Aims. Early detection of developmental dysplasia of the hip (DDH) is associated with improved outcomes of conservative treatment. Therefore, we aimed to evaluate a novel screening programme that included both the primary risk factors of breech presentation and family history, and the secondary risk factors of oligohydramnios and foot deformities. Methods. A five-year prospective registry study investigating every live birth in the study’s catchment area (n = 27,731), all of whom underwent screening for risk factors and examination at the newborn and six- to eight-week neonatal examination and review. DDH was diagnosed using ultrasonography and the Graf classification system, defined as grade IIb or above or rapidly regressing IIa disease (≥4. o. at four weeks follow-up). Multivariate odds ratios were calculated to establish significant association, and risk differences were calculated to provide quantifiable risk increase with DDH, positive predictive value was used as a measure of predictive efficacy. The cost-effectiveness of using these risk factors to predict DDH was evaluated using NHS tariffs (January 2021). Results. The prevalence of DDH that required treatment within our population was 5/1,000 live births. The rate of missed presentation of DDH was 0.43/1000 live births. Breech position, family history, oligohydramnios, and foot deformities demonstrated significant association with DDH (p < 0.0001). The presence of breech presentation increased the risk of DDH by 1.69% (95% confidence interval (CI) 0.93% to 2.45%), family history by 3.57% (95% CI 2.06% to 5.09%), foot deformities by 8.95% (95% CI 4.81% to 13.1%), and oligohydramnios nby 11.6% (95 % CI 3.0% to 19.0%). Primary risk factors family history and breech presentation demonstrated an estimated cost-per-case detection of £6,276 and £11,409, respectively. Oligohydramnios and foot deformities demonstrated a cost-per-case detected less than the cost of primary risk factors of £2,260 and £2,670, respectively. Conclusion. The inclusion of secondary risk factors within a national screening programme was clinically successful as they were more cost and resource-efficient predictors of DDH than primary risk factors, suggesting they should be considered in the national guidance. Cite this article: Bone Jt Open 2023;4(4):234–240

Universal neonatal screening of developmental dysplasia of the hip (DDH) remains controversial and a few centres have adapted this practice in the United Kingdom. Our institute has established a DDH screening programme for many years. The following shows our result after a recent hospital relocation and changes to the screening programme. All infants born in Coventry are screened for DDH by a clinical examination and ultrasound scan (USS). 5,084 babies were born over a 12-months period. Normal examination and USS were detected in over 90% of the cases. Abnormality detected through either clinical examination or USS was referred to a special orthopaedic/USS clinic. However, in the majority of the cases, subsequent assessments were normal and only 23 babies required treatments. In these cases, the majority had not shown any signs of clinical abnormality. However, serial USS had shown persistent abnormality of at least Graf grade II or higher. The average time from birth to a treatment with a Pavlik Harness was 35 days and the average duration of a treatment was 48 days. Those with Graf III or higher at initial presentation, but spontaneous reduced without treatment were follow-up to one year. The acetabular index in these cases was normal. Apart from one case, all the babies were treated successfully. The unsuccessful cases had a Graf grade IV at the presentation and had shown no sign of improvement on sequential USS. While the sensitivity of detecting DDH through clinical examination remains poor, USS has become an essential tool in our screening programme. Many initial abnormalities are secondary to hip immaturity and they tend to resolve. Those with clinical instability and persistent USS Graf grade II or higher should be treated with early Pavlik Harness. Early detection has led to better results than late diagnosis, and in addition to this, the overall number of operations required could be reduced

Introduction: Ideally any screening system should use a simple reliable test with good intraobserver reproducibility. This is important in DDH as once there is an established abnormality surgical intervention is frequently required. The aim of early detection (within six weeks) is to increase the number of children that may be treated nonoperatively. We have evaluated the effectiveness of our selective screening program by determining the late presentation rate of DDH in our region. Methods: Between January 2001 and December 2003 we looked retrospectively at all patients presenting with DDH in our region. We recorded their age at scan and presentation, the Graf classification if recorded, their management, the presence of risk factors for DDH, referral source and presence of a positive clinical examination. All these were entered into a database and analyzed specifically with regard to patients presenting late. Results: In the period between January 2001 and June 2002 prior to selective ultrasound screening (Group 1) there were 9441 live births and 26 cases of DDH (incidence of 2.75). There were 11 late presenters with an incidence of 1.12 per 1000 per year. Between July 2002 and December 2003 (Group 2) there were 9428 live births and 20 cases of DDH (incidence of 2.12). There were 3 late presenters with an incidence of 0.3 per 1000 per year. Discussion: We have shown that a program of selective ultrasound screening in our region has decreased the number of children presenting late with DDH. It must be remembered however, that in the absence of any risk factors, clinical examination remains critical in identifying those with DDH in a selective screening program

Universal neonatal screening of developmental dysplasia of the hip (DDH) remains controversial and a few centres have adapted this practice in the United Kingdom. Our institute has established a DDH screening programme over the last 19 years. The following shows our result after a recent change in our screening programme protocol. All infants born in Coventry are screened for DDH by a clinical examination and ultrasound scan (USS). 5,084 babies were born over a 12-months period. Normal examination and USS were detected in over 90% of the cases. Abnormality detected through either clinical examination or USS was referred to a special orthopaedic/USS clinic. However, in the majority of the cases, subsequent assessments were normal and only 23 babies required treatment. In these cases, the majority had not shown any signs of clinical abnormality. However, serial USS had shown persistent abnormality of at least Graf grade II or higher. The average time from birth to a treatment with a Pavlik Harness was 35 days and the average duration of a treatment was 48 days. Apart from one case, all the babies were treated successfully. The unsuccessful cases had a Graf grade IV at the presentation and had shown no sign of improvement on sequential USS. No complications were noted. While the sensitivity of detecting DDH through clinical examination remains poor, USS has become an essential tool in our screening programme. Many initial abnormalities are secondary to hip immaturity and they tend to resolve. Those with clinical instability and persistent USS Graf grade II or higher should be treated with early Pavlik Harness. Early detection has led to better results than late diagnosis, and in addition to this, the overall number of operations required could be reduced. Yet, the need for a major surgical intervention has been all but eliminated

The use of targeted ultrasound screening for ‘at risk’ hips in order to reduce the rate of surgery in developmental dysplasia of the hip (DDH) are unproven. A prospective trial was undertaken in an attempt to clarify this matter. Over an 8-year period, there were 28,676 live births. Unstable and ‘at risk’ hips were routinely targeted for ultrasound examination. One thousand eight hundred and six infants were ultrasounded, 6.3% of the birth population. Twenty-five children (18 dislocations and 7 dysplasias) required surgical intervention (0.87 per 1000 births for DDH / 0.63 per 1000 births for dislocation). Targeted ultrasound screening does not reduce the overall rate of surgery compared with the best conventional clinical screening programmes. The development of a national targeted ultrasound screening programme for ‘at risk’ hips cannot be justified on a cost or result basis

Background. In surgeon controlled bundled payment and service models, the goal is to reduce cost but preserve quality. The surgeon not only takes on risk for the surgery, but all costs during 90 days after the procedure. If savings are achieved over a previous target price, the surgeon can receive a monetary bonus. The surgeon is placed in a position to optimize the patients preoperatively to minimize expensive postoperative readmissions in a high risk population. Traditionally, surgeons request that primary care providers medically clear the patient for surgery with cardiology consultation at their discretion, and without dictating specific testing. Our participation in the Bundled Payments for Care Improvement (BPCI) program for total hip and knee replacement surgeries since 1/1/15 has demonstrated a significant number of patients having costly readmissions for cardiac events. Objective. To determine the medical effectiveness and cost savings of instituting a new innovative cardiac screening program (Preventive Cardio-Orthopaedics) for total hip and knee replacement patients in the BPCI program and to compare result to those managed in the more traditional fashion. Methods. The new screening program was instituted on 11/1/17 directed by an advanced cardiac imaging cardiologist (EH). Testing included an electrocardiogram, echocardiogram, carotid and abdominal ultrasound, and coronary computed tomography angiography (CCTA). If needed, a 3 day cardiac rhythm monitor was also performed. Four of the ten physicians in our group performing hip and knee replacement surgeries participated. Charts of readmitted patients were reviewed to determine past medical history, method of cardiac clearance, length and cost of readmission. Results. 2,459 patients had total hip or knee replacement in the BPCI program between 1/1/15 and 10/31/17 prior to instituting the new program. All had complete 90 day postoperative readmission data supplied by the CMS, with 25 (1%) of these patients having readmissions for cardiac events for a total cost of readmissions of %149,686. 14 of 25 had a preoperative clearance by a cardiologist. In 19 of the 25 patients, the only preoperative cardiac screening tool performed was an electrocardiogram. Since instituting the new program, 842 additional surgeries were performed, 463 by the four surgeons involved. 126 patients were agreeable to be evaluated through the Preventive Cardio-Orthopaedics program. 4 patients of the four physicians still screened via the traditional cardiac program had a cardiac event readmission. The average readmission hospital stay was 3.33 days at a total cost of %42,321. 2 patients of the four physicians evaluated by the Preventive Cardio-Orthopaedics program had a cardiac related readmission, at an average hospital stay of 2 days, and at a total cost of %10,091. Conclusions. Risk sharing programs have forced surgeons to take a more active role in optimizing their patients medically; otherwise they will be penalized with a decreased reimbursement. Traditionally, we have abdicated this responsibility to primary care and cardiology physicians but have noted a high cardiac readmission risk. In response, we have begun using a unique cardiac screening model. Our preliminary experience predicts fewer cardiac readmissions thereby improving care, and at a lower cost

Background. The Bundled Payments for Care Improvement (BPCI) was developed by the US Center for Medicare and Medicaid (CMS) to evaluate a payment and service delivery model to reduce cost but preserve quality. 90 day postoperative expenditures are reconciled against a target price, allowing for a monetary bonus to the provider if savings were achieved. The surgeon is placed in a position to optimize the patients preoperatively to minimize expensive postoperative cardiovascular readmissions in a high risk population. Traditionally, surgeons request that primary care providers medically clear the patient for surgery with or without additional cardiology consultation, without dictating specific testing. Typical screening includes an EKG, occasionally an echocardiogram and nuclear stress test, and rarely a cardiac catheterization. Our participation in the BPCI program for total hip and knee replacement surgeries since 1/1/15 has demonstrated a significant number of patients having readmissions for cardiac events. Objective. To determine the medical effectiveness and cost savings of instituting a new innovative cardiac screening program (Preventive Cardio-Orthopaedics) for total hip and knee replacement patients in the BPCI program and to compare result to those managed in the more traditional fashion. Methods. The new screening program was instituted on 11/1/17 directed by an advanced cardiac imaging cardiologist (EH). Testing included an electrocardiogram, echocardiogram, carotid and abdominal ultrasound, and coronary computed tomography angiography (CCTA). If needed, a 3 day cardiac rhythm monitor was also performed. Four of the ten physicians in our group performing hip and knee replacement surgeries participated. Charts of readmitted patients were reviewed to determine past medical history, method of cardiac clearance, length and cost of readmission. Results. 1,361 patients had total hip or knee replacement in the BPCI program between 1/1/15 and 1/28/18 and all had complete 90 day postoperative readmission data supplied by the CMS, with 25 of these patients evaluated through the Preventive Cardio- Orthopaedics program. 12 (0.90%) screened via the traditional cardiac program had a cardiac event readmission. The average readmission hospital stay was 3.67 days at a total cost of $69,378. 7 of 12 had a preoperative clearance by a cardiologist. In 9 of the 12 patients, the only preoperative cardiac screening tool performed was an electrocardiogram. None of these 25 patients evaluated through the new program has been readmitted. 84 more patients have been evaluated in this program since 1/28/18, but 90 day readmission data is still incomplete. Preliminary data suggests that the highest risk in these patients is not severe coronary artery disease, but atrial fibrillation, hypertension with left ventricular hypertrophy, and cardiac plaques with ulceration. Conclusions. Risk sharing programs have forced joint replacement surgeons to take a more active role in optimizing their patients medically; otherwise they will be penalized with a decreased reimbursement. Traditionally, we have abdicated this responsibility to primary care and cardiology physicians but have noted a high readmission risk with a cardiac event. In response, we have begun using a unique cardiac screening model. Our preliminary experience predicts fewer cardiac readmissions thereby improving care, and at a lower cost

From mid-1992 to 2000 and in conjunction with our paediatric department, we have run a screening program to detect congenital orthopaedic abnormalities. Over this period, we have been referred 245 patients with a provisional diagnosis of clubfeet, of these 54 or 22% were true CTEV (78 feet) giving an incidence in the general population of 0.18% while the rest were diagnosed as having simple postural clubfoot (0.6%). Each patient was assessed clinically and classified according to the Harrold and Walker scale as well as being checked for other congenital/neurological abnormalities. 83% of patients were seen within two weeks of referral. Initial management entailed strapping for 6 weeks with further periods of plaster immobilization (required by 46%). Those who failed to respond or who deteriorated underwent surgical correction with sub-talar release. A small percentage required secondary procedures such as Tibialis Anterior transfer, Tendoachillis release and revision. Patients were continued in the program until at least 6 years of age. While there was a wide variation of other abnormalities in those with type 2 CTEV, those with type 3 had a high incidence of neurological conditions and in particular, arthrogryphosis (59%). These patients did worse and 55% required further surgery after the initial sub-talar release. We would like to present the findings of an 8.5 year prospective study looking at the incidence of the condition, the frequency of other abnormalities and the results of conservative and surgical treatment for each grade

The use of targeted ultrasound screening for ‘at risk’ hips in order to reduce the rate of surgery in developmental dysplasia of the hip (DDH) is unproven. A prospective trial was undertaken in an attempt to clarify this matter. Over an 8-year period, there were 28, 676 live births. Unstable and ‘at risk’ hips were routinely targeted for ultrasound examination. One thousand eight hundred and six infants were ultrasounded, 6. 3% of the birth population. Twenty-six children (19 dislocations and 7 dysplasia) required surgical intervention (0. 91 per 1000 births for DDH/0. 66 per 1000 births for dislocation). Targeted ultrasound screening does not reduce the overall rate of surgery compared with the best conventional clinical screening programmes. The development of a national targeted ultrasound screening programme for ‘at risk’ hips cannot be justified on a cost or result basis

The aim of this study was to ascertain the results and effectiveness of targeted screening of babies.

All the newborn babies (30585 births from 1997 to 2002) in the geographical area served by our trust were assessed by the paediatricians (neonatologists) and general practitioners (GP). They were assessed for abnormal hip examination finding including clinical instability and risk factors for DDH. The risk factors were positive family history, abnormal lie or presentation other than vertex during pregnancy or at birth, oligohydramnios or other congenital abnormalities. On referral, they were assessed clinically and by ultrasound (US) scan in a special Hip screening clinic.

The data were obtained prospectively. Over the period of these six years, 2742 babies were examined in the clinic. Many had more than one risk factor or abnormal hip examination finding (15.9% of babies with abnormal hips and 7.4% of babies with normal hips). Only five babies presented at or after 4 months of age (delayed presentation). They had been treated by the GP (1 patient), at a private hospital (1 patient) or were from outside our area (3 patients). All had abnormal hips on clinical examination. Of these, 3 were 3A or 3B Graf grade (US scan), 1 was 2B and another 2A+.

Screening of babies with above risk factors has identified all patients with abnormal hips in our area, thus avoiding late presentation of DDH. Raising awareness of GPs and paediatricians about these factors should also reduce the number babies to be seen in the hip screening clinic to minimum yet safe levels.

Aims. Developmental dysplasia of the hip (DDH) can be managed effectively with non-surgical interventions when diagnosed early. However, the likelihood of surgical intervention increases with a late presentation. Therefore, an effective screening programme is essential to prevent late diagnosis and reduce surgical morbidity in the population. Methods. We conducted a systematic review and meta-analysis of the epidemiological literature from the last 25 years in the UK. Articles were selected from databases searches using MEDLINE, EMBASE, OVID, and Cochrane; 13 papers met the inclusion criteria. Results. The incidence of DDH within the UK over the last 25 years is 7.3/1,000 live births with females making up 86% of the DDH population (odds ratio 6.14 (95% confidence interval 3.3 to 11.5); p < 0.001). The incidence of DDH significantly increased following the change in the Newborn and Infant Physical Examination (NIPE) guidance from 6.5/1,000 to 9.4/1,000 live births (p < 0.001). The rate of late presentation also increased following the changes to the NIPE guidance, rising from 0.7/1,000 to 1.2/1,000 live births (p < 0.001). However, despite this increase in late-presenting cases, there was no change in the rates of surgical intervention (0.8/1,000 live births; p = 0.940). Conclusion. The literature demonstrates that the implementation of a selective screening programme increased the incidence of DDH diagnosis in the UK while subsequently increasing the rates of late presentation and failing in its goal of reducing the rates of surgical intervention for DDH. Cite this article: Bone Jt Open 2023;4(8):635–642

Aims. A national screening programme has existed in the UK for the diagnosis of developmental dysplasia of the hip (DDH) since 1969. However, every aspect of screening and treatment remains controversial. Screening programmes throughout the world vary enormously, and in the UK there is significant variation in screening practice and treatment pathways. We report the results of an attempt by the British Society for Children’s Orthopaedic Surgery (BSCOS) to identify a nationwide consensus for the management of DDH in order to unify treatment and suggest an approach for screening. Methods. A Delphi consensus study was performed among the membership of BSCOS. Statements were generated by a steering group regarding aspects of the management of DDH in children aged under three months, namely screening and surveillance (15 questions), the technique of ultrasound scanning (eight questions), the initiation of treatment (19 questions), care during treatment with a splint (ten questions), and on quality, governance, and research (eight questions). A two-round Delphi process was used and a consensus document was produced at the final meeting of the steering group. Results. A total of 60 statements were graded by 128 clinicians in the first round and 132 in the second round. Consensus was reached on 30 out of 60 statements in the first round and an additional 12 in the seond. This was summarized in a consensus statement and distilled into a flowchart to guide clinical practice. Conclusion. We identified agreement in an area of medicine that has a long history of controversy and varied practice. None of the areas of consensus are based on high-quality evidence. This document is thus a framework to guide clinical practice and on which high-quality clinical trials can be developed. Cite this article: Bone Joint J 2023;105-B(2):209–214

Aims. To monitor the performance of services for developmental dysplasia of the hip (DDH) in Northern Ireland and identify potential improvements to enhance quality of service and plan for the future. Methods. This was a prospective observational study, involving all infants treated for DDH between 2011 and 2017. Children underwent clinical assessment and radiological investigation as per the regional surveillance policy. The regional radiology data was interrogated to quantify the use of ultrasound and ionizing radiation for this population. Results. Evidence-based changes were made to the Northern Ireland screening programme, including an increase in ultrasound scanning capacity and expansion of nurse-led screening clinics. The number of infant hip ultrasound scans increased from 4,788 in 2011, to approximately 7,000 in 2013 and subsequent years. The number of hip radiographs on infants of less than one year of age fell from 7,381 to 2,208 per year. There was a modest increase in the treatment rate from 10.9 to 14.3 per 1,000 live births but there was a significant reduction in the number of closed hip reductions. The incidence of infants diagnosed with DDH after one year of age was 0.30 per 1,000 live births over the entire period. Conclusion. Improving compliance with the regional infant hip screening protocols led to reduction in operative procedures and reduced the number of pelvic radiographs of infants. We conclude that performance monitoring of screening programmes for DDH is essential to provide a quality service. Cite this article: Bone Joint J 2020;102-B(4):495–500

Introduction: Infants referred under the Hip Screening Programme undergo both a clinical and ultrasonic assessment of hip stability. The majority are reviewed for repeat clinical assessment and X-ray of the hips before a diagnosis of DDH will be excluded. If we could safely rely on the ultrasound findings, then the number of children routinely reviewed with a hip radiograph could be reduced. As a result, many children would avoid the unnecessary and potentially harmful exposure to radiation. In addition, the burden on both the Orthopaedic Outpatients Department and the Radiology Department could be eased. Objective: The aim of the study was to assess the sensitivity of the ultrasound screening programme for DDH over a four year period. Study Design: A retrospective review of the 501 infants referred for hip screening between January 1997 and December 2000. Results: 28 patients were treated for DDH during the period of January 1997 to December 2000. Thirteen patients (46.4%) of those treated for DDH were referred via the Hip Screening Programme after their initial baby check by the paediatricians showed that they had a risk factor. The risk factors include Family History, Breech Deliver, and clinical instability. The remaining fifteen patients (53.6%) were referred via GP’s, Health Visitors and Paediatricians, following abnormal clinical findings ranging from ‘clicky hip’, abnormal skin creases, and decreased hip abduction at follow up baby checks. The average age of the infant in this group was 5.5 months. These 15 were diagnosed with X-ray only. All patients (501 patients) referred via the Hip screening programme underwent an ultrasound scan of both hips initially, and a pelvic X-ray 4–6 months after this. We identified 5 cases where the ultrasound had originally been interpreted as normal, yet the infant developed DDH as diagnosed by a later X–ray. Five infants (38.5%) of the thirteen diagnosed with DDH via the screening programme is unacceptable. These five infants could easily have been missed until they were a lot older, and subsequently their prognoses would have been worse. Three (20%) of the fifteen patients diagnosed with DDH which were not referred via the Hip Screening Programme had an identifiable risk factor at birth, yet were not sent for orthopaedic review and ultrasound examination via the Screening Programme. Conclusion: Normal ultrasound scan does not exclude a subsequent diagnosis of Developmental Dysplasia of the hip. X-ray is still considered the gold standard in assessing a child’s hips. Both the performance and interpretation of the hip ultrasound is skill with a steep learning curve and, for the meantime, will have to go hand in hand with pelvic X-rays in diagnosing DDH

Objective: The aim of this study was to show the effect of a universal (all neonates) ultrasound screening in newborns on the incidence of operative treatment of hip dysplasia. Materials: A retrospective study was performed and all newborns of the county Tyrol (Austria) between 1978 and 1998 (8257 births / year ((range: 7766 – 8858)) were reviewed regarding hip dysplasia and following hip surgeries. Between 1978 and 1983 clinical examination alone was performed to detect hip dysplasia. Between 1983 and 1988 an ultrasound screening programme according to Graf was initiated in our county. Between 1988 and 1998 ultrasound screening was performed in all newborns. Hence two observation periods were determined: 1978–1983 and 1993–1998. The time period between 1983 and 1993 was excluded to minimize bias and learning curve regarding the initiation of the ultrasound screening programme. A retrospective comparative analysis of the two observation periods regarding surgical treatment and costs caused by hip dysplasia was performed. During the observation period indication for surgery did not change, however new treatment techniques were introduced. Patients with neuromuscular and Perthes diseases were excluded. According to age dependent surgical procedures three patient samples were determined: Group A: 0–1.5 years, Group B: 1.5–15 years and Group C: 15–35 years. Results: Comparison of the two observation periods showed no influence on the number of interventions for dysplastic hips in group C (pelvic osteotomies and VDROs). In group A, a decrease of hip reductions was seen from 25.6±3.2 to 7.0± 1.4 cases per year. In group B, there was a decrease of operative procedures for dysplastic hips from 18.0±3.2 to 3.4±1.3 interventions per year. Since the introduction of universal hip ultrasound screening the decrease of the total number of interventions for all groups was 78.6%. Comparison of costs of the two observation periods showed an increase of all costs caused by DDH and CDH of 57.000 euro/ year for the time period between 1993 and 1998 which was mainly caused by the ultrasound screening programme. There was a significant reduction of costs regarding operative and non operative treatment for dysplastic hips from 410.000 euro (1978–1983) to 117.00 euro (1993–1998). Conclusion: Initially there were higher costs caused by the screening method, but on the other hand total number and costs for operative and nonoperative treatment of dysplastic hips were significantly reduced by the universal ultrasound screening programme. In our mind patient’s and family distress and pain related to interventions performed for CDH and DDH justify the slight increase of costs caused by the universal screening programme. We therefore recommend universal hip ultrasound screening for neonates

Introduction: There is some debate about the pros and cons of selective screening of DDH in neonates as opposed to general screening. General screening puts a lot of stress on the resources available, especially in the modern day NHS, but the advocates state that this minimises the cost incurred in treating a missed DDH (by selective screening) with surgery later on. Aim: The aim of this retrospective study was to find out the effectiveness of the Southampton selective screening of babies with risk factors for DDH by finding out the number of patients presenting late with an established DDH. Materials And Methods: 6116 babies out of 26,932 live births (22.7%) in Southampton were screened between 1998 and 2003. The details of the individual outcomes and the reasons for the late presentation were obtained from the patient notes and the records of the screening program which are maintained in the clinics and by the senior author. Results: 248 new patients had Pavlik’s harness fitted for the treatment of DDH which presents a treatment rate of 0.92%. 8 patients (0.03%) presented late because they did not undergo ultrasound scanning as they did not have the risk factors as required by this selective program. 10 (0.036%) failed Pavlik’s and needed late surgery to have their DDH treated. The total operation rate was 0.066%. Discussion: The late presentation of patients in this screening program is very low and comparable to the other papers from this department and from around the world. The cost implications of treating these 8 late presenting patients was found to be a lot cheaper than carrying out a general screening program which would mean, in this case 4 times more than the cost of the present screening program

The aim of our survey was to study the current practice to manage DDH in UK by the members of the British Society for Children's Orthopaedic Surgery. An online questionnaire link to ask about the management of DDH was emailed to 204 members of the British Society for Children's Orthopaedic Surgery. The response rate was 39%. 73% respondents have a local screening programme, 19% screen only high risk children and 8% had no screening programme. Pavlik harness was used by 87% respondents for Graf Type 2, 96% for Graf type 3 and 90% for Graf type 4. 14% respondents will only observe for Graf Type 2. 36% respondents will follow up children every week, 45% every 2 weeks, 3% every 3 weeks, 9% every 4 weeks, 4% every 6 weeks and 3% will decide the follow up according to severity of DDH and treatment.1.3% respondents will follow up these patients for 6 months, 13% for 12 months, 10.5% each for 24 months, 36 months, 48 months and 50% until skeletal maturity. After the failure of initial splintage, 7% respondents will consider surgery immediately, 13.5% at 3 months, 36.5% at 6 months, 4% at 9 months, 28% at 12 months, 5.4% according to HIP-OP Trial and 5.6% according to the situation. There was no consensus about the treatment of DDH. 73% respondents have a local screening programme. The most common splintage method used was Pavlik harness. 45% respondents will follow up children every 2 weeks following the start of treatment. 50% respondents will follow up these patients until skeletal maturity. 36% respondents will consider surgery at 6 months following the failure of splintage. This survey highlights the fact that the management of DDH is an art based on the scientific evidence, parent's choice and personal expertise

Total joint arthroplasty is commonly associated with post-operative anemia. Blood conservation programs have been developed to optimise patients prior to surgery. Epoetin Alfa (Eprex) or intravenous (IV) iron transfusions are two modalities that can be used pre-operatively to optimise hemoglobin and ferritin levels. There are, however, potential complications and increased costs associated with their use. Oral iron is a less costly option for those undergoing surgery but requires more time to take effect. There are no studies to date that examine the effects of an early screening program utilising oral iron supplementation prior to total joint arthroplasty. The purpose of this study is to evaluate the effect of implementing early pre-operative oral iron supplementation on patients prior total joint arthroplasty. A retrospective review of patients undergoing total joint arthroplasty was performed using our institution clinical informatics database. We identified all patients seen in pre-admission clinic (PAC) between Jan 1, 2009 and March 31, 2010 representing our control group. We then identified all patients seen in PAC between October 1, 2012 and December 31, 2013. Patients in this cohort received screening blood work when booked for surgery, and oral iron supplementation was given to patients with hemoglobin of less than 135g/L or ferritin less than 100ug/L, thus representing our treatment group. Patients undergoing revision, uni-compartment knee arthroplasty and bilateral arthroplasties were excluded from the study. Pearson Chi-Square tests were used to calculate significance between groups with main outcomes including pre-admission hemoglobin, and pre-operative requirements for Eprex or IV iron. In our control group, we identified 354 patients (25.6%) with hemoglobin less than 130 g/L at time of pre-admission clinic. In our treatment group, this number dropped significantly to only 16.4% of patients (p<0.005). Implementation of an early screening program using oral iron supplementation resulted in a decrease in the number of patients with hemoglobin lower than 130 g/L at the time of pre-admission clinic. There was also a significant decrease in the use of Eprex and IV iron pre-operatively in the patients in the early screening program. These results encourage the use of early oral iron supplementation for patients with hemoglobin less than 135 g/L or ferritin less than 100ug/L in order to optimise patients prior to total joint arthroplasty

Aims. Open reduction in developmental dysplasia of the hip (DDH) is regularly performed despite screening programmes, due to failure of treatment or late presentation. A protocol for open reduction of DDH has been refined through collaboration between surgical, anaesthetic, and nursing teams to allow same day discharge. The objective of this study was to determine the safety and feasibility of performing open reduction of DDH as a day case. Methods. A prospectively collected departmental database was visited. All consecutive surgical cases of DDH between June 2015 and March 2020 were collected. Closed reductions, bilateral cases, cases requiring corrective osteotomy, and children with comorbidities were excluded. Data collected included demographics, safety outcome measures (blood loss, complications, readmission, reduction confirmation), and feasibility for discharge according to the Face Legs Activity Cry Consolidability (FLACC) pain scale. A satisfaction questionnaire was filled by the carers. Descriptive statistics were used for analysis. Results. Out of 168 consecutive DDH cases, 16 patients fit the inclusion criteria (age range 10 to 26 months, 13 female). Intraoperative blood loss ranged from "minimal" to 120 ml, and there were no complications or readmissions. The FLACC score was 0 for all patients. The carers satisfaction questionnaire expressed high satisfaction from the experience with adequate information and support provided. Conclusion. Open reduction in DDH, without corrective osteotomy, is safe and feasible to be managed as a day case procedure. It requires a clear treatment pathway, analgesia, sufficient counselling, and communication with carers. It is even more important during the COVID-19 pandemic when reduced length of hospital stay is likely to be safer for both patient and their parents. Cite this article: Bone Joint Open 2021;2(4):271–277

Introduction. There is little evidence surrounding the clinical implications of a diagnosis of IIa hip dysplasia with no consensus as to its efficacy as a predictor pathological dysplasia or treatment. Therefore, we evaluated the importance of categorising 2a hip dysplasia in to 2a- and 2a+ to better understand the clinical outcomes of each. Methods. A 9-year retrospective cohort study of patients with a diagnosis of type IIa hip dysplasia between 2011 – 2020 (n=341) in our centre. Ultrasound scans were graded using Graf's classification, assessment of management and DDH progression was completed through prospective data collection by the authors. Results. The prevalence of IIa hip dysplasia within our population was 6.7/1000 live births. There was significantly higher incidence of treatment in the IIa- (31.4%, n=17/54) group when compared to the 2a+ group (10%, n=28/287), (p<0.01). In those that had an abnormality (torticollis and/or foot abnormality) treatment rates (24% n=7/29) were significantly (p<0.05) higher than those without anatomical abnormality (15%, n=48/312). Conclusion. This study has demonstrated the significant clinical impact of a IIa- diagnosis on progression to pathological dysplasia and therefore higher rates of treatment in IIa- hips. Furthermore, we have demonstrated the importance of detection of IIa hips through a national screening program, to allow for timely intervention to prevent missing the acetabular maturation window. Therefore, it is our recommendation that all patients with additional anatomical abnormalities and those with a diagnosis of type IIa- hip dysplasia be considered for immediate treatment or urgent follow up following their diagnosis to prevent late conservative intervention