The UK falls behind other European countries in the early detection of Developmental Dysplasia of the hip (DDH) and there remains controversy surrounding screening strategies for early detection. Clinical detection of DDH is challenging and recognised to be dependent on examiner experience. No studies exist assessing the number of personnel currently involved in such assessments.

Our objective was to study the current screening procedure by studying a cohort of new-born babies in one teaching hospital and assess the number of health professionals involved in neonatal hip assessment and the number of examinations undertaken during one period by each individual.

This was a retrospective observational study assessing all babies born consecutively over a 14-week period in 2020. Record of each initial baby check was obtained from Maternity or Neonatal Badger. Follow-up data on ultrasound or orthopaedic outpatient referrals were obtained from clinical records.

1037 babies were examined by 65 individual examiners representing 9 different healthcare professional groups. The range of examinations conducted per examiner was 1- 97 with a mean of 15.9 examinations per person. 49% individuals examined 5 or less babies across the 14 weeks, with 18% only performing 1 examination. Of the 5 babies (0.48%) treated for DDH, one was picked up on neonatal assessment.

In a system where so many examiners are involved in neonatal hip assessment the experience is limited for most examiners. It is unsurprising that high current rates of late presentation of DDH are observed locally, which are in accordance with published national experience.

Mirels’ score predicts the likelihood of sustaining pathological fractures using pain, lesion site, size and morphology. The aim is to investigate its reproducibility, reliability and accuracy in upper limb bony metastases and validate its use in pathological fracture prediction.

A retrospective cohort study of patients with upper limb metastases, referred to an Orthopaedic Trauma Centre (2013–18). Mirels’ was calculated in 32 patients; plain radiographs at presentation scored by 6 raters. Radiological aspects were scored twice by each rater, 2-weeks apart. Inter- and intra-observer reliability were calculated (Fleiss’ kappa test). Bland-Altman plots compared variances of individual score components &total Mirels’ score.

Mirels’ score of ≥9 did not accurately predict lesions that would fracture (11% 5/46 vs 65.2% Mirels’ score ≤8, p<0.0001). Sensitivity was 14.3% &specificity was 72.7%. When Mirels’ cut-off was lowered to ≥7, patients were more likely to fracture (48% 22/46 versus 28% 13/46, p=0.045). Sensitivity rose to 62.9%, specificity fell to 54.6%. Kappa values for interobserver variability were 0.358 (fair, 0.288–0.429) for lesion size, 0.107 (poor, 0.02–0.193) for radiological appearance and 0.274 (fair, 0.229–0.318) for total Mirels’ score. Values for intraobserver variability were 0.716 (good, 95% CI 0.432–0.999) for lesion size, 0.427 (moderate, 95% CI 0.195–0.768) for radiological appearance and 0.580 (moderate, 0.395–0.765) for total Mirels’ score.

We showed moderate to substantial agreement between &within raters using Mirels’ score on upper limb radiographs. Mirels’ has poor sensitivity &specificity predicting upper limb fractures - we recommend the cut-off score for prophylactic surgery should be lower than for lower limb lesions.

Prophylactic pinning of the contralateral hip in unilateral Slipped Upper Femoral Epiphysis (SUFE) persists as a source of debate with the majority of surgeons selecting this option in a proportion of patients whom they regard as at increased risk of a subsequent slip.

Universal prophylactic pinning was introduced in our region in 2005 after an audit of ten years local practice identified 25% of unilateral cases presented with a subsequent slip. This study reports our experience between 2005 and 2020.

In this prospective study, 44 patients presented with 55 affected hips compared with 60 patients with 67 affected hips in the original study. Two patients were excluded as their initial slip had not been treated in our unit. Of the 42 hips seven were bilateral, 34 of the 35 unilateral hips underwent prophylactic pinning. The one exception subsequently underwent prophylactic pinning due to developing pain.

Consistent with our original series, at a minimum follow up of 13 months there have been no complications of infection, fracture, chondrolysis or avascular necrosis subsequent to prophylactic pinning.

Over 25 years 70 patients have undergone prophylactic pinning without complication. On the premise that 25% of our unpinned hips presented with subsequent slips before instituting our policy we estimate that we have prevented 17 subsequent slips over 25 years including the consequences which can be significant. We continue to advocate universal prophylactic pinning as an effective and safe practice in the management of SUFE.

Historically avoidance of avascular necrosis (AVN) has been the primary objective in the management of an acute unstable slipped upper femoral epiphysis (SUFE). When achieved through pinning in situ it was invariably associated with significant malunion. With increasing appreciation of the consequences of femoroacetabular impingement, modern techniques aim to correct deformity and avoid AVN.

Exactly what constitutes an acute unstable SUFE is a source of debate but should represent 5–10% of all cases.

This audit reviewed cases over the past 25 years treated in one region. Of 89 patients with 113 slips, 21 hips were recorded as unstable. During this period the management has evolved from closed reduction and stabilization through pinning in situ, to open reduction.

Radiographic outcomes following these three treatment methods were compared with record of any subsequent surgery in the form of osteotomy or total hip arthroplasty.

Currently the lowest reported incidence of AVN in patients with an acute unstable slip is associated with the Parsch technique which combines open arthrotomy, digital reduction and screw fixation. Early outcomes with this technique are in accordance with those reported in the literature and represents a significant improvement in outcome when compared to earlier techniques used in the management of the severe unstable SUFE.

Prophylactic fixation of the contralateral hip in cases of unilateral slipped capital femoral epiphysis (SCFE) remains contentious. Our senior author reported a 10 year series in 2006 that identified a rate of subsequent contralateral slip of 25percnt; when prophylactic fixation was not performed. This led to a change in local practice and employment of prophylactic fixation as standard. We report the 10 year outcomes following this change in practice.

A prospective study of all patients who presented with diagnosis of SCFE between 2004 and 2014 in our region. Intra-operative complication and post-operative complication were the primary outcomes. 31 patients presented during the study period: 16 male patients and 15 female patients. The mean age was 12.16 (8–16, SD 2.07). 25 patients had stable SCFE and 5 had unstable SCFE. Stability was uncertain in 1 patient. 25 patients had unilateral SCFE and 6 had bilateral SCFE. 24 patients who had unilateral SUFE had contralateral pinning performed. 1 unilateral SCFE did not have contralateral pinning performed as there was partial fusion of physis on contralateral side.

In the hips fixed prophylactically there was 1 cases of transient intraoperative screw penetration into the joint and 1 case of minor wound dehiscence. There were no cases or chondrolysis or AVN. There were no further contralateral slips. This change in practice has been adopted with minimal complication. The fixation of the contralateral side is not without risk but by adopting this model the risk of subsequent slip has been reduced from 25percnt; to 0percnt;.

Following the neonatal examination the 6–8 week ‘GP check’ forms the second part of selective surveillance for developmental dysplasia of the hip (DDH) in the UK. We aim to investigate the effectiveness of this 6–8 week examination for DDH.

This is a observational study including all infants born in our region over 5 years. Early presentation was defined as diagnosis within 14 weeks of birth and late presentation after 14 weeks. Treatment record for early and late DDH as well as referrals for ultrasound (US) following the 6–8 week check were analysed. The attendance at the 6–8 week examination in those patients who went on to present with a late DDH was also analysed.

23112 live births, there were 141 confirmed cases of DDH. 400 referrals for ultrasound were received from GP; 6 of these had a positive finding of DDH. 27 patients presented after 14 weeks and were classified as late presentations. 25 of these patients had attended the 6–8 week examination and no abnormality had been identified. The sensitivity of the examination was 19.4%, its specificity was 98% and it had a positive predictive value of 1.5%

For many years the 6–8 week ‘check’ has been thought of as a safety net for those children with DDH not identified as neonates, however we found that 4 out of every 5 children with DDH were not identified. It is essential efforts are made to impove detection as the long term consequences of late presentation can be life changing.

The initial management of slipped upper femoral epiphysis (SUFE) can determine the occurrence of longterm disability due to complications. Previous surveys have concentrated on orthopaedic surgeons with a specialist paediatric interest. In many units in Scotland, the initial responsibility for management may be an admitting trauma surgeon with a different subspecialty interest.

All Orthopaedic surgeons in Scotland participating in acute admitting were invited to complete a web based survey to ascertain current practice in the initial management of adolescents presenting with SUFE.

92/144 (64%) of surgeons approached responded. When faced with a severe stable slip, 53% of respondents were happy to pin in situ, whilst 47% would refer either to a colleague or specialist paediatric unit. With an unstable slip of similar magnitude, 38% would self-treat, 18% refer to a colleague and 44% refer to a paediatric orthopaedic unit. Of those treating, 58% stated their treatment was selected irrespective of timing of presentation. 79% of respondents had treated 5 or less cases in the preceding 5 years with 7% more than 10 cases. Universal prophylactic pinning was supported in 29%, selective in 62% and never in 9%.

The responses obtained confirm the variance in management of SUFE that exists amidst acute admitting units in Scotland. Management of a stable slip is uncontroversial except possibly in severe cases. This contrasts with the acute unstable slip, in which various factors are thought to influence the outcome, such as instability and the issue of timing, which are not universally appreciated.

Introduction

Catastrophic neck injury is rare in rugby, however the consequences are invariably devastating. Schoolboys have previously been identified as a group at risk. This study came about as a result of a recent increase in admissions of schoolboy rugby players to the National spinal injuries unit in Glasgow.

Introduction

Prophylactic pinning of the contralateral hip in the treatment of slipped upper femoral epiphysis (SUFE) has been shown to be safer than continued observation of the contralateral hip. This treatment remains controversial due to the potential for harm caused to an apparently unaffected hip.

There is evidence that pinning of an already slipped epiphysis causes growth disturbance of the proximal femur, however this has been questioned in that the slip occurs at the hypertrophic layer of the growth plate with no damage to the germative layer.

Prophylactic pinning of the contralateral hip in the treatment of slipped upper femoral epiphysis has been shown to be safer than continued observation of the contralateral hip. This treatment remains controversial due to the potential for harm caused to an apparently unaffected hip. There is evidence that pinning of an already slipped epiphysis causes growth disturbance of the proximal femur, however Hagglund showed that there is not necessarily growth arrest at the physis after pinning, as the slip occurs at the hypertrophic layer of the growth plate with no damage to the germative layer. This was confirmed by Guzzanti who confirmed that a single screw provided epiphyseal stability and preserved potential for growth. We conducted a pilot study to determine whether prophylactic pinning affects subsequent growth of the unaffected hip.

In order to determine the effect of prophylactic pinning we compared radiographs skeletally mature patients who had either undergone the procedure (group 1), not undergone the procedure but had pinning of the affected side (group 2), and adults with no history of SUFE (group 3). We measured the articulo-trochanteric distance and calculated the ratio of the trochanteric-trochanteric distance to articulo-trochanteric distance. These measures have been used in previous studies and shown to be reliable indicators of disturbed proximal femoral growth. As this was a pilot study we recruited 8 to each group.

The absolute sum of the ATDs were 219mm (average 27.3mm) Group 1, 213mm (average 26.6mm) Group2 and 258mm (average 32.5mm). The average trochanter-trochanter: ATD ratio in group 1 was 2.7 (1.9 - 3.8) compared to 2.7 (2.3 - 3.2) and 2.3 (1.9 - 2.7) in groups 2 and 3 respectively.

Our results suggest no difference in subsequent growth between hips that are prophylactically pinned and those that are not. They also show that unpinned hips go on to grow abnormally when compared to normal hips suggesting perhaps sub-clinical SUFE.

These results have prompted expansion of the study to include much a higher number of patients.

The consequences of the complications associated with the management of slipped upper femoral epiphysis are a major source of disability in young adults. Whilst the management of chondrolysis, avascular necrosis or malunion of the femoral neck is usually undertaken by paediatric orthopaedic surgeons the initial management of SUFE in many regions is as part of an adult trauma service. This retrospective audit assessed the outcome of the management of SUFE in one such health region in which treatment occurred at three sites by a number of surgeons of varying experience, during the period July 1994 to June 2004. The aim was to compare our outcomes with those published and to identify whether our service should be altered as a consequence.

The case notes and x-rays as recorded in theatre records were retrieved. Of the 64 cases that were treated during this period adequate records for 60 patients were available. Of these 60 patients there were 7 bilateral cases. Fixation in all 67 cases was by a single cannulated screw. In the 53 unilateral cases 17 underwent prophylactic pinning, the remaining 36 remained under observation. Of these nine patients presented with subsequent slips, eight of which were unstable and two had slip angles greater than 60° in which one developed avascular necrosis. Four other cases of avascular necrosis were observed (incidence 6%). Chondrolysis occurred in one patient with persistent pin penetration. In the remaining 73 cannulated screws used for stabilisation and 17 for prophylactic fixation no complications were observed.

The complication rates observed in this series are within those accepted in the literature. The high incidence of subsequent slips and the attendant severity of these when compared with the relative safety of contemporary cannulated screw fixation has led us to recommend prophylactic pinning in our region.

Introduction: The Pavlik harness is widely used in the management of developmental dysplasia of the hip and its efficacy in the treatment of instability and acetabular dysplasia is well established. There are some hips which although reducible consistently fail to stabilise in a harness irrespective of the age of application. We report three cases in which through altering the method of application of the harness, stability and subsequent normal development was achieved.

Method: Three patients age one week, six weeks and twelve weeks failed to stabilise in a harness applied in the conventional fashion. By rerouting the posterior “abduction strap” in front of the anterior “flexion” strap and attaching it as usual distally we observed improved abduction and more restriction of movement such that the unstable hip was held reduced. Reduction was confirmed by anterior ultrasound. The harness was converted back to the conventional application at four weeks by which time all of the hips had stabilised clinically. It was retained for a further eight weeks.

Results: Significant dysplasia was evident in all three hips at presentation ( alpha angles 32, 48 and 34). At average follow up of 23 months all hips were concentrically reduced with no significant persisting dysplasia nor evidence of avascular necrosis.

Discussion: Early reduction and stabilisation of the femoral head in DDH is important if subsequent intervention is to be minimised and it has been suggested that the more rigid Von Rosen splint is more effective than the Pavlik in achieving this. Our early experience with this simple modification has been successful in treating three unstable hips which would otherwise have failed splintage in our hands. We recommend it as an option to consider in the unstable hip, in conjunction with anterior ultrasound to confirm that reduction has been achieved from the outset.

Introduction: The consequences of the complications associated with the management of slipped upper femoral epiphysis are a major source of disability in young adults. Whilst the management of chondrolysis, avascular necrosis or malunion of the femoral neck is usually undertaken by paediatric orthopaedic surgeons the initial management of SUFE in many regions is as part of an adult trauma service. This retrospective audit assessed the outcome of the management of SUFE in one such health region in which treatment occurred at three sites by a number of surgeons of varying experience. The aim was to compare our outcomes with those published and to identify any local issues.

Method: Review of case notes and xrays of all patients treated over a ten year period as recorded in theatre records. Fixation in all cases was by a single cannulated screw.

Results: Of the 64 cases that presented during this period adequate records for 60 patients were retrieved. 75 slips were recorded, 15 of which were bilateral. In 17 patients prophylactic pinning was performed in the remaining 43 patients nine presented with subsequent slips. Of these, eight were unstable of which two had slip angles greater than 60°, in one of these avascular necrosis developed. Three other cases of avascular necrosis occurred (incidence 5%) all in unstable slips. Chondrolysis occurred in one patient with persistent pin penetration. In the remaining 91 cannulated screws that were inserted no complications were observed.

Discussion: The complication rates observed in this series are within those accepted in the literature. The high incidence of subsequent slips and the attendant severity of these when compared with the relative safety of contemporary cannulated screw fixation has lead us to recommend prophylactic pinning in our region.

Aim: Alcohol-abuse is a well-recognised problem in the West of Scotland. This retrospective case-note study aims to assess the presentation, management and early outcome of alcohol-abusing patients sustaining displaced intracapsular fractures compared to age-matched controls.

Methods: Patients were identified from a prospectively-collected database of trauma admissions from 1998 to 2002. Alcohol-abuse was defined by documented evidence of excessive and chronic alcohol intake.

Results: 35 alcohol-abusing patients under the age of 65 (mean age 57.5 years) with displaced intracapsular fractures were identified and followed-up for a mean of 3.87 years, and compared with 39 age-matched controls (mean follow-up 3.35 years).

There was a significant difference between groups in interval between injury and surgery, with alcohol-abusers undergoing surgery 40.2 hours after injury compared to 22.2 hours for controls (p=0.039). Post-operative stay was also significantly different, with discharge at 7.0 and 5.0 days post-operatively for abusers and controls respectively (p=0.002). 26% of abusers required increased level of care after discharge compared with 15% of non-abusers, although this did not reach statistical significance.

Reduction and fixation was employed in 26 alcohol-abusing patients and 30 controls. Early postoperative complications were similar in both groups with the exception of delirium tremens (17% of abusers). Of patients treated with internal fixation, four patients in the alcohol-abuse group required revision surgery (15%) compared to three of the control group (10%, no significant difference). Two patients within the abusers group developed avascular necrosis (7.7%) compared to three within the control population (10%, no significant difference); only two of these five required revision surgery with femoral head replacement.

During the follow-up period, alcohol-abusers had a five-fold higher rate of subsequent fractures of their contralateral hip or elsewhere (p=0.02).

Conclusions: Alcohol-abusing patients with displaced intracapsular fractures have an increased economic burden compared to controls requiring longer inpatient stays and more frequent subsequent fractures. However, despite increased intervals between injury and surgery, this study finds no evidence that they are at greater risk of failure of internal fixation as compared to controls.