The Pavlik harness (PH) is commonly used to treat infantile dislocated hips. Variability exists in the duration of brace treatment after successful reduction of the dislocated hip. In this study we evaluate the effect of prescribed time in brace on acetabular index (AI) at two years of age using a prospective, international, multicenter database.

We retrospectively studied prospectively enrolled infants with at least one dislocated hip that were initially treated with a PH and had a recorded AI at two-year follow-up. Subjects were treated at one of two institutions. Institution 1 used the PH until they observed normal radiographic acetabular development. Institution 2 followed a structured 12-week brace treatment protocol. Hip dislocation was defined as less than 30% femoral head coverage at rest on the pre-treatment ultrasound or IHDI grade III or IV on the pre-treatment radiograph.

Fifty-three hips met our inclusion criteria. Hips from Institution 1 were treated with a brace 3x longer than hips from institution 2 (adjusted mean 8.9±1.3 months vs 2.6±0.2 months)(p < 0 .001). Institution 1 had an 88% success rate and institution 2 had an 85% success rate at achieving hip reduction (p=0.735). At 2-year follow-up, we observed no significant difference in AI between Institution 1 (adjusted mean 25.6±0.9˚) compared to Institution 2 (adjusted mean 23.5±0.8˚) (p=0.1). However, 19% of patients from Institution 1 and 44% of patients from Institution 2 were at or below the 50th percentile of previously published age- and sex- matched AI normal data (p=0.049). Also, 27% (7/26) of hips from Institution 1 had significant acetabular dysplasia, compared to a 22% (6/27) from Institution 2 (p=0.691). We found no correlation between age at initiation of bracing and AI at 2-year follow-up (p=0.071).

Our findings suggest that prolonged brace treatment does not result in improved acetabular index at age two years. Hips treated at Institution 1 had the same AI at age two years as hips treated at Institution 2, while spending about 1/3 the amount of time in a brace. We recommend close follow-up for all children treated for dislocated hips, as ~1/4 of infants had acetabular index measurements at or above the 90th percentile of normal. Continued follow-up of this prospective cohort will be critical to determine how many children require acetabular procedures during childhood. The PH brace can successfully treat dislocated infant hips, however, prolonged brace treatment was not found to result in improved acetabular development at two-year follow-up.

In response to the COVID-19 pandemic public health measures were implemented to limit virus spread. After initial implementation of a province-wide lockdown (Stage 1), there followed a sequential ease of restrictions through Stages 2 and 3 over a 6-month period from March to September 2020 (Table 1). We aimed to determine the impact of COVID-19 public health measures on the epidemiology of operative paediatric orthopaedic trauma and to determine differential effects of each stage of lockdown.

A retrospective cohort study was performed comparing all emergency department (ED) visits for musculoskeletal trauma and operatively treated orthopaedic trauma cases at a Level-1 paediatric trauma center during Mar-Sep 2020 (pandemic), compared with Mar-Sep 2019 (pre-pandemic). All operative cases were analyzed based on injury severity, mechanism of injury (MOI) and anatomic location (AL). Comparisons between groups were assessed using chi-square testing for categorical variables, and student t-tests and Fisher's exact tests for continuous variables.

During the pandemic period, ED visits for orthopaedic trauma decreased compared to pre-pandemic levels by 23% (1370 vs 1790 patients) and operative treatment decreased by 28% (283 vs 391 patients). There was a significant decrease in the number of operative cases per day in lockdown Stage 1 (1.25 pandemic vs 1.90 pre- pandemic; p < 0 .001) and Stage 2 (1.65 pandemic vs 3.03 pre-pandemic; p< 0.001) but no difference in operative case number during Stage 3 (2.18 pandemic vs 2.45 pre-pandemic; p=0.35). Significant differences were found in MOI and AL during Stage 1 (p < 0 .001) and Stage 2 (p < 0 .001) compared to pre-pandemic. During Stage 1 and 2, playground injuries decreased by 95% and 82%, respectively; sports injuries decreased by 79% and 13%, and trampoline injuries decreased 44% and 43%, compared to pre-pandemic. However, self-propelled transit injuries (bicycles/skateboards) increased during Stage 1 and Stage 2 by 67% and 28%, respectively compared to pre- pandemic. During lockdown Stage 3 there were no differences in MOI nor AL. There were no significant differences in injury severity in any lockdown stage compared to pre-pandemic.

COVID-19 lockdown measures significantly reduced the burden of operative paediatric orthopaedic trauma. Differences in volume, mechanism and pattern of injuries varied by lockdown stage offering evidence of the burden of operative trauma related to specific childhood activities.

These findings will assist health systems planning for future pandemics and suggest that improvements in safety of playgrounds and self-propelled transit are important in reducing severe childhood injury requiring operative intervention.

For any figures or tables, please contact the authors directly.

There is no consensus regarding the optimum frequency of ultrasound for monitoring the response to Pavlik harness (PH) treatment in developmental dysplasia of hip (DDH). The purpose of our study was to determine if a limited-frequency hip ultrasound (USS) assessment in children undergoing PH treatment for DDH had an adverse effect on treatment outcomes when compared to traditional comprehensive ultrasound monitoring.

This study was a single-center non-inferiority randomized controlled trial. Children aged less than six months of age with dislocated, dislocatable and stable dysplastic hips undergoing a standardized treatment program with a PH were randomized, once stability had been achieved, to our current standard USS monitoring protocol (every clinic visit) or to a limited-frequency ultrasound protocol (USS only until hip stability and then end of treatment). Groups were compared based on alpha angle at the end of treatment, acetabular indices (AI) and IHDI grade on follow up radiographs at one-year post harness and complication rates. The premise was that if there were no differences in these outcomes, either protocol could be deemed safe and effective.

One hundred patients were recruited to the study; after exclusions, 42 patients completed the standard protocol (SP) and 36 completed the limited protocol (LP). There was no significant difference between the mean age between both groups at follow up x-ray (SP: 17.8 months; LP: 16.6 months; p=0.26). There was no difference between the groups in mean alpha angle at the end of treatment (SP: 69°; LP: 68.1°: p=0.25). There was no significant difference in the mean right AI at follow up (SP: 23.1°; LP: 22.0°; p=0.26), nor on the left (SP:23.3°; LP 22.8°; p=0.59). All hips in both groups were IHDI grade 1 at follow up. The only complication was one femoral nerve palsy in the SP group. In addition, the LP group underwent a 60% reduction in USS use once stable.

We found that once dysplastic or dislocated hips were reduced and stable on USS, a limited- frequency ultrasound protocol was not associated with an inferior complication or radiographic outcome profile compared to a standardized PH treatment pathway. Our study supports reducing the frequency of ultrasound assessment during PH treatment of hip dysplasia. Minimizing the need for expensive, time-consuming and in-person health care interventions is critical to reducing health care costs, improving patient experience and assists the move to remote care. Removing the need for USS assessment at every PH check will expand care to centers where USS is not routinely available and will facilitate the establishment of virtual care clinics where clinical examination may be performed remotely.

The use of total hip arthroplasty in adolescents for end-stage degenerative hip disease is controversial with few reported outcomes in the literature. The purpose of the study was to report the outcomes of total hip arthroplasty in a cohort of adolescents managed by a multidisciplinary team of paediatric and adult orthopaedic surgeons from a single centre.

A multidisciplinary clinic consisting of paediatric and adult hip surgeons was established in 2013 to identify, treat and prospectively follow adolescents who would potentially beneift from a total hip arthoplasty. To date 29 consecutive adolescent patients (20 female, 9 male, 32 hips) with end stage degenerative hip disease have undergone cementless primary total hip arthroplasty. Mean age at decision to treat was 15.7 years (age 11.4–18.5). Ten different underlying paediatric specific pathologies were documented including DDH, cerebral palsy, JIA, skeletal dysplasias, SCFE and idiopathic chondrolysis. Three patients had bilateral staged procedures. Clinical baseline and outcomes were measured using Oxford Hip Score (OHS), WOMAC score and ASKp scores. Radiographic follow-up was conducted at 6 weeks, 6 months and yearly thereafter. Post-operative complications were recorded.

Twenty-five hips were eligible for minimum 2-year follow-up scoring at a mean 2.7 years (2.0–3.6 years). No intraoperative complications occurred. One case of recalcitrant postoperative psoas tendonitis occured. OHS improved from 25 (7–43) to 41 (23–48). WOMAC improved from 48 (12–8) to 12 (1–44), and ASKp improved from 78% (33–98%) to 93% (73–100%). Radiographic review revealed acceptable alignment of all components with no signs of loosening or wear. No revision of components was required. One patient died at 6 months post op from an unrelated condition.

The early term results of total hip arthroplasty in adolescents from our multidisciplinary program are encouraging. Improvements in quality of life to normal values were seen as were hip scores consistent with satisfactory joint function. Depite the range of complex and varied causes of arthritis seen in this population the establishment of combined paediatric and adult orthopaedic surgical teams appears to be a successful model to manage end-stage degenerative hip disease in adolescents.

Developmental Dysplasia of the Hip (DDH) is the most common orthopaedic disorder in newborns. Whilst the Pavlik harness is one of the most frequently used treatments for DDH, there is immense variability in treatment parameters reported in the literature and in clinical practice, leading to difficulties in standardising teaching and comparing outcomes. In the absence of definitive quantitative evidence for the optimal Pavlik harness management strategy in DDH, we addressed this problem by scientifically obtaining international expert-based consensus on the same.

An initial list of items relevant to Pavlik harness treatment was derived by systematic review of the literature according to PRISMA criteria and reviewed by two expert clinicians in DDH management. Delphi methodology was used to guide serial rounds of surveying and feedback to content matter experts from the International Hip Dysplasia Institute (IHDI), a collaborative group of paediatric orthopaedic surgeons with expertise in the management of DDH. Rounds of surveying continued in the same manner until consensus was reached.

Importance ratings were derived from each round of surveying by calculating median score responses on the 5-point Likert scale for each item. Items requiring clarification or those with a median score of below 4 (“agree”) were modified as needed prior to each subsequent round. Consensus was considered reached when 90% or more of the items had an interquartile range (IQR) of ≤ 1. This value indicates low sample deviation and is accepted as having achieved consensus. This was followed by a corroboration of face validity to derive the final set of management principles.

The literature search and expert review identified an initial list of 66 items in 8 categories relevant to Pavlik harness management. Four rounds of structured surveying were required to reach consensus. Following a final round of face validity, a definitive list of 33 items in 8 categories met consensus by the experts. These items were tabulated and presented as “General Principles of Pavlik Harness Treatment for DDH” and “Pavlik Harness Treatment by Severity of Hip Dysplasia”. Furthermore, highly contentious items were identified as important future areas of study and will be discussed.

We have developed a comprehensive set of principles derived by expert consensus to assist clinicians, and for use as a teaching resource, in the non-operative management of DDH using the Pavlik harness. We have gained consensus on both the general principles of Pavlik harness treatment as well as the detailed treatment of hip subtypes seen across the spectrum of pathology of DDH. Furthermore, this study has also served to generate a list of the most controversial areas in the non-operative management of DDH which should be considered high priority for future study to further refine and optimise the outcomes of children with developmental hip dysplasia.

Introduction

Numerous musculoskeletal and systemic conditions may affect the hips of paediatric patients. While the large majority of patients go on to achieve positive outcomes, a small number will progress to end stage arthropathy with significant functional impairment. Management options have been significantly limited for this population. An adolescent hip arthroplasty program was developed with the aim to improve symptoms and quality of life for patients with pain and disability refractory to joint preserving management strategies.

Simulated learning is increasingly prevalent in many surgical training programs as medical education moves towards competency based curricula. In orthopaedic surgery, developmental dysplasia of the hip is a commonly treated diagnosis where the standard of care in patients less than six months of age is an orthotic device such as the Pavlik Harness. However, despite widespread use of the Pavlik Harness and the potential complications that may arise from inappropriate application, no formal educational methods exist.

A video and model based simulated learning module for Pavlik Harness application was developed. Two novice groups (residents and allied health professionals) were exposed to the module and at pre-intervention, post-intervention and retention testing were evaluated on their ability to apply a Pavlik Harness to the model. Evaluations were completed using a previously validated Objective Structured Assessment of Technical Skill (OSATS) and a Global Rating Scale (GRS) specific to Pavlik Harness application. A control group who did not undergo the module was also evaluated at two time points to determine if exposure to the Pavlik Harness alone would affect ability. All groups were compared to a group of clinical experts who were used as a competency benchmark. Statistical analysis of skill acquisition and retention was conducted using t-tests and ANOVA.

Exposure to the learning module improved resident and allied health professionals' competency in applying a Pavlik Harness (p<0.05) to the level of expert clinicians and this level of competency was retained one month after exposure to the module. Control subjects who were not exposed to the module did not improve nor did they achieve competency.

The simulated learning module has been shown to be an effective tool for teaching the application of a Pavlik Harness and learners demonstrated retainable skills post intervention. This learning module will form the cornerstone of formal teaching for Pavlik Harness application in developmental dysplasia of the hip.

Aim

To compare the rate and severity of avascular necrosis following medial open and closed reduction in developmental hip dysplasia and the resulting influence on femoral and acetabular development.

The first 101 posterior cruciate retaining modular tibial components of a single design performed by a single surgeon in 75 patients were evaluated at a minimum 20-year follow-up. All components were fixed with cement. These patients had been prospectively followed at five-year intervals and evaluated clinically using Knee Society ratings and documenting any need for reoperation. Serial radiographs were evaluated for radiolucencies, osteolysis or component migration until the time of patient death or at minimum 20-year follow-up.

At minimum 20-year follow-up, five knees (5%) had required a revision operation. All revisions occurred greater than 10 years following the index procedures. Benefits of modularity (i.e. retention of the tibial tray) were utilized in three of five cases in this closely followed cohort. Survivorship from any revision was 90.8% at 20 years. For the 16 living patients with 22 knees, the average Knee Society Clinical and Functional scores were 91 and 59, respectively, and the average range of motion was 115 degrees.

When considering gamma irradiated in air polyethylene and a first generation locking mechanism were utilized, these results encourage the authors to continue to use modular tibial trays.

Introduction: The management of deformities of the lower extremity in children with spina bifida is challenging. Surgery is fraught with high complication and recurrence rates. The Ilizarov technique has shown to be a successful tool in the management of complex lower limb deformity. There are few published series in the literature dealing specifically with Ilizarov correction of complex lower limb deformities in spina bifida. In this paper we present our experience of the Ilizarov technique for complex deformities in children with spina bifida.

Methods: From 1989 to 2006, 33 patients with spina bifida underwent 48 corrections of their lower extremity deformity using the Ilizarov technique at one of three tertiary care centres (Royal Children’s Hospital, Melbourne, Australia, Musgrave Park Hospital, Belfast, Northern Ireland and Birmingham Children’s Hospital, Birmingham, UK). Notes were reviewed retrospectively. Patient demographics, indications for surgery, deformity analysis and the extent of surgery were recorded. Complications of the surgery and outcomes were noted.

Results: Group I comprised of 12 fixed knee flexion deformities and one unstable neuropathic joint. Group II comprised 15 external tibial rotational deformities. Group III comprised 20 complex foot deformities. The mean age of the patients was 12.1 years (5.2–20.6 years). Prior to their treatment using the Ilizarov technique patients had undergone a mean of 1.6 previous surgeries (range: 0–5) on the affected limb. The mean duration of treatment in the frame was 9.3 weeks (range: 2–26 weeks). The mean follow-up is 4.0 years (range 0.3–9.0 years). Thirteen problems occurred in the 48 procedures (27.1%). Five obstacles occurred in the 48 procedures (10.4%). Thirteen complications occurred in the 48 procedures (27.1%). Further surgical procedures are either planned, or have been performed, in 8 of the 33 patients (24.2%). Following treatment, all feet were recorded to be plantigrade. All were comfortable in their respective orthoses where appropriate.

Conclusion: Through the pitfalls in treating the complex lower limb deformity in spina bifida, the Ilizarov technique offers a refreshing approach. It offers distinct advantages throughout the treatment period. It modifies both the intraoperative and postoperative environment to address the morbidity of the significant complications associated with the traditional approach to the correction of the limb deformity in the child with spina bifida.

Significance: This is a large series of complex limb reconstruction cases in spina bifida showing excellent results, an acceptable complication rate and recommendations for further use of this technique.

Purpose: In slipped capital femoral epiphysis (SCFE) with increasing slip angle and increasing impingement, pain, stiffness, limping and degenerative change may follow. Currently there are no accepted guidelines to guide management in patients with stable SCFE. The main purpose of this study was to evaluate the proximal femoral geometry in stable SCFE using a postero-anterior radiograph of the hip in the extended position and to determine its use in predicting subsequent surgical management.

Methods: Over a 7 year period, we evaluated the proximal femoral geometry in a consecutive series of 31 adolescents with stable SCFE using the prone extension hip radiograph and statistically analysed the relationship between lateral slip angle (LSA), the morphology of the metaphyseal-epiphyseal (ME) junction, pain and hip range of motion.

Results: The mean age was 13.5 years and statistical analysis shows that ME anatomy is strongly related to LSA and pain. Linear regression analysis shows a strong significant relationship between LSA and hip range of movements.

Conclusions: The prone extension hip x-ray, is capable of accurately predicting the response to a flexion valgus intertrochanteric osteotomy and will clearly demonstrate the degrees of flexion and valgus required to restore the proximal femoral anatomy to allow a more functional range of motion by reducing impingement. The prone extension hip x-ray will also indicate when an additional cheilectomy may be required or alternatively define degrees of proximal femoral deformity which are beyond the scope of intertrochanteric osteotomy and in which a more radical correction at the epiphyseal-metaphyseal junction is required.

Significance: We found the prone extension hip radiograph useful in selecting those hips amenable to management by flexion valgus intertrochanteric osteotomy and other surgical Methods:

Purpose: Few reports are available at minimum 15 year follow-up of cemented modular cruciate retaining TKA, especially where all polyethylene patella components were utilized. This paper addresses the questions “What is the durability of cemented modular cruciate retaining TKA with all polyethylene patella components at 15 years?” and “Did modular tibial trays demonstrate their utility in terms of the potential for less costly and less complex revisions?”

Method: 101 Press Fit Condylar TKA’s were performed consecutively over a 27 month interval and followed prospectively for a minimum of 15 years. The average age at surgery was 72 years. Clinical Knee Society scores, need for revision, radiographic evidence of loosening, and osteolysis were recorded. All patients were recalled at 5 year intervals.

Results: At minimum 15 year follow-up, 34 patients with 45 knees were living and 40 patients with 54 knees were deceased (one patient [2 knees] was lost to follow-up). 81% of living patients had 15 year radiographs. 6 knees were revised (all related to wear and osteolysis). Average Knee Society clinical scores only deteroriated from 92 points to 89 points between 10 and 15 years.

Conclusion: This cemented modular CR TKA performed well at 15 years with only 6% of knees requiring revision. All revisions occurred after 10 years and were related to wear and osteolysis. 2/3 of the revisions could be salvaged without tibial component revision in this closely followed series. Hopefully these results can be improved with better wear-resistant designs and better quality polyethylene. Especially into the second decade, patients with modular tibial tray TKA constructs should be closely followed to optimize their utility allowing less costly and less complex revisions in cases with polyethylene wear.

INTRODUCTION – Tuberosity fractures of the calcaneum are rare injuries. The traditional operative treatment involves open reduction and internal fixation with a tension band wire construct. We have developed a new technique of fixing these fractures with internal fixation using cannulated screws and a figure of eight wire. This paper describes the new technique outlining its advantages and compares the 2 methods of fixation biomechanically to determine their properties with respect to fracture fixation.

METHOD – 20 sections of bovine bone were taken to act as an experimental model for the calcaneum. They were osteotomised to create the posterior process fracture model. 10 were fixed using a traditional tension band wire construct and 10 were fixed using the cannulated screw and wire construct. Each construct was subjected to biomechanical testing to identify the stiffness, energy to failure and load to failure.

RESULTS – During loading the cannulated screw and wire constructs showed a significant increase in stiffness and energy to failure compared to the tension band wire constructs

CONCLUSION – The increased stability of the cannulated screw construct demonstrated by the testing offers biomechanical benefit over the traditional tension band wire construct. This, as well as the improved technical aspects of the cannulated screw fixation, may be beneficial for clinical use.

INTRODUCTION. We conducted a review of the Leeds Regional Bone Tumour Registry for primary bone tumours of the spine since establishment in 1958 until year 2000.

AIM. To analyze the incidence of primary tumours of the spine and to record the site of occurrence, sex distribution, survival and pathology of these tumours.

Summary of the Background Data. Primary tumours of the spine are particularly rare, accounting for between 4% and 13% of published series of primary bone tumours.

METHOD. The Leeds Bone Tumour Registry was reviewed and a total of 2750 cases of bone tumours and tumour-like cases were analyzed. Consultants in orthopaedic surgery, neurosurgery, oncology and pathology in North and West Yorkshire and Humberside contribute to the Registry.

RESULTS. Primary bone tumours of the osseous spine constitute only 126 of the 2,750 cases (4.6%). Chordoma was the most frequent tumour in the cervical and sacral regions, while the most common diagnosis overall was multiple myeloma and plasmacytoma. Osteosarcoma ranked third. The mean age of presentation was 42 years and pain was the most common presenting symptom, occurring in 95% of malignant and 76% of benign tumours. Neurological involvement occurred in 52% of malignant tumours and usually meant a poor prognosis,

CONCLUSIONS. The establishment of Bone Tumour Registries is the only way that sufficient data on large numbers of these rare tumours can be accumulated to provide a valuable and otherwise unavailable source of information for research, education and clinical follow-up.

Purpose: We conducted a review of the Leeds Regional Bone Tumour Registry for primary bone tumours of the axial skeleton since establishment in 1958 until year 2000 to analyze the incidence of primary tumours of the axial skeleton and to record their site of occurrence, sex distribution, survival and pathology.

Method: Primary tumours of the axial skeleton are particularly rare, accounting for between 4% and 13% of published series of primary bone tumours. The Leeds Bone Tumour Registry was reviewed and a total of 2750 cases of bone tumours and tumour-like cases were analyzed. Consultants in orthopaedic surgery, neurosurgery, oncology and pathology in North and West Yorkshire and Humberside contribute to the Registry.

Results: Primary bone tumours of the axial skeleton constitute only 126 of the 2,750 cases (4.6%). Chordoma was the most frequent tumour in the cervical and sacral regions, while the most common diagnosis overall was myeloma. Osteosarcoma ranked third. Mean age of presentation was 42 years. Pain was the most common presenting symptom, occurring in 95% of malignant and 76% of benign tumours. Neurological involvement occurred in 52% of malignant tumours and usually meant a poor prognosis,

Conclusions: The establishment of Bone Tumour Registries is the only way that sufficient data on large numbers of these rare tumours can be accumulated to provide a valuable and otherwise unavailable source of information for research, education and clinical follow-up.