News for general practitioners | May 2016

Perthes disease and slipped upper femoral epiphysis (SUFE) – what’s new in 2016?

First described around 1910 independently be three surgeons, Legg, Calve and Perthes, it was perhaps Waldenstrom who should be credited with the majority of the early work into this curious condition. Over one hundred years on today, it’s exact aetiology remains unknown and the various treatment options are often hotly debated in paediatric orthopaedic meetings around the world.

What is known in the UK is that the incidence seems to be on the decline, with 1 in 10,000 new cases per year. More common in boys (x4), it typically presents between 4 and 8 years of age and tends to more common in active children.

A vascular insult to all, or part of the femoral head causes osteonecrosis, which with mechanical load is followed by collapse and fragmentation.

Over time the blood supply will reconstitute to the area and reossification is then followed by remodelling. This whole pathological and healing process can take from 18 months to 2 years.

Children usually present with a painless limp, but symptoms can fluctuate and be very subtle, (mild thigh or knee ache). Any child with reduced range of movement of the hip, particularly internal rotation should be sent for plain X ray’s.

There are numerous classification systems available which suggests not one is superior or used universally to guide management.

Treatment goals include pain relief, (analgesics, anti-inflammatories and activity restriction) maintaining range of motion (physiotherapy and/or hydrotherapy) and containment of the femoral head within the acetabulum (via femoral or pelvic osteotomies) The ultimate aim is a round head in a round socket at skeletal maturity, so that the risk of early arthritis and need for total hip replacement is minimised.

At present there remains no good randomised controlled trials (RCTs) of current treatments to guide best practice.

SUFE remains a challenging condition to treat. The terminology is actually misleading, as it’s actually the metaphysis (neck) that slips, as the epiphysis maintains its normal anatomical relationship within the acetabulum.

Unlike Perthes the incidence of SUFE is almost certainly on the increase, most likely related to increasing childhood obesity, not only in the UK but worldwide.

The overall incidence is slightly less, however it’s still more common in boys than girls.

The exact cause of SUFE usually is unknown but most likely is multifactorial with mechanical, hormonal and genetic factors all playing a role in its development.

Clinical symptoms like Perthes can be often subtle and diagnosis, unfortunately can be delayed. Examination findings reveal an externally rotated foot position and again limitation or pain with internal rotation. A frog lateral pelvic x-ray remains the gold standard in diagnosis.

Perthes disease, a hip disorder in children, is defined as idiopathic avascular necrosis of the capital femoral epiphysis.

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Over the past 20 or so years, there have been many advances in the fields of gastroenterology and hepatology. These include the discovery and now cure of hepatitis C and the use of biologic therapy in inflammatory bowel disease which has been life changing for many.

enquiries@circlereading.co.uk | circlereading.co.uk | facebook.com/CircleReadingUseful numbers: General enquiries: 0118 922 6888

SUFE is generally classified into its stability (the ability to weight bear through the affected side) and it’s chronicity. Avascular necrosis remains the most terrible and devastating complication of this condition. Adolescents with unstable slips, of the more acute nature are most at risk.

Traditionally treatment after diagnosis, has involved in situ

screw fixation of the slip to prevent further slip and then, depending on remodelling potential the possibility of a late subtrochanteric osteotomy to tackle residual deformity.

More recently, there has been real interest in a more aggressive surgical approach, reducing the slip via an open dislocation of the hip and carefully preserving the blood supply. This acute

subcapital realignment osteotomy and fixation, restores near anatomical relationships at the outset. The technique has received mixed reviews in the paediatric orthopaedic world. Here in Reading, we have developed a niche specialist centre and have a small cohort of 10 patients who have undergone this procedure, with the vast majority showing excellent results.

The BOSS study (British Orthopaedic surgery surveillance study) is an exciting new development in the field of paediatric orthopaedics and is being led by Dan Perry and his research team from the University of Liverpool. It’s an all inclusive, nationwide reporting

mechanism to determine the true epidemiology and present outcomes in rare orthopaedic diseases. The idea is to gather valuable information on different cohorts of patients starting with Perthes and SUFE to enable better understanding of these conditions, and to inform the development of RCTs. In Reading we are recruiting all our hip patients into this and value your help in educating patients and parents into why this work is so important. For more information please see www.boss.surgery.

If you would like Mr Davies to visit your practice to talk about children’s hips or any other area of paediatric orthopaedics, please contact Julie Deadfield.

What has also changed is the patients’ attitude to health and disease. When I was a doctor in training the patient accepted what a specialist said, almost without question. In those days,

the patient was not involved in any decisions, and “trust me, I’m a doctor” could lead to poor outcomes.

A lot has changed. We now have a local population who have access to unlimited information and opinion via the Internet. This can be an advantage, once a firm diagnosis has been made. There are numerous disease specific websites that are hugely informative and supportive, such as Crohn’s and Colitis UK and the Coeliac Society. However, anyone reading this will also

curse websites such as Wrong Diagnosis, which makes Rocky Mountain Spotted fever a real possibility in the South East of England, if it is to be believed.

So – what do patients want? They want the time for someone to listen to their problems. They want someone to look at the whole problem and put it into a context and they want to be relieved of their health worries, and if there is something seriously amiss they want a diagnosis made in a timely manner, and with compassion and they want to

be involved in any management plans.

What do GPs want? They want access to secondary care for their patients again in a timely manner. They want a sound opinion and a management plan for the future.

What do specialists want? They, like all healthcare professionals, want to do a good job for their patients, and fulfil the needs of both the patient and the GP if it is possible. That’s certainly what I have always tried to do.

What patients want.What GPs want.What hospital doctors want.

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Dear colleague,

I’d like to take this opportunity to introduce myself as the newly appointed General Manager at CircleReading hospital. My entire career has been spent in UK healthcare, firstly in the NHS, and for the last 17 years

in the independent sector. I am not totally new to the area, having run a hospital in Wexham for a number of years, so I may have had the pleasure of meeting some of you previously.

I’ve already been struck by the passion for excellence shown by the team here at CircleReading, and their total commitment to individual, personalised care for our patients. We are continually striving for improvement however, and as such I would be very happy to receive feedback from you or your practice team on the services we offer, and suggestions on how we could do better going forwards.

Please do not hesitate to contact me personally at paula.naylor@circlereading.co.uk.

Note from Paula, General Manager

It has been a while since my last newsletter and a very busy time. We have hosted many successful events over the last few months; Sports Injury Management here at CircleReading in our Atrium, Educational curry night at a local restaurant in Finchampstead, e-Referral (formerly Choose and Book) workshops and regular monthly basic life support (BLS) training training for GPs.

Forthcoming educational events will be announced with dates shortly, we have planned a gastroenterology evening with guest speakers Margaret Myszor, Nisch Chandra and Jonathan Booth. Before the end of the summer we, have planned a gynaecology/well woman event with our team of consultant gynaecologists; Kevin Smith, Rajee Vijayanand, Alex Swanton and Bill Kuteesa.

Please also remember that our consultants are happy to come along and present with an hour’s educational talk at any of your GP practices, training improving patient services, or CCG meetings – please let me know if you have not yet seen my educational talks brochure, with all topics and speakers listed. Lunch and equipment is provided by me.

Finally can I remind you of our FREE monthly BLS training sessions for GPs, which are hosted at CircleReading hospital from 7–9pm. Hot food is served on arrival and certificates given on the evening. This training includes adult and paediatric BLS. Dates are published on our website, but please do reserve your place with me as soon as possible, as the slots are going fast!

For more information, please email julie.deadfield@circlereading.co.uk or call her on 07734 464227.

GP liaison updateJulie Deadfield

CircleReading hospital is pleased to offer a new satellite clinic at Nettlebed GP Surgery. The new clinic offers both physiotherapy and consultant surgeon services to the door of local people.

Circle’s specialist physiotherapists are experts in movement and function and will help their patients manage a variety of healthcare conditions. They offer specialist knowledge in a range of musculoskeletal and orthopaedic conditions – neck/low back pain, tennis/golfers elbow, wrist/hand pain, and

shoulder impingement, for example – and utilise cutting edge technology, such as extracorporeal shockwave therapy and isokinetic muscle testing, to provide their patients with the best possible outcome.

All patients attending the physiotherapy clinic will be given an initial one-hour appointment to assess the problem and provide treatment. This will be followed by 30-minute appointments. If patients require access to further diagnostic tests or consultant appointments,

the physiotherapist can offer rapid access to these advanced diagnostic services.

The new physiotherapy service will be available between the hours of 8.30am and 4.30pm, Monday to Thursday, to self-pay and private patients.

For further information on the service or to self-refer, please contact us via telephone on 0118 922 6980 or email: physio@circlereading.co.uk

NEW satellite clinic at Nettlebed GP Surgery

Perthes SUFE

The Art Scope Gallery at CircleReading hospital is now open to the public. The atrium gallery is a large beautiful space, ideal for the exhibition of contemporary art. All the art is for sale and all profits go to Alexander Devine Children’s Hospice Service. So far, we have raised a total of £24,221.40 for the two hospice charities we have supported.

There is a wonderful café experience in the atrium too, so this is an unusual, relaxing and rewarding place to visit.

A preview of the art on show can be seen at artscopegallery.co.uk

Like us on Facebook at facebook.com/ArtScopeGallery

Open Monday to Friday, 8am to 6pm

The Art Scope Gallery at CircleReading hospital

ScopeG A L L E R Y

Artat CircleReading

On March 10th, CircleReading hospital opened its door to over 1,000 men for its 3rd annual prostate event, in association with the Reading Lions. The car park was flooded from as early as 3pm, and the queue was endless.

The final count past 10pm was 1,108. The team at the hospital were so proud to have put on an event as such, and intend to continue this annual event.

Prostate event