Selective sonographic screening for developmental dysplasia of the hip - increasing trends in late diagnosis

There are concerns that selective sonographic screening for developmental dysplasia of the hip (DDH) may be suboptimal. Our aim was to test this hypothesis by identifying trends in presentation and surgical treatment in patients with DDH. This is a retrospective review of children born between 1997-2018 who were treated surgically for DDH at our sub- regional paediatric orthopaedic unit. Demographic data, risk factors, age of diagnosis and surgical treatments were analysed. Late diagnosis was defined as greater than 4 months. 103 children (14 male, 89 female) underwent surgery. 93 hips were operated for dislocation and 21 for dysplasia. 13 patients presented with bilateral hip dislocations. The median age at diagnosis was 10 months (95% CI: 4-15). 62/103 (60.2%) were diagnosed late (after 4 months) and the median age for diagnosis in this group was 18.5 months (95% CI: 16-20.5). Significantly more patients were referred late (p=0.0077). The presence of risk factors (breech presentation or family history) was associated with early diagnosis. Over the duration of our study the operation rate per 1000 live births gradually increased, and on Poisson regression analysis there was a statistically significant increasing trend towards late diagnosis in recent years (p=0.0237), which necessitated more aggressive surgical management. In the UK, the current selective sonographic screening programme for DDH has shown a deterioration over the years of this study and this questions its current effectiveness. It appears that the majority of irreducible hip dislocations are diagnosed late, with an increased need for surgical management.

Splinting for the non-operative management of developmental dysplasia of the hip (DDH) in children under six months of age

BACKGROUND

Developmental dysplasia of the hip (DDH) describes the abnormal development of a hip in childhood, ranging from complete dislocation of the hip joint to subtle immaturity of a hip that is enlocated and stable within the socket. DDH occurs in around 10 per 1000 live births, though only one per 1000 are completely dislocated. There is variation in treatment pathways for DDH, which differs between hospitals and even between clinicians within the same hospital. The variation is related to the severity of dysplasia that is believed to require treatment, and the techniques used to treat dysplasia.

OBJECTIVES

To determine the effectiveness of splinting and the optimal treatment strategy for the non-operative management of DDH in babies under six months of age.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, seven other electronic databases, and two trials registers up to November 2021. We also checked reference lists, contacted study authors, and handsearched relevant meetings abstracts.

SELECTION CRITERIA

Randomised controlled trials (RCTs), including quasi-RCTs, as well as non-RCTs and cohort studies conducted after 1980 were included. Participants were babies with all severities of DDH who were under six months of age. Interventions included dynamic splints, static splints or double nappies (diapers), compared to no splinting or delayed splinting.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and performed risk of bias and GRADE assessments. The primary outcomes were: measurement of acetabular index at years one, two and five, as determined by radiographs (angle): the need for operative intervention to achieve reduction and to address dysplasia; and complications. We also investigated other outcomes highlighted by parents as important, including the bond between parent and child and the ability of mothers to breastfeed.

MAIN RESULTS

We included six RCTs or quasi-RCTs (576 babies). These were supported by 16 non-RCTs (8237 babies). Five studies had non-commercial funding, three studies stated 'no funding' and 14 studies did not state funding source. The RCTs were generally at unclear risk of bias, although we judged three RCTs to be at high risk of bias for incomplete outcome data. The non-RCTs were of moderate and critical risk of bias. We did not undertake meta-analysis due to methodological and clinical differences between studies; instead, we have summarised the results narratively. Dynamic splinting versus delayed or no splinting Four RCTs and nine non-RCTs compared immediate dynamic splinting and delayed dynamic splinting or no splinting. Of the RCTs, two considered stable hips and one considered unstable (dislocatable) hips and one jointly considered unstable and stable hips. No studies considered only dislocated hips. Two RCTs (265 babies, very low-certainty evidence) reported acetabular index at one year amongst stable or dislocatable hips. Both studies found there may be no evidence of a difference in splinting stable hips at first diagnosis compared to a strategy of active surveillance: one reported a mean difference (MD) of 0.10 (95% confidence interval (CI) -0.74 to 0.94), and the other an MD of 0.20 (95% CI -1.65 to 2.05). Two RCTs of stable hips (181 babies, very low-certainty evidence) reported there may be no evidence of a difference between groups for acetabular index at two years: one study reported an MD of -1.90 (95% CI -4.76 to 0.96), and another study reported an MD of -0.10 (95% CI -1.93 to 1.73), but did not take into account hips from the same child. No study reported data at five years. Four RCTs (434 babies, very low-certainty evidence) reported the need for surgical intervention. Three studies reported that no surgical interventions occurred. In the remaining study, two babies in the dynamic splinting group developed instability and were subsequently treated surgically. This study did not explicitly state if this treatment was to achieve concentric reduction or address residual dysplasia. Three RCTs (390 babies, very low-certainty evidence) reported no complications (avascular necrosis and femoral nerve palsy). Dynamic splinting versus static splinting One RCT and five non-RCTs compared dynamic versus static splinting. The RCT (118 hips) reported no occurrences of avascular necrosis (very low-certainty evidence) and did not report radiological outcomes or need for operative intervention. One quasi-RCT compared double nappies versus delayed or no splinting but reported no outcomes of interest. Other comparisons No RCTs compared static splinting versus delayed or no splinting or staged weaning versus immediate removal.

AUTHORS' CONCLUSIONS

There is a paucity of RCT evidence for splinting for the non-operative management of DDH: we included only six RCTs with 576 babies. Moreover, there was considerable heterogeneity between the studies, precluding meta-analysis. We judged the RCT evidence for all primary outcomes as being of very low certainty, meaning we are very uncertain about the true effects. Results from individual studies provide limited evidence of intervention effects on different severities of DDH. Amongst stable dysplastic hips, there was no evidence to suggest that treatment at any stage expedited the development of the acetabulum. For dislocatable hips, a delay in treatment onset to six weeks does not appear to result in any evidence of a difference in the development of the acetabulum at one year or increased risk of surgery. However, delayed splinting may reduce the number of babies requiring treatment with a harness. No RCTs compared static splinting with delayed or no splinting, staged weaning versus immediate removal or double nappies versus delayed or no splinting. There were few operative interventions or complications amongst the RCTs and the non-randomised studies. There's no apparent signal to indicate a higher frequency of either outcome in either intervention group. Given the frequency of this disease, and the fact that many countries undertake mandatory DDH screening, there is a clear need to develop an evidence-based pathway for treatment. Particular uncertainties requiring future research are the effectiveness of splinting amongst stable dysplastic hips, the optimal timing for the onset of splinting, the optimal type of splint to use and the need for 'weaning of splints'. Only once a robust pathway for treatment is established, can we properly assess the cost-effectiveness of screening interventions for DDH.

Congenital Talipes Equinovarus: Results of Treatment and Are We Bracing Effectively?

The aim of this retrospective study was to assess our management of Congenial Talipes Equinovarus (CTEV) in relation to national standards published by the British Society for Children's Orthopaedic Surgery (BSCOS). A secondary aim was to evaluate if a more tailored bracing regime than advocated in the traditional Ponseti technique, would be appropriate for some cases of CTEV. One hundred and thirty-three feet in 96 patients were treated between June 2006 and January 2016. All patients were clinically assessed prospectively by the senior author at initial presentation using the Harrold & Walker classification system. A combination of the senior author's database, Elogbook and trust IT systems were used for data collection. The results of Ponseti surgical procedures such as tendoachilles release and tibialis transfer fell within the BSCOS guidelines. The rate of radical subtalar surgical release was higher than advocated (12.3%) which was partly due to the number of primary syndromal patients in the series. There was a significantly lower mean time spent in bracing of 14.3 months (95% confidence interval 14.8-19.3) compared to recommended national guidelines. There was a clinically significant difference in the lower relapse rate of female patients compared to male patients and also a higher propensity of surgical intervention in male patients. In addition, there was a statistically significant difference in both time spent in bracing, between H&W classifications and between patients who had bracing removed pre walking age or post walking age. This potentially demonstrates a more tailored bracing regime may be possible when applied to less severely affected feet and the condition may be more benign in female cases.

The positive predictive value of asymmetrical skin creases in the diagnosis of pathological developmental dysplasia of the hip

Aims

The aim of this study was to identify the association between asymmetrical skin creases of the thigh, buttock or inguinal region and pathological developmental dysplasia of the hip (DDH).

Patients and Methods

Between 1 January 1996 and 31 December 2016, all patients referred to our unit from primary or secondary care with risk factors for DDH were assessed in a "one stop" clinic. All had clinical and sonographic assessment by the senior author (RWP) with the results being recorded prospectively. The inclusion criteria for this study were babies and children referred with asymmetrical skin creases. Those with a neurological cause of DDH were excluded. The positive predictive value (PPV) for pathological DDH was calculated.

Results

A total of 105 patients met the inclusion criteria. There were 71 girls and 34 boys. Only two were found to have pathological DDH. Both also had unilateral limited abduction of the hip in flexion and a positive Galeazzi sign with apparent leg-length discrepancy. Thus, if the specialist examination of a patient with asymmetrical skin creases was normal, the PPV for DDH was 0%.

Conclusion

Isolated asymmetrical skin creases are an unreliable clinical sign in the diagnosis of pathological DDH. Greater emphasis should be placed on the presence of additional clinical signs to guide radiological screening in babies and children. Cite this article: Bone Joint J 2018;100-B:675-9.

Clicky hip alone is not a true risk factor for developmental dysplasia of the hip

AIMS

A clicky hip is a common referral for clinical and sonographic screening for developmental dysplasia of the hip (DDH). There is controversy regarding whether it represents a true risk factor for pathological DDH. Therefore a 20-year prospective, longitudinal, observational study was undertaken to assess the relationship between the presence of a neonatal clicky hip and pathological DDH.

PATIENTS AND METHODS

A total of 362 infants from 1997 to 2016 were referred with clicky hips to our 'one-stop' paediatric hip screening clinic. Hips were assessed clinically for instability and by ultrasound imaging using a simplified Graf/Harcke classification. Dislocated or dislocatable hips were classified as Graf Type IV hips.

RESULTS

The mean age at presentation was 13.8 weeks (12.8 to 14.7). In all 351 out of 362 children (97.0%) had Graf Type I hips (normal) that required no treatment. Nine children (2.5%) had Graf Type II hips but all resolved to Graf Type I hips on follow-up scans. One child (0.3%) had Graf Type III hip dysplasia and one child (0.3%) had an irreducible hip dislocation. The two pathological hips were associated with unilateral limited hip abduction. Mean referrals increased from 12.9 to 23.3 each year (p = 0.002) from the first decade of the study to the second, driven by increasing primary care referrals (5.5 versus 16.7 per year, p < 0.001).

CONCLUSION

Most clicky hips required no treatment other than reassurance to parents. Clicky hips with a normal hip examination should be considered a variant of normal childhood and not a risk factor for DDH. However, an abnormal hip examination including unilateral limited hip abduction should prompt urgent further investigations. Cite this article: Bone Joint J 2017;99-B:1533-6.

'The psychological problem is looking at you, are you looking for it?': psychological associations with symptomatic musculoskeletal referrals

It is important that paediatric orthopaedic surgeons recognise that psychological conditions may present with musculoskeletal symptoms. Identification through careful and sensitive history taking is vital. There is a lack of training in this regard in paediatric orthopaedics. We present a series of cases initially referred for a musculoskeletal complaint. Further probing revealed an underlying psychological problem which was neither picked up by the referring physician nor volunteered by the patient. In our opinion, it is important that this training omission is addressed as such psychological problems may be devastating for these individuals and their families.

Screening in Developmental Dysplasia of the Hip (DDH)

Screening for Developmental Dysplasia of the Hip (DDH) is a controversial subject. Screening may be by universal neonatal clinical examination (Ortolani or Barlow manoeuvres) with the addition of sonographic imaging of the hip (selective 'at risk' hips or universal screening in the neonate). In the UK, the NIPE guidelines recommend universal neonatal clinical assessment of the hip joints, a General Practitioner 6-8 week clinical 'hip check' and assessment clinically with sonographic imaging at 4-6 weeks for certain 'at risk' hips for pathological DDH. The effectiveness and difficulties arising from the UK current screening policy (clinical and sonographic) are highlighted. The purpose of the review was to assess the risk factors and efficacy of diagnostic methods in DDH, based on longitudinal cohort studies of 10 years or more.

CONCLUSION

Hip screening in DDH does not meet most of the World Health Organisation's criteria for an effective screening programme and should only be considered as surveillance due to its low sensitivity and positive predictive value (PPV). There is a significant risk of over diagnosis and over treatment. There is no International consensus on screening in DDH. Pathological DDH is mainly a female condition and 'at risk'/General Practitioner screening identifies few pathological cases in male subjects. The General Practitioner 6-8 week 'hip check' has a very low PPV for pathological DDH and is of doubtful value in screening and diagnosis. Unilateral limitation of hip abduction is a time dependent and useful clinical sign in the diagnosis of pathological DDH. The majority of the previously considered 'at risk' factors are not true risk factors with little or no association with pathological DDH.

Is congenital talipes equinovarus a risk factor for pathological dysplasia of the hip? : a 21-year prospective, longitudinal observational study

There is controversy whether congenital foot abnormalities are true risk factors for pathological dysplasia of the hip. Previous United Kingdom screening guidelines considered congenital talipes equinovarus (CTEV) to be a risk factor for hip dysplasia, but present guidelines do not. We assessed the potential relationship between pathological dysplasia of the hip and fixed idiopathic CTEV. We present a single-centre 21-year prospective longitudinal observational study. All fixed idiopathic CTEV cases were classified (Harrold and Walker Types 1 to 3) and the hips clinically and sonographically assessed. Sonographic Graf Type III, IV and radiological irreducible hip dislocation were considered to be pathological hip dysplasia. Over 21 years there were 139 children with 199 cases of fixed idiopathic CTEV feet. Sonographically, there were 259 normal hips, 18 Graf Type II hips, 1 Graf Type III hip and 0 Graf Type IV hip. There were no cases of radiological or sonographic irreducible hip dislocation. Fixed idiopathic CTEV should not be considered as a significant risk factor for pathological hip dysplasia. This conclusion is in keeping with the current newborn and infant physical examination guidelines in which the only risk factors routinely screened are family history and breech presentation. Our findings suggest CTEV should not be considered a significant risk factor in pathological dysplasia of the hip.

Is limitation of hip abduction a useful clinical sign in the diagnosis of developmental dysplasia of the hip?

AIM

The relationship between the presence and severity of sonographically diagnosed developmental dysplasia of the hip (DDH) and the clinical abnormality of limitation of hip abduction (LHA) was investigated.

METHODS

A prospective, longitudinal, selective 'at risk' and neonatal instability hip ultrasound programme between 1 January 1996 and 31 December 2005. 2876 neonates/infants were initially screened for DDH by clinical examination and by hip ultrasound imaging. Pathological sonographically evaluated DDH was considered to be Graf Type III, IV and irreducible hip dislocation. Inclusion criteria were cases of unilateral or bilateral limitation of hip abduction hip.

EXCLUSION CRITERIA

syndromal, neuromuscular and skeletal dysplasia cases.

RESULTS

492 children presented with LHA (55 unilateral LHA). The mean age of neonates/infants with either unilateral or bilateral LHA was significantly higher than those without (p<0.001). In the sonographic diagnosis of Graf Type III and IV dysplasias, unilateral LHA had a PPV of 40% compared with only 0.3% for bilateral LHA. The sensitivity of unilateral LHA increased to 78.3% and a PPV 54.7% after the age of 8 weeks for Graf Types III, IV and irreducible hip dislocation.

CONCLUSIONS

This study identifies a time-dependent association with unilateral LHA in the diagnosis of 'pathological' DDH after the age of 8 weeks. The presence of bilateral LHA in the young infant may be a normal variant and is an inaccurate clinical sign in the diagnosis of pathological DDH. LHA should be actively sought after 8 weeks of age and if present should be followed by a formal ultrasound or radiographic examination to confirm whether or not the hip is developing in a satisfactory manner.

Screening of selected risk factors in developmental dysplasia of the hip: an observational study

BACKGROUND

Developmental dysplasia of the hip (DDH) is the most common neonatal musculoskeletal condition. In 2008, the NHS Newborn and Infant Physical Examination committee added selective 'at risk' screening to the existing universal neonatal and general practitioner clinical hip screening guidelines.

OBJECTIVE

Assessment of breech and family history risk factors in DDH.

DESIGN

A 15 year prospective, observational, longitudinal cohort study.

METHOD

Breech presentation and evidence of a strong family history for DDH were the 'risk factors' studied. All infants referred were clinically and sonographically screened by one consultant paediatric orthopaedic surgeon.

RESULTS

From a cohort of 64 670 live births, 2984 neonates/infants, 46.1 (95% CI 44.6 to 47.8) per 1000 live births, were referred and sonographically screened with these risk factors alone. 1360 were male, of which four were identified as having 'pathological' DDH (an incidence of 0.003 (95% CI 0.001 to 0.008)). 1624 were female, of which 45 were identified as having 'pathological' DDH (an incidence of 0.028 (95% CI 0.021 to 0.037)). This difference in incidence of 0.025 (95% CI 0.016 to 0.033) was statistically significant (p<0.001). From those who were clinically stable and screened with either or both of the two risk factors, four individuals were diagnosed with irreducible hip dislocation (0.06 (95% CI 0.024 to 0.159) per 1000 live births). All were females.

CONCLUSIONS

This study questions the current UK screening policy for DDH in clinically stable males referred with risk factors, and may influence future DDH screening programme policy.

MRSA screening in orthopaedic surgery: clinically valuable and cost effective? A prospective analysis of 8,867 patients

This study aimed at assessing the prevalence of MRSA colonisation in Trauma and Orthopaedics. Risk factors, decolonisation, and subsequent infection rates were investigated. Cost-analysis of the MRSA screening program was performed. The validity and effectiveness of the MRSA screening program was reviewed. A prospective analysis was made of all orthopaedic admissions in East Lancashire Hospital Trust. A total number of 13,155 swabs were taken in 8,867 patients in 2010. This MRSA screening program was compared to the ideal screening criteria set out by Wilson and Junger (WHO 1968). The MRSA prevalence in Trauma and Orthopaedics in 2010 was 0.47%. The decolonisation rate was 55%. There was no correlation between MRSA colonisation and subsequent infection. The total cost of MRSA screening at ELHT was calculated as a minimum of 184,170 Pounds. This could extrapolate to a national expense of around 16 million pounds in England and Wales in Orthopaedics alone. The MRSA screening program did not meet 4 out of 9 screening criteria of Wilson and Junger. The vast majority of Trauma and Orthopaedic patients are not at risk of MRSA colonisation or infection and therefore should not be screened. MRSA infection is a risk in certain high risk groups which should be screened. The MRSA screening program is ineffective when assessed to WHO standards. The program should be considered to be surveillance of MRSA, not an effective screening program for pathological MRSA infection.

Vitamin D: a poor screening tool for biochemical and radiological rickets

This retrospective study aims to determine if a relationship exists between serum 25-hydroxyvitamin D level and the diagnosis of biochemical or radiological rickets in children with bone and joint pain, muscle fatigue or varus/valgus knees. A retrospective biochemistry database and case note study was undertaken on 115 new patients referred to the senior authors' elective Paediatric Orthopaedic Clinic in 2010. Their mean age was 10.95 years (95% CI 10.24-11.68). Mean serum vitamin D was 18.27 mcg/l (95% CI 16.13-20.41), while 30 mcg/l is the normal threshold. One hundred and three children (88%) had vitamin D levels below normal. Winter/springtime blood samples were more likely to be deficient and this was statistically significant. Three Asian females (2.61%) were diagnosed with radiological rickets. Vitamin D levels below normal are common in children presenting with vague limb or back pain, but this rarely presents with biochemical or radiological rickets. Serum vitamin D level is not a suitable screening tool for biochemical or radiological rickets. Vitamin D requirement in children is unclear and requires further study.

Beware the syndrome in neonatal hip instability: follow up assessment is required after apparent resolution

Developmental dysplasia of the hip is one of the most common congenital musculoskeletal disorders of childhood, affecting 1-3% of newborns. An early diagnosis and prompt treatment is essential to avoid complex treatments and achieve improved results. Since 1992, we have undertaken a screening programme for clinical instability and at risk patients. During this time, there have been only two cases which have been normal on both clinical, and, static and dynamic ultrasound assessment, that have subsequently deteriorated. In these two cases there was an underlying syndrome associated with hyperlaxity, which behaves unpredictably compared to 'true' developmental dysplasia of the hip. In conclusion, if a hip has been referred as unstable but it is found to have a primary syndromal cause (especially if hyper lax) with sonographically normal hips at one to two weeks of age, it is best to review clinically and sonographically at 6 weeks and 3 months of age to confirm that the hip is maintaining stability.

A 14-year longitudinal comparison study of two treatment methods in clubfoot: Ponseti versus traditional

The optimal management of idiopathic clubfoot has changed over three decades. Recently there has been an enthusiastic embracing of the Ponseti technique with a move away from the traditional stretch and strap technique. The purpose of this 14-year comparative prospective longitudinal study was to directly assess the differences in results between these two treatment methods. Over the period of this study there were 52,514 births in the local population and all newborns with clubfoot were referred directly to the paediatric orthopaedic surgeon. Patient demographics, the Harrold & Walker Classification, and associated risk factors for clubfoot were collected prospectively and analyzed. If conservative treatment failed to correct the deformity adequately, a radical subtalar release (RSR) was undertaken (the primary outcome measure of the study). There were 114 feet (80 patients): 64 feet treated 'traditionally' and 50 feet with the Ponseti technique. Idiopathic clubfoot was present in 76.25% of patients. Mean time to RSR was 333 and 44.1 weeks for the traditional and Ponseti groups respectively. In the traditional group 65.6% (CI: 53.4 to 76.1%) of feet underwent RSR surgery compared to 25.5% (CI : 15.8 to 383%) in the Ponseti group. When idiopathic clubfoot alone was analysed, these rates reduce to 56.5% (CI: 423 to 69.8%) and 15.8% (CI: 7.4 to 30.4%) respectively. The Relative Risk of requiring RSR in traditional compared to Ponseti groups was 2.58 (CI: 1.59 to 4.19) for all patients and 3.58 (CI: 1.65 to 7.78) for idiopathic clubfoot. Introduction of the Ponseti technique into our institution significantly reduced the need for RSR in fixed clubfoot.

The presentation of rickets to orthopaedic clinics: return of the English disease

Rickets is a potentially treatable disease of the bone that is most commonly due to deficiency of vitamin D and is increasing in incidence in developed countries. Risk factors include dietary factors, the practice of covering up and darker skin pigmentation. This small retrospective case study set out to examine all cases of rickets presenting to the Paediatric Orthopaedic clinic over a 15-month period. Rickets presented in a bimodal fashion in the 6 cases identified: in males and females aged 3 or less and female adolescents aged 10 and above. This is in keeping with what is known regarding the rapid phases of growth during development. Five cases were from ethnic minority groups. Both female adolescents presented with genu valgum. Rickets can present primarily to Orthopaedic clinics with vague musculoskeletal symptoms. We recommend that biochemical screening be performed on patients from ethnic minorities who may be 'at risk'.

Bone and joint tuberculosis in children in the Blackburn area since 2006: a case series

This report describes a series of four cases of children between the ages 5 and 14 years with bone or joint infection with Mycobacterium tuberculosis diagnosed between June 2006 and March 2008 in the Blackburn area of England. All of the cases were of South Asian descent. The diagnosis was confirmed by the presence of M. tuberculosis on the culture of bone, synovium or joint fluid, or by the presence of the typical histology of tuberculosis (TB). The sites of tuberculous disease were the hip joint, the sacro-iliac joint and the talus. A recent paper by Sandher et al. (J Bone Joint Surg Br 89:1379-1381, 2007) illustrated only two cases of childhood bone and joint TB in the same geographical area in the preceding 17 years.

Incidence and aetiology of talipes equino-varus with recent population changes

This study looks at the changing incidence and aetiology of congenital talipes equinovarus due to the recent population changes within the area. Between 1st June 1992 and the 31st May 2006, 83 consecutive children (121 feet) born with fixed talipes equinovarus (TEV) were assessed and treated (an incidence of 1.6 per 1000 live births) in an observational longitudinal cohort study assessing associated factors. There were 17 syndromal cases in the fixed group (20.8%), 6 cases of non-syndromal distal arthrogryposis (7.2%), and a strong family history in 12 cases (14.5%). This study would suggest that genetic and primary causes of fixed TEV are more common than previously considered. Many of the primary aetiologies were diagnosed months or years after birth.

Developmental dysplasia of the hip: ultrasound screening and treatment. How are they related?

An assessment of the current clinical and ultrasound screening programmes. Early treatment by splintage is advocated for instability and Graf type III dysplasia of the hip.

Turner syndrome - an accidental finding?

We report the case of a 9-year-old girl with bilaterally reduced pedal pulses following emergency surgery for unilateral subtrochanteric femoral fracture. This incidental postoperative finding of differential blood pressures between the upper and lower limbs led to the diagnosis of aortic coarctation and subsequent karyotype analysis confirmed the rare diagnosis of Turner syndrome.

The significance of at-risk factors in ultrasound surveillance of developmental dysplasia of the hip. A ten-year prospective study

Of the 34,723 infants born between 1 June 1992 and 31 May 2002, the hips of 2578 with clinical instability or at-risk factors for developmental dysplasia of the hip were imaged by ultrasound. Instability of the hip was present in 77 patients, of whom only 24 (31.2%) had an associated risk factor. From the 'at-risk' groups, the overall risk of type-III dysplasia, instability and irreducibility was 1:15 when family history, 1:27 when breech delivery and 1:33 when foot deformity were considered as risk factors. Of those hips which were ultrasonographically stable, 88 had type-III dysplasia. A national programme of selective ultrasound screening of at-risk factors for the diagnosis of hip dislocation or instability alone cannot be recommended because of its low predictive value (1:88). However, the incidence of type-III dysplasia and hip dislocation or dislocatability in the groups with clinical instability, family history, breech position and possibly postural foot deformity as risk factors could justify a programme of selective ultrasound imaging.

Management of neonatal hip instability and dysplasia

The diagnosis and treatment of neonatal hip instability and dysplasia is controversial. Different countries have different algorithms and guidelines on which hips should be screened or treated. German speaking countries have introduced universal ultra sound hip screening programmes resulting in relatively high splintage rates in certain centres. Some Scandinavian centres have organised selective screening programmes with serial ultrasound observation of hip instabilities, leading to comparatively low splintage rates. Though most experts would treat clinical hip instability (confirmed by ultrasound evaluation), the natural history and epidemiology of dysplasia is less well understood. The treatment regimes for neonatal dysplasia are varied with wide differences in the rates of splintage. 'Late' dislocation may be secondary to prenatal dislocation (teratogenic), neonatal hip instability or to persistent major dysplasia of the hip. The term 'missed' dislocation should not be used as this suggests negligence on the part of the examiner, when this may not be the case. Which splint to use (rigid or dynamic), at what age, and for how long, are questions currently unresolved as no proper controlled trials have been undertaken. However, a sensible treatment algorithm can be advocated. Complications secondary to splintage are rare, though nerve damage, avascular necrosis of the hip, redislocation and skin problems have been described.

Screening for hip abnormality in the neonate

Clinical screening policies for the detection of hip instability or dysplasia of the hip vary internationally. There is general agreement in the Western world that at birth all hip joints should be clinically assessed by the Ortolani and Barlow tests. Currently, there is no consistency regarding who should undertake the examination, the results being worse when inexperienced personnel are used. These clinical tests have poor sensitivity and should be regarded as surveillance, not screening methods. Since the 1980s ultrasonographic assessment of the hip has become a valuable diagnostic tool. However there is continuing controversy on whether this imaging method should be used universally or selectively for 'at risk' and clinically unstable hip joints. Universal ultrasonographic evaluation may result in over-treatment and selective screening may be no better than the best clinical screening programs in reducing the incidence of 'late' irreducible dislocation of the hip. It is generally accepted that all clinically unstable hips should be imaged by ultrasound by static and dynamic methods in order to confirm the diagnosis and to monitor treatment.

Non traumatic dislocation of the patella in children: the case for a dysplastic aetiology

Congenital dislocation of the patella may be a phenotype, which has several genotypes, i.e. it may be congenital or acquired. This hypothesis is suggested with three illustrative case studies. Risk factors predictive of the development of irreducible dislocation of the patella in infancy are suggested. As there is a spectrum of possible aetiologies, 'late' diagnosis and a number of 'risk' factors but a common pathology, the word 'congenital' is not always appropriate. We suggest 'Developmental dysplasia and dislocation of the patella (DDDP)' is a more appropriate term for this rare condition.

Congenital and irreducible non-traumatic dislocation of the patella--a modified soft tissue procedure

Many procedures have been described for the correction of congenital dislocation of the patella. Most operations entail extensive soft tissue releases through curved skin incisions. A modification of the Langenskiold and Ritsila procedure is described. The main alterations include a limited and straight anterior skin incision, a fashioning of a 'buckle' of the transferred distal-patellar tendon to a distally based flap and the transposition of an extensive medial rotation flap. This report describes the early results (mean=19 months) of the modified procedure in three cases of congenital lateral dislocation of the patella.

Partial percutaneous epiphyseodesis in patients with congenital abnormalities of the growth plates

We present a rare series of a small cohort of seven patients with 12 valgus knees. This is the largest series of children with underlying growth plate disorders published so far. Prediction of remaining growth in these children is difficult as most existing methods of growth prediction focus on normal patients. These methods of growth prediction in otherwise normal children are only 86-94% accurate at best. Hence we chose to use an educated guess based on the method by Menelaus to predict the right timing for surgery in our patients. Partial percutaneous epiphyseodesis has been shown to be an effective and minimally invasive method in the treatment of angular deformities of the knee. The successful partial ablation of the physes through a percutaneous approach was achieved in all of our patients. However, due to difficulties in the accurate assessment of remaining growth the results were not ideal. The mean preoperative deformity was 23 degrees of valgus and an average correction of 18 degress was achieved. Five patients with five knees (41.6%) had overcorrection or undercorrection of 10 degrees or more. Four of them required further surgical intervention. Difficulty arose mainly with the correct prediction of growth arrest in patients with abnormal physes. We review and discuss the current literature on partial epiphyseodesis and methods for the prediction of remaining growth.

Displaced supracondylar humeral fractures in children: results of a national survey of paediatric orthopaedic consultants

Several aspects of the management of displaced supracondylar fractures in children remain controversial. Displaced supracondylar humeral fractures (Type III) in children have traditionally been considered orthopaedic emergencies. Recent studies have suggested that closed Type III supracondylar fractures without vascular compromise may be treated in a delayed manner without compromise to functional and cosmetic outcome. Debate continues over the fixation method of choice in these difficult fractures. A postal questionnaire of 121 practising paediatric orthopaedic consultants in the UK was performed to explore these issues. Seventy-seven replies were obtained (63.6%). The 54.5% of the respondents managed displaced supracondylar fractures without vascular compromise in a delayed manner (more than 8h from presentation). The incidence, initial assessment and factors which influence the timing of surgery of these fractures are discussed. The fixation method of choice reported was closed reduction and the use of smooth Kirshner wires (93.4%). Of these, crossed pin fixation is used by 83.9% of respondents and 9.7% employed laterally placed wires. The majority of consultants (69.7%) considered the operative treatment of these fractures a consultant-led procedure. This survey has established an overview of the current practices of paediatric orthopaedic consultants in the UK in the management of these difficult fractures.

Eight-year prospective targeted ultrasound screening program for instability and at-risk hip joints in developmental dysplasia of the hip

The use of targeted ultrasound screening for at-risk hips to reduce the rate of surgery in developmental dysplasia of the hip is unproven. A prospective trial was undertaken in an attempt to clarify this matter. This study was undertaken between May 1992 and April 2000. There were 28,676 live births. Unstable and at-risk hips were routinely targeted for ultrasound examination. One thousand eight hundred six infants underwent ultrasound examination (6.3% of the birth population). Twenty-five children (18 with dislocations, 7 with dysplasia) required surgical intervention in the form of open reduction of the hip or pelvic or femoral osteotomy (0.87 per 1,000 births for dysplasia, 0.63 per 1,000 births for dislocation). Targeted ultrasound screening does not reduce the overall rate of surgery compared with the best conventional clinical screening programs. The development of a national targeted ultrasound screening program for at-risk hips cannot be justified on a cost or result basis.

Unilateral limitation of abduction of the hip. A valuable clinical sign for DDH?

Between 1992 and 1997, we undertook a prospective, targeted clinical and ultrasonographic hip screening programme to assess the relationship between ultrasonographic abnormalities of the hip and clinical limitation of hip abduction. A total of 5.9% (2 of 34) of neonatal dislocatable hips and 87.5% (7 of 8) of 'late' dislocated hips seen after the age of six months, presented with unilateral limitation of hip abduction. All major (Graf type III) and 44.5% of minor (Graf type II) dysplastic hips presented with this sign. Statistically, bilateral limitation of hip abduction was not a useful clinical indicator of underlying hip abnormality because of its poor sensitivity, but unilateral limitation of abduction of the hip was a highly specific (90%) and reasonably sensitive sign (70%). It was more sensitive than the neonatal Ortolani manoeuvre, which has been considered to be the method of choice. It was, however, not sensitive enough to be of value as a routine screening test in developmental dysplasia of the hip. We consider unilateral limitation of hip abduction to be an important clinical sign and its presence in an infant over the age of three to four months makes further investigation essential.

Preoperative equinus angle and prognosis in congenital talipes equinovarus: a preliminary report

This study examines the hypothesis that the preoperative, clinically determined, equinus angle of congenital talipes equinovarus correlates with the surgical outcome. Data were obtained on 30 feet from 20 patients. All the patients had failed to respond to conservative measures of serial strapping and/or casting, and underwent radical primary subtalar release. Postoperatively, the Magone, Turco and McKay score systems were used for evaluation with 2 years minimum follow-up (range, 24-60 months; average, 42 months). There was a negative mathematical correlation between the equinus angle and the three system scores (Magone, Turco and McKay). In the three systems, the Pearson correlation with the equinus angle was negative and statistically highly significant: Magone, r = -0.629, P < 0.001; Turco, r = -0.651, P < 0.001; McKay, r = -0.717, P < 0.001. The correlation coefficients between the scoring systems were highly significant demonstrating a very close relationship between the systems. Excellent category outcomes were associated with smaller equinus angles.

Ultrasound screening for hips at risk in developmental dysplasia. Is it worth it?

Between May 1992 and April 1997, there were 20,452 births in the Blackburn District. In the same period 1107 infants with hip 'at-risk' factors were screened prospectively by ultrasound. We recorded the presence of dislocation and dysplasia detected under the age of six months using Graf's alpha angle. Early dislocation was present in 36 hips (34 dislocatable and 2 irreducible). Of the 36 unstable hips, 30 (83%) were referred as being Ortolani-positive or unstable; 25 (69%) of these had at least one of the risk factors. Only 11 (31%) were identified from the 'at-risk' screening programme alone (0.54 per 1000 live births). Eight cases of 'late' dislocation presented after the age of six months (0.39 per 1000 live births). The overall rate of dislocation was 2.2 per 1000 live births. Only 31% of the dislocated hips belonged to a major 'at-risk' group. Statistical analysis confirmed that the risk factors had a relatively poor predictive value if used as a screening test for dislocation. In infants referred for doubtful clinical instability, one dislocation was detected for every 11 infants screened (95% confidence interval (CI) 8 to 17) whereas in infants referred because of the presence of any of the major 'at-risk' factors the rate was one in 75 (95% CI 42 to 149). Routine ultrasound screening of the 'at-risk' groups on their own is of little value in significantly reducing the rate of 'late' dislocation in DDH, but screening clinically unstable hips alone or associated with 'at-risk' factors has a high rate of detection.

Percutaneous intramedullary elastic wiring of displaced diaphyseal forearm fractures in children. A modified technique

Under the age of 11 years there are specific anatomic considerations which favour intramedullary wiring of displaced forearm fractures. The isthmus of radius and ulna is narrow (range = 3-6 mm). The medulla is at its widest proximally in the (ulna) and distally in the radius. These are the optimum entry points for intramedullary progression of the wire. At these points there is a low stress raising effect minimising the risk of iatrogenic fracture. A 1.6 mm Kirschner wire is elastic enough to be prebent into a large radius. It is strong enough to resist deformity on entry, though elastic enough to achieve stability by intramedullary three-point contact. The tip of the wire is prebent to 30 degrees aiding closed reduction of displaced fractures. An oblique 4.5 mm drill hole is made through a < 2 cm skin incision avoiding the epiphysis. This allows the wire to be introduced into the intramedullary canal at an optimum angle of 30 degrees. A smaller hole would not allow intramedullary progression e.g.; in a 2.5 mm hole the angle of insertion would be 55 degrees. Wire is now held with a cannulated T-handle, which is tapped with a hammer thus bouncing the wire of the side wall into the medulla. Rotating the handle aids reducing of displaced fractures. There are advantages to this method over other methods of intramedullary fixation e.g.; Steinman pins, Rush pins, or Nancy nails. Also holds advantage over plating. Over the last 12 months 11 cases were treated by the above methods without significant complications.

The 'black hole' sign: a visual ultrasonographic sign of hip dislocation

Visual analysis of dynamic ultrasonography was employed in the assessment of hip stability in the neonate/infant. The 'black hole' sign visually describes the clearly recognizable ultrasonographic image of hip dislocation/dislocatability. This sign adds objectivity to the technique of visual analysis and is to be recommended.

Ultrasound compared with radiographic assessment in developmental dysplasia of the hip

Two hundred and seventy-two patients 'at risk' for hip dislocation underwent ultrasound examination. From this group 60 patients had ultrasound evidence of DDH (developmental dysplasia of the hip). Thirty-eight of these were also assessed radiographically. The diagnosis of dislocation was more accurate with sonography, where there was only one scan showing an equivocal dislocation (not dislocated on arthrography). On radiographic evaluation there were six cases of equivocal dislocation, and one case which was wrongly diagnosed as dislocation (dysplastic on sonography and arthrogram). A high level of agreement was found between the two methods in the diagnosis of dysplastic and normal hips (88 and 86% respectively). In view of the advantages of sonographic evaluation of the dislocated and dysplastic hip: safe (no ionizing radiation), dynamic and static assessment, accurate (prior to femoral epiphysis ossification) and non-invasive (compared with arthrogram), radiographic and arthrographic assessment of the hip has been largely abandoned in our practice.

Ultrasound screening for congenital dislocation of the hip: a limited targeted programme

Abnormal hips, arising from a clinical universal neonatal hip screening programme, were referred to a specialist paediatric orthopaedic surgeon for ultrasound (US) assessment. Two different methods of US screening were undertaken in consecutive years: (a) Clinically abnormal hips were assessed for dynamic stability without formal assessment of dysplasia; and (b) Morphologic and dynamic assessment was undertaken in clinically abnormal and "at risk" hips. US has been reported as an accurate method for initial diagnosis of instability of the hip joint. The incidence of late congenital dislocation of the hip (CDH) was not reduced by extending the US programme to include "at risk groups" and morphologic assessment of the hips. Morphologic assessment of the hip alone cannot be recommended as a secondary screening programme for the diagnosis of hip dislocation. However, it may be of value in evaluation of persistent dysplasia and its relationship with dislocation. Targeted screening programmes may reduce the rate of late CDH requiring operative procedures; further trials of US are necessary.

Role of ultrasound assessment and harness treatment in the management of developmental dysplasia of the hip

The effect of the introduction of a programme combining clinical hip screening supplemented by limited targeted ultrasound assessment on splintage for developmental dysplasia of the hip (DDH) was evaluated over a 3-year period. The use of ultrasound is of both diagnostic and therapeutic value as it allows monitoring of the effects of splintage and decreases the total treatment time required. In all, 82 dysplastic hips were identified in 65 infants and the period of splintage averaged 6.3 weeks (range 3-12 weeks). The overall splintage rate can also be reduced as hips with only minor dysplasia can be assessed by serial scans until resolution or progression occurs rather than automatic treatment of all abnormal hips and in this series the rate was 6 per 1000 (0.6%). The Wheaton-Pavlik harness is a dynamic light-weight splint which is user friendly, easy to apply and adjust, and with no major complications being encountered in this series. Unnecessary exposure to radiation was reduced as plain radiographs were not performed before ossification of the capital epiphysis; prolonged splintage was prevented and a weaning period from the brace was not used. All children remained under follow-up for 1 year after the hips were confirmed to be clinically and radiologically normal and there were no cases of late re-dislocation or subluxation. There were no cases of avascular necrosis and a markedly reduced need for diagnostic arthrograms, with only two being performed during the 3 years. This regimen has resulted in a low rate of late presenting DDH requiring surgery of 0.28/1000, as well as a low splintage rate of 6/1000 (0.6%). Most of the improvement in the results can be attributed to the more accurate evaluation of DDH by ultrasound, but the absence of avascular necrosis and other complications is likely to be due to the shorter period of time spent in a dynamic splint without the use of excessive abduction.

A clinicopathological study of idiopathic CTEV

Clubfeet were assessed preoperatively, intra-operatively, postoperatively and histologically. There appeared to be a variety of distinct pathobiological groups. A type I/type II fibre area ratio of equal to or greater than 0.9 may be of prognostic value.

Carpometacarpal dislocation: an aid to diagnosis

Although the 'true' lateral radiograph of the hand has improved diagnosis of carpometacarpal dislocation, cases can still be missed if only the carpometacarpal joint area is inspected, as overlap of the adjoining joints can make interpretation difficult. Measurement of the angle between the long axis of the second and fifth metacarpal bones on a true lateral radiograph, in cases of fifth carpometacarpal dislocation is advocated, as the carpometacarpal angle is increased compared with controls (38.5 degrees compared with 9.8 degrees). A lesser increase in the carpometacarpal angle is suggestive of subluxation of this joint and this should be examined under anaesthesia.

Doppler assessment of blood flow to the lower limb associated with total knee arthroplasty

Arterial blood flow was assessed before and after operation by the pressure index method (Doppler ultrasonography), in 51 consecutive patients treated with primary total knee arthroplasty. This method was chosen since it is non-invasive, inexpensive, easy to apply and readily available in most hospitals. It is a sensitive technique for assessing flow in occlusive arterial disease. Moderate arterial disease, correction of moderate knee deformity and tourniquet times of up to 2 h did not significantly affect postoperative blood flow when compared with the preoperative assessment. It can be concluded that total knee arthroplasty did not significantly affect blood flow to the distal leg except in one case of severe occlusive vascular disease.

Pathologic fracture through a solitary enchondroma of the radial diaphysis: case report

Solitary enchondromata are rare but well recognised benign bone tumours. They are extremely rare in the radius. We report the case of a pathologic fracture through a solitary enchondroma in the radial diaphysis and its successful treatment.

V-Y plasty for correction of varus fifth toe

V-Y plasty has been used for greater than 35 years for correction of the varus fifth toe. During this time, there has been no study of the results of this operation on children with long-term follow-up. We report the results of 20 operations in 16 children. The short-term results were good in 70%. However, postoperative review at a mean time of 2 years 1 month showed marked deterioration, with only 30% good results. V-Y plasty is not recommended for correction of the varus fifth toe.

Hemiarthroplasty of the hip and dislocation

A retrospective study was undertaken on 171 patients who had suffered a subcapital fracture of the neck of the femur between 1982 and 1986. The aim was to compare the dislocation rates in bipolar and monopolar endoprostheses. The basic surgical approaches were utilized: the posterior and direct lateral. Four endoprostheses were employed: Thompson's Moore's (monopolar), Monk's 'hard top', and Charnley-Hastings' (bipolar). There was no significant difference in the dislocation rates between monopolar and bipolar devices. It is concluded that the bipolar devices do not offer any additional protection against dislocation when compared with the traditional monopolar devices.