children since 1979 is not associated with an increased risk of cancer in up to 36 years of follow up. LEVEL OF EVIDENCE: 2.

Screening for Carpal Tunnel Syndrome in Patients With Mucopolysaccharidosis.

Mucopolysaccharidoses (MPSs) are a group of rare lysosomal storage diseases with multisystem manifestations, including carpal tunnel syndrome (CTS). This study comprised a systematic review of literature and hospital guidelines addressing the method and frequency of screening for carpal tunnel syndrome in mucopolysaccharidosis patients and a review of carpal tunnel syndrome in patients seen in the multidisciplinary mucopolysaccharidosis clinic of a pediatric hospital, in order to develop screening recommendations. The literature reported the importance of routine carpal tunnel syndrome screening from early childhood in patients with mucopolysaccharidosis I, II, IV, and VI. Screening methods included physical examination, nerve conduction studies, electromyography, and ultrasonography. Ten of 20 mucopolysaccharidosis patients in our series underwent carpal tunnel syndrome surgery. Given the high incidence of carpal tunnel syndrome at a young age in mucopolysaccharidosis, the authors recommend performing physical examination and obtaining patient and caregiver history for carpal tunnel syndrome every 6 months from the time of mucopolysaccharidosis diagnosis, supplemented by annual nerve conduction studies in cases with poor history or equivocal examination.

Children bouncing to the emergency department: Changes in trampoline injury patterns.

AIM: To compare trampoline injuries and injury costs sustained at a commercial trampoline park versus private homes presenting to a major Australian children's hospital over a 12-month period. METHODS: Children presenting with a trampoline injury to the paediatric emergency department in 2015 were identified using a keyword search of triage information. A comparison of injuries sustained at a commercial trampoline park and private homes was performed. RESULTS: A total of 392 children presented with injuries, and the majority of injuries (68.9%) occurred at a private home; 19.4% were from a commercial trampoline park. Significant differences were seen between patients from a private home and commercial park for median age (5.6 vs. 12.8 years; P < 0.001), gender (48.2 vs. 61.8% female; P = 0.03) and season of injury. Of the injuries, 27.3% occurred when children fell off the trampoline, and fractures (39.5%) were the most common injury; 17.4% required hospital admission, and 12.8% required surgical intervention. Commercial park injuries had a significantly longer median length of stay (37.4 vs. 22.8 h; P = 0.03). The estimated total acute cost for these trampoline injuries in 1 year was $546 786. Commercial trampoline park injuries accounted for 21.7% of the estimated cost and private homes for 68.2%. CONCLUSIONS: Paediatric trampoline injuries remain a common source of hospital presentation and admission, despite the introduction of a Voluntary Australian Standard. Paediatric trampoline injuries usually occur in private homes; however, the increasing popularity of commercial trampoline parks contributes to a change in the profile of trampoline injuries. Commercial park injuries were more expensive to treat.