Clinical consensus recommendations for the non-surgical treatment of children with Perthes' disease in the UK

Aims

The aim of this study was to produce clinical consensus recommendations about the non-surgical treatment of children with Perthes' disease. The recommendations are intended to support clinical practice in a condition for which there is no robust evidence to guide optimal care.

Methods

A two-round, modified Delphi study was conducted online. An advisory group of children's orthopaedic specialists consisting of physiotherapists, surgeons, and clinical nurse specialists designed a survey. In the first round, participants also had the opportunity to suggest new statements. The survey included statements related to 'Exercises', 'Physical activity', 'Education/information sharing', 'Input from other services', and 'Monitoring assessments'. The survey was shared with clinicians who regularly treat children with Perthes' disease in the UK using clinically relevant specialist groups and social media. A predetermined threshold of ≥ 75% for consensus was used for recommendation, with a threshold of between 70% and 75% being considered as 'points to consider'.

Results

A total of 40 participants took part in the first round, of whom 31 completed the second round. A total of 87 statements were generated by the advisory group and included in the first round, at the end of which 31 achieved consensus and were removed from the survey, and an additional four statements were generated. A total of 60 statements were included in the second round and 45 achieved the threshold for consensus from both rounds, with three achieving the threshold for 'points to consider'. The recommendations predominantly included self-management, particularly relating to advice about exercise and education for children with Perthes' disease and their families.

Conclusion

Children's orthopaedic specialists have reached consensus on recommendations for non-surgical treatment in Perthes' disease. These statements will support decisions made in clinical practice and act as a foundation to support clinicians in the absence of robust evidence. The dissemination of these findings and the best way of delivering this care needs careful consideration, which we will continue to explore.

"Waiting for the best day of your life". A qualitative interview study of patients' and clinicians' experiences of Perthes' disease

Aims

Perthes' disease is an idiopathic avascular necrosis of the developing femoral head, often causing deformity that impairs physical function. Current treatments aim to optimize the joint reaction force across the hip by enhancing congruency between the acetabulum and femoral head. Despite a century of research, there is no consensus regarding the optimal treatment. The aim of this study was to describe the experiences of children, their families, and clinicians when considering the treatment of Perthes' disease.

Methods

A qualitative study gathered information from children and their families affected by Perthes' disease, along with treating clinicians. Interviews followed a coding framework, with the interview schedule informed by behavioural theory and patient and public involvement. Transcripts were analyzed using the framework method.

Results

A total of 24 interviews took place, with 12 child/family dyads and 12 clinicians from UK NHS centres. Interviews identified widespread variation of routine care. Children/their families recounted positive experiences when included in the decision-making process for treatment. There is a strong desire from clinicians and children/families for consistent guidance from everyone involved in care, which should be based on clinical consensus.

Conclusion

This is the first study to describe how children/families and clinicians experienced receiving or providing treatment in Perthes' disease. The results indicate the need for robust evidence to support treatment decisions. Children and families valued feeling involved in the clinical decision-making process. Clinicians acknowledged the central importance of providing patient-centred care, particularly in the absence of robust evidence to guide the optimal treatment decisions. This study will inform a future Delphi project to develop clinical consensus guidelines for the treatment of Perthes' disease.

A systematic review of the non-surgical treatment of Perthes' disease

Aims

Perthes’ disease is a condition leading to necrosis of the femoral head. It is most common in children aged four to nine years, affecting around one per 1,200 children in the UK. Management typically includes non-surgical treatment options, such as physiotherapy with/without surgical intervention. However, there is significant variation in care with no consensus on the most effective treatment option.

Methods

This systematic review aims to evaluate the effectiveness of non-surgical interventions for the treatment of Perthes’ disease. Comparative studies (experimental or observational) of any non-surgical intervention compared directly with any alternative intervention (surgical, non-surgical or no intervention) were identified from: Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMcare, Allied and Complementary Medicine Database (AMED), and the Physiotherapy Evidence Database (PEDro). Data were extracted on interventions compared and methodological quality. For post-intervention primary outcome of radiological scores (Stulberg and/or Mose), event rates for poor scores were calculated with significance values. Secondary outcomes included functional measures, such as range of movement, and patient-reported outcomes such as health-related quality of life.

Results

In all, 15 studies (1,745 participants) were eligible for inclusion: eight prospective cohort studies, seven retrospective cohort studies, and no randomized controlled trials were identified. Non-surgical interventions largely focused on orthotic management (14/15 studies) and physical interventions such as muscle strengthening or stretching (5/15 studies). Most studies were of high/unknown risk of bias, and the range of patient outcomes was very limited, as was reporting of treatment protocols. Similar proportions of children achieving poor radiological outcomes were found for orthotic management and physical interventions, such as physiotherapy or weightbearing alteration, compared with surgical interventions or no intervention.

Conclusion

Evidence from non-randomized studies found no robust evidence regarding the most effective non-surgical interventions for the treatment of children with Perthes’ disease. Future research, employing randomized trial designs, and reporting a wider range of patient outcomes is urgently needed to inform clinical practice.

Cite this article: Bone Jt Open 2020;1-12:720–730.

A case review to describe variation in care following diagnosis of Perthes' disease

Aims

Perthes' disease is a condition which leads to necrosis of the femoral head. It is most commonly reported in children aged four to nine years, with recent statistics suggesting it affects around five per 100,000 children in the UK. Current treatment for the condition aims to maintain the best possible environment for the disease process to run its natural course. Management typically includes physiotherapy with or without surgical intervention. Physiotherapy intervention often will include strengthening/stretching programmes, exercise/activity advice, and, in some centres, will include intervention, such as hydrotherapy. There is significant variation in care with no consensus on which treatment option is best. The importance of work in this area has been demonstrated by the British Society for Children's Orthopaedic Surgery through the James Lind Alliance's prioritization of work to determine/identify surgical versus non-surgical management of Perthes' disease. It was identified as the fourth-highest priority for paediatric lower limb surgery research in 2018.

Methods

Five UK NHS centres, including those from the NEWS (North, East, West and South Yorkshire) orthopaedic group, contributed to this case review, with each entre providing clinical data from a minimum of five children. Information regarding both orthopaedic and physiotherapeutic management over a two-year post-diagnosis period was reviewed.

Results

Data were extracted from the clinical records of 32 children diagnosed with Perthes' disease; seven boys and 25 girls. The mean age of the children at diagnosis was 6.16 years (standard deviation (SD) 3.001). In all, 26 children were referred for physiotherapy. In the two-year period following diagnosis, children were seen a median of 7.5 times (interquartile range (IQR) 4.25 to 11) by an orthopaedic surgeon, and a median of 9.5 times (IQR 8 to 18.25) by a physiotherapist. One centre had operated on all of their children, while another had operated on none. Overall, 17 (53%) of the children were managed conservatively in the two-year follow-up period, and 15 (47%) of the children underwent surgery in the two-year follow-up period.

Conclusion

The results of this case review demonstrate a variation of care provided to children in the UK with Perthes' disease. Further national and international understanding of current care is required to underpin the rationale for different treatment options in children with Perthes' disease.Cite this article: Bone Joint Open 2020;1-11:691-695.

Frameshift mutation in PRKDC, the gene for DNA-PKcs, in the DNA repair-defective, human, glioma-derived cell line M059J

Anderson, C. W., Dunn, J. J., Freimuth, P. I., Galloway, A. M. and Allalunis-Turner, M. J. Frameshift Mutation in PRKDC, the Gene for DNA-PKcs, in the DNA Repair-Defective, Human, Glioma-Derived Cell Line M059J. Radiat. Res. 156, 2-9 (2001). The glioma-derived cell line M059J is hypersensitive to ionizing radiation, lacks DNA-PK activity, and fails to express protein for the catalytic subunit, DNA-PKcs, while a sister cell line, M059K, derived from the same tumor, has normal DNA-PK activity. Both cell lines are near pentaploid and have multiple copies of chromosome 8, the chromosome on which the DNA-PKcs gene, PRKDC, is located. Sequence analysis of PCR-amplified exons revealed the loss in M059J cells of a single "A" nucleotide in exon 32, corresponding to the first nucleotide of codon 1351 (ACC, Thr) of PRKDC. Loss of the "A" nucleotide would terminate the DNA-PKcs reading frame early in exon 33. DNA from M059K cells had only the wild-type sequence. An analysis of sequences surrounding PRKDC exon 32 from 87 unrelated individuals revealed no polymorphic nucleotides except for a triplet repeat near the 3' end of this exon; no individual had a frameshift mutation in exon 32. No other sequence differences in PRKDC between M059J and M059K cells were observed in approximately 15,000 bp of genomic sequence including the sequences of exons 5 through 38 and surrounding intron sequence, suggesting a possible reduction to homozygosity at this locus prior to acquisition of the mutation leading to the M059J cell line.

cDNA expression array analysis of DNA repair genes in human glioma cells that lack or express DNA-PK

M059J cells provide the only example of DNA-PKcs (now known as PRKDC) deficiency in a human cell line. M059K cells, derived from the same tumor specimen, express PRKDC protein and activity and, together with M059J, provide a useful model in which to study the role of DNA-PK in cellular responses to DNA-damaging agents. Because these cells are of tumor origin, we used Atlas human cancer cDNA expression arrays to investigate possible differential expression of other DNA repair genes in control and irradiated samples. cDNA array results indicated differential expression of 14 genes. Northern blotting confirmed relatively greater expression of replication factor C 37-kDa subunit mRNA in M059J cells compared to M059K cells and reduced expression of DNA ligase IV compared to ligase III in both cell lines independent of irradiation. These results suggest that other DNA repair proteins are altered in these cell lines and that repair mechanisms predicted from the study of normal tissues may be fundamentally altered in human cancer cells.

Correlative imaging findings in seven dogs and one cat with spinal arachnoid cysts

Information regarding 7 dogs and 1 cat with a spinal arachnoid cyst is presented. All patients were evaluated with survey radiographs and myelography. Computed tomography (CT) following myelography, magnetic resonance (MR) imaging, and sonography, were used in some of the patients. These imaging techniques were evaluated to determine their efficacy in diagnosing arachnoid cysts, ascertaining the extent and internal cyst architecture and detecting associated spinal cord abnormalities. Survey radiographs were nondiagnostic in all patients. Myelographically, the arachnoid cyst was visible in all patients, with partial blockage to flow of contrast medium. CT provided additional information on localization and lateralization of the cyst, and allowed measurement of the degree of spinal cord compression. MR imaging enabled identification of an associated syringomyelia. Sonography was useful for defining the cyst wall and characterizing the internal architecture of the cyst cavity and adjacent spinal cord. Measurements of the degree of spinal cord compression could be made and were similar to measurements made from CT. Additionally, sonography was considered a useful technique for orientating the surgeon to the location and extent of the cyst. In the absence of the availability of CT or MR imaging for evaluating patients with an arachnoid cyst, sonography is considered a valuable technique for directly assessing the spinal cord for associated disease. Decompressive surgery was performed on 4 dogs and 1 cat, all with successful outcomes.

Hansen type I disk disease at T1-2 in a dachshund

A 7-year-old Dachshund was presented with chronic left thoracic limb lameness and acute neurological deficits to the hind limbs following trauma. A lesion was suspected between C7 and T2 on the basis of neurological examinations. Radiography and myelography identified a calcified intervertebral disk at C7-T1 and an extradural unilateral compressive lesion at T1-2. Computed tomography scans of the cranial thoracic spine revealed extrusion of disk material from the T1-2 intervertebral space resulting in marked spinal cord compression. Intervertebral disk disease is rarely reported at this location. The neurological condition deteriorated after a second myelogram, which was done to examine the thoracolumbar spine. A modified dorsal decompression of T1-2 was performed. The dog was euthanased due to further neurological deterioration 8 days after surgery.

Differential stability of the DNA-activated protein kinase catalytic subunit mRNA in human glioma cells

DNA-dependent protein kinase (DNA-PK) functions in double-strand break repair and immunoglobulin [V(D)J] recombination. We previously established a radiation-sensitive human cell line, M059J, derived from a malignant glioma, which lacks the catalytic subunit (DNA-PKcs) of the DNA-PK multiprotein complex. Although previous Northern blot analysis failed to detect the DNA-PKcs transcript in these cells, we show here through quantitative studies that the transcript is present, albeit at greatly reduced (approximately 20x) levels. Sequencing revealed no genetic alteration in either the promoter region, the kinase domain, or the 3' untranslated region of the DNA-PKcs gene to account for the reduced transcript levels. Nuclear run-on transcription assays indicated that the rate of DNA-PKcs transcription in M059J and DNA-PKcs proficient cell lines was similar, but the stability of the DNA-PKcs message in the M059J cell line was drastically (approximately 20x) reduced. Furthermore, M059J cells lack an alternately spliced DNA-PKcs transcript that accounts for a minor (5-20%) proportion of the DNA-PKcs message in all other cell lines tested. Thus, alterations in DNA-PKcs mRNA stability and/or the lack of the alternate mRNA may result in the loss of DNA-PKcs activity. This finding has important implications as DNA-PKcs activity is essential to cells repairing damage induced by radiation or radiomimetric agents.

Lack of correlation between ATM protein expression and tumour cell radiosensitivity

PURPOSE

Cells derived from individuals in which the ataxia telangiectasia (ATM) gene is mutated are hypersensitive to ionizing radiation. Whether differences in ATM protein levels exist among human malignant glioma cell lines and whether such differences are correlated with cellular radiosensitivity were determined.

MATERIALS AND METHODS

Polyclonal antibodies were raised to separate regions of the ATM protein. ATM protein expression in human malignant glioma cell lines, SV40 transformed normal human fibroblasts and SV40 transformed AT fibroblasts was analysed by Western blotting. Reverse transcriptase polymerase chain reaction (RT-PCR) was used to assess the presence of ATM transcript.

RESULTS

While ATM protein was detected in all cell extracts, significant differences in the level of expression were observed. There was no apparent correlation between cellular radiosensitivity and differences in ATM protein levels in these human glioma cells. Extremely low levels of ATM protein were observed in M059J cells, which provide the only example of DNA-dependent protein kinase (DNA-PKcs) deficiency in a cell line of human origin.

CONCLUSIONS

Variations in the levels of ATM protein are insufficient to explain the differences in cellular radiosensitivity observed in a panel of human malignant glioma cell lines.

Recombination-dependent mutation in non-dividing cells

Over the past 6 years an unexpected way of making mutations in bacteria has challenged concepts of the genetic mechanisms behind evolution. Mechanistic studies of these so called 'adaptive' mutations are revealing a novel molecular mechanism involving DNA double-strand breaks, genetic recombination, probable DNA polymerase errors, and the possible suspension of mismatch repair during the reversion of a lac frameshift mutation in Escherichia coli. The molecular details of this process are altering our understanding of how mutations form in non-dividing cells.

Adaptive mutation sequences reproduced by mismatch repair deficiency

Adaptive reversions of a lac frameshift mutation in Escherichia coli are -1 deletions in small mononucleotide repeats, whereas growth-dependent reversions are heterogeneous. The adaptive mutations resemble instability of simple repeats, which, in hereditary colon cancer, in yeast, and in E. coli occurs in the absence of mismatch repair. The postulate that mismatch repair is disabled transiently during adaptive mutation in E. coli is supported here by the demonstration that the growth-dependent mutation spectrum can be made indistinguishable from adaptive mutations by disallowing mismatch repair during growth. Physiologically induced mismatch repair deficiency could be an important mutagenic mechanism in cancers and in evolution.

Disseminated opportunistic fungal disease in dogs: 10 cases (1982-1990)

Medical records of 10 dogs in which fungal infection was diagnosed between 1982 and 1990 were reviewed. In each dog, infection was determined to be caused by a single species of fungus, either Aspergillus terreus, Penicillium sp, Paecilomyces sp, Chrysosporium sp, or Pseudallescheria boydii. Nine dogs were German Shepherd Dogs; 1 was a German Shepherd Dog cross, and 9 were females. The most common clinical signs were signs of neck or back pain (9 dogs), weight loss (7 dogs), anorexia (6 dogs), pyrexia (6 dogs), paresis (3 dogs), and paralysis (3 dogs). All 10 dogs had evidence of multiple sites of diskospondylitis. Urine sediment was examined in 6 dogs, and all 6 had fungal hyphae. Urine samples from these dogs produced a medium to heavy pure growth of fungi when placed on Sabaraud's medium. Predisposing causes were not identified in any of the dogs. Four dogs were euthanatized immediately after diagnosis because of paralysis or paresis. The other 6 dogs were treated, and 4 of the 6 received itraconazole. One dog was euthanatized for an unrelated problem after 21 months of treatment; 1 dog was still alive after 4 years of continuous treatment with itraconazole. The other 4 dogs were euthanatized because of eventual paralysis or paresis. Our results suggest that German Shepherd Dogs are predisposed to infection with opportunistic fungi, possibly because of a specific inability to mount an effective response. This predisposition needs to be further studied.

Metabolic processing of cyclobutyl pyrimidine dimers and (6-4) photoproducts in UV-treated human cells. Evidence for distinct excision-repair pathways

A new nuclease digestion assay was developed to elucidate the human excision-repair system operating on cyclobutyl pyrimidine dimers and (6-4) photoproducts. We analyzed lesions that accumulated in excised oligonucleotide fragments during incubation of UV-treated cultured fibroblasts. (6-4) photoproducts were removed intact, whereas excised cyclobutyl dimers often contained ruptured interpyrimidine phosphodiester bonds, raising the possibility that the intradimer backbone-cleavage reaction may help promote the bypass of unexcised dimers by the DNA replication or RNA transcription machinery. Cell strains representing eight different inherited forms of the cancer-prone skin disease xeroderma pigmentosum (XP) were generally found to exhibit characteristic abilities to excise the two classes of photolesions, ranging from total deficiency in groups A and G to normal proficiency in the variant. The capacity of any given XP group to act on one class of photoproducts in no way predicted its ability to act on the other. Finally, in those XP strains displaying significant levels of dimer removal, the ratio of intact-versus-modified dimers was normal, implying that rupture of the intradimer backbone linkage occurs independently of subsequent excision-repair reactions. Our data indicate that cyclobutyl dimers and (6-4) photoproducts are processed by distinct nucleotide-excision-repair pathways in human cells.