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Papers by Peter Cundy

Journal of Children's Orthopaedics

Purpose: A common question faced by clinicians is when a child may return to sport after treatmen... more Purpose: A common question faced by clinicians is when a child may return to sport after treatment for a pediatric forearm fracture. There are few published recommendations and fewer supported by evidence. The aims of this study were to summarize existing published recommendation for return to sport after pediatric forearm fractures and to conduct a survey to determine usual clinical recommendations. Methods: A scoping review was performed on Ovid MEDLINE, Cochrane Central Register of Controlled Trials, Embase, Scopus, and Google Scholar in accordance with the Joanna Briggs Institute guidelines. In addition, 64 orthopedic surgeons were anonymously surveyed asking for recommendations regarding return to sport after pediatric forearm fractures. Participants were to assume children were 9 years old and played a sport with an average risk of forearm injury. Results: Twenty-two publications for return to sport were retrieved. Children with distal radius buckle fractures safely commonly r...

Journal of Pediatric Orthopaedics, 2021

Background: Several options for grafting exist; iliac crest bone grafting, allografts, and bone s... more 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 m...

JBI Database of Systematic Reviews and Implementation Reports, 2015

The objective of this review is to assess the effectiveness of selective thoracic fusion as a for... more The objective of this review is to assess the effectiveness of selective thoracic fusion as a form of treatment in adolescent idiopathic scoliosis (AIS). This will be compared with all other forms of operative management for major structural thoracic curves. Background Scoliosis is defined as a lateral curvature of the spine of at least 10 degrees, as measured by the Cobb angle. It can be categorized into three broad categoriesneuromuscular, congenital and idiopathic. Of these categories, idiopathic is by far the most common, and is a diagnosis of exclusion. Idiopathic scoliosis can then be further broken down into categories based on age of onset. Of these, AIS (children presenting at 10 years of age or older) accounts for 80-85% of cases. 1 Scoliosis curves have a proven complex deformity, consisting of a three-dimensional deformity involving the coronal, sagittal and rotational planes. Each curve (of which there may be many in one patient) can be described with an apex (the vertebra with the greatest lateral distance from the centre of the spine) and the two vertebrae at the end of the curve (named the end vertebrae). The Cobb angle, measured by the intersection of parallel lines from the endplates of the superior and inferior end vertebrae, is the standard way of quantifying the magnitude of scoliosis curves. Major or primary curves are the largest abnormal curves as classified by the Cobb angle. These curves are almost always structural. In addition, secondary or tertiary curves are described as structural if the Cobb angle cannot be reduced to under 25 degrees, on side bending radiographs. 2 Due to the permanent nature of physiological and morphological change of the vertebral bodies and ligaments, structural curves will usually progress as the patient matures, usually at 1 degree per year

Spine, 2010

Study Design. Case-control study. Objective. To determine whether serum metal ion levels and eryt... more Study Design. Case-control study. Objective. To determine whether serum metal ion levels and erythrocyte chromium levels in adolescents with stainless steel spinal instrumentation are elevated when compared with 2 control groups. Summary of Background Data. Instrumented spinal arthrodesis is a common procedure to correct scoliosis. The long-term consequences of retained implants are unclear. Possible toxic effects related to raised metal ion levels have been reported in the literature. Methods. Thirty patients who underwent posterior spinal arthrodesis with stainless steel instrumentation for scoliosis (group 1) were included. Minimum postoperative duration was 3 years. Serum chromium, molybdenum, iron, and ferritin levels were measured. Participants with elevated above normal serum chromium levels (n ϭ 11) also underwent erythrocyte chromium analysis. Comparisons were made with 2 control groups; 10 individuals with scoliosis with no spinal surgery (group 2) and 10 volunteers without scoliosis (group 3). All control group participants underwent serum and erythrocyte analysis. Results. Elevated above normal serum chromium levels were demonstrated in 11 of 30 (37%) group 1 participants. Elevated serum chromium levels were demonstrated in 0 of 10 participants (0%) in group 2 and 1 of 10 (10%) in group 3. There was a statistically significant elevation in serum chromium levels between group 1 and group 2 participants (P ϭ 0.001). There was no significant association between groups 1, 2, and 3 for serum molybdenum, iron, and ferritin levels. Erythrocyte chromium measurements were considered within the normal range for all participants tested (n ϭ 31). Conclusion. Raised serum chromium levels were detected in 37% of patients following instrumented spinal arthrodesis for correction of scoliosis. This new finding has relatively unknown health implications but potential mutagenic, teratogenic and carcinogenic sequelae. This is especially concerning with most scoliosis patients being adolescent females with their reproductive years ahead.

Journal of Pediatric Orthopaedics, 1989

Archives of Disease in Childhood - Fetal and Neonatal Edition, 2005

Background: Developmental dysplasia of the hip (DDH) is common, affecting 7.3 per 1000 births in ... more Background: Developmental dysplasia of the hip (DDH) is common, affecting 7.3 per 1000 births in South Australia. Clinical screening programmes exist to identify the condition early to gain the maximum benefit from early treatment. Although these screening programmes are effective, there are still cases that are missed. Previous research has highlighted key risk factors in the development of DDH. Objective: To compare the risk factors of cases of DDH identified late with those that were diagnosed early. Methods: A total of 1281 children with DDH born in 1988-1996 were identified from the South Australian Birth Defects Register. Hospital records of those who had surgery for DDH within 5 years of life were examined for diagnosis details. Twenty seven (2.1%) had been diagnosed at or after 3 months of age and were considered the late DDH cases (a prevalence of 0.15 per 1000 live births). Various factors were compared with early diagnosed DDH cases. Results: Female sex, vertex presentation, normal delivery, rural birth, and discharge from hospital less than 4 days after birth all significantly increased the risk of late diagnosis of DDH. Conclusions: The results show differences in the risk factors for early and late diagnosed DDH. Some known risk factors for DDH are in fact protective for late diagnosis. These results highlight the need for broad newborn population screening and continued vigilance and training in screening programmes.

Acta Orthopaedica Scandinavica, 1990

Acta Orthopaedica, 2005

Factors predicting redisplacement in the cast and early complications in distal radial physeal in... more Factors predicting redisplacement in the cast and early complications in distal radial physeal injuries have not been analyzed before. We analyzed 109 consecutive children with displaced physeal fractures of the distal radius treated by manipulation under anesthesia Acute carpal tunnel syndrome developed in 2 patients. Posttraumatic swelling necessitating trimming, splitting or removal of the primary circular cast occurred in one-sixth of the patients. Half of the fractures healed in malunion despite an anatomic primary reduction in 85% of the cases. According to logistic regression models, marked initial malposition of the fracture (< 50% displacement or < 20% angulation) was an independent risk factor for complications and redisplacement. Non-anatomic reduction of the fracture was an additional independent risk factor for redisplacement. The risk of an acute carpal tunnel syndrome should be remembered in patients with marked primary displacement of the fracture. To avoid redislocation, pin fixation of the fracture in patients close to skeletal maturity should be considered if there is a marked initial malposition of the fracture, or if fully anatomic reduction cannot be achieved.

Acta Orthopaedica Scandinavica, 1996

Aim We studied ‘hip health’ in a population-based cohort of adolescents and young adults with cer... more Aim We studied ‘hip health’ in a population-based cohort of adolescents and young adults with cerebral palsy to investigate associations between hip morphology, pain, and gross motor function. Method Ninety-eight young adults (65 males, 33 females) from the birth cohort were identified as having developed hip displacement (migration percentage >30) and were reviewed at a mean age of 18 years 10 months (range 15–24y). Hip morphology was classified using the Melbourne Cerebral Palsy Hip Classification Scale (MCPHCS). Severity and frequency of pain were recorded using Likert scales. Gross motor function was classified by the Gross Motor Function Classification System (GMFCS). Results Hip pain was reported in 72% of participants. Associations were found between pain scores and both hip morphology and GMFCS. Median pain severity score for MCPHCS grades 1 to 4 was 2 (interquartile range [IQR] 1.0–3.0) compared to 7 (IQR 6.0–8.0) for grades 5 and 6 (severe subluxation or dislocation). H...

Spine

STUDY DESIGN Prospective 2-year study with operative sampling and in-vitro analysis of chromium i... more 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 pre-operative, intra-operative and post-operative 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 eleven children undergoing posterior instrumentation for scoliosis. Administered drugs, cell-saver fluids and intra-operative 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 intra-operative chromium ions. RESULTS High chromium levels were detected in all samples from the wound irrigation fluid prior to insertion of metal implants. Immediate post-operative 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 intra-operative and early post-operative 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 intra-operative chromium ion load is suggested. Alternative electrosurgery electrode tips or other methods to coagulate during surgery could be considered. LEVEL OF EVIDENCE 2.

Journal of Children's Orthopaedics

Purpose This study was designed to evaluate the impact of the COVID-19 pandemic on paediatric ort... more 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% receiv...

SPINE

STUDY DESIGN spinal surgery cohort OBJECTIVE.: The authors assess the risk of cancer in children ... more 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 Standardised 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 to1.79). For females the SIR was 0.83 (95% CI 0.33 to 1.70) and for males the SIR was 1.33 (95% CI 0.36 to 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.

Journal of Paediatrics and Child Health

To compare trampoline injuries and injury costs sustained at a commercial trampoline park versus ... more 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.

BMJ open, Jan 29, 2018

Developmental dysplasia of the hip (DDH) affects 4-6 per 1000 live births in developed countries.... more Developmental dysplasia of the hip (DDH) affects 4-6 per 1000 live births in developed countries. Effective treatment to realign the hip is necessary to avoid long-term morbidities and maximise functional outcome. Treatment options depend on patient age but typically involve hip bracing and/or reduction under general anaesthetic. Some centres also employ prereduction hip traction. Historical papers suggest traction reduces risk of avascular necrosis (AVN) femoral head and reduces requirement for open reduction. However, several studies including a large retrospective cohort study, dispute this. We propose to perform the first systematic review and meta-analysis to clarify the value of prereduction hip traction in the management of DDH in children under the age of 3 years by identifying whether it impacts on the rate of successful closed reduction (CR) and risk of AVN. We will search MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials to identify potentially releva...

The Medical Journal of Australia

Modern digital radiological techniques include “stitching” together multiple x-ray images. This p... more Modern digital radiological techniques include “stitching” together multiple x-ray images. This provides one overall image of the area of interest, such as the entire spine or lower limbs, for deformity assessment. Dedicated software automatically combines separate exposures and allows for overlap. Image acquisition is rapid, minimising patient motion artefact and reducing distortion. However, if images are inappropriately put together (digitally stitched), stitching errors may occur with this computer-driven process. If not manually corrected by the radiology technician, the supplied image may hide pathology or give the false impression of abnormality. Four cases of digital stitching error have recently occurred in our tertiary referral paediatric hospital.

Spine, Jan 7, 2017

Systematic Review OBJECTIVE.: To determine the indications and outcomes for surgical treatment of... more Systematic Review OBJECTIVE.: To determine the indications and outcomes for surgical treatment of thoracolumbar kyphosis in patients with mucopolysaccharidoses (MPS) in order to define future studies. Improvements in the medical treatment of MPS have increased lifespan and improved quality of life for many patients, but with no effect on thoracolumbar kyphosis. A greater number of these challenging patients may now be considered spinal surgical candidates. In accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a PubMed database search was conducted using relevant keywords to identify articles describing MPS patients with thoracolumbar kyphosis treated surgically. Information was collected regarding demographics, indications for surgery, surgical details and outcomes. 16 articles describing 58 patients were included for review. The median age at surgery was 7 years (range 2.4 - 65 years) and median follow-up was 3.7 years (range...

ANZ journal of surgery, Jan 30, 2016

Mini C-arm image intensifiers (IIs) are promoted to permit lower radiation dose than traditional ... more Mini C-arm image intensifiers (IIs) are promoted to permit lower radiation dose than traditional IIs with a lower purchase price and without the need for a radiographer, saving time. In real-world usage, radiation dose is not always lower. A retrospective review of prospectively collected data for 620 children undergoing forearm fracture reduction in theatre was undertaken. Imaging was performed with the Fluoroscan mini C-arm or a comparison traditional II. Radiation dose and theatre time were recorded. There was no significant difference in radiation dose as measured by dose-area product (0.013 versus 0.014 Gy.cm(2) , P = 0.22). We noted an inverse association between operator experience and radiation dose. The mini C-arm allowed a shorter procedure time (26 versus 30 min, P < 0.001) and theatre time (13 versus 16 min, P < 0.001). Re-displacement rates were similar (1.3 versus 2.2%). The Fluoroscan is AU$120 000 cheaper to purchase and AU$35 283 cheaper to run per year than t...

Journal of Children's Orthopaedics

Purpose: A common question faced by clinicians is when a child may return to sport after treatmen... more Purpose: A common question faced by clinicians is when a child may return to sport after treatment for a pediatric forearm fracture. There are few published recommendations and fewer supported by evidence. The aims of this study were to summarize existing published recommendation for return to sport after pediatric forearm fractures and to conduct a survey to determine usual clinical recommendations. Methods: A scoping review was performed on Ovid MEDLINE, Cochrane Central Register of Controlled Trials, Embase, Scopus, and Google Scholar in accordance with the Joanna Briggs Institute guidelines. In addition, 64 orthopedic surgeons were anonymously surveyed asking for recommendations regarding return to sport after pediatric forearm fractures. Participants were to assume children were 9 years old and played a sport with an average risk of forearm injury. Results: Twenty-two publications for return to sport were retrieved. Children with distal radius buckle fractures safely commonly r...

Journal of Pediatric Orthopaedics, 2021

Background: Several options for grafting exist; iliac crest bone grafting, allografts, and bone s... more 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 m...

JBI Database of Systematic Reviews and Implementation Reports, 2015

The objective of this review is to assess the effectiveness of selective thoracic fusion as a for... more The objective of this review is to assess the effectiveness of selective thoracic fusion as a form of treatment in adolescent idiopathic scoliosis (AIS). This will be compared with all other forms of operative management for major structural thoracic curves. Background Scoliosis is defined as a lateral curvature of the spine of at least 10 degrees, as measured by the Cobb angle. It can be categorized into three broad categoriesneuromuscular, congenital and idiopathic. Of these categories, idiopathic is by far the most common, and is a diagnosis of exclusion. Idiopathic scoliosis can then be further broken down into categories based on age of onset. Of these, AIS (children presenting at 10 years of age or older) accounts for 80-85% of cases. 1 Scoliosis curves have a proven complex deformity, consisting of a three-dimensional deformity involving the coronal, sagittal and rotational planes. Each curve (of which there may be many in one patient) can be described with an apex (the vertebra with the greatest lateral distance from the centre of the spine) and the two vertebrae at the end of the curve (named the end vertebrae). The Cobb angle, measured by the intersection of parallel lines from the endplates of the superior and inferior end vertebrae, is the standard way of quantifying the magnitude of scoliosis curves. Major or primary curves are the largest abnormal curves as classified by the Cobb angle. These curves are almost always structural. In addition, secondary or tertiary curves are described as structural if the Cobb angle cannot be reduced to under 25 degrees, on side bending radiographs. 2 Due to the permanent nature of physiological and morphological change of the vertebral bodies and ligaments, structural curves will usually progress as the patient matures, usually at 1 degree per year

Spine, 2010

Study Design. Case-control study. Objective. To determine whether serum metal ion levels and eryt... more Study Design. Case-control study. Objective. To determine whether serum metal ion levels and erythrocyte chromium levels in adolescents with stainless steel spinal instrumentation are elevated when compared with 2 control groups. Summary of Background Data. Instrumented spinal arthrodesis is a common procedure to correct scoliosis. The long-term consequences of retained implants are unclear. Possible toxic effects related to raised metal ion levels have been reported in the literature. Methods. Thirty patients who underwent posterior spinal arthrodesis with stainless steel instrumentation for scoliosis (group 1) were included. Minimum postoperative duration was 3 years. Serum chromium, molybdenum, iron, and ferritin levels were measured. Participants with elevated above normal serum chromium levels (n ϭ 11) also underwent erythrocyte chromium analysis. Comparisons were made with 2 control groups; 10 individuals with scoliosis with no spinal surgery (group 2) and 10 volunteers without scoliosis (group 3). All control group participants underwent serum and erythrocyte analysis. Results. Elevated above normal serum chromium levels were demonstrated in 11 of 30 (37%) group 1 participants. Elevated serum chromium levels were demonstrated in 0 of 10 participants (0%) in group 2 and 1 of 10 (10%) in group 3. There was a statistically significant elevation in serum chromium levels between group 1 and group 2 participants (P ϭ 0.001). There was no significant association between groups 1, 2, and 3 for serum molybdenum, iron, and ferritin levels. Erythrocyte chromium measurements were considered within the normal range for all participants tested (n ϭ 31). Conclusion. Raised serum chromium levels were detected in 37% of patients following instrumented spinal arthrodesis for correction of scoliosis. This new finding has relatively unknown health implications but potential mutagenic, teratogenic and carcinogenic sequelae. This is especially concerning with most scoliosis patients being adolescent females with their reproductive years ahead.

Journal of Pediatric Orthopaedics, 1989

Archives of Disease in Childhood - Fetal and Neonatal Edition, 2005

Background: Developmental dysplasia of the hip (DDH) is common, affecting 7.3 per 1000 births in ... more Background: Developmental dysplasia of the hip (DDH) is common, affecting 7.3 per 1000 births in South Australia. Clinical screening programmes exist to identify the condition early to gain the maximum benefit from early treatment. Although these screening programmes are effective, there are still cases that are missed. Previous research has highlighted key risk factors in the development of DDH. Objective: To compare the risk factors of cases of DDH identified late with those that were diagnosed early. Methods: A total of 1281 children with DDH born in 1988-1996 were identified from the South Australian Birth Defects Register. Hospital records of those who had surgery for DDH within 5 years of life were examined for diagnosis details. Twenty seven (2.1%) had been diagnosed at or after 3 months of age and were considered the late DDH cases (a prevalence of 0.15 per 1000 live births). Various factors were compared with early diagnosed DDH cases. Results: Female sex, vertex presentation, normal delivery, rural birth, and discharge from hospital less than 4 days after birth all significantly increased the risk of late diagnosis of DDH. Conclusions: The results show differences in the risk factors for early and late diagnosed DDH. Some known risk factors for DDH are in fact protective for late diagnosis. These results highlight the need for broad newborn population screening and continued vigilance and training in screening programmes.

Acta Orthopaedica Scandinavica, 1990

Acta Orthopaedica, 2005

Factors predicting redisplacement in the cast and early complications in distal radial physeal in... more Factors predicting redisplacement in the cast and early complications in distal radial physeal injuries have not been analyzed before. We analyzed 109 consecutive children with displaced physeal fractures of the distal radius treated by manipulation under anesthesia Acute carpal tunnel syndrome developed in 2 patients. Posttraumatic swelling necessitating trimming, splitting or removal of the primary circular cast occurred in one-sixth of the patients. Half of the fractures healed in malunion despite an anatomic primary reduction in 85% of the cases. According to logistic regression models, marked initial malposition of the fracture (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 50% displacement or &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 20% angulation) was an independent risk factor for complications and redisplacement. Non-anatomic reduction of the fracture was an additional independent risk factor for redisplacement. The risk of an acute carpal tunnel syndrome should be remembered in patients with marked primary displacement of the fracture. To avoid redislocation, pin fixation of the fracture in patients close to skeletal maturity should be considered if there is a marked initial malposition of the fracture, or if fully anatomic reduction cannot be achieved.

Acta Orthopaedica Scandinavica, 1996

Aim We studied ‘hip health’ in a population-based cohort of adolescents and young adults with cer... more Aim We studied ‘hip health’ in a population-based cohort of adolescents and young adults with cerebral palsy to investigate associations between hip morphology, pain, and gross motor function. Method Ninety-eight young adults (65 males, 33 females) from the birth cohort were identified as having developed hip displacement (migration percentage >30) and were reviewed at a mean age of 18 years 10 months (range 15–24y). Hip morphology was classified using the Melbourne Cerebral Palsy Hip Classification Scale (MCPHCS). Severity and frequency of pain were recorded using Likert scales. Gross motor function was classified by the Gross Motor Function Classification System (GMFCS). Results Hip pain was reported in 72% of participants. Associations were found between pain scores and both hip morphology and GMFCS. Median pain severity score for MCPHCS grades 1 to 4 was 2 (interquartile range [IQR] 1.0–3.0) compared to 7 (IQR 6.0–8.0) for grades 5 and 6 (severe subluxation or dislocation). H...

Spine

STUDY DESIGN Prospective 2-year study with operative sampling and in-vitro analysis of chromium i... more 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 pre-operative, intra-operative and post-operative 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 eleven children undergoing posterior instrumentation for scoliosis. Administered drugs, cell-saver fluids and intra-operative 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 intra-operative chromium ions. RESULTS High chromium levels were detected in all samples from the wound irrigation fluid prior to insertion of metal implants. Immediate post-operative 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 intra-operative and early post-operative 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 intra-operative chromium ion load is suggested. Alternative electrosurgery electrode tips or other methods to coagulate during surgery could be considered. LEVEL OF EVIDENCE 2.

Journal of Children's Orthopaedics

Purpose This study was designed to evaluate the impact of the COVID-19 pandemic on paediatric ort... more 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% receiv...

SPINE

STUDY DESIGN spinal surgery cohort OBJECTIVE.: The authors assess the risk of cancer in children ... more 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 Standardised 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 to1.79). For females the SIR was 0.83 (95% CI 0.33 to 1.70) and for males the SIR was 1.33 (95% CI 0.36 to 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.

Journal of Paediatrics and Child Health

To compare trampoline injuries and injury costs sustained at a commercial trampoline park versus ... more 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.

BMJ open, Jan 29, 2018

Developmental dysplasia of the hip (DDH) affects 4-6 per 1000 live births in developed countries.... more Developmental dysplasia of the hip (DDH) affects 4-6 per 1000 live births in developed countries. Effective treatment to realign the hip is necessary to avoid long-term morbidities and maximise functional outcome. Treatment options depend on patient age but typically involve hip bracing and/or reduction under general anaesthetic. Some centres also employ prereduction hip traction. Historical papers suggest traction reduces risk of avascular necrosis (AVN) femoral head and reduces requirement for open reduction. However, several studies including a large retrospective cohort study, dispute this. We propose to perform the first systematic review and meta-analysis to clarify the value of prereduction hip traction in the management of DDH in children under the age of 3 years by identifying whether it impacts on the rate of successful closed reduction (CR) and risk of AVN. We will search MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials to identify potentially releva...

The Medical Journal of Australia

Modern digital radiological techniques include “stitching” together multiple x-ray images. This p... more Modern digital radiological techniques include “stitching” together multiple x-ray images. This provides one overall image of the area of interest, such as the entire spine or lower limbs, for deformity assessment. Dedicated software automatically combines separate exposures and allows for overlap. Image acquisition is rapid, minimising patient motion artefact and reducing distortion. However, if images are inappropriately put together (digitally stitched), stitching errors may occur with this computer-driven process. If not manually corrected by the radiology technician, the supplied image may hide pathology or give the false impression of abnormality. Four cases of digital stitching error have recently occurred in our tertiary referral paediatric hospital.

Spine, Jan 7, 2017

Systematic Review OBJECTIVE.: To determine the indications and outcomes for surgical treatment of... more Systematic Review OBJECTIVE.: To determine the indications and outcomes for surgical treatment of thoracolumbar kyphosis in patients with mucopolysaccharidoses (MPS) in order to define future studies. Improvements in the medical treatment of MPS have increased lifespan and improved quality of life for many patients, but with no effect on thoracolumbar kyphosis. A greater number of these challenging patients may now be considered spinal surgical candidates. In accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a PubMed database search was conducted using relevant keywords to identify articles describing MPS patients with thoracolumbar kyphosis treated surgically. Information was collected regarding demographics, indications for surgery, surgical details and outcomes. 16 articles describing 58 patients were included for review. The median age at surgery was 7 years (range 2.4 - 65 years) and median follow-up was 3.7 years (range...

ANZ journal of surgery, Jan 30, 2016

Mini C-arm image intensifiers (IIs) are promoted to permit lower radiation dose than traditional ... more Mini C-arm image intensifiers (IIs) are promoted to permit lower radiation dose than traditional IIs with a lower purchase price and without the need for a radiographer, saving time. In real-world usage, radiation dose is not always lower. A retrospective review of prospectively collected data for 620 children undergoing forearm fracture reduction in theatre was undertaken. Imaging was performed with the Fluoroscan mini C-arm or a comparison traditional II. Radiation dose and theatre time were recorded. There was no significant difference in radiation dose as measured by dose-area product (0.013 versus 0.014 Gy.cm(2) , P = 0.22). We noted an inverse association between operator experience and radiation dose. The mini C-arm allowed a shorter procedure time (26 versus 30 min, P < 0.001) and theatre time (13 versus 16 min, P < 0.001). Re-displacement rates were similar (1.3 versus 2.2%). The Fluoroscan is AU$120 000 cheaper to purchase and AU$35 283 cheaper to run per year than t...