Aims & Background

Congenital Talipes Equinovarus (CTEV) is the most common congenital musculoskeletal birth defect affecting 1 in 1000 births per annum. We have compared our surgical results to the British Society of Children's Orthopaedics (BSCOS) published guidelines

Background

Patients who undergo elective hip and knee arthroplasty often have multiple risk factors increasing their likelihood of suffering from hyponatraemia post operatively. Consequently suffering from hyponatraemia post elective hip and knee arthroplasty is common. Consequently we wanted to assess the occurrence of hyponatraemia in our elective arthroplasty unit, assess our effectiveness in managing this and importantly assess how its occurrence impacted on length of patient stay.

Purpose

This 20-year prospective longitudinal observational study aims to determine the incidence of pathological developmental dysplasia of the hip (DDH) in children referred with clicky hips and define the risk posed to inform neonatal hip screening programmes including the role of ultrasound.

Purpose

To clarify the true association with pathological DDH and ASC (asymmetrical skin crease).

Purpose

There is concern that the positive predictive value (PPV) of neonatal screening for instability may have deteriorated over recent years, this study aims to evaluate this.

The aim was to assess the value of the GP 6–8 week hip examination.

In a 15-year prospective observational longitudinal cohort study, every infant referred by the GP with suspected pathological developmental dysplasia of the hip (DDH) had their hip joints clinically and sonographically examined in a specialist hip screening clinic. Graf Type IV and dislocated hips were classified as pathological. Screening failures were defined as those who had not been identified by the 6–8 week check and presented with late instability. Secondary univariate and multivariable analysis was performed to determine which clinical findings are predictive of instability.

64,518 infants underwent the 6–8 week GP check. Of 176 referrals, 5 had pathological hips. 13 screening failures, presented between the ages of 17 and 80 weeks. The 6–8 week check has a sensitivity of 28% and a specificity of 99.7%.

Univariate analysis revealed positive Ortolani tests and patients referred as ‘unstable hip’ to be significant predictors of hip pathology. Clicky hips, asymmetric skin creases, and leg length inequality were not predictive of pathological hips. A multivariable model showed a positive Ortolani test to be the sole independent predictor of instability at 6–8 weeks.

This is the first attempt to test the validity of the 6–8 week GP clinical hip check. A low rate of hip pathology was identified. The high rate of false negatives raises questions about the value of screening at this age. At 6–8 weeks, clinical signs of hip instability are unreliable as hips become irreducible and stiff.

Based on our findings, we recommend that at 6–8 weeks, referrals are only made if the Ortolani test is positive. We advocate the reintroduction of the 8-month check, including an assessment for limited hip abduction, which may improve the detection rate of those missed by initial screening.

Aim:

An assessment of the relationship between pathological Developmental Dysplasia of the Hip (DDH) and Congenital Talipes Equinovarus (CTEV).

Aim

Assess the incidence of Vitamin D deficiency from a cohort of new referrals to a general Paediatric Orthopaedic outpatient clinic and evaluate the relationship between Vitamin D deficiency and the diagnosis of radiological or biochemical nutritional rickets.

Background

The optimal management of idiopathic clubfoot has changed over three decades. Recently there has been an enthusiastic embracing of the Ponseti technique. The purpose of this 14-year comparative prospective longitudinal study was to directly assess the differences in results between these two treatment methods.

Developmental dysplasia of the hip (DDH) is the commonest musculoskeletal condition diagnosed in neonates. Two previous studies showed no statistical advantage with the addition of ultrasound to clinical screening. In the UK, the Standing Medical Advisory Committee (SMAC) (1969) recommended clinical examination at birth and at 6 weeks. The Newborn Infant Physical Examination (NIPE) (2008) guidelines in addition advised ultrasound scanning for clinically unstable hips or for those with risk factors (breech presentation or family history).

We compared SMAC and NIPE in the two main hospitals of the East Lancashire Hospitals NHS Trust: Burnley General Hospital (BGH) and the Royal Blackburn Hospital (RBH), respectively. Our outcome measure was the number of irreducible hip dislocations over a two year period (2007–2008).

The records of the lead Paediatric Orthopaedic Surgeon were used to identify all cases of irreducible hip dislocations born in 2007 and 2008. Maternity records provided information on birth statistics. Syndromal cases were excluded from further analysis.

BGH had 5382 live births and 7 irreducible hip dislocations (incidence 1.3/1000 births). 4/7 met SMAC recommendations and 6/7 met NIPE guidelines. 2/7 had equivocal clinical examinations at birth. 13 children were referred to the clinic with unstable hips (2.42/1000 births).

RBH had 7899 total births and 3 irreducible hip dislocations (incidence 0.38/1000 births). 2/3 met NIPE guidance and 1/3 met SMAC recommendations. 33 were referred to the clinic with unstable hips (4.18/1000 births).

The difference in the numbers of irreducible hips did not reach statistical significance (p=0.12).

This study found no statistically significant advantage with the addition of selective ‘at risk’ ultrasound screening to clinical screening alone. Confounding factors in this study included the age of referral of cases to clinic and the numbers of cases referred as primary instability. These findings are in keeping with two previous studies in Norway.

Purpose of study

The results clinically & statistically of a 14 year longitudinal study comparing the traditional ‘stretch & strap’ method (1994-2002) with the Ponseti technique (2002-2008)

Purpose of study

Results clinically & statistically of a 10 year prospective observational longitudinal study of the effects of sonographic screening for ‘risk’ factors in DDH.

An 11 year prospective longitudinal study assessed the relationship between major neonatal foot deformities and developmental dysplasia of the hip (DDH). From 41,474 infants born between 01/01/1996 and 31/12/2006 with 614 foot deformities were referred as ‘risk factors’ in a screening/surveillance programme for DDH. All hips were clinically examined and sonographically imaged in a specialist Paediatric Orthopaedic clinic.

The 614 cases were subdivided into: 436 postural equinovarus deformities (TEV), 60 fixed congenital talipes equinovarus (CTEV), 93 congenital talipes calcaneovalgus (CTCV) & 25 metatarsus adductus. The overall risk of sonographic dysplasia/instability was as follows: TEV 1:27, CTEV 1:8.6, CTCV 1:5.2, Metatarsus adductus 1:25

The Relative Risk (RR) of sonographic dysplasia/instability in TEV vs CTEV was 0.31 (95% CI 0.12–0.80; p=0.0057; OR=0.29). The Relative Risk of dysplasia/instability in CTCV vs. Postural TEV is 5.27 (95% CI 2.57–10.8; p< 0.0001; OR=6.30).

The risk of Type IV hip instability or irreducible dislocation in CTCV was 1:15.4 (6.5%), 1:25 (4%) in metatarsus adductus and 1:436 (0.2%) in TEV. There were no cases of hip instability (Type IV) or irreducible dislocation in the CTEV cases.

The routine screening for DDH in cases of postural TEV and fixed CTEV is no longer advocated. Postural TEV is poorly defined as a deformity in the literature leading to the over diagnosis of a possibly spurious condition. Sonographic imaging and surveillance of the hips in cases of CTCV and metatarsus adductus should continue.

We describe a successful modified operative procedure at an average 19 months follow-up in 3 patients with congenital dislocation of the patella and compare its merits to the other procedures already reported in the literature.

Congenital dislocation of the patella may be associated with other congenital conditions or syndromes i.e. Down’s syndrome, congenital vertical talus and cerebral palsy. Numerous operative techniques have been described in the literature which may be divided into 3 basic groups. A modification of the Langenskiold & Ritsila procedure is described. The original procedure describes an extensive lateral release with detachment and medial transfer of the patellar tendon through a curved incision. The tendon is routed through a fold of synovium medially and fixed distally to bone with sutures through drill holes in the proximal tibia. We found at surgery this synovium was too fragile to hold the transferred tendon and the use of drill holes unnecessary. 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 which avoids drill holes in the growing bone. This modification of the Langenskiold procedure was used successfully in 3 cases, including a revision of a failed Goldthwaite- Roux procedure in a mentally handicapped child. The results at average 19 months follow-up are successful. The early results confirm that the patella remains located and tracks normally. The valgus and flexion deformities have significantly improved.

This modification of the Langenskiold & Ritsila procedure requires less dissection than other operations, with no bony surgery and a cosmetic scar. The Langen-skiold & Ritsila procedure has been successful and we feel that this modification simplifies and improves on the original technique.

Introduction: The results of a 10 year prospective hip ultrasound surveillance programme of ‘at risk’ or clinically unstable hips are analysed.

Method: Between June 1992 and may 2002, there were 34723 births in the Blackburn area. Over this period 2,578 infants with unstable hips and or risk factors for developmental dysplasia of the hip were assessed with bilateral hip ultrasound scans. Clinically unstable hips were imaged within two weeks post natally and those with ‘at risk’ groups within eight weeks. All results were collected prospectively by the senior author. The degree of Dysplasia was classified using Graf’s alpha angle. Dynamic instability or irreductable dislocation was recorded.

Results: Early dislocation was present in 77 patients of which 53 (68.8%) were referred as being Ortolani-positive or unstable, only 24 were identified from the screening programme alone. The dislocation rate was 2.6 per 1000 live births. There were 21 irreducible dislocations in 19 infants, a rate of 0.54 per 1000 live births.

Only 31.2 % of the dislocated hips belonged to the major ‘at risk’ group. In infants referred for possible clinical instability one dislocation was detected for every 8.5 infants screened, whereas in the ‘at risk’ group this number rose to 1 in 88. From the ‘at risk’ groups those with breech and a positive family history were most likely to reveal a dislocation. There was a 1:45 chance of instability/irreducibility in family history, compared with a 1:70 chance in breech presentation or 1:71 chance in foot abnormality. No patients with oligohydramnios alone had evidence of hip instability or dislocation. If type III dysplasia is assessed there is a 1:22 chance in family history, a 1:43 chance in breech presentation and a 1:61 chance in foot deformity.

Discussion: Screening groups with possible risk factors such as oligohydramnios or Caesarian section cannot be justified. Selective ultrasound screening of the clinical instability, family history, breech presentation and foot abnormality groups looking for dislocation or type III dysplasia may be justified on a National basis.

Aims: To compare the results of early splintage against delayed splintage with ultrasound surveillance in neonatal hip instability. Methods: Between 1992 and 1997, all unstable hips (Ortolani or Barlow positive) referred by the Paediatric Department were seen within 1 to 2 weeks of birth. They were assessed clinically and by static and dynamic ultrasound. Those with proven instability were treated in a Wheaton Pavlick splint. Between 1998 and 1999, with the same assessments made, all hips with proven instability were treated by close surveillance in the form of serial ultrasound and were splinted if there was persistent instability or dysplasia. Any neonate presenting later than 2 weeks was excluded from this study. Results: From 1992 to 1997, 37 neonates were treated with 59 unstable hips. Mean time to splintage was 6.35 days (1–14 days), and mean splintage time was 6.13 weeks (4–11 weeks). All patients in this group developed normally, and no surgical intervention was required. From 1998 to 1999, 11 neonates were treated with 16 unstable hips. 9 hips required splintage after an average of nine weeks. 7 hips stabilised with no splintage. Two hips required surgical intervention, one for Ôlateñ dislocation and one for persistent dysplasia. These results show a statistically signiþcant difference for the two treatment groups. (p=0.04, Fishers exact test)Conclusion: We conclude from these results that neonatal hip instability is best treated by splintage within two weeks of birth.

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.

This study was undertaken between May 1992 and April 2002 in a hospital where there was a targeted screening programme for Developmental Dysplasia of the Hip. All data was collected prospectively. 2,578 infants with clinically unstable or at risk hips underwent bilateral hip ultrasound examination. This was performed by the senior author. At risk hips were considered to be those where there was a history of breech presentation, foot deformity, oligohydramnios on prenatal maternal ultrasound scans or a strong family history of Developmental Dysplasia of the Hip. There were significant changes in the reasons for referral for targeted screening over the ten year period. In the first year of the study 1.5% of referrals were because of oligohydramnios. In the last year of the survey 16.5% of referrals were because of oligohydramnios. The number of referrals for screening because of oligohydramnios increased sixty fold between the first year and last year of the study period. The overall number of infants referred for targeted screening more than doubled between the first and the last year of the study period. Of the infants that were found to have unstable or dislocated hips, no infants had oligohydramnios as a risk factor. The number of referrals for targeted ultrasound screening is increasing. In a targeted screening programme for Developmental Dysplasia of the Hip we suggest that oligohydramnios should not be used as a possible risk factor.

Aim: To compare the results of early splintage against delayed splintage with ultrasound surveillance in neonatal hip instability.

Methods: Between 1992 and 1997, all unstable hips (Ortolani or Barlow positive) referred by the Paediat-ric Department were seen within 1 to 2 weeks of birth. They were assessed clinically and by static and dynamic ultrasound. Those with proven instability were treated in a Wheaton Pavlick splint. Between 1998 and 1999, with the same assessments made, all hips with proven instability were treated by close surveillance in the form of serial ultrasound and were splinted if there was persistent instability or dysplasia. Any neonate presenting later than 2 weeks was excluded from this study.

Results: From 1992 to 1997, 37 neonates were treated with 59 unstable hips. Mean time to splintage was 6.35 days (1-14 days), and mean splintage time was 6.13 weeks (4-11 weeks). All patients in this group developed normally, and no surgical intervention was required. From 1998 to 1999, 11 neonates were treated with 16 unstable hips. 9 hips required splintage after an average of nine weeks. 7 hips stabilised with no splintage. Two hips required surgical intervention, one for ‘late’ dislocation and one for persistent dysplasia. These results show a statistically significant difference for the two treatment groups. (p=0.04, Fishers exact test)

Conclusion: We conclude from these results that neonatal hip instability is best treated by splintage within two weeks of birth.

There have been major changes in practice in Orthopaedics and Anaesthetics in Britain over recent years. The Royal College of Anaesthetists in Britain in its document on the provision of paediatric services stated that the anaesthetic service for children should be led by consultants who anaesthetise children regularly. This has affected the range of conditions that Orthopaedic Surgeons in District General Hospitals have been able to operate.

The Children’s Orthopaedic Group in the North West Region of England was surveyed in 1996 and 2001. Age limits for elective procedures and the range of procedures performed were analysed. The orthopaedic procedures looked at were for scoliosis, DDH / Dysplasia, Perthes’ disease, CTEV, Leg lengthening and genu varum/valgum.

The demographic map of the region was studied. This highlighted the variation in Children’s Orthopaedic Services in the region. Some large population centres had minimal Paediatric Orthopaedic Services.

In 1996, 91% of non children’s hospitals could perform elective surgery on children under 1 compared to 60% in 1996. The average minimum age for elective surgery in District General Hospitals increased from 8.5 months in 1996 to 17 months in 2001.

Baseline services are needed at each DGH to support the paediatric units. These services should include gait abnormalities, conservative treatment of CTEV, postural problems, straight forward cerebral palsy, assessment of hip instability and Perthes disease. Paediatric physiotherapists and Community Paediatricians may be involved in this aspect of care as part of the Multidisciplinary team. A hub and spoke regional service may be required where paediatric orthopaedic specialists undertake outreach clinics in District General Hospitals in order to assess more complex problems such as resistant CTEV, DDH and complex Cerebral Palsy. Such a system already exists in other specialities such as paediatric neurology. Clinical networks may improve service standards.