BJJ Podcast with Specialty Editor for Children's Orthopaedics, Daniel Perry – highlights from the past year

Listen to Andrew Duckworth & our Children's Orthopaedics Editor, Daniel Perry, discuss four papers published in The Bone & Joint Journal.

Hip displacement and dislocation in a total population of children with cerebral palsy in Scotland

Surgical management of symptomatic osteonecrosis and utility of core decompression of the femoral head in young people with acute lymphoblastic leukaemia recruited into UKALL 2003

Quality of patient-reported outcomes used for quality of life, physical function, and functional capacity in trials of childhood fractures

Treatment of completely displaced distal radial fractures with a straight plaster or manipulation under anaesthesia 

Transcript

[00:00:00] Welcome everyone. I'm Andrew Duckworth and I'd like to thank you for joining us for our podcast for the month of April. We hope you're all keeping safe and well, as we all hope that brighter times are on the horizon in the months ahead. We also hope that you've enjoyed our podcasts so far this year. We kicked the year off with a great discussion on the effects of antibiotic-loaded bone cement on risk of revision, following hip and knee arthoplasty. And in February, we chatted about the latest trial from the WHiTE group that compared the X-bolt dynamic plating system and the sliding hip screw for fixation of trochanteric fractures of the hip. As always, we hope you're enjoying the content from the knowledge translation team here at The BJJ and that we are achieving our aim to improve the accessibility and visibility of the studies we published here at the journal. 

As part of this over the upcoming year, as some of you already know, we are producing special edition podcasts with our guests being the incredibly hardworking and invaluable specialty editors here at the journal. The aim of these will be to give our listeners an insight into the vital work they do at here at a journal, what they feel the current research trends are in their area, as well as highlighting some papers from the past year that we've published. 

We started these in March with a great session with Sam Oussedik, our specialty editor for knee. And today I have the [00:01:00] great pleasure of being joined by our fantastic specialty editor for children's  orthopaedics, Mr. Dan Perry. Welcome Dan, and thanks so much for joining us today. 

Thanks for having me Andrew.

So Dan, before we discuss the highlight papers, which you've kindly picked for us, I've just been asking you all, you know, 2020 was a strange and challenging year for all of us, so can you maybe give us a brief overview of your own insights, both with regards your clinical practice and Children's Orthopaedics, but also in your role as Specialty Editor here at The BJJ.

Yeah, I mean, what a year . I guess working in a children's hospital, so I work at Alder Hey and  Alder Hey is solely a children's hospital. So we've been quite protected relative to the rest of you guys. So I feel quite fortunate. We had a tiny spattering of COVID patients, so we admitted some adults into our hospital for the first time since the war so that kind of changed the dynamic a little bit in the hospital, but we only had at most, it was a handful of patients, a handful of adults, but that was enough to disrupt some services. Obviously, a lot of what we did still changed. So you know PPE and all of that stuff, you [00:02:00] know, but our elective capacity only, ever really dropped to about half. But we have carried on pretty much throughout and we've been at full pelt in terms of our elective work now for a good few months.

That's great. That's good to hear. Have you had much experience of, unfortunately, of COVID in any of your patients or any patients in the orthopaedic area? 

There's been a few children who have tested positive on our wards, but none have fortunately been sick. I think we've only had one child in a hospital who was being poorly with COVID. And that was , you know, a child who otherwise had other problems. But aside from that no,there is an occasional positive patient, but nothing that's concerning.

 Absolutely. One saving grace of this disease, isn't it? That the kids don't seem to be quite badly affected. And how about in terms of research in children's orthopaedics, I suppose, for yourself and in general. Has that been affected much by the pandemic in terms of, you know, maybe recruitment to trials or anything like that? 

Yeah, so  I have got quite a few trauma trials going on and the pandemic was certainly [00:03:00] not good for them, you know, trauma or trauma rates massively failed throughout COVID-19 and I know that was solid across the whole country and even across the whole world. We've had lots of submissions to document that to The Bone & Joint Journal, which I'm sure other people have spoken about. So that really impacted on recruitment and it wasn't just the fact that it was stopping recruitment because the children weren't there. But also the fact that nurses were being pulled away quite rightly to do other studies, you know, the NIHR who deliver all of my studies. NIHR who led the world in recovery, in the recovery trial and the other trials. And quite rightly the research nurses were pulled away to deliver that, that urgent public health research. But now my mission is very firmly to pull them back and start to do trauma trials again, because that hasn't stopped and that's not really slowed down. 

Do you feel that the tide is potentially turning with that done, do you think we are close to starting getting back to those things?

Yeah, I think so. And actually there were some good bits about [00:04:00] the pandemic and so it forced surgeons to think about what they were doing and forced them to think about the ways of treating fractures. And in many ways it opened people's eyes again to the old fashioned ways of treating fractures. And you may know one of my trials in particular is called the craft study and it's about offending distal radius fractures and a lot of surgeons before the pandemic wouldn't ever contemplate treating them non-operatively, but actually they were kind of forced to, and it's been really helpful for me in some ways and you can open people's eyes.

No, I think that's right. I think we've seen the same in an adult trauma. Maybe people have resettled a little bit and a lot of these things that we maybe have sort of fizzled out with time and you know,  non-operative management of these fractures sort of has taken over, but I think we have sort of reset our thinking and thinking maybe, maybe that is okay. And maybe that does work. And I think that's like you say that there's always a positives that come out of of difficult and adverse times like this. 

Before we move on to the highlight papers though, in terms of over the past year, maybe 18 months when things were [00:05:00] a bit more normal, what do you feel have been the main sort of themes and areas of research in the children orthopedic section, when you get to BISCOS or the journal itself? What's been the main things you've seen coming through.

   So I think there's always the typical topics from childrens orthopedics. There's always lots of deviates. There's always a spattering of *inadubile*. So there's always all of that. There's loads of enthusiasm around the world at the moment for trials, for trials in children's orthopedics. And that's both within the UK, but also within the US so there's a group called the IMPACT group who are trying to align a lot of what they're doing with the stuff that we're doing in the UK. And also our studies are starting to reach out now into New Zealand and Australia. So there's this big global effort now for delivering multicenter international research. So a lot of the stuff that's coming through is starting to feed into that and it's starting to bring together those big collaborative groups, because increasing that, that's, what's driving the world of research, these big collaboratives. So I guess that's the most exciting thing. And in the UK that started with a [00:06:00] study called BOSS, which was the British Orthopedic Surgery Surveillance study and we're just about to publish that now. So yeah, there's lots of good stuff going on. 

It does seem that as well with the pandemic, these sort of collaborations, they sort of have, if anything, got stronger haven't they? And they are drawing the world together with these things. really great to see, and a lot of the work, like you say, that you've been doing just dragging all these people together and creating some fantastic studies and some of which we'll come on to as well. That's that's really interesting. Do you feel, just before we move on to those papers Dan, has there been more of a shift towards trauma research in paediatrics, would you say? Do you think is trauma, getting more and more, shine on it?   

So trauma is getting quite a lot of shine on it at the moment. I think certainly within the UK, one of the reasons that trauma is getting  shine on it, well, so about in 2018, we published the research priorities for the British society of childrens orthopaedics and we listed some trauma research objectives and some elective research objectives. And I think the national Institute of health research in the UK who were the big funding body , I think they looked at the [00:07:00] trauma questions and saw that they or felt that they were more deliverable, easier to answer. And because we were a relatively research life group, they decided to focus their investment at the trauma to see if we can deliver it. And if we can deliver it, then they're going to extend that money elsewhere. Yeah. So, I think that's why trauma has got so much focus because it's kind of the low hanging fruit - you can deliver this look, hey, you can deliver the really big questions. And I think that's what it's about. 

That's really interesting. That's great. So, Dan, if we move on to some of the papers, you've really kindly picked for us. We've got four to discuss. So the first paper is actually from my colleagues here in Edinburgh. And the aim of that study was to compare the prevalence of hip displacement and dislocation, in a population of children with CP in Scotland before and after the initiation of a hip surveillance programme. And some of the background to this study is sort of related to some of the hip surveillance studies that have been set up in Scandinavian countries, such as Sweden, which they mention in their paper. So what made you pick this paper Dan? What was it you liked about this? [00:08:00] 

We spoke about this collaboratives and what difference collaboratives make and I think this is one of the really big successes of a collaborative that is going on at the moment. So obviously you mentioned that the cerebral palsy surveillance program started in Sweden and really James Rob and Mark Gaston really championed it in Scotland  and championed its development in Scotland. And I think it's been a huge success. But because, more than anything, it's got all the surgeons working together in a really systematic way, which you know, is really cool in itself before you've even got any results, the fact that they are following a protocol is cool.

Yeah. That's really good. That's really good. And it's quite amazing. The numbers from the Swedish one alone, they say in their introduction fell from 8% to 0.5% and they have seen similar improvements in terms of the introduction of their surveillance program.

Yeah. So it's roughly 50% reduction, displacement and dislocation. So that's pretty cool. So by reduction, that means that they're [00:09:00] intervening earlier . So that it doesn't  come to the severe effects or the severe end of the spectrum. So, I mean, I guess one of the criticisms that people may say is, well, actually you're still operating. You're just changing when you operate.  And you know, so does it truly make a difference, you know, is it better to do this active early intervention or is it better to, to be more reactive? And, we don't truly know the answer to that, but nevertheless, I think this is a really great study and, you know CPIPS, this cerebral palsy integrated examination system, it's very much spreading now  across the whole of the UK.  I know Steve Cook in Coventry's very much championing it in England. But it's going very much UK wide. 

That's interesting. And I think it's amazing, isn't it a big study like this? And like you say, there are limitations to it, like they discuss and you know, they're not really determining surgical protocol or anything like that, but it's the start, isn't it? And it's where things can sort of develop from really isn't it from this?

No. Absolutely. And, you know, I think increasingly there will be more and more [00:10:00] protocolized aspects of it. Yeah. But I think it's very much the start. 

That's great. That's great. So if we move on to the next paper Dan, we'll discuss, which is actually from the team in Leeds and similar lines in terms of collaboration and what you can do. And particularly, I suppose, answering difficult questions with rare conditions or rare problems. And they basically looked at determining the surgeries that are undertaken for osteonecrosis hip in patients, who've undergone treatment for AL, L or acute lymphoblastic leukemia. And they looked at timing of operations and subsequent procedures, and also looked at some of the sort of management options for it. Was it similar reasons, Dan, you found this interesting? I mean, I thought it was a really interesting paper actually. 

Yeah, so this group of patients they're so difficult, you know, they'll come to you in clinic and they've had such tough lives. At the end of all of their treatment, they have had loads of chemotherapy, loads of steroids, and the end of all of it they've got this horrible joint. And you look at them and you think, Oh my gosh, you know, what can I do for you? And you feel like [00:11:00] you have got no real idea what to do and people talk about core decompression, but when you've really got nothing to hang your hat on, whether you should or shouldn't do anything, and as you say this came from a really solid base, you know. It was from a big ALL study that ran across, you know, across the whole UK for a big time periods, 40 centers. So it was a really powerful, kind of really powerful study.  I kind of loved it from where it has come from him in a DELPHI study  very much championing the orthopaedic side of the scene in Leeds. 

Yeah, that's very interesting. I thought it was interesting, their results that suggested that core decompression of the femoral head doesn't seem to delay or improve the rates of femoral head revival. Was that what you sort of expected? And what, from your experience and the experience of others, does that sort of confirm that? 

Yeah, I think it does confirm my prejudice, which is why everyone likes a good paper, you know, if it confirms what you thought all along then, it's a good paper. So  I mean, I think it's quite powerful because you do look at those [00:12:00] children across from you in the clinic room and you're thinking, what can I do? I have to do something. And this is actually quite a powerful paper to say, look perhaps doing something isn't always the best thing, you know? It's like a huge proportion. So there were 85 kids they looked at with avastin necrosis. There were 93 operations, so huge amount of operations and you know, there were a huge proportion of them ended up getting total hip arthroplasty or total joint arthroplasty. 

Definitely. Definitely. It's very interesting. Isn't it? The numbers there are surprising. You know, it's just the amount of intervention that's there, but like you said, it's just the idea that maybe sometimes nothing might be a good thing to do for the patient. Do you think it is one of these situations as well, cause  it's such a relatively rare condition that  we can't really do a trial on it, but good data from studies we can use to sort of get some information about how to manage these rare conditions.

Yeah, I think it's just about getting the best data, you know, can we do a trial? I think a trial would be really hard to deliver.  But having said all of that, I guess if there's one group of patients who are going to be [00:13:00] able to do a rare disease trial, it's going to be cancer patients because the cancer networks so well set up and also there's quite a lot of funding around that for them.

Yeah. 

So while I don't think it's impossible, certainly on an international kind of multi-centre basis, I think it would be a really tough trial to deliver and certainly not one we're ready for yet. 

No, absolutely. Absolutely. That's great Dan. So if we move on to the last two papers and these are, we will sort of discuss these together, so I will just introduce them both briefly. So both papers are from our team in Nottingham and our good friend, Ben Olliveres group. And the first is a systematic review that looked at the quality of PROMs reports in childhood fracture trials, and sort of recommends outcomes and quality of life uses of the Cosmin standards and the other paper is from the same team. And that's sort of a retrospective study, which I am sure is very close to your heart because of the outcomes of surgical and nonsurgical management of fractures in children with at least two years of potential growth remaining. What was it about these two studies Dan that really caught your attention?

So we've talked about this increasing drive to [00:14:00] do proper multicentre research in childrens orthopaedics and and Ben Marson, who's the first author on both of these papers, he is doing a PhD very much to kind of drive what outcomes best. And a lot of people will read these papers and kind of not think, but perhaps not think they're overly interesting. But these, well certainly the outcomes paper, so the systematic view of what outcomes are used, it's very much understanding what the research process is and we as orthopaedic surgeons haven't necessarily been that engaged and able to understand what the research process is and the research process is to speak the language of the funders. And so the funders are NIHR, NIH in the US,  the Canadian or Australian funders, whoever it may be. They're generally not with orthopaedic surgeons. They don't care about orthopaedics. They've got no interest in what your disease is or what outcomes is. All they're going to do is look at a grant and on that grant they need really clear evidence as to why you've chosen the outcome you've chosen. [00:15:00] And it cant be just because it's your favorite outcome.

 So this that Ben's created is a really simple kind of a way for funders just to see that someone's reviewed the evidence properly, according to some really key guidelines, some well-recognized guidelines called the Cosmin guidelines. And he has said, look, you know, we've looked at all of the evidence for what's the best outcome in children's trauma and we cautiously recommend at the moment, either promise or the activity scale for kids. So, ASK. So I mean, it's not the biggest groundbreaking paper in the world, but in terms of communicating to funders and driving the next stage of research it's really, really key. And that's why I chose it. 

What's your sort of experience of PROMiSe so far, because obviously that does seem to be getting a lot of traction and a lot of potentially popularity. Do you think that is maybe the answer to not just for childrens orthopaedics, but for a lot of orthopaedics potentially? 

Yeah. So I like PROMiSe, I think is PROMiSe good. [00:16:00] So to have those who dont know it, I cant remember what PROMiSe stands for, I'm not sure I can remember what PROMiSe stands for, but PROMiSe is an NIHR measure. And I like PROMiSe because it's a computer adaptive test and what that means is that, so in kids, there's an upper limb score and there's a lower limb score which there's just not in anything else, kind of like no other specific scores in kids that are well validated and this is. So the kind of generation of it all was really properly well done. And there's a bank of about 30 questions for the upper limb and on average it asks eight questions in order to give a score. So it's kind of clever. So because it's all done online, if the kid answers, I can't do anything with my limb at all then it's not going to say, can you throw a javelin because that question's completely irrelevant. So it's kind of cool. So it gives you a score based on the previous question, it changes responses. So I kinda like it. I think it's cool. I think kids like it, there's a few questions that aren't necessarily relevant to [00:17:00] the UK audience, like lifting a pitcher for a joke. But we got permission from PROMISE to adapt that slightly and so that's what we're doing in our trials, but PROMISE features in all of the trials that I do. So CRAFFT, which we talked about or science, which is a media combo. 

I think, like you say, I think that one of the big things to my eyes, you know, nothing frustrates patients more than the having to answer a question like I'm struggling to walk and then you're asking questions about whether you can run five miles, you know, and that adaptive nature of it, I think is good for the patients isn't it? Cause it is less frustrating for them to fill in and it's a much more efficient way to get their outcome really. 

Yeah, no, absolutely. I think one of the concerns is that there may be some seeding effects. And I do think that's a concern, so certainly in the science trials. So my medial condyle study we also ask the sports and performing arts elements of dash. Patients told us that that kind of seemed right. So we asked that to submit to PROMISE. 

Yeah. Nice. That's great. So that leads on to the other study, which is again the [00:18:00] guys from Nottingham, which is looking at the treatment of completely displaced distal radius fractures with a *inaudible*, and this would be fair to say methodology a bit weaker than the other studies you've picked in terms of size, but really interesting study, I think all the same. 

Yeah. I mean, this feeds into, you know, this feeds into the pandemic and this feeds into people's fears, such surgeons fears about what they should do with these fractures. And so, there was a paper in the American Journal which was commenting on the crawford study which demonstrated that leaving these fractures alone these often distal radius fractures, that they remodel and they remodel beautifully in very little time at all. And you will take the cast off at six weeks on all the x-rays it will look bent and a bit wonky. The kids arm is amazing. It looks normal and the kids are like I dont understand what all the fuss is about. So there's been a kind of a creep internationally to treat these non-operatively. So I went to Gillette hospital just before the pandemic and I spoke to the guys there and this was kind of standard practice. And in Nottingham, it's [00:19:00] also been standard practice, so James Hunter who's the senior guy in Nottingham, changed his practice in order to offer this as standard care. And I think James who's actually also *inaudibe* in the UK has been the only kind of surgeon who's been promoting this as standard care. So it's really nice to see his outcomes, which of course are beautiful. I mean, his outcomes in, you know, of his practice over the last few years in the UK. So for that reason, I thought it was nice just to say to people, look, guys, this is cool. 

And like we say it's not starting the biggest series or anything, but that to me is the great thing in terms of it drives the equipoise isn't it? You know, people don't know the answer because that shows that you can do another thing non-operative management and they do very well. And that sort of questions all those missed that potentially are out there that people have maybe. 

Interesting Dan,  you just mentioned it, how'd you feel maybe in a different sort of healthcare system, maybe America, is that as well catching on over there in terms of this idea of non-emergent management of these completely off ended [00:20:00] fractures, are they accepting of that idea as well?

What's interesting is if anything, the US are far more ahead of us.  So there was a Posner RCT which was a relatively smaller RCT but it won the Posner prize a couple of years ago, after the Crawford study demonstrated how safe and effective this was. As I say, the guys from Gillette have kind of already adopted it in some of their practice and already across the US it's been just accepted. So if anything, it's us in the UK who are surprisingly more operative and aggressive in these. And also I know the Australians are quite aggressive as well. That's interesting because I would say probably in the adult trauma, it's maybe the other way round in terms of, you know, the aggression of operative management. 

That's fascinating. And I think that's it's a great paper that isn't that? And I think, like you say it's cool. It shows that this system works. 

And remodeling's amazing, isn't it? Like the whole of the remodeling thing, people just forget how cool it is. 

Yeah. Yeah, absolutely.

I think like you say it is just something we've just forgotten with time and actually was always there and it's [00:21:00] just being brought back into our attention really. And that's great. Isn't it? No, I totally agree. 

So I think introducing it through a trial, introducing it through a CRAFFT study its  a really kind of, it's a safe way to do it. And that's one of the great benefits of doing this big multicentre study and also the IMPACT group in the US they're just waiting to find out whether they've got funding for a trial in the US to do the same, same as CRAFFT across the US that they just got a lot more money for it. It's $7 million in the US instead of my $1.5 million. 

That's right. That's right. So just a bit before we finish up, I mean, we've touched on it already, but what do you think maybe challenges are ahead for research in your, in your area? What are the next big questions that you guys need to need to ask?

So I think one of the most powerful things I've ever published in The Bone & Joint Journal was our research priorities. And we laid out what our research priorities are and I mean, our key research priorities are related to well, I think the number one research priority was about [00:22:00] *inaudible*, whether we do a big formal dislocation of reduction or whether we pin it in sight in stable ones. And we've actually just got funding for that trial called the big BOSS study so *inaudible* funded that. I'm not sure I was meant to tell you, but oh well it's done now. And then there's a whole list of other priorities as well and Perthes disease, should we operate? Shouldn't we operate you know, there's lots of kind of tinkering going on around the world, but really we just need to bite the bullet and do the trial. 

And then I think the other big thing the children's orthopedic surgeons love and love to hate is DDH screening. And DDH screening is controversial throughout the world and it's done in different ways throughout the world. There's been some changes with the system in England recently, which has caused a little bit of controversy. But there just ultimately needs to be a DDH screening trial. Because that's the only way that it's going to put this whole process to bed. So, I'm really, really, really keen on that cause I do [00:23:00] think you know, a universal system of DDH screening will be good, but we've got to prove it is cost effective and the only way do it is through a trial. So, so that's my mission. 

Excellent. That's great. That's really interesting. I that's the great thing about the trials though. Isn't it? Is that when there is so much, well, maybe not uncertainty, but argument and that's where a trial comes in, because that means there is equipoise and people don't know. So that's a great reason for them. 

Absolutely. So childrens orthopaedics has been untouched by research pretty much so it's a great place to be at the moment. 

Yeah. 

I guess one of your only one of the only fears is where the money so funding body money will dry up. We've been very fortunate in childrens orthopaedics. We've got 10 million pounds of research in the last five years, so we're doing quite well, but I'm very conscious that the money's gonna be tight for governments around the world.

Absolutely. Well, I think that's all we have time for, but thank you so much. That was a really excellent overview of your area. A really fun and interesting discussion. So thanks so much for doing this and that was great. 

[00:24:00] You're welcome. 

And to our listeners, we do hope you've enjoyed joining us. Feel free to tweet or post about anything we've discussed here today. Thanks for listening everyone and take care.