programme bscos 2014...2.25-2.35 osseointegration of tutobone when used in lateral column...

BSCOS 2014

ABERDEEN

13 & 14 MARCH

BSCOS

The British Society for

Children’s Orthopaedic Surgery

2 BSCOS 2014 Aberdeen

Sponsors We extend our sincere thanks to the following sponsors who have generously supported this event:

Ortholink

BSCOS 2014 Aberdeen 3

Contents Welcome to Aberdeen 4 Conference venue 5 Thursday 14th Programme 7

Abstracts 8 Friday 15th Programme 21

Abstracts 22

Local information 35 Maps 37 Feedback form 39 Inserts:

Delegate list, Certification


Welcome to BSCOS 2014 Dear delegate A warm welcome to the city of Aberdeen and to our annual scientific meeting. Please take a moment to familiarize yourself with the contents of this delegate pack. You will find an up to date programme, useful local numbers and information, maps, your attendance certificate and feedback form. Please take time to complete the feedback form and leave it at registration desk the end of the meeting to validate the 9.5 CME points that the meeting has been awarded. Please take time to visit our industry sponsors during the meeting. We are grateful for their support in helping to make the meeting affordable. If you have any questions, please don’t hesitate to speak with Diane at the registration desk or with another member of the local organizing team. Our thanks go to our guest speakers, Messrs Mehlman and Dietz, to those who present their original research at this meeting and to you, the delegates for coming to Aberdeen and participating. We very much hope that you have an enjoyable and stimulating experience.

Simon Barker Kirsten Elliott Tim Dougall


Conference venue: Aberdeen Once upon a time there were two Aberdeens! You are now in the Old Royal Burgh of Aberdeen which grew around the University and Cathedral at the mouth of the Don River. A little south is the ‘new’ city centre – focused around the harbor, though there’s no separation now. The University of Aberdeen was founded in 1495 by Bishop William Elphinestone whose tomb lies just outside these halls. It is the fifth eldest in the English speaking world. The Chapel with its crown tower dates from 1500, the Old Town House at the end of the High St (now the museum) was once the Burgh’s seat of government, and gaol.

In 1497 King James IV endowed the ‘Mediciner’ (Chair of Medicine) at King's College, and in 1506 medicine was recognised as a proper subject of study. The foundation charter of Marischal College, Aberdeen's second college-‐university (founded 1593), made provision for the teaching of medical subjects within the liberal arts curriculum, and a chair was established in 1700.

After generations of rivalry the Catholic King’s college and the Protestant Marischal college (now Aberdeen City Hall) were merged in 1860 and the campus around you has grown to cover 35 hectares.

The Medical School is now co-‐located within the 125 acre Foresterhill Health Campus which unites research, education and the three big hospitals in Aberdeen – the Royal Infirmary, the Maternity Hospital and the Children’s Hospital. Allied Health Professionals are trained at Robert Gordon’s University in the south of the city.

Children’s Orthopaedic Surgery in Aberdeen in recent memory was delivered through Royal Aberdeen Children’s Hospital by Tom Scotland, Peter Gibson and James Maclaughlin. A little over 5 years ago the new children’s hospital was built to serve Grampian, and the Orkney and Shetland Islands, along with it has come a new generation of Orthopaedic surgeons in Tim Dougall, Kirsten Elliott, Neil Forrest and Simon Barker. We are immensely grateful for the legacy of our forebears, not least in teaching each of us, and Tom will join us at the dinner on Thursday evening to address the haggis…

6 BSCOS 2014 Aberdeen 13th March – Today the conference takes place in Elphinestone Hall. There is an industry exhibition in the adjacent Linklater rooms – please do take time to visit the stands during breaks. Tea and coffee will be served during breaks at the back of the main meeting room. Lunch will be a sandwich buffet served to the tables in the main hall. There will be a dedicated lunchtime meeting for allied health professionals – please take lunch and head through the industry exhibition to the furthest Linklater room to access this meeting. If you wish to leave bags or coats, there is a cloakroom in Elphinestone – but please note we cannot accept any responsibility for loss or damage – they are deposited entirely at your own risk. You are advised not to leave anything of value. Please remember to collect all items at the end of the day. Washroom facilities are in Elphinestone Hall. 14th March – The conference moves to Kings college conference centre. This is located immediately adjacent to Elphinestone Hall, just to the right behind the Chapel as you face Elphinestone Hall. The industry exhibition will be in the atrium – please take the opportunity during breaks to visit the stands. Lunch will be served as a buffet in the atrium. If you wish to leave bags or coats, they may be left behind the registration desk in the atrium – but please note we cannot accept any responsibility for loss or damage – they are deposited entirely at your own risk. You are advised not to leave anything of value. Please remember to collect all items at the end of the day. Washroom facilities are in the atrium.

Taxis – an important note If you plan to journey to/from the conference venue by taxi at any point, you are strongly advised to pre-‐book. There can be considerable delays during rush hours in Aberdeen – see ‘local information’ at the back for numbers. [15th March – if you have signed up for the UKCCG traveling clinic/meeting, this will take place on the 3rd floor of Royal Aberdeen Children’s Hospital, Foresterhill, Aberdeen, AB25 2ZG from 9am.]


Programme -‐ Thursday 13th March 9-‐11.00 Executive Meeting [BSCOS Exec only]

Linklater (far) 11-‐11.25 Registration, Coffee & Exhibition Linklater (near) Session 1 Elphinestone Hall Welcome to Aberdeen 11.30-‐12.15 The failed clubfoot Prof F Dietz, Iowa 12.15-‐1 In memorium: Mark Paterson – J Robb, President The Paterson Lecture: The Iowa treatment of cavovarus foot Prof F Dietz, Iowa 1-‐1.45 Lunch

and AHP Session Linklater (far) 1.45-‐3.15 Session 2 Elphinestone Free papers -‐ see below 3.15-‐3.45 Tea & Posters Linklater (near) 3.45-‐5.15 Session 3 Elphinestone Controversies -‐ Two debates Chair: Prof C Melman, Cincinatti 5.15-‐5.30 Report: DDH Early/Late RCT -‐ N Clarke 5.30-‐6.00 Demonstration of BSCOS Registries Elphinestone Mr D Rowland 7.30-‐11.00 Dinner Elphinestone approx


Abstracts Thu 13th March 13.45-‐15.45

Presenters: Please take your talk slides to the AV technician well in advance of your presentation (you may do so from 10.15am onwards). Please note talks are strictly limited to 6 minutes – please assume a level of Orthopaedic knowledge and do not waste time with background content that your audience will already know.

1.45-‐1.55 CURRENT UK PRACTICE FOR HIP SCREENING IN CEREBRAL PALSY: A

SURVEY AND LITERATURE REVIEW 1.55-2.05 DETERMINANTS OF STIFF KNEE GAIT IN CEREBRAL PALSY 2.05-2.15 THE INTERACTION OF THE EDINBURGH VISUAL GAIT SCORE (EVGS)

WITH 3D GAIT ANALYSIS PARAMETERS (MAP AND GPS), AND THE EFFECT ON ORTHOPAEDIC SURGERY IN DIPLEGIC CEREBRAL PALSY

2.15-2.25 KINEMATIC DIFFERENCES BETWEEN NEUTRAL AND FLATFOOTED

CHILDREN AND THEIR RELATIONSHIP WITH QUALITY OF LIFE. 2.25-2.35 OSSEOINTEGRATION OF TUTOBONE WHEN USED IN LATERAL

COLUMN LENGTHENING FOR PLANOVALGUS FEET 2.35-2.45 THE CURRENT DDH SCREENING PROGRAMME APPEARS TO BE

CAUSING AN INCREASE IN LATE PRESENTATIONS AND OPEN REDUCTIONS

2.45-2.55 FAILURE OF UNIFORM SCREENING SERVICES FOR DEVELOPMENTAL

DYSPLASIA OF THE HIP PROVIDES EVIDENCE TO SUPPORT THE NEED FOR AT LEAST A SELECTIVE AT-RISK SCREENING POLICY

2.55-3.05 FAILED PAVLIK HARNESS TREATMENT FOR DDH AS A RISK FACTOR FOR AVASCULAR NECROSIS

3.05-3.15 UNIVERSAL OR SELECTIVE ULTRASOUND SCREENING FOR

DEVELOPMENTAL DYSPLASIA OF THE HIP? A COMPARATIVE COHORT STUDY

3.15-3.25 STRICT CRITERIA FOR THE ACCEPTANCE OF CLOSED REDUCTION IN

DEVELOPMENTAL DYSPLASIA OF THE HIP - DOES IT INFLUENCE RATE OF OSTEONECROSIS ?

3.25-3.35 PERIACETABULAR OSTEOTOMIES – NOT ALL THEY’RE CRACKED

OUT TO BE! 3.35-3.45 TRANSVERSE ACETABULAR PLANE AND VERSION FOLLOWING

DEGA LIKE OSTEOTOMY IN TREATMENT OF DDH

BSCOS 2014 Aberdeen 9 1.45-1.55 CURRENT UK PRACTICE FOR HIP SCREENING IN CEREBRAL PALSY: A

SURVEY AND LITERATURE REVIEW K R Price, J Chandrasenan, R A Rajan Royal Derby Hospital, UK. Purpose To establish current opinion regarding hip screening in cerebral palsy from the published literature and from a survey of UK surgeons prior to the design of a new screening programme. Methods A Survey Monkey questionnaire was created to establish current practice regarding hip screening and the management of hip pathology in cerebral palsy. This survey was sent to all current BSCOS members and the responses were analysed. A literature search was performed using the Medline database to ascertain published opinion on this subject. Results Hip screening programmes in the UK are predominantly led by community paediatricians or orthopaedic surgeons, many units adopting a multidisciplinary team approach. It is universally accepted that those with a GMFCS of IV or V need to screened regularly for hip subluxation, the majority of professionals screening annually. A migration percentage of 40% is commonly the threshold for surgical intervention or at least an increased frequency of hip screening to monitor the rate of progression. For hip dislocation, the management of choice is hip reconstruction unless there are clear degenerative changes within the femoral head, in which case salvage procedures are indicated. It is clear that there is no consensus on the management of a unilateral hip dislocation, and surgeons require further large scale studies or the development of a national database to answer this question.

Conclusions Ideally, hip screening should be performed in a dedicated MDT clinic. For children with a GMFCS of III or less, we would recommend a single pelvic radiograph between 4 and 6 years of age unless there are any concerns regarding the hips clinically. For children with a GMFCS of IV or V we would recommend an initial radiograph at approximately 18 months of age, with repeated clinical and radiological examinations annually. Level of evidence: IV

10 BSCOS 2014 Aberdeen 1.55-2.05 DETERMINANTS OF STIFF KNEE GAIT IN CEREBRAL PALSY R S Jeffery†, E Compton‡, G Shum‡, B Bradley†, J Marsden‡ ‡School of Health Professions, Faculty of Health and Human Sciences, Plymouth University; † Plymouth Hospitals NHS Trust Purpose of the Study: To investigate impairments that contribute to stiff knee gait in people with cerebral palsy (CP) Method: We investigated the relationship between the range of knee flexion during the gait cycle and 1) plantarflexor strength, 2) hip flexor strength, 3) knee extensor spasticity 4) knee extensor passive stiffness and 5) minimum knee flexion during stance. Lower limb walking kinematics and kinetics were recorded using 3D motion analysis (Codamotion, UK). Isometric muscle strength was measured using dynamometry (Biodex, USA). Stereotyped stretches at slow (5o/s) and fast (160o/s) speeds, combined with surface electromyography, were used to quantify knee extensor passive stiffness and spasticity respectively. Twenty-eight people with CP (GMFCS I-II, age 6-43) and 20 matched controls participated. Paired t-tests assessed between-group impairment measures and factors affecting stiff-knee gait in people with CP were analysed using Pearson’s correlation multiple regression analysis. Results: Ankle plantarflexion and hip flexor strength were weaker in people with CP (p<0.001). They had higher knee extensor passive (p<0.002), stretch-mediated (p<0.001) and total stiffness (p<0.001). The range of knee flexion was reduced (p<0.05) and there was greater knee flexion in stance (p<0.05), allowing for co-variance due to walking speed. The range of knee flexion during the gait cycle correlated inversely with knee extensor spasticity (R= -0.57 p<0.05) and minimum knee flexion in stance (R= -0.61 p<0.05). There was no significant correlation with plantarflexor or hip flexor strength or with knee extensor passive stiffness. Stepwise linear regression revealed that knee extensor spasticity and minimum knee flexion in stance accounted for 47% of the variance in range of knee flexion (R2= 0.47 p<0.01). Conclusion: Knee extensor spasticity has a strong correlation with the severity of stiff knee gait. Knee flexion during the swing phase is also affected by the degree of crouch in the stance phase. Level of Evidence: Level III

BSCOS 2014 Aberdeen 11 2.05-2.15 THE INTERACTION OF THE EDINBURGH VISUAL GAIT SCORE (EVGS) WITH

3D GAIT ANALYSIS PARAMETERS (MAP AND GPS), AND THE EFFECT ON ORTHOPAEDIC SURGERY IN DIPLEGIC CEREBRAL PALSY

L W Robinson, N Clement, J E Robb, M S Gaston Royal Hospital for Sick Children, Edinburgh The purpose of the present study was to determine the relationship between the Edinburgh Visual Gait Score and recently introduced summative 3DGA (3 dimensional gait analysis) parameters (Movement Analysis Profile (MAP) and Gait Profile Score (GPS)), compare these with functional assessment scores, and finally determine their significance in clinical practice in the context of orthopaedic surgery. All patients with diplegic cerebral palsy undergoing gait analysis at our institution between 2007 and 2013 were included. In total, 156 patients had kinematic MAP and GPS and Edinburgh Visual Gait Score (EVGS) data available, alongside a functional assessment score in the form of the Gross Motor Function Classification System (GMFCS). Forty-five patients had baseline and follow-up data and were split into surgical (16) and non-surgical cohorts (29). The EVGS was found to correlate strongly with GPS (PPMCC = 0.816). Correlation between gait score, in the form of both GPS and EVGS, and functional assessment (GMFCS) was significantly non-zero (p < 0.001) and linear regression calculated a Minimal Clinically Important Difference (MCID) of 2.6 for GPS, 7.6 for EVGS, that corresponds to a one-point improvement in the GMFCS level. Surgical patients witnessed a significant mean reduction in both gait scores (-3.68 GPS, -7.53 EVGS) compared to non-surgical controls (0.123 GPS, -0.3 EVGS) (p<0.01). This highlights that these gait assessment measures are responsive to orthopaedic surgical intervention and that orthopaedic intervention achieves an average improvement in gait score comparable to the level of the MCID calculated by the present study. The strong correlation of GPS with EVGS implies any advances from the use of GPS can be applied to centres without 3DGA facilities by using the EGVS. The MCIDs infer the gait score improvement required by orthopaedic intervention to be significantly confident of initiating an improvement in function – an outcome achieved in the studied cohort. Level of evidence: III


2.15-2.25 KINEMATIC DIFFERENCES BETWEEN NEUTRAL AND FLATFOOTED

CHILDREN AND THEIR RELATIONSHIP WITH QUALITY OF LIFE. A Kothari,1 P C Dixon2, J Stebbins3, A B Zavatsky2, T Theologis1

1Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK 2Department of Engineering Science, University of Oxford, Oxford, UK 3Oxford Gait Laboratory, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford UK Purpose To identify whether children with flat feet demonstrate altered gait kinematics compared to children with neutral foot posture and to assess if these relate to quality of life (QoL). Methods Fifty-six children (age 8-15, 30 with neutral foot posture (NF) and 26 with flexible flat feet (FF)) completed the Oxford Ankle Foot Questionnaire for Children (OXAFQ_C) and underwent gait analysis using a Vicon MX system (Vicon UK), with the Oxford Foot Model (OFM) and Plug in Gait marker sets. The OFM measures relative movement between four segments; tibia, hindfoot, forefoot and hallux. OFM angles at heel strike (HS), toe off (TO) as well as maxima, minima and range of motion (ROM) were obtained. Differences at discrete time points between groups were assessed using the Student’s t-test and for the whole gait cycle via 95% Bootstrap confidence bands (BCBs). Pearson’s R was used to correlate OXAFQ_C scores with absolute foot angles where kinematic differences were displayed by the FF group. Results The BCBs showed significant differences in all OFM foot segment kinematics between the NF group and the FF group. The FF hindfeet were more valgus throughout stance; most pronounced at HS (varus; FF 0.6o vs NF 4o, p=0.02). FF children had more forefoot supination particularly at HS (FF 11.6o vs NF 6.4o, p<0.01). The Hallux was more abducted in the FF group compared to the NF group. The OXAFQ_C scores were strongly, negatively correlated with forefoot supination at HS (p<0.01) and at TO (p<0.01). The scores did not correlate with any other variables. Conclusion Children with FF demonstrate altered foot kinematics compared to those with NF. From these, only forefoot supination in relation to the hindfoot relates to QoL. Increased forefoot supination may be driven in part by increased hindfoot valgus, but is associated, independently, with worsening QoL. Level of evidence: II

BSCOS 2014 Aberdeen 13 2.25-2.35 OSSEOINTEGRATION OF TUTOBONE WHEN USED IN LATERAL COLUMN

LENGTHENING FOR PLANOVALGUS FEET S Shyamsundar, L Pearn, D Wright, A Bass Alder hey children’s hospital NHS Foundation Trust

Purpose: To assess osseointegration of Tutobone in hind foot surgery for the correction of flat foot deformity in neuromuscular conditions Method: Tutobone is a solvent-preserved cancellous bovine bone substitute. We have been using it as a wedge graft in an os calcis lengthening procedure to correct planovalgus deformity. We performed a review of all os calcis lengthening surgery performed by the neuromuscular team in out tertiary children’s hospital from 1 May 2009 to September 2012. The osteotomy was done 1cm proximal to the calcaneo cuboid joint and a wedge of tutobone inserted at osteotomy site and supported with a plate. All except one had a primary underlying neuromuscular problem. Integration was assessed with serial follow up radiographs at 6-8 weeks, 3-4 months and further imaging if integration had not occurred. Results: There were twenty three patients (37 feet) who had tutobone used in their osteotomy. 35 out of the 37 feet integrated completely by 4 months. One of them developed a deep infection and had a salvage triple arthrodesis done. Another patient took 9 months to undergo complete osseointegration. There were three other complications. One patient had one of the screws backing out and hence had to have metal work removal at a year and another had a prominent plate and had to be revised at 6 weeks to another plate and one patient developed superficial wound infection. All these three patients went on to complete osseointegration by 4 months.

Conclusion: Tutobone is an effective xenograft that provides reliable osseointegration when used in hind foot surgery and can be used instead of iliac crest autograft, thus avoiding the morbidity of harvesting the graft. Level of evidence: II

14 BSCOS 2014 Aberdeen 2.35-2.45 THE CURRENT DDH SCREENING PROGRAMME APPEARS TO BE CAUSING AN INCREASE IN LATE PRESENTATIONS AND OPEN REDUCTIONS K R Price, R Dove, J B Hunter University Hospital Nottingham, UK. Purpose To establish if there has been an increase in late presentation and open reduction rates for DDH following the implementation of the NIPE programme in 2008. Methods This was a retrospective review of a prospectively collected database of all children requiring treatment for DDH at our institution from 1990 to 2010. Patients were grouped according to age at presentation to the clinic, and numbers of children requiring any intervention and particularly open reduction surgery were recorded. Overall treatment and open reduction rates were then calculated per 100,000 live births. Microsoft Excel was used to calculate correlation coefficients to ascertain treatment trends from 1990 to 2008, and then from 2007 to 2010 to allow an assessment of the impact of the 2008 guidelines. Average cost of treatment per year was calculated based on the costing data published by this group in 2013. Results There has been a slight increase in the number of referrals to the hip instability clinics from 1990 to 2010. Prior to 2008, overall treatment, late presentation and open reduction rates for DDH were virtually stable. From 2007 to 2010 there was a marked increase in treatment rates, late presentations and the proportion of open reductions performed. The average cost of treatment per child increased from previous years with the increasing magnitude of treatment. Conclusion This study suggests that there has been an increase in late presentations and open reduction surgery following the implementation of the NIPE programme in 2008. The authors recommend that there be consideration of implementing an opportunistic screening examination at 3-5 months in conjunction with immunisations to off-set this negative effect.

BSCOS 2014 Aberdeen 15 2.45-‐2.55 FAILURE OF UNIFORM SCREENING SERVICES FOR DEVELOPMENTAL

DYSPLASIA OF THE HIP PROVIDES EVIDENCE TO SUPPORT THE NEED FOR AT LEAST A SELECTIVE AT-RISK SCREENING POLICY.

Dr K Dayananda MB BCh, 1

Dr C Malcolm BSc, MB BCH,2 Mr N Price MB BCh FRCS Tr & Orth2

Miss E C Carpenter MB BCh, FRCS Tr & Orth, 1 Mr D P Thomas MB BCh, FRCS Tr & Orth, 1

Mr P R Williams BSc Hons, MB BCh, FRCS Tr & Orth 2

Cardiff and Vale University Health Board (CVUHB) 1, Wales Abertawe Bro Morgannwg University Health Board (ABMU), 2 Wales Aim To assess non-uniform USS screening in Wales in preventing late presentation and surgical treatment of DDH and compare to selective USS risk factor screening guidelines. Methods and Results Over a 5 year period from January 1st 2007 to December 31st 2011 all surgically treated DDH cases were identified in Cardiff and Vale University Health Board (CVUHB), Abertawe Bro Morgannwg University Health Board (ABMU), and those referred in from surrounding Health Boards, in order to determine the number of late presentations (age greater than 6 months at presentation) and compare the effectiveness of the varying screening protocols per 1000 live births. 33% of cases had identifiable risk factors that would have indicated the need for selective USS screening under the 2010 NNIPE guidelines. These cases could be regarded as “avoidable” had an adequate selective screening protocol been in place. None of these came from the Swansea & Neath / Port Talbot area where a risk factor based selective screening has been rigorously employed for many years. Here the surgical intervention rate was as low as 0.18 per 1000 live births. In areas where no formal screening system is in place the surgical treatment rate was up to 4 times higher at 0.73 per 1000 live births. Conclusions The adequacy of screening for DDH impacts the rate of surgical treatment significantly. At minimum a uniform selective screening policy in line with the NNIPE guidelines needs to be enforced, perhaps via health legislation to convert the current “guidelines” into minimum “standards”, to reduce surgical rates and morbidity from DDH. Level of Evidence: III

16 BSCOS 2014 Aberdeen 2.55-3.05 FAILED PAVLIK HARNESS TREATMENT FOR DDH AS A RISK FACTOR FOR

AVASCULAR NECROSIS Madhu T, Reading I, Clarke NMP Southampton General Hospital Background Avascular necrosis (AVN) of the femoral head is an irreversible complication seen in the treatment of Developmental Dysplasia of Hip (DDH) with the Pavlik Harness. Its incidence is reported to be low after successful reduction of hip and high if the hip is not relocated. We aim to investigate its incidence after failed Pavlik harness treatment. Methods We prospectively followed a group of children who failed Pavlik harness treatment for DDH treated at our institution by the senior author between 1988 and 2001 and compared their rates of AVN with a group of children who presented late and hence were not treated with the Pavlik harness. AVN was graded as described by Kalamchi and MacEwen and only Grade 2- 4 AVN was considered significant and included in the analysis. Results Thirty-seven hips were included in the Failed Pavlik group (group 1) and 86 hips in the no Pavlik group (group 2). Ten hips in group 1 developed AVN (27%) while only 7 hips in group 2 (8%) developed AVN, the odds of developing AVN after failed Pavlik treatment was 4.7 (95% confidence interval 1.3-14.1) (p=0.009) with relative risk of 3.32 (1.37-8.05). Conclusions There was no statistically significant association noted with duration of harness and severity of AVN (Spearman’s correlation -0.46, p=0.18). However, there was a positive correlation with age at presentation and severity of AVN. We therefore advise close monitoring of hips in Pavlik harness and discontinue its use if the hips are not reduced within first 2 weeks. Level of evidence: III

BSCOS 2014 Aberdeen 17 3.05-‐3.15 UNIVERSAL OR SELECTIVE ULTRASOUND SCREENING FOR

DEVELOPMENTAL DYSPLASIA OF THE HIP? A COMPARATIVE COHORT STUDY

E Shears, D Butler, SJ Cooke, A Gaffey University Hospital Coventry The purpose of this study was to compare the outcomes of universal ultrasound screening versus selective ultrasound screening for developmental dysplasia of the hip (DDH) in a UK setting. Methods In 2008, the city of Coventry changed its screening programme for DDH from universal to selective ultrasound screening. Two consecutive three-year cohorts (pre- and post-2008) were compared: universal neonatal ultrasounds (10,018 babies), and selective ultrasounds (18,053 babies). These cohorts were compared by retrospective analysis at a minimum follow-up of 2 years. Results The rate of late diagnosis (>3 months) was 5 times greater in the selectively-screened cohort (p=0.03). The rate of Pavlik harness treatment was 1.7 times greater in the universally-screened cohort (p<0.01). There were trends towards more frequent surgical treatment and severe avascular necrosis in the selectively-screened cohort, although statistical significance was not reached. Conclusion This is the largest published comparative study of universal versus selective ultrasound screening for DDH, and the sole comparative study in a UK setting. Due to the significant difference in late diagnosis between the two strategies. we recommend universal ultrasound hip screening for babies in the United Kingdom. Level of evidence: III

18 BSCOS 2014 Aberdeen 3.15-‐3.25 STRICT CRITERIA FOR THE ACCEPTANCE OF CLOSED REDUCTION IN

DEVELOPMENTAL DYSPLASIA OF THE HIP - DOES IT INFLUENCE RATE OF OSTEONECROSIS ?

R Maheshwari, S Dorman, H George, R Davies, N Garg, CE Bruce Alder Hey Children's NHS Trust, Liverpool, United Kingdom Purpose of study: Adherence to strict criteria for acceptance of closed reduction in Developmental Dysplasia of the Hip (DDH) can significantly limit the incidence of Avascular Necrosis (AVN) associated with the procedure and we present our experience in children under 12 months of age. Methods: From our database, we identified 200 hips in 188 patients with closed or open reduction after failed Pavlik harness treatment or late presentation, in the period between 2005 and 2013. Treatment included closed reduction, medial open reduction or anterior open reduction (hip spica in all). Strict criteria for accepting closed reduction consisted of specific arthrogram findings (Apex / north pole of femoral head medial to tip of labrum), safe and wide zone of stability and satisfactory CT scans post reduction. AVN was diagnosed according to Kalamchi and MacEwen system and was quantified using the height:width ratio. Results: Out of 188 patients (200 hips), 169 were female (89%). 114 had left sided DDH and 12 bilateral. 77 hips had closed reduction, 95 hips with medial open reduction and 28 with anterior open reduction with or without Salter’s osteotomy at a later stage. Mean age for 68 patients (77 hips) in the closed reduction group was 6 months and 6 days (range 91 to 338 days). One hip failed (redislocation) and needed medial open reduction. 13 of these hips needed Salter’s osteotomy as a secondary procedure. 10 hips have been found to have AVN to date (12.9%). Conclusion: Higher rates of AVN (up to 48%) have been reported with closed reduction and controversy lies in the method of treatment in infants with DDH. In our study the AVN rate is low and we believe this is due to following the strict criteria, which also helps us decide whether closed or open reduction should be undertaken. Level of evidence: IV


3.25-3.35 PERIACETABULAR OSTEOTOMIES – NOT ALL THEY’RE CRACKED OUT TO

BE! S Dalgleish, DC Campbell, JGB MacLean Ninewells Hospital & Medical School, Dundee Aim: To assess the accuracy and reproducibility of periacetabular osteotomy, as determined by 3D CT scan, and whether variation in procedure affected outcome as reflected by change in standard measurements for dysplasia from pre and post operative plain x-rays. Plain radiographic assessment fails to demonstrate the complex three dimensional anatomy of the pelvis, and in particular, changes as a consequence of a periacetabular osteotomy. Many different osteotomies are described for the treatment of acetabular dysplasia with subtle anatomical variations perceived to confer different advantages over each other. Our supposition was that inadequate imaging might fail to distinguish such variations. Method: Postoperative 3D spiral CT scans performed on a cohort of children undergoing simultaneous periacetabular and upper femoral osteotomy for treatment of acetabular dysplasia were scrutinised independently. The patient group studied consisted of 26 children, 16 with developmental dysplasia of the hip (DDH), 10 with cerebral palsy (CP) of whom two underwent bilateral surgery. In the DDH patients, 7 underwent primary procedures with simultaneous open reduction (age 1.5 -4.2 years), 9 were secondary procedures (age 4.8 – 14.6 years). All 12 osteotomies in the CP patients were primary procedures (age 3.8 - 13.5 years) and open reduction was included in two patients. Preoperative plain radiographic measurements were compared with those taken one year post surgery. Results: In all but 2 cases a Dega was intended. Interpretation of the scans was subjective; however, of the 28 osteotomies, six were felt to be Degas, four Pembersals, three Pembertons and in 15 a variant of the Dega No difference was observed between the type of osteotomy, the correction achieved, nor the primary pathology. Conclusion: Despite attempting a consistent surgical approach three dimensional imaging demonstrated significant variance in what had been achieved. This, however did not appear to affect the outcome.

Level of Evidence: III

20 BSCOS 2014 Aberdeen 3.35-3.45 TRANSVERSE ACETABULAR PLANE AND VERSION FOLLOWING

DEGA LIKE OSTEOTOMY IN TREATMENT OF DDH D Lawniczak, Sanjeev S Madan, J A Fernandes Department of Paediatric Orthopaedics, Sheffield Children’s Hospital Purpose: Redirectional osteotomies or acetabuloplasties are used in the treatment of DDH to correct dysplasia and improve coverage. Salter’s osteotomy creates retroversion of the acetabulum and may predispose to impingement. This study was to quantify transverse plane cover and acetabular version after Dega like acetabuloplasty. Materials and methods: 44 children (47 hips), with mean age of 2.5 yrs (1.3-6.3) were surgically treated for DDH in between 2005 and 2013. Routine post op CT scans following open reduction and Dega like acetabuloplasty were analysed. Acetabular version, depth of acetabulum, and total acetabular index (TAI), anterior acetabular index (AAI) and posterior acetabular index (PAI) were measured. In 41 cases contralateral hip was normal, therefore was used as control group. Unpaired t test was used for statistical analysis. Results: All operated hips maintained acetabular anteversion with mean anteversion angle (AAA) of 17.6° (SD 5.5°). Anteversion in control group was 13.3° (SD 5.0°) p value = 0.0002. Average depth of acetabulum was similar 5.1mm (SD 0.2mm) and 5.9mm (SD 0.3mm) for DDH and control group respectively, p=0.132. Mean TAI was 126.8° (SD 10.9°) for DDH group and 128.4° (SD 7.8°) for control group, p=0.423. Mean AAI was 71.8° (SD 6.8°) for DDH group and 67.4° (SD 7.2°) for control group, p=0.0046. Mean PAI was 54.9° (SD 9.5°) for DDH group and 61.0° (SD 5.8°) for control group, p=0.007. Conclusion: Dega like acetabuloplasty corrects transverse plane dysplasia of DDH and maintains the acetabulum in it’s anteverted position. Normalisation of anterior and posterior transverse plane indices of the abnormal hip with maintenance of version is well achieved. Dega like acetabuloplasties may prevent the late complications associated with Salter’s osteotomy. Level of evidence: III


Programme – Friday 14th 8.15-‐8.40 Coffee & Exhibition Kings Atrium

Session 4 Kings Conference

8.40-‐9 Medical Administration: A Challenge for Physicans Prof P Armstrong, Shriners, IN 9-‐9.45 Child Protection update Dr E Myerscough, Aberdeen 9.45-‐10 Paediatric Polytrauma update Prof C Melman, Cincinatti 10.30-‐11 Coffee & Exhibition Kings Atrium 11-‐12.30 Session 5 Kings Conference 11-‐11.45 'Tricky Tibial fractures' Prof C Mehlman, Cincinatti 11.45-‐12.30 Regional Pain Syndrome type I in children Prof F Dietz, Iowa 12.30-‐1.15* Lunch Kings Atrium 1.15-‐1.45 Business Meeting (BSCOS members only) Kings Conference 1.45-‐3.45 Session 6 Kings Conference Free Papers -‐ see below 3.45 Closing Remarks -‐ A Hashemi-‐Nejad, President [* Lunch break for non-‐members extends to 1.45]


Abstracts Fri 14th March 13.45-‐15.45

Presenters: Please take your talk slides to the AV technician well in advance of your presentation (you may do so from 8.30am onwards). Please note talks are strictly limited to 6 minutes – please assume a level of Orthopaedic knowledge and do not waste time with background content that your audience will already know. 1.45 -1.55 IMPROVEMENT OF ANKLE CALCANEUS IN CHILDREN BY GUIDED

GROWTH USING TENSION BAND PLATES 1.55-‐2.05 THE MORBIDITY ASSOCIATED WITH ANTERIOR ILIAC CREST BONE

GRAFT HARVEST IN CHILDREN UNDERGOING ORTHOPAEDIC SURGERY: A PROSPECTIVE REVIEW

2.05-‐2.15 THE POTENTIAL FOR MIS-INTERPRETATION OF TIBIAL-TUBERCLE-

TROCHLEAR-GROOVE DISTANCE FROM MODERN MRI SCANS 2.15-2.25 THE EPIDEMIOLOGY OF TRANSIENT SYNOVITIS WITHIN

MERSEYSIDE 2.25-2.35 THE EFFECT OF SOCIAL DEPRIVATION ON PAEDIATRIC FRACTURES 2.35-2.45 A NEW CLINICAL PREDICTION RULE FOR DIAGNOSING SEPTIC

ARTHRITIS OF THE HIP IN CHILDREN 2.45-2.55 DISPLACED SUPRACONDYLAR HUMERUS FRACTURES IN CHILDREN:

A MAJOR TRAUMA CENTRE EXPERIENCE AND PARENTAL OUTCOME ASSESSMENT.

2.55-3.05 TRANSPHYSEAL ACL RECONSTRUCTION IN THE ADOLESCENT- THE

RELATIVE TUNNEL SIZE AND EFFECT ON THE GROWING PHYSIS. 3.05-3.15 CURRENT MANAGEMENT OF SLIPPED UPPER FEMORAL EPIPHYSIS IN

SCOTLAND: IS THERE A PLACE FOR CHANGE? 3.15-3.25 DEMOGRAPHICS AND MANAGEMENT OF SLIPPED CAPITAL

FEMORAL EPIPHYSIS BETWEEN 2007 AND 2012-A Multicentre audit 3.25-3.35 SLIPPED CAPITAL FEMORAL EPIPHYSIS: IS IT WORTH THE RISK AND

COST NOT TO OFFER PROPHYLACTIC FIXATION OF THE CONTRALATERAL HIP?

3.35-3.45 THE TREATMENT OF SLIPPED CAPITAL FEMORAL EPIPHYSIS USING

THE HANSSON PIN

BSCOS 2014 Aberdeen 23 1.45-1.55 IMPROVEMENT OF ANKLE CALCANEUS IN CHILDREN BY GUIDED

GROWTH USING TENSION BAND PLATES A Sinha, D Selvan, A Sinha, L A James Alder Hey Children Hospital, Liverpool, United Kingdom Purpose: We present our experience of using tension band plates to achieve guided growth in children for correction of calcaneus deformity of the ankle. Methods: 11 consecutive patients (13 ankles) fulfilled the inclusion criteria over a 4-year period. All underwent surgical treatment using a flexible two hole plate and screws on the posterior aspect of distal tibial physis. Measurements were done on preoperative, intraoperative screening and 1-year post operative plain AP and lateral ankle radiographs. The anterior distal tibia angle (ADTA), lateral distal tibial angle (LDTA) and screw divergence angle (angle subtended by lines passing through the long axis of the screws) were used to assess the deformity correction. A 2 tailed student t-test was carried out on the initial and 1-year post-op measurements to determine statistical significance with a p value <0.05 considered as significant Results: There were 10 residual clubfoot deformities, 2 post-traumatic deformities and 1 spinal tumor causing deformity. The average age of the patients was 10 years 5 months (range 4 to 13 years). There were 9 males and 2 females. The ADTA showed a statistically significant change with a p value of 0.0008 with a mean correction of 8.6 degrees (range of 2.3 to 15.6 degrees). The SDA demonstrated a mean correction of 15.4 degrees (range 0.3 to 41.8 degrees), p=0.002. The LDTA did not change significantly (p= 0.08), thus confirming no coincidental coronal plane deformity had occurred. 5 ankles required revision of fixation due to metalwork reaching its maximum limit of divergence at an average of 1 year. 2 ankles had screw pulled out due to osteolysis around the screw. There were no cases of infection. Conclusions: We report satisfactory short-term results of correction of calcaneus deformity using a flexible tension band plate and screws system. Level of evidence: IV

24 BSCOS 2014 Aberdeen 1.55-2.05 THE MORBIDITY ASSOCIATED WITH ANTERIOR ILIAC CREST BONE

GRAFT HARVEST IN CHILDREN UNDERGOING ORTHOPAEDIC SURGERY: A PROSPECTIVE REVIEW

A L Clarke, JA Fernandes, M Flowers, AG Davies, S Giles, SS Madan S Jones Sheffield Children’s Hospital To prospectively evaluate the degree of morbidity associated with the procedure in a paediatric population. Children undergoing anterior iliac crest bone graft harvest as part of an orthopaedic procedure were prospectively recruited to this study. They were given a Visual Analogue Scale (VAS) based questionnaire to fill out at various time points following surgery for both the iliac crest and recipient site. In addition the harvest site was evaluated for complications at 2, 6 weeks and 1 year. 33 patients with a mean age of 12.55 (range 7 - 17 years) were recruited. Pain in the immediate post-operative period was found to be high, with some patients reporting scores of 10 out of 10. Levels of pain reduced from two days after surgery, with scores not statistically significantly different from baseline VAS score from 4 weeks after surgery onwards (fig 1). Only 3 patients reported some pain at 3 months. Hospital stay was not prolonged because of the bone graft procedure. The only complication was a case of lateral cutaneous nerve injury (3%).

Fig 1. Box and whisker plot of Visual Analogue Score at the iliac crest at each measurement point of the study The low complication rate and minimal pain levels supports the continued use of this procedure in this population. Level of evidence: II

BSCOS 2014 Aberdeen 25 2.05-2.15 THE POTENTIAL FOR MIS-INTERPRETATION OF TIBIAL-TUBERCLE-

TROCHLEAR-GROOVE DISTANCE FROM MODERN MRI SCANS Aarvold A, Pope A, Ayer RV, Sakthivel K Poole Hospital NHS Foundation Trust, Dorset University Hospital Southampton, Hampshire Purpose To assess whether the introduction of dedicated MRI knee coils for knee imaging has an effect on measurement of tibial-tubercle-trochlear-groove distance (TTD), compared to traditional CT scans or MR body coils. Methods and Results 32 knees (28 patients) had simultaneous knee MR scans performed in both a dedicated knee coil (which obligates partial flexion) and a body coil (which allows full knee extension, like a CT scan). Patients’ ages ranged from 10 to 27 years (mean 15 years). Mean TTD in the dedicated knee coil (partially flexed knee) was 11.3mm compared to 20.0mm in the body coil (that permits full knee extension). The mean difference was 8.6mm which was highly significant (p<0.0001, unpaired t-test). A normal TTD is usually referenced at <20mm, based on population studies performed on scans with the knee in full extension. Of the knees that recorded a TTD within the ‘normal’ range on the dedicated knee coil scans, 60% demonstrated a ‘pathological’ (≥20mm) TTD on the corresponding body coil images. Conclusion This study has identified a highly significant difference in TTD measurement when knees are scanned in an MR dedicated knee coil compared to a body coil. This is due to tibial internal rotation that occurs with normal knee flexion, which is how the knee lies in the dedicated knee coil. With the widespread use of such coils, it is critical for surgeons and radiologists managing patello-femoral instability to appreciate this profound difference. TTD measured on images taken in dedicated knee coils may have implications on patients being falsely re-assured or erroneously denied treatment. Level of evidence: II

26 BSCOS 2014 Aberdeen 2.15-2.25 THE EPIDEMIOLOGY OF TRANSIENT SYNOVITIS WITHIN MERSEYSIDE W. Harrison, A. Vooght, R. Singhal, C. Bruce, D. Perry Alder Hey Children’s Hospital, Liverpool, UK Purpose The epidemiology is poorly understood, and the aetiology is unknown, although a suggestion of a viral association predominates. This population-based study investigates the epidemiology, to formulate aetiological theories of pathogenesis. Methods Cases in Merseyside were identified between 2004-2009. 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 used to examine for trends. Results 259 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 of 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 of disease presentation, suggests a specific disease entity. 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 previous suggestion of an association with Perthes’ disease. This paper provides evidence to challenge existing aetiological theories, though transient synovitis remains an enigma. Level of Evidence: II

BSCOS 2014 Aberdeen 27 2.25-‐2.35 THE EFFECT OF SOCIAL DEPRIVATION ON PAEDIATRIC FRACTURES R.Ramaesh, N.Clement, L.Rennie, C.Court-Brown, M.Gaston Royal Hospital for Sick Children, Edinburgh, United Kingdom Purpose To examine the effect of social deprivation on incidence of fractures in childhood. Methods All paediatric fractures (aged less than 16) from three county districts in the South East of Scotland presenting to one hospital were collected between January 2000 and December 2000 using a prospective database. X-rays were checked by an independent reviewer to confirm the fracture and data was collated on epidemiology, type of fracture, mode of injury and post-code. Deprivation scores were calculated using the Scottish Index for Multiple Deprivation (SIMD). Spearman’s correlation was used to calculate the correlation between quintiles and odds ratios between the most affluent and least affluent and significance was calculated. Results There were a total of 2195 consecutive fractures presenting over a 12-month period. There was a significant correlation of deprivation with incidence of fractures (p = 0.0083, r = 1.00) - the most deprived children had rates of 2420/100,000/yr compared with the least deprived at 1775/100,000/yr. Deprivation was associated with an increased risk in most types of fractures including distal humerus, metacarpals and clavicle fractures. The mode of injury also showed variations between the most and least deprived. The poorest fifth of children are more likely to suffer injuries as a result of falls (OR =1.5, p<0.0001), blunt trauma (OR=1.5, P=0.026) and road traffic accidents (OR=2.7, p<0.0001) compared to the wealthiest fifth. Discussion – This study is the first to show that social deprivation is a significant risk factor for sustaining a fracture in childhood. This could be explained by the decreased availability of safety equipment and poor design of social housing or reduced supervision as well as inadequate access to safe-play areas or insufficient traffic calming measures in deprived areas. These findings have important implications for public health interventions and preventative measures, to reduce the overall fracture morbidity load. Level of evidence:

28 BSCOS 2014 Aberdeen 2.35-‐2.45 A NEW CLINICAL PREDICTION RULE FOR DIAGNOSING SEPTIC

ARTHRITIS OF THE HIP IN CHILDREN R Ramaesh, A D Duckworth, C D Russell, N D Clement, M S Gaston Royal Hospital for Sick Children, Edinburgh, United Kingdom Objectives: The primary aim was to describe factors associated with a diagnosis of septic arthritis (SA) and to construct clinical prediction rules that could aid the diagnose of a limping child requiring admission. The secondary aim was to independently validate previous clinical prediction rules used to diagnose SA. Methods: We performed a retrospective analysis of all SA and transient synovitis (TS) cases hospitalised over 6 years. Data was collected on clinical findings, blood tests and radiological imaging. Multivariate binary logistic regression analysis determined the significant predictors of true septic arthritis and ROC curves were used to define cut-off values for laboratory indices. Results: There were 22 (22.9%) confirmed septic arthritis. Using Kocher criteria, when all four factors were positive, the probability of infection was only 50%. On univariate analysis, a preceding infection (p=0.025), inability to weight bear (p<.001), elevated CRP (p<0.001), elevated ESR (p<0.001) and effusion on ultrasound (p=0.011) correlated with positive diagnosis for septic arthritis. Using ROC analysis, a CRP equal to or greater than 30 or an ESR equal to or greater than 40 were diagnostic. Using backwards-stepwise regression, the following equation was produced (R2=0.839) X = (6.254 if unable to weight bear) + (CRP*0.050) + (ESR*0.085) + (3.902 if positive effusion on ultrasound) – 13.38 Probability of septic arthritis (%) = ([ex] × 100)/(1 + ex) The probability of septic arthritis in a patient who is unable to weight bear, has a CRP 50, an ESR 50 and a positive effusion on ultrasound has a 97% probability of septic arthritis. Conclusion: We have identified factors associated with a true diagnosis of SA in children admitted to hospital with a suspected SA and produced a clinical prediction rule that could be used to facilitate the diagnosis of a limping child and avoid unnecessary investigation and hospitalisation of children with a benign limp. Level of evidence: III

BSCOS 2014 Aberdeen 29 2.45-‐2.55 DISPLACED SUPRACONDYLAR HUMERUS FRACTURES IN CHILDREN: A

MAJOR TRAUMA CENTRE EXPERIENCE AND PARENTAL OUTCOME ASSESSMENT.

A.Rehm, Z Alshameeri, K Stöhr. Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom Assessment of management of displaced supracondylar humerus fractures in children in a non-paediatric orthopaedic setting. Retrospective study of all displaced supracondylar humerus fractures in children managed between January 2005 and December 2012 in our institution. The fractures were classified according to the Wilkins modification of the Gartland classification. The radiographs and records of 147 children with 148 fractures (68 type IIb, 80 type III) were reviewed. Parents were sent a visual questionnaire asking about alignment, function and symptoms with a response rate of 65%. Eight children needed repeat manipulation, 2 children sustained an intra-operative ulnar nerve injury and one child developed a pin site infection. Based on post-operative radiographs 56 fractures (37.8%) had inadequate alignment or loss of reduction as defined in the literature. Inadequate radiological reduction was associated with the age of the child (p=0.035, t test) but not with the severity of the fracture (p=0.80), the seniority of the surgeon (p=0.10) or the configuration of K wire fixation (p=0.44). As judged by parental assessment, there were no statistically significant differences in movements or alignments between those who had adequate and inadequate radiological reduction; p=0.75 and p=0.8 respectively (fishers exact test). 24% of responding parents reported residual symptoms with 65% of those children having had an adequate post-operative reduction and 35% not. vi. Management of displaced supracondylar humerus fractures in children within a mixed adult and paediatric trauma service is associated with a high rate of inadequate radiological reductions. However, this did not correlate with residual symptoms and parental assessment of elbow function and alignment. Level of evidence: IV

30 BSCOS 2014 Aberdeen 2.55-3.05 TRANSPHYSEAL ACL RECONSTRUCTION IN THE ADOLESCENT- THE

RELATIVE TUNNEL SIZE AND EFFECT ON THE GROWING PHYSIS. L Mills, Y Jabbar, H Pananwala, Q Dao. The Childrens Hospital at Westmead, Sydney, Asutralia. Introduction: There are concerns regarding the consequences of an adult type transphyseal ACL reconstruction on the growing physis. Animal studies suggest that physeal injury greater than 7-9% has the potential to result in growth disturbance. There are no publications at present looking at the relative surface area of the ACL tunnel to the surface area of the physis in an adolescent ACL reconstruction. Aim: The aim of this prospective study was to look at the relative surface area of the tunnel as it crosses the physis and the potential physeal disturbance in an adolescent population who have undergone an adult type anatomical (transphyseal) ACL reconstruction. Method: 27 patients age 10.9-18 years were enrolled in the study prior to undergoing an ACL reconstruction with hamstring autograft. Data collected included preoperative MRI’s, CT scanograms, KT2000 measurements and quality of life data; a plain knee radiograph was taken 6/52 post-op. At one year post-op MRI, CTscanograms, KT2000 and quality of life data were again collected. On the MRI images the tibial physis and ACL tunnel surface areas were measured and a relative tunnel size was calculated. Results: 25 patients had transphyseal procedures (2 were extraphyseal and therefore excluded). The size of the tibial drill ranged from 7.5 to 9.0mm; the percentage surface area of the tibial ACL tunnel (relative to the physis) ranged between 0.8 and 5.6%. There was no correlation with the patient age or drill size used. The CT scanogram confirmed no leg length discrepancy or angular malalignment at one year. All patients with physeal closure during the study were bilateral and age appropriate. Conclusion: An ACL transphyseal tunnel is less than 7% and does not result in growth disturbance at one year. Level of evidence: II

BSCOS 2014 Aberdeen 31 3.05-‐3.15 CURRENT MANAGEMENT OF SLIPPED UPPER FEMORAL EPIPHYSIS IN

SCOTLAND: IS THERE A PLACE FOR CHANGE? S Dalgleish, DC Campbell, JGB MacLean Ninewells Hospital & Medical School, Dundee. Aim: To ascertain current practice in the management of adolescents presenting with SUFE in Scotland. The initial management of SUFE can determine the occurrence of longterm disability due to complications. Previous surveys have concentrated on orthopaedic surgeons with a specialist paediatric interest. In many units in Scotland, the initial responsibility for management may be an admitting trauma surgeon with a subspecialty interest other than paediatric orthopaedics. Method: All Orthopaedic surgeons in Scotland participating in acute admitting were invited to complete a web based survey on their initial management of SUFE.

Results: To date 86/116 (74%) of surgeons approached have responded. When faced with a severe stable slip 56% of respondents were happy to pin in situ whilst 44% would refer either to a colleague or specialist paediatric unit. With an unstable slip of similar magnitude 40% would self treat, 20% refer to a colleague and 40% refer to a paediatric orthopaedic unit. Of those treating, 56% stated their treatment was selected irrespective of timing of presentation. 78% of respondents had treated 5 or less cases in the preceding year with 7% more than 10 cases. Universal prophylactic pinning was supported in 29%, selective in 62% and never in 9%. Observation: The responses obtained confirm the variance in management of SUFE that exists amidst acute admitting units in Scotland. Management of a stable slip is uncontroversial except possibly in severe cases. This contrasts with the acute unstable slip, in which various factors are thought to influence the outcome. The relevance of instability and the issue of timing to treatment are not universally appreciated. Conclusion: That all unstable cases should be referred to or discussed with a paediatric orthopaedic surgeon at presentation. Level of Evidence: IV

32 BSCOS 2014 Aberdeen 3.15-3.25 DEMOGRAPHICS AND MANAGEMENT OF SLIPPED CAPITAL FEMORAL

EPIPHYSIS BETWEEN 2007 AND 2012-A Multicentre audit

F Bintcliffe1, S Thomas1, UK SCFE Collaborative, M Ramachandran2 Bristol Royal Hospital for Children, Bristol, UK The Royal London and St Bartholomew’s Hospitals, London, UK Introduction To inform a working group of UK paediatric surgeons (the UK SCFE Study Group) convened to design pertinent trials in slipped capital femoral epiphysis (SCFE), twelve centres across the UK (Alder Hay, Barts and The London, Birmingham, Bristol, Cardiff, Margate, Middlesbrough, Newcastle, Oswestry, Oxford, Reading, Swansea and Warwick) reviewed the demographics and management of children with SCFE presenting between 2007 and 2012. Objective: To investigation the demographics and management of patients with SCFE within the UK. Methods: At all contributing centres with digital PACS records for a minimum of 5 years, a search for the following terms was made of PACS reports: slipped capital femoral epiphysis, slipped upper femoral epiphysis, SCFE and SUFE. From the results, radiographs and electronically stored clinic letters were assessed to confirm the diagnosis and ascertain age at presentation, incidence of bilaterality, chronicity, stability (Loder criteria), management and complications. Results: A total of 601 SCFEs presented between 2007 and 2012 to the twelve units. The mean age at presentation was 12.5 years (range 7-17 years). The left hip was nearly twice as commonly involved compared to the right (R: L = 3.3: 5.1), with bilateral presentation in 22% of patients. The most common mode of presentation was acute-on-chronic. Stable slips were over twice as common as unstable. The most common intervention was percutaneous pinning in situ. Open reduction, osteotomy and stabilisation were required in 24% of cases. The most common complications were osteonecrosis (10.5%), screw migration/penetration, leg length discrepancy and symptomatic secondary cam with femoroacetabular impingement were also seen. Conclusion: This data concurs with earlier smaller audits and highlights current demographics and contemporary management of SCFE throughout the UK and informs the subject and content of potential future randomized control trials. Level of evidence: III

BSCOS 2014 Aberdeen 33 3.25-‐3.35 SLIPPED CAPITAL FEMORAL EPIPHYSIS: IS IT WORTH THE RISK AND

COST NOT TO OFFER PROPHYLACTIC FIXATION OF THE CONTRALATERAL HIP?

ND Clement, A Vats, MS Gaston, AW Murray Department of Orthopaedics and Trauma, Royal Hospital of Sick Children Edinburgh 9 Sciennes Road, Edinburgh, EH9 1LF, UK The aim of this study was to compare the complication rates, functional status, radiographic evidence of cam lesions and osteoarthritis in patients presenting with a unilateral SCFE that underwent prophylactic fixation of the contralateral hip with those who did not, and to perform a cost economic analysis. During a 10 year period 90 consecutive patients presented to the study centre with either unilateral or bilateral SCFE. The decision as to whether the contralateral hip was prophylactically fixed was at the discretion of the consultant in charge of that patients care. There were 56 males and 34 females with an average age of 12.3 years (range 9 to 16 years). Eight-six patients presented with unilateral SCFU and four had bilateral SCFE. Fifty patients had unilateral fixation and 40 had bilateral fixation, with 36 patients having a prophylactic screw fixation on the contralateral side (Figure).

The risk of complications was greater, the functional outcome according to joint specific (Oxford hip score) and generic measures (short form 12 score) was worse, and the rate of radiographic cam lesions were more prevalent for the contralateral hip in patients presenting with unilateral SCFE than those that underwent prophylactic fixation of their “unaffected hip”. Furthermore prophylactic fixation of the contralateral hip was revealed to be a cost effective procedure at the time of last follow-up (mean 8 years). When accounting for the cost of additional surgery associated with unilateral fixation the cost of prophylactic fixation was found to be £641 with an ultimate cost of £1,431 per QALY gained. This study suggests that the contralateral hip in patients presenting with unilateral SCFE should be routinely offered prophylactic fixation to avoid a further slip and the potential morbidity associated with a secondary cam lesion, and is a cost effective intervention. Level of evidence: III

34 BSCOS 2014 Aberdeen 3.35-3.45 THE TREATMENT OF SLIPPED CAPITAL FEMORAL EPIPHYSIS USING THE

HANSSON PIN H S Dabasia, P S Sauve, R H Richards Queen Alexandra Hospital, Portsmouth, UK Purpose: To determine the potential for remodeling following treatment of slipped capital femoral epiphysis (SCFE) using the Hansson pin; a cylindrical pin inserted in a drill hole which attaches to the femoral head via a hook. Method & Results: A retrospective study of consecutive SCFE presentations treated with a Hansson pin from June 2006 to 2013. The pre-treatment lateral epiphyseal shaft angle (p-LES) was measured and the Southwick angle was also calculated. The final lateral epiphyseal shaft angle (f-LES) was recorded at follow-up. The degree of remodeling was assessed from the difference between the p-LES and f-LES. A cohort for whom stabilisation was achieved using a screw was used for comparison. Fifteen patients underwent primary stabilisation with a Hansson pin. Three had bilateral involvement, thus a total of 18 SCFEs were treated. Prophylactic stabilisation of the contra-lateral hip was undertaken in 6 patients. The average follow up period was 19.1 months. The mean age at presentation was 12.9 years (range 8.7 to 15.5). The mean Southwick angle on presentation was 27.2 degrees (range 17 to 57), with 11 graded a mild slip and 7 a moderate slip. The mean p-LES and f-LES angles of the affected hip were 35.6 and 28.2 degrees, respectively. The average remodeling of the LES angle was 7.4 degrees (range 0 to 17.7). No remodeling of the LES angle was observed in the cohort treated with a screw. No chondrolysis or avascular necrosis was observed. Conclusion: We have experienced the Hansson pin to be a safe and reliable technique. In contrast to fixation with a screw, the femoral neck still retains the potential for longitudinal growth as ‘no threads’ cross the physis. This permits the potential for remodeling. Further investigation with a larger cohort of patients is needed to accurately determine this remodeling potential. Level of Evidence: IV


Local information Cashpoints There is a Bank of Scotland Cash point at the branch on High St – come out of the Conference venue and turn right along High St . There is a Clydesdale Cash point at the ‘Student Hub’ on Elphinestone Road – parallel to and directly behind High St. Taxis Comcab 01224 353535 Rainbow City 01224 878787 or 494949 Central 01224 890089 or 898989 Airport 01224 232426 Important: Demand frequently exceeds the supply of taxis in Aberdeen. If you really can’t wait you should pre-‐book! This is strongly advised for airport connections. Allow up to one hour to get to the airport and 40 minutes for the rail station at peak times. Nearest shops High Street – turn right after quad along High St from Conference venue

• Bakery • Café • Newsagent • Bookshop • Bank of Scotland

University Road – turn left after quad and then first left • Chemist

St Machar Drive – turn immediate right in front of Elphinestone and right again onto St Machar Drive

• Spar (including Post Office) Nearest Pubs St Machar Bar – turn right along High St

The Bobbin – turn left along High St, then left again down University Road – at end of road the pub is across King St

Nearest buses

No.20 runs from outside Kings Conference Centre every 15 minutes to central Aberdeen Buses on King St run frequently towards the city centre.

36 BSCOS 2014 Aberdeen Things to do locally

• Kings College Chapel – beautiful interior, home to Bishop Elphinestone’s remains -‐ well worth a look – often the side door into the small quadrangle is open, if not ask at the Sacrists office if you can be let in.

• King’s Museum – at the end of High Street in the ‘Auld Toon Hoose’ – rotating exhibits from the University’s huge collection. Look out for the old town gaol cell.

• New Library – across the campus, looks like a giant sugar cube – inside it has an exhibition area for the special collections and the glass lifts will take you to a great view at the top – just ask for a visitors pass at the reception desk.

• St Machar Cathedral – Along High Street, past the Auld Toon Hoose and along Chanonry – 12th Century cathedral – well worth a walk round.

• In the city centre the Art gallery and the Maritime Museum are the two

biggest (free) attractions.

• For those interested in WW1, the Gordon Highlanders Museum is best reached by taxi (about 15 mins away from the venue). It has some very interesting and sobering exhibits.

• The Beach ‘boulevard’ in Aberdeen has the usual Cineworld multiplex

cinema and windswept promenade for bracing walks with some cafés for warming up.

Further afield • Crathes Castle and Castle Fraser are both about 40 minutes drive from

Aberdeen and are well worth a visit. • Dunottar Castle near Stonehaven is a dramatic cliff top ruin for the

adventurous.

Shopping – there are retail parks nearby but nothing you won’t find in any city. For the serious shopper the city centre is the place

• Union Square – the newest indoor shopping centre – all the upmarket brands – Hollister, White Company etc etc

• Trinity Centre – across the road from Union Square – Debenhams and Waterstones amongst others.

• St Nicholas Centre – smaller shopping centre along Union Street (the main road in Aberdeen) – M&S

• Bon Accord Centre – large shopping centre close to St Nicholas Centre – all the usual shops – and John Lewis

• For boutique shops its outdoors – Thistle Street or Little Belmont Street where you will find ‘the Academy’ shopping centre near the Art Gallery


1 Zoology Building 2 Cruickshank Building 3 23 St Machar Drive 4 King’s Museum (Old Town House) 5 The Hub 6 St Mary’s 7 Fraser Noble Building 8 Elphinstone Road Halls 9 The Sir Duncan Rice Library10 Meston Building11 Chaplaincy Centre12 Confucius Institute13 Security Office/Mailroom14 Counselling Service15 Edward Wright Building16 Edward Wright Annexe17 MacRobert Building18 William Guild Building19 Arts Lecture Theatre20 Taylor Building21 Old Brewery 22 New King’s23 Regent Building24 University Office25 Elphinstone Hall26 Linklater Rooms27 King’s College Chapel28 King’s College Centre29 King’s College30 King’s Pavilion31 50-52 College Bounds32 Butchart Centre33 Crombie Annexe34 Crombie Halls35 Rocking Horse Nursery36 King’s Hall37 Powis Gate/Muslim Prayer Room38 Johnston Hall39 Humanity Annexe40 Humanity Manse41 Bedford Road Workshops42 Johnston Central Block

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Maps University – Old Aberdeen Campus

Elphinestone Hall – venue for Thursday 13th Kings College Centre – venue for Friday 14th


11/02/2014 15:00united kingdom - Google Maps

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Pre-conference information

Structure of meeting

13th March venue: Elphinestone

Catering

Session 1

Session 2

Session 3

14th March venue: Kings College

Catering

Session 4

Session 5

Session 6

Was there enough time for discussion?

Will anything change your practice? Y/N Anything you particularly liked? Anything you think could be done better? _________________________________________________________________ Did the meeting avoid undue commercial bias? Y/N Did you visit Industry stands? Y/N Were they helpful ? Y/N Appropriate? Y/N Please add any further comments or suggestions overleaf then leave at the registration desk.

40 BSCOS 2014 Aberdeen Reverse of feedback form – blank for comments:

programme bscos 2014...2.25-2.35 osseointegration of tutobone when used in lateral column...

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