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The question of operative management of post-traumatic deformity was queried in 13 cases, but the network advised operation in only nine cases, with five for realignment surgery. Three cases were referred out of the region: two complex malunions and one hip labral tear. Nine cases relating to infection were discussed: divided evenly between sequelae of septic arthritis and osteomyelitis Table 1. Further investigation was recommended for five cases, resulting in one diagnosis of juvenile rheumatoid arthritis and three patients were recommended an operation Table 1.

An infection-like presentation was seen in two children and these were subsequently referred to the paediatric rheumatologists.

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Patients and parents were informed that their case would be discussed and the outcome explained at their next clinic appointment. In general, the patients did not attend the meetings to minimise distress and the burden of travel. Two patients did attend a meeting, both with complex multilevel problems due to cerebral palsy and dysplasia and did not describe any distress, either at the meeting or subsequently to the local consultant.

After discussion with the network, of the 70 patients with complete documented follow-up, However, after the meeting only After the network meeting, the clinical outcome of treatment was reported back to the group as successful in There were 24 successful cases of non-operative treatment and 19 good results after one further operation. Some patients required further input from the network after the initial recommendation, including five good results achieved after two further operations.

Of these complex cases, 5. The consultant body chose patients for presentation for at least one of a variety of reasons Fig. Gaining a consensus opinion to confirm the local management plan was the most common reason, with the proposed local management being non-operative in The next most common reason was to receive new guidance to plan a new operative treatment locally In all, Another There was a mean average of 8. The most cases were presented by consultants within ten to 12 years of commencing their post Fig. Clinical networks are an effective mechanism for the integration of care, creating a climate of continual learning and development, and delivery of care as locally as possible for the patient.

There are few published data on this complex paediatric orthopaedic case-load, the interaction between secondary and tertiary care centres and their subsequent management. The data from this study of the network serve to highlight which conditions produce difficulties in clinical decision-making.

Pediatric Orthopaedics

Furthermore, it illustrates the impact of the meetings on the patient journey and why these cases need further discussion. The cases discussed were those which gave particular concern to the treating consultant and their distribution reflects the paediatric workload Fig. DDH was the most common condition discussed, with recurrent subluxation being the most common complication. Many of the cases discussed had presented beyond the at-risk screening programme.

The outcomes for later operative intervention are known to be less favourable 22 and it is consistent that these gave the network the most concern. In cases where there is concern regarding radiographic findings in asymptomatic children, the consensus was to observe. The rationale was that remodelling and physiotherapy would enable resolution of symptoms. Fewer cases of malignant bone tumours were discussed than might be expected for this large population, because of the well-established principle of managing these in national network of bone tumour centres.

The timely diagnosis and treatment of bone lesions is vital, 23 and after presentation to the network, one-third of these patients were promptly referred outside the South West region. The remaining patients with benign lesions did not need onward referral out of the region, because of the reassurance given by face-to-face discussion with senior colleagues. Thus, the network provides both confidence to the treating consultant and supports an appropriate and timely onward referral if required.

The incidence of paediatric fractures is approximately 20 per per annum 24 and complication rates can be high. The corrective effects of delayed healing and remodelling are well documented 27 and may account for this low rate of concern by the clinicians. The clinician's combined long-term experience of the benefit of waiting for remodelling is also reflected in the fact that realign-ment procedures were recommended to only five out of the 19 children.

Our study suggests that local systems successfully manage the vast majority of post-traumatic complications. Complications after paediatric bone and joint infection are not unusual and the difficult cases discussed reflect the literature. The network was also particularly useful for clarifying atypical causes of infection-like conditions and advising on further imaging and biopsy.


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Subsequently, the multidisciplinary team environment facilitated referral to rheumatology colleagues. Similarly, ruling out an infection in the context of an inflammatory arthropathy can be challenging 28 and the support of a body of consultant opinion can be useful in preventing unnecessary diagnostic procedures.

Trauma and Orthopedic Surgery in Clinical Practice

However, after discussion in the group and advice given to the local consultant, Overall, approximately three-quarters of those children with complete follow-up available had their entire treatment locally, following reassurance or advice from the network meeting Fig. Five out of the patients were advised by the group to see an out-of-region expert, thereby avoiding an unhelpful referral to the hub and expediting the referral pathway.

The outcomes of the cases have been audited to ensure good results are maintained 9 and to identify any concerns or areas for improvement. The results are discussed at subsequent meetings and thus the experience gained is shared through the network. Cases with poor outcomes did occur but were uncommon and ongoing cases, such as those who may require further procedures or network input, are re-discussed at subsequent meetings.

Consequently, the network has reduced the burden of travel for patients, expedited their treatment and provided a mechanism for re-discussion of unresolved issues by a panel of experts.

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Networks provide a means for communication between different healthcare providers and enable equitable access to services across geographical boundaries. The consultant network can provide clinical reassurance to the treating consultant and the patient, reflected in the fact that reassurance of the management plan was the most frequent cause for discussion. The clinician's habit of lifelong learning requires insight into areas for improvement aided by discussion with colleagues 31 and we found a trend for consultants reaching a decade of experience to raise more cases for discussion.

This might be explained by the progress of clinicians to a stage where they undertake more challenging cases. In addition, consultants with the most experience brought the majority of teaching cases, demonstrating the utility of the network in supporting the development of junior colleagues. The activity of this network demonstrates the potential for a regular, scheduled mechanism to gain second opinions, re-assurance and enable direct referrals. The network did not receive any specific funding and administrative costs were minimal.

Nevertheless, consultants and healthcare professionals who attended were not able to carry out other duties and these costs should be considered. Management of the cases which were discussed may have been delayed until the outcome of the meeting was known. However, this should be balanced against the benefit of the expert input given by the network. Additionally, the alternative would be to enter a waiting list for a referral to another consultant for a second opinion. Cases which required urgent management may therefore need discussion by another mechanism.

While various specialties were present at the meetings, few members of the wider multidisciplinary team attended. This may be as most discussions relate to potential operative intervention but wider participation could be beneficial to the debate. There is a potential bias to cases presented, particularly for teaching, with those with successful outcomes being presented.

Nevertheless, the network offered a confidential space to discuss difficulties. Models of care continue to evolve and managed clinical networks are best suited to specialties with a wide range of rare conditions with potentially serious complications. This paper describes an established clinical network in paediatric orthopaedics and highlights the potential benefits. The activity demonstrates the paediatric orthopaedic workload and areas contributing complex problems, with hip conditions contributing the most cases. It has enabled rapid referrals to national specialists or another specialty, thus reducing the time to treatment.

For the clinician, the network helped to confirm the management plan and provide reassurance.

This is also beneficial in the context of potential litigation. Consultants around the tenth year of practice presented the most cases, which may reflect career progression for taking on more complex cases, while the most senior surgeons brought the most cases for teaching.

Future development will include the evolution of pathways of care through the network which will contribute towards service commissioning. We recommend the implementation of regional networks for paediatric orthopaedic services. Subscribe to eTOC. Advanced Search. Toggle navigation.

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Subscribe Register Login. September - Volume 33 - Issue 9. Editor-in-Chief: Roy W. September - Volume 33 - Supplement 6. Periprosthetic Fractures of the Hip and Knee: With our elderly population living longer and staying more active, the number of patients undergoing total hip and knee arthroplasty continues to increase. A coinciding rise in periprosthetic fractures is also expected, and these clinical scenarios can be extremely challenging. In this case-based supplement, specific, common clinical scenarios are reviewed, along with salient technical pearls and pitfalls to avoid in the treatment of periprosthetic hip and knee fractures.

Publication support provided by DePuy Synthes. Published September Other Supplements. August - Volume 32 - Supplement 5. The articles in this supplement jointly address a fundamental aspect of care in patients undergoing surgery for hip fracture, postsurgical pain management. She then went on become a ward manager and completed an MSc.

Search Menu. Meet the Team. Karen Barnard Committee Member. Vikki Flynn Committee Member. Pamela Moore Committee Member.