Publications by authors named "Mark Flowers"

17 Publications

  • Page 1 of 1

What Can We Learn From COVID-19 Protocols With Regard to Management of Nonoperative Pediatric Orthopaedic Injuries?

J Pediatr Orthop 2021 Sep;41(8):e600-e604

Department of Trauma and Orthopaedics, Sheffield Children's NHS Foundation Trust, Sheffield Children's Hospital, Sheffield, UK.

Introduction: The COVID-19 pandemic has resulted in significant changes to normal practice in pediatric outpatient orthopaedics, with the instigation of telephone fracture clinic appointments, and the use of self-removable casting. We aim to determine any beneficial or detrimental short-term effects of these changes.

Methods: All patients referred to fracture clinic from the emergency department during the period March 24, 2020 to May 10, 2020 (national lockdown) were assessed for number of face to face and telephone appointments, number of radiographs performed, time to discharge, use of a removable cast, any cast complications, other complications, reattendance or re-referral after discharge. They were compared with patients referred in the same period in 2019. Follow-up was to 6 months for every patient.

Results: In 2019, 240 patients were reviewed and 110 in 2020. Changes in practice resulted in significant differences in the number of face to face appointments per patient [2 (1 to 6) 2019 vs. 1 (0 to 5) 2020 (P<0.00001)] and increase in telephone appointments [0 (0 to 1) 2019 vs. 1 (0 to 2) 2020]. Number of radiographs per patient [1 (1 to 7) 2019 vs. 1 (1 to ) 2020 (P=0.0178)] and time to discharge [29 d (0 to 483) 2019 vs. 16 d (0 to 216) 2020 (P<0.00001)] also reduced significantly. Use of a self-removable casting technique increased significantly (2.4% of casts in 2019 vs. 91.8% in 2020 (P<0.00001). There were no significant differences in complications related to cast or otherwise, unplanned attendance or reattendance after discharge. Use of self-removable casts for supracondylar fractures and for simple injuries (including distal radius, forearm, Toddler's, and ankle fractures) also demonstrated no change in complication rate. Significant potential cost savings of >£185 000 per annum could be demonstrated through clinic appointment and cast removal reductions.

Discussion: Changes to the normal management of pediatric orthopaedic trauma brought about by the COVID-19 pandemic have been demonstrated to be safe in the short term with no increase in complications demonstrated. Potential cost savings are possible both to the health care provider and also to the patient because of reduced hospital attendance. It is feasible to continue these practices for the potential benefits as they appear safe in the short term.

Level Of Evidence: Level III-therapeutic study-retrospective comparative study.
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September 2021

Paediatric orthopaedics in lockdown: A study on the effect of the SARS-Cov-2 pandemic on acute paediatric orthopaedics and trauma.

Bone Jt Open 2020 Jul 2;1(7):424-430. Epub 2020 Nov 2.

Department of Trauma and Orthopaedics, Sheffield Children's Hospital, Sheffield, United Kingdom.

Aims: To determine the impact of COVID-19 on orthopaediatric admissions and fracture clinics within a regional integrated care system (ICS).

Methods: A retrospective review was performed for all paediatric orthopaedic patients admitted across the region during the recent lockdown period (24 March 2020 to 10 May 2020) and the same period in 2019. Age, sex, mechanism, anatomical region, and treatment modality were compared, as were fracture clinic attendances within the receiving regional major trauma centre (MTC) between the two periods.

Results: Paediatric trauma admissions across the region fell by 33% (197 vs 132) with a proportional increase to 59% (n = 78) of admissions to the MTC during lockdown compared with 28.4% in 2019 (N = 56). There was a reduction in manipulation under anaesthetic (p = 0.015) and the use of Kirschner wires (K-wires) (p = 0.040) between the two time periods. The median time to surgery remained one day in both (2019 IQR 0 to 2; 2020 IQR 1 to 1). Supracondylar fractures were the most common reason for fracture clinic attendance (17.3%, n = 19) with a proportional increase of 108.4% vs 2019 (2019 n = 20; 2020 n = 19) (p = 0.007). While upper limb injuries and falls from play apparatus, equipment, or height remained the most common indications for admission, there was a reduction in sports injuries (p < 0.001) but an increase in lacerations (p = 0.031). Fracture clinic management changed with 67% (n = 40) of follow-up appointments via telephone and 69% (n = 65) of patients requiring cast immobilization treated with a 3M Soft Cast, enabling self-removal. The safeguarding team saw a 22% reduction in referrals (2019: n = 41, 2020: n = 32).

Conclusion: During this viral pandemic, the number of trauma cases decreased with a change in the mechanism of injury, median age of presentation, and an increase in referrals to the regional MTC. Adaptions in standard practice led to fewer MUA, and K-wire procedures being performed, more supracondylar fractures managed through clinic and an increase in the use of removable cast.Cite this article: 2020;1-7:424-430.
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July 2020

Outcomes of distally un-threaded screw fixation of slipped capital femoral epiphysis at skeletal maturity: a matched cohort study.

J Pediatr Orthop B 2020 Sep 11. Epub 2020 Sep 11.

Department of Orthopaedic, Sheffield Children's Hospital NHS Trust, Sheffield.

The most common treatment for slipped capital femoral epiphysis worldwide is in situ fixation with a threaded screw. Un-threaded screws are designed to prevent slip progression without hindering residual growth of the proximal femur. This study aimed to compare growth, remodelling and long-term outcomes after fixation with un-threaded screws and a matched cohort of patients treated with a standard screw. Six patients (nine hips) treated with un-threaded screws and 16 patients (21 hips) treated with standard screws matched for age, skeletal maturity, sex and Southwick angle were recruited. Clinical records were reviewed for patient demographics, medical history and complications. Radiographs were reviewed for residual growth and time to physeal closure. Growth velocity was calculated. Absence of cam deformity signified complete remodelling. Clinical assessment was graded from excellent to poor and patient-reported outcomes were recorded. There was significantly more growth recorded in the un-threaded screw group in femoral neck length (7.6 mm, P = 0.003), articulo-lesser trochanter distance (5.3 mm, P = 0.028), pin-joint ratio (7.439%, P = 0.006) and pin-physis ratio (8.244%, P = 0.001). The probability of revision operations due to ongoing growth was higher in this group (risk ratio: 6.57, P = 0.0008). Time to physeal closure was not significantly different, but growth velocity was significantly higher in the un-threaded group. The lower probability of cam deformity was not significant. Functional and clinical results were not significantly different at average 11.2 years' follow-up. Un-threaded screws allow for significantly more growth than standard threaded screws. The un-threaded screw could not be recommended due to the higher re-operation rates, without any proven benefit.
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September 2020

Comparison of Complication and Reoperation Rates for Minimally Invasive Versus Open Cheilectomy of the First Metatarsophalangeal Joint.

Foot Ankle Int 2020 01 6;41(1):31-36. Epub 2019 Sep 6.

Northern General Hospital, Sheffield, UK.

Background: Dorsal cheilectomy of the first metatarsophalangeal joint is an accepted treatment to alleviate dorsal impingement, pain, and reduced dorsiflexion in hallux rigidus. Traditionally performed via an open incision, this procedure has more recently been performed using minimally invasive techniques despite limited supportive published evidence.

Methods: From December 2012 through December 2017, a retrospective analysis of all cheilectomies performed in our institution was done. The surgical technique was recorded along with any subsequent procedures performed for either persistent or recurrent pain, and complications were also noted. A comparison between open and minimally invasive outcomes was performed. In total, 171 cheilectomies were performed during this period. There were 38 open and 133 minimally invasive procedures.

Results: At a mean 3-year follow-up, the reoperation rates of the 2 groups were different with only 1 (2.6%) of the open group requiring a fusion, while 17 (12.8%) of the minimally invasive surgical (MIS) group required further surgery (relative risk, 4.86; = .059). In the open group, there was 1 (2.6%) complication, compared with 15 (11.3%) in the minimally invasive group (relative risk, 4.29; = .076).

Conclusion: While patients may opt for MIS cheilectomy with a proposed faster recovery time and better cosmesis, they should be counseled about the risks and benefits of both methods, and that the technique of MIS cheilectomy utilized in this study appears to have an increased relative risk of requiring a further procedure.

Level Of Evidence: Level III, retrospective comparative series.
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January 2020

Scarf-Akin osteotomy for hallux valgus in juvenile and adolescent patients.

J Pediatr Orthop B 2015 Nov;24(6):535-40

Department of Trauma & Orthopaedics, Sheffield Children's NHS Trust, Sheffield, UK.

Hallux valgus (HV) has been reported to affect 22-36% of adolescents, with a recurrence rate of around 30-40%. Operative treatment may be indicated in symptomatic deformities where conservative management has failed to halt progression of the deformity. There remains genuine concern with respect to high complication rates including recurrence and stiffness of the metatarsophalangeal joint following operative treatment in adolescents. We report the clinical, functional and radiological outcomes of the Scarf-Akin procedure in the treatment of juvenile and adolescent HV. A review of single surgeon series was carried out of all children who underwent Scarf and Akin osteotomies as a combined procedure for HV between February 2001 and 2010. The preoperative and postoperative intermetatarsal angle (IMA1-2), hallux valgus angle, distal metatarsal articular angle and ratio of the length of first metatarsal to that of the second metatarsal were determined. The American Orthopaedic Foot and Ankle Score was used for functional assessment. Twenty-nine patients (47 feet) underwent Scarf-Akin osteotomies for moderate to severe HV. The average age of the patients at surgery was 11.7 years. The 6-week postoperative radiographs confirmed a significant improvement in the IMA, hallux valgus angle and distal metatarsal articular angle, in all the 47 feet, but 10 patients (14 feet, 29.8%) reported recurrence of hallux valgus at subsequent reviews. The radiological recurrence rate in our series was 29.8%, with 21.3% of patients symptomatic enough to require a revision operation. We report a high recurrence rate in hallux valgus operation in children and hence recommend postponement of correction until skeletal maturity.
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November 2015

Do we need to follow up an early normal ultrasound with a later plain radiograph in children with a family history of developmental dysplasia of the hip?

Eur J Orthop Surg Traumatol 2015 Oct 15;25(7):1171-5. Epub 2015 Jul 15.

Sheffield Children's Hospital, Western Bank, Sheffield, S10 2TH, UK.

Background: We routinely perform a pelvic radiograph between 6 and 12 months of age for children with a family history of developmental dysplasia of hip (DDH). We conducted this study to determine whether children with a family history of DDH and a normal hip ultrasound after birth require any further radiological follow-up.

Methods: We identified all children referred to our hip-screening clinic in a 3-year period between August 2008 and August 2011 with a family history of DDH and a normal hip ultrasound after birth. A total of 119 patients with a normal hip ultrasound after birth had a pelvic radiograph at a median age of 6.6 months.

Results: Six patients had residual dysplasia (acetabular index >30°) on the initial radiograph; five of these had resolved spontaneously by age 12 months, and the remaining patient had a normal radiograph at 21 months of age and was discharged.

Conclusion: We have found no cases of residual hip dysplasia requiring treatment in children with a family history of DDH and a normal hip ultrasound after birth. We have therefore changed our practice accordingly and no longer routinely followed up such cases.

Level Of Evidence: Diagnostic study, Level II.
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October 2015

A novel method for assessing postoperative femoral head reduction in developmental dysplasia of the hip.

J Child Orthop 2014 Aug 4;8(4):319-24. Epub 2014 Jul 4.

Department of Orthopaedics, Sheffield Children's Hospital, Western Bank, Sheffield, S10 2TH, UK.

Purpose: Developmental dysplasia of the hip (DDH) affects approximately 1 % of live births. Dislocated hips require reduction and stabilisation in a spica cast, and reduction efficacy is assessed radiologically. Numerous measurements are used to ascertain the adequacy of reduction but can be inconsistent in evaluating femoral head position. This study describes the morphology of the developing acetabulum in DDH and validates a novel method to assess adequate reduction of the dysplastic hip following closed or open reduction.

Methods: A retrospective review was performed of 66 consecutive patients undergoing reduction of hip dislocation over a 2-year period. Three independent reviewers evaluated postoperative CT scans to assess anterior-posterior (AP) displacement and modified Shenton's line. Acetabular morphology was also assessed along with hip congruency using a described novel 'posterior neck line'.

Results: Dislocated hips were successfully identified using the posterior neck line with a sensitivity of 0.71 and specificity of 0.88 giving a negative predictive value of 0.97. The interobserver reliability of this technique was higher in comparison against both (AP) displacement and modified Shenton's line.

Conclusions: We have shown a novel approach in assessing the acetabular morphology of DDH and a novel technique to accurately confirm the reduction of dislocated hips following open or closed reduction.
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August 2014

Medium term outcomes of planovalgus foot correction in children using a lateral column lengthening approach with additional procedures 'a la carte'.

Foot Ankle Surg 2014 Mar 7;20(1):26-9. Epub 2013 Sep 7.

Department of Paediatric Orthopaedic and Trauma Surgery, Sheffield Children's Hospital NHS Foundation Trust, Western Bank, Sheffield S10 2TH, UK. Electronic address:

Background: We report our medium term outcomes following surgery for symptomatic planovalgus malalignment in children. The technique we describe commences with lateral column lengthening and includes subsequent bony and soft tissue procedures which are carried out 'a la carte' in response to the underlying pathology and the behaviour of the foot to the lateral column lengthening.

Methods: Surgery was undertaken on twenty five symptomatic planovalgus feet in 15 patients at a mean age of 12 years and 6 months (5 years 7 months to 16 years and 3 months). The case-mix was principally idiopathic pes planovalgus but included overcorrected club foot and skewfoot deformity. Following lateral column lengthening (using a tricortical interpositional os calcis bone graft) the 'a la carte' elements of the surgery undertaken included both bony and soft tissue elements: heel shift; medial cuneiform osteotomy with iliac crest tricortical bone grafting, peroneus brevis/peroneus longus transfer; plantar fascia release; tibialis posterior advancement. VAS FA and AOFAS scores, clinical findings and complications were recorded.

Results: Twelve patients (20 feet) were available for follow up at a mean of 4 years and 6 months years (2 years and 8 months to 6 years and 3 months). VAS FA and AOFAS scores were 82±17 (50-99), 87±14 (61-100) and 80±10 (62-100), respectively. In all patients the reconstituted medial arch was maintained. Three patients (5 feet) required a second corrective procedure.

Conclusion: We propose lateral column lengthening with additional 'a la carte' procedures in the surgical treatment of symptomatic pes planovalgus in childhood as a reliable corrective surgical procedure on the basis of favourable medium term functional outcomes.
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March 2014

Complications of Elastic Stable Intramedullary Nailing for treating paediatric long bone fractures.

J Orthop 2013 26;10(1):17-24. Epub 2013 Feb 26.

Consultant Orthopaedic Surgeon, Sheffield Children's Hospital, Western Bank, Sheffield, United Kingdom.

This study reports the complications observed in children with long bone fractures treated using Elastic Stable Intramedullary Nailing (ESIN). One hundred and sixty-four (n = 164) fractures in 160 patients under the age of 16 years formed the basis of our review. This included 108 boys and 52 girls with the median age of 11 years and median follow up of 7.5 months. The analysis included fractures of the radius/ulna, humerus, femur and tibia. All pathological fractures were excluded. In this series 54 patients (34%) had complications however majority of these were minor complications with irritation due to prominent nail ends being the commonest complication. No long-term sequelae were encountered in our patients.
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January 2014

Proximal tibiofibular joint instability in a child: stabilization with Tightrope.

J Pediatr Orthop B 2013 Jul;22(4):363-6

Department of Paediatric Orthopaedics, Sheffield Childrens Hospital, Sheffield, UK.

Proximal tibiofibular instability is a rarely reported clinical entity in children. In this case report, we describe such a case in an 8-year-old boy successfully stabilized using a minimally invasive technique with a Tightrope device. The child remained pain free and asymptomatic at 2 years of follow-up. The surgical technique is described as well as potential complications and a review of the literature.
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July 2013

Complex primary arthrodesis of the first metatarsophalangeal joint after bone loss.

Foot Ankle Int 2011 Oct;32(10):968-72

Background: Complications associated with a failed Keller procedure or joint replacement include bone loss and shortening of the first ray. We treated failed Keller resection arthroplasty and joint replacement arthroplasty cases with metatarsophalangeal joint arthrodesis, using an interpositional tricortical autograft from the iliac crest and a low-profile titanium plate.

Methods: This was a retrospective case note review of the patients treated by four consultant surgeons in a university teaching hospital. A Keller procedure was considered to have failed when patients presented with a short, painful great toe with valgus cock-up deformity. Prosthetic joint replacements were considered to have failed based on the clinico-radiological loosening with associated pain. Metatarsophalangeal joint arthrodesis was carried out using an interpositional tricortical bone autograft and a titanium plate. Patients were assessed for resolution of pain, clinical and radiological evidence of fusion and complications. Ten operated feet in nine female patients, with a mean age of 55.9 (range, 37.8 to 80.2) years were followed for a mean of 12.6 (range, 6 to 26) months. Six patients presented with failed prosthetic joint replacements and four with failed Keller arthroplasty.

Results: Full clinicoradiological union was achieved in nine of the ten patients as judged by an independent consultant musculo-skeletal radiologist. Four patients needed removal of implants, one for infection, two for prominent hardware and one for implant failure. Eight of the ten patients were satisfied with the relief of pain.

Conclusion: Failed arthroplasty or Keller procedure is a difficult problem to manage. We recommend complex primary arthrodesis with an interpositional iliac crest autograft and a low profile plate as a salvage procedure.
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October 2011

Dorsal cortical comminution as a predictor of redisplacement of distal radius fractures in children.

Injury 2011 Feb;42(2):173-7

Sheffield Children’s Hospital, Sheffield, UK.

Background: The purpose of this study was to evaluate the various factors, which could contribute towards redisplacement of distal radius fractures, including comminution of the dorsal cortex of the distal radius, treated in our department.

Methods: In this retrospective study, we evaluated the risk of redisplacement of distal radius fractures in our department and also looked at the probable factors predisposing to this risk. A total of 134 fractures(129 children) were included in the study after exclusions. The variables that were assessed as possible causes of redisplacement were age, gender, fracture pattern (apex), degree of initial displacement,presence/absence of comminution, presence/absence of ulnar fracture, grade of surgeon, quality of initial reduction and Cast index.

Results: After excluding the fractures without a known outcome, 124 fractures (120 children) were available for analysis. The average age of children was 10.6 years (range 2–16 years) with more boys (89)than girls (31). Redisplacement after an initial reduction occurred in 30 children (24%). Six of these children(4.8% of the entire study group) required further intervention. The factors associated with an increased risk of redisplacement were complete initial displacement of fracture (p = 0.02),dorsal bayonet fracture pattern(p = 0.007), presence of comminution (p = 0.001) and the quality of the initial reduction (p = 0.002).Forward stepwise logistic regression analysis revealed comminution at the fracture site to be the most significant factor associated with redisplacement, increasing the odds of redisplacement by 5.82 (95%confidence interval (CI): 2.08–16.22, p = 0.001). There seemed to be a trend towards a reduced risk of redisplacement when K-wiring was done in the presence of comminution (p = 0.12).

Conclusion: The presence of dorsal cortical comminution at the fracture site on initial radiographs should alert the treating surgeon to a significantly higher risk of redisplacement and supplemental K-wiring should be considered in this situation.
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February 2011

Flexor digitorum longus tendon exposure for flatfoot reconstruction: A comparison of two methods in a cadaveric model.

Foot Ankle Surg 2010 Jun 18;16(2):87-90. Epub 2009 Aug 18.

Sheffield Teaching Hospitals Foundation Trust, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK.

Background: A novel method for harvesting the flexor digitorum longus (FDL) tendon has been described via a plantar approach based on a surface coordinate. The aim of this investigation is to provide a comparison with the traditional medial midfoot dissection for tendon harvest.

Methods: The FDL tendon was exposed in 10 cadaveric feet via a limited plantar approach and also medially as far as could be accessed via the knot of Henry. The FDL was marked with a metal clip in each approach. The lengths of the skin incisions were recorded and the distance between the two markers was measured.

Results: The mean additional length of tendon accessed via the plantar approach was 22.9 mm with a mean reduction in skin incision length of 15.6 mm.

Conclusion: Using the plantar exposure, a longer length of tendon can be obtained through a smaller skin incision which has been quantified here.
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June 2010

Closed reduction and stabilization of supracondylar fractures of the humerus in children: the crucial factor of surgical experience.

J Pediatr Orthop B 2010 Jul;19(4):298-303

Department of Paediatric Orthopaedics and Trauma Surgery, Sheffield Children's Hospital, UK.

We reviewed the outcome following operative management of displaced (Gartland II and III) supracondylar fractures of the humerus in children over a 2-year period and tried to correlate the outcome with various factors including experience of the treating surgeon. Of the 71 children who formed the study group, 62 (87.3%) had a good outcome irrespective of the treatment modality. Closed reduction followed by plaster immobilization or percutaneous pinning resulted in a better outcome than open reduction. There was a direct involvement of the consultant in the primary management of these injuries in 17 cases (24%), none of which had a poor outcome. Of the 54 cases in whom the primary management was carried out independently by trainees without any consultant supervision, nine patients (17%) developed complications or needed reoperations. The proportion of unsatisfactory outcomes increased to 20.3% when failure to achieve a satisfactory reduction by closed means was also considered as a perioperative complication. There is a learning curve associated with percutaneous pinning after closed reduction and experience of the surgeon seems to be one of the factors that have an influence on the outcome.
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July 2010

Overcorrection and generalized joint laxity in surgically treated congenital talipes equino-varus.

J Pediatr Orthop B 2006 Jul;15(4):273-7

Department of Orthopaedic Surgery, Sheffield Teaching Hospitals NHS Trust, Sheffield S10 2TH, UK.

Fifty patients with 70 previously operated clubfeet were assessed for overcorrection (using Tachdjian's flat foot grade) and generalized joint laxity. Twenty-eight patients (40 feet) had signs of generalized joint laxity using the Biro score and of these 25 feet were overcorrected. Of the 22 patients (30 feet) who did not have signs of joint laxity, only three overcorrected. This difference was statistically significant (P<0.001). A significant correlation exists between flat foot grade and laxity score (P<0.01). Overcorrection is a complication largely ignored in the published literature but we believe it is a serious complication of open release often resulting in poor long-term function. For those patients requiring surgery, the authors urge caution and recommend a limited surgical release, particularly if joint laxity is suspected, or the Ponseti method of treatment, which will probably avoid this complication.
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July 2006

Factors predicting the outcome of primary clubfoot surgery.

Can J Surg 2006 Apr;49(2):123-7

Hospital for Sick Children, Toronto, ON.

Background: We aimed to determine the rate of further surgery, the functional outcome and the factors associated with outcome after primary clubfoot surgery.

Method: We conducted a retrospective study of a cohort of all children who were less than 2 years of age at the time of surgery for idiopathic clubfoot deformity at the Hospital for Sick Children, Toronto, Ont., a tertiary care pediatric hospital. Of the 91 families who could be contacted, 63 agreed to return. The children's charts were reviewed, and their feet were given a Functional Rating System (FRS) score.

Results: Of the original operated population (n = 126), 75% were male and 41% had bilateral clubfoot. The average age at the time of surgery was 8 months, and the mean follow-up was 80.6 months. Further surgery was performed in 19% of cases. The mean FRS outcome score was 79. On average, the FRS score increased by 1.9 points as age at the time of surgery increased by 1 month. Only the presurgical talocalcaneal index was associated with the need for further surgery.

Conclusion: The need for further surgery was 19% overall. Children who had surgery closer to 12 months of age had better functional results. Therefore, surgery should probably be performed in the second, rather than the first, 6 months of life.
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April 2006

The development of a nurse-led outpatient orthopaedic clinic.

Nurs Times 2003 Sep 16-22;99(37):32-4

Harrogate District Hospital.

In the past 18 months nurses at the orthopaedic outpatients department at Harrogate District Hospital have radically transformed their roles by developing a nurse-led joint replacement follow-up clinic. This clinic, initiated in response to both local and national developments, has led to increased nurse autonomy as well as a demonstrable improvement in patient services.
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November 2003