Aims. Abduction bracing is commonly used to treat developmental dysplasia of the hip (DDH) following closed reduction and spica casting, with little evidence to support or refute this practice. The purpose of this study was to determine the efficacy of abduction bracing after closed reduction in improving acetabular index (AI) and reducing secondary surgery for residual hip dysplasia. Methods. We performed a retrospective review of patients treated with closed reduction for DDH at a single tertiary referral centre. Demographic data were obtained including severity of dislocation based on the International Hip Dysplasia Institute (IHDI) classification, age at reduction, and casting duration. Patients were prescribed no abduction bracing, part-time, or full-time wear post-reduction and casting. AI measurements were obtained immediately upon cast removal and from two- and four-year follow-up radiographs. Results. A total of 243 hips underwent closed reduction and 82% (199/243) were treated with abduction bracing. There was no difference between those treated with or without bracing with regard to sex, age at reduction, severity of dislocation, spica duration, or immediate post-casting AI (all p > 0.05). There was no difference in hips treated with or without abduction brace with regard to AI at two years post-reduction (32.4° (SD 5.3°) vs 30.9° (SD 4.6°), respectively; p = 0.099) or at four years post-reduction (26.4° (SD 5.2°) vs 25.4° (SD 5.1°), respectively; p = 0.231). Multivariate analysis revealed only IHDI grade predicted AI at two years post-reduction (p = 0.004). There was no difference in overall rate of secondary surgery for residual dysplasia between hips treated with or without bracing (32% vs 39%, respectively; p = 0.372). However, there was an increased risk of early secondary surgery (< two years post-reduction) in the non-braced group (11.4% vs 2.5%; p = 0.019). Conclusion. Abduction bracing following closed reduction for DDH treatment is not associated with decreased residual dysplasia at two or four years post-reduction but may reduce rates of early secondary surgery. A prospective study is indicated to provide more definitive recommendations. Cite this article: Bone Joint J 2023;105-B(12):1327–1332

Aims. Guided growth has been used to treat coxa valga for cerebral palsy (CP) children. However, there has been no study on the optimal position of screw application. In this paper we have investigated the influence of screw position on the outcomes of guided growth. Methods. We retrospectively analyzed 61 hips in 32 CP children who underwent proximal femoral hemi epiphysiodesis between July 2012 and September 2017. The hips were divided into two groups according to the transphyseal position of the screw in the coronal plane: across medial quarter (Group 1) or middle quarter (Group 2) of the medial half of the physis. We compared pre- and postoperative radiographs in head-shaft angle (HSA), Reimer’s migration percentage (MP), acetabular index (AI), and femoral anteversion angle (FAVA), as well as incidences of the physis growing-off the screw within two years. Linear and Cox regression analysis were conducted to identify factors related to HSA correction and risk of the physis growing-off the screw. Results. A total of 37 hips in Group 1 and 24 hips in Group 2 were compared. Group 1 showed a more substantial decrease in the HSA (p = 0.003) and the MP (p = 0.032). Both groups had significant and similar improvements in the AI (p = 0.809) and the FAVA (p = 0.304). Group 1 presented a higher incidence of the physis growing-off the screw (p = 0.038). Results of the regression analysis indicated that the eccentricity of screw position correlated with HSA correction and increases the risk of the physis growing-off the screw. Conclusion. Guided growth is effective in improving coxa valga and excessive femoral anteversion in CP children. For younger children, despite compromised efficacy of varus correction, we recommend a more centered screw position, at least across the middle quarter of the medial physis, to avoid early revision. Cite this article: Bone Joint J 2020;102-B(9):1242–1247

Aim. This study presents the early results of a novel procedure, both in timing and surgical technique, aimed to treat those cases of congenital hip dysplasia that present late or fail conservative treatment. Methods. 48 patients and 55 hips treated over the period from December 2004 to February 2011 were retrospectively reviewed. All were treated with adductor and psoas tenotomy, open reduction, capsulorrhaphy and acetabuloplasty by the senior author. Results. Thirty-five of the cases (72.92%) were late presentations whilst 13 (27.08%) cases represented failure of conservative treatment with Pavlik harness. According to the IHDI classification, there was 1 (1.82%) grade I, 9(16.36%) grade II, 13 (23.64%) grade III, and 32 (58.18%) grade IV. The age of the patients at surgery averaged 16.01 months and the mean follow-up was 31.07 months (10.13–84.20 months). The average pre-operative AI was 37.97 ° (range 23 to 49). AI fell steadily over time reaching an average of 24.7° (range 14.7° to 30°) at 22 months post-acetabuloplasty. One of the earliest cases had some residual lateralisation requiring a Shelf acetabuloplasty 4 years after the index procedure. There were no infections, nerve palsies or graft displacement in the series. Seven cases (12.73%) developed AVN graded II or over (five grade II, one grade III, and one grade IV). The incidence of AVN significantly associated with previous failed conservative treatment (p<0.05) and was not related to pre-operative IHDI classification or AI (p=0.42 and p=0.31 respectively). Conclusion. This one-stop procedure seems to be safe whilst providing reliable outcomes; igniting the remodelling process that results in a concentric and stable hip. However, pelvic anatomy is not distorted and hence, additional pelvic osteotomies may be utilised if needed

The medial approach for the treatment of children with developmental dysplasia of the hip (DDH) in whom closed reduction has failed requires minimal access with negligible blood loss. In the United Kingdom, there is a preference for these children to be treated using an anterolateral approach after the appearance of the ossific nucleus. In this study we compared these two protocols, primarily for the risk of osteonecrosis. Data were gathered prospectively for protocols involving the medial approach (26 hips in 22 children) and the anterolateral approach (22 hips in 21 children) in children aged <  24 months at the time of surgery. Osteonecrosis of the femoral head was assessed with validated scores. The acetabular index (AI) and centre–edge angle (CEA) were also measured. . The mean age of the children at the time of surgery was 11 months (3 to 24) for the medial approach group and 18 months (12 to 24) for the anterolateral group, and the combined mean follow-up was 70 months (26 to 228). Osteonecrosis of the femoral head was evident or asphericity predicted in three of 26 hips (12%) in the medial approach group and four of 22 (18%) in the anterolateral group (p = 0.52). The mean improvement in AI was 8.8° (4° to 12°) and 7.9° (6° to 10°), respectively, at two years post-operatively (p = 0.18). There was no significant difference in CEA values of affected hips between the two groups. Children treated using an early medial approach did not have a higher risk of developing osteonecrosis at early to mid-term follow-up than those treated using a delayed anterolateral approach. The rates of acetabular remodelling were similar for both protocols. Cite this article: Bone Joint J 2014;96-B:406–13

Aims

Brace treatment is the cornerstone of managing developmental dysplasia of the hip (DDH), yet there is a lack of evidence-based treatment protocols, which results in wide variations in practice. To resolve this, we have developed a comprehensive nonoperative treatment protocol conforming to published consensus principles, with well-defined a priori criteria for inclusion and successful treatment.

Aims

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

Purpose. To investigate the effect of soft tissue release (STR) and the length of postoperative immobilisation on the long term outcomes of closed reduction (CR) of the hip for developmental dysplasia of the hip. Materials. 77 hips (72 patients) who had undergone closed reduction (CR) between 1977-2005 were studied retrospectively to review their outcome (Severin grade), identify the reasons for failure and to assess factors associated with residual dysplasia. Particular attention was paid to the use of a STR at the time of CR (to improve initial hip stability) and the duration of postoperative immobilisation. Results. The mean age at CR was 10.5 months (5-24months) and mean follow up 97 months. A STR (adductor ± psoas tenotomies) was performed in 65%. Post-operative immobilisation time varied between 3-12 months (mean 6.3 months). 6 hips (all Tonnis grade 3) failed CR within 2-6 weeks. In the remaining 49 hips, 85% were Severin Grade 1 at age 5yrs. Acetabular index (AI) decreased in all patients over time: 80% hips had an AI <20. 0. at age 5yrs. Neither a STR, nor the time of post-operative immobilisation conferred any additional benefit on the final AI. 2/55 hips required a pelvic osteotomy for residual dysplasia. This was not related to initial Tonnis grade, age at reduction or use of STR. Conclusion. A STR is often required for initial hip stability. Once a stable hip is achieved, an excellent long term outcome from CR in infants <24months old can be expected with remodelling of the acetabular dysplasia in ≥95%. Significance. Hip stability is the key to a good outcome. The optimal length of post-operative bracing has not been determined from this study but 3-6months immobilisation of the stable hip is adequate

Between June 1988 and December 1997, we treated 332 babies with 546 dysplastic hips in a Pavlik harness for primary developmental dysplasia of the hip as detected by the selective screening programme in Southampton. Each was managed by a strict protocol including ultrasonic monitoring of treatment in the harness. The group was prospectively studied during a mean period of 6.5 ± 2.7 years with follow-up of 89.9%. The acetabular index (AI) and centre-edge angle of Wiberg (CEA) were measured on annual radiographs to determine the development of the hip after treatment and were compared with published normal values. The harness failed to reduce 18 hips in 16 patients (15.2% of dislocations, 3.3% of DDH). These required surgical treatment. The development of those hips which were successfully treated in the harness showed no significant difference from the normal values of the AI for the left hips of girls after 18 months of age. Of those dysplastic hips which were successfully reduced in the harness, 2.4% showed persistent significant late dysplasia (CEA < 20°) and 0.2% persistent severe late dysplasia (CEA < 15°). All could be identified by an abnormal CEA (< 20°) at five years of age, and many from the progression of the AI by 18 months. Dysplasia was considered to be sufficient to require innominate osteotomy in five (0.9%). Avascular necrosis was noted in 1% of hips treated in the harness. We conclude that, using our protocol, successful initial treatment of DDH with the Pavlik harness appears to restore the natural development of the hip to normal. We suggest that regular radiological surveillance up to five years of age is a safe and effective practice

Aims

Hip disease is common in children with cerebral palsy (CP) and can decrease quality of life and function. Surveillance programmes exist to improve outcomes by treating hip disease at an early stage using radiological surveillance. However, studies and surveillance programmes report different radiological outcomes, making it difficult to compare. We aimed to identify the most important radiological measurements and develop a core measurement set (CMS) for clinical practice, research, and surveillance programmes.

We report five children who presented at the mean age of 1.5 years (1.1 to 1.9) with a progressive thoracolumbar kyphosis associated with segmental instability and subluxation of the spine at the level above an anteriorly-wedged hypoplastic vertebra at L1 or L2. The spinal deformity appeared to be developmental and not congenital in origin. The anterior wedging of the vertebra may have been secondary to localised segmental instability and subsequent kyphotic deformity.

We suggest the term ‘infantile developmental thoracolumbar kyphosis with segmental subluxation of the spine’ to differentiate this type of deformity from congenital displacement of the spine in which the congenital vertebral anomaly does not resolve. Infantile developmental kyphosis with segmental subluxation of the spine, if progressive, may carry the risk of neurological compromise. In all of our patients the kyphotic deformity progressed over a period of three months and all were treated by localised posterior spinal fusion. At a mean follow-up of 6.6 years (5.0 to 9.0), gradual correction of the kyphosis was seen on serial radiographs as well as reconstitution of the hypoplastic wedged vertebra to normality. Exploration of the arthrodesis was necessary at nine months in one patient who developed a pseudarthrosis.

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The aim of this study was to utilize a national paediatric inpatient database to determine whether obesity influences the operative management and inpatient outcomes of paediatric limb fractures.

Aims

The objective of this study was to evaluate the clinical and radiological outcomes of patients younger than six months of age with developmental dysplasia of the hip (DDH) managed by either a Pavlik harness or Tübingen hip flexion splint.

Purpose. To compare the early medial open approach (MO) with the anterior approach (AO) performed after the appearance of the ossific nucleus for DDH that has failed closed reduction or presented late. Methods. We present the experience of 2 UK surgeons with prospectively gathered data for MO (26 hips) compared with that of a third surgeon in the same unit for the AO (21 hips) in 41 children under 24 months of age at index surgery. Femoral head osteonecrosis (FHO) risk was predicted using the height-to-width index of Bruce et al, measured at 12–18 months post reduction, and graded with the Kalamchi and MacEwen classification where follow-up exceeded 3 years. Acetabular index (AI) was measured at or close to 2 years post reduction. Results. Age at time of surgery averaged 11.2 months (3.1–24) for the MO group and 17.8 months (12–24) for the AO group. Average follow-up was 4.3 years (13 months to 12 years). FHO was evident or strongly predicted in 2/26 hips (7.7%) in the MO group and 2/21 (9.5%) in the AO group. AI improved by 8.8° (4–12°) and 7.9° (6–10°) respectively at 2 years post reduction (p>0.05). One case of early recurrent dislocation in the MO group required revision surgery via an anterior approach. The height to width index cut-off value of 0.357 at 12–18 months post reduction accurately predicted FHO risk in cases with longer follow-up. Conclusions. The medial open approach was not associated with a higher risk of FHO compared to a protocol of waiting for the appearance of the ossific nucleus before proceeding to reduction via an anterior approach. There was no significant difference in acetabular remodeling in the first two postoperative years between the protocols despite earlier reduction in the MO group

Aims

The diagnosis of developmental dysplasia of the hip (DDH) is challenging owing to extensive variation in paediatric pelvic anatomy. Artificial intelligence (AI) may represent an effective diagnostic tool for DDH. Here, we aimed to develop an anteroposterior pelvic radiograph deep learning system for diagnosing DDH in children and analyze the feasibility of its application.

AIMS. We present a retrospective study of bilateral CDH. We analysed the correlation of complications to the confounding factors. MATERIAL AND METHODS. We reviewed all bilateral CDH patients treated by the same surgeon at Southampton between 1988-2006. The patient recruitment was carried out as follows: . Group A – failed Pavlik harness;. Group B – late presentations not treated in Pavlik harness. RESULTS. The series included 50 patients (5 males; 45 females). The average age at presentation was 21 weeks (1-160). The average age at reduction was 15 months (4-45). The average follow-up was 6.7 years (4-15). 4 hips required revision due to loss of reduction. The number of surgical interventions throughout the treatment course ranged 4-12 (average – 7.3). AVN occurred in 17 hips (17%). Previous Pavlik harness treatment, CR and higher height of dislocation (HD) were associated with an increased rate of AVN. 42 pelvic (PO) and 12 femoral (FO) osteotomies (54%) were performed. CR and greater HD increased the pelvic osteotomy rate, while Pavlik harness treatment failure did not affect it. The mean AI demonstrated a gradual decline following reduction. While there was no difference between OR vs CR, and Group A vs B, the HD≥3 was associated with a significant acetabular development delay when compared to HD≤2. CONCLUSIONS. Despite the complexity of CDH cases, it is possible to achieve an acceptable level of inevitable complication (AVN – 17%, PO – 42%, FO – 12%, revision reduction – 4%). The rate of AVN was independently negatively affected by CR and prolonged immobilisation. Only the hips with initial HD of ≤2 had their acetabular index return to normal (<21°) before the age of 4 years. This is the first comprehensive analysis of bilateral CDH cases, emphasising the difficulty of treatment of this condition and providing the foundation for an outcomes-predicting system

The recognition of hips at risk of displacement in children with cerebral palsy (CP) is a difficult problem for the orthopaedic surgeon. The Gross Motor Function Classification System (GMFCS) and head–shaft angle (HSA) are prognostic factors for hip displacement. However, reference values for HSA are lacking. This study describes and compares the development of HSA in normal hips and children with CP.

We selected 33 children from a retrospective cohort with unilateral developmental dysplasia of the hip (DDH) (five boys, 28 girls) and 50 children (35 boys, 15 girls) with CP with GMFCS levels II to V. HSA of normal developing hips was measured at the contralateral hip of unilateral DDH children (33 hips) and HSA of CP children was measured in both hips (100 hips). Measurements were taken from the radiographs of the children at age two, four and seven years. The normal hip HSA decreased by 2° per year (p < 0.001). In children with CP with GMFCS levels II and III HSA decreased by 0.6° (p = 0.046) and 0.9° (p = 0.049) per year, respectively. The HSA did not alter significantly in GMFCS levels IV and V.

Between the ages of two and eight years, the HSA decreases in normal hips and CP children with GMFCS level, II to III but does not change in GMFCS levels IV to V. As HSA has a prognostic value for hip displacement, these reference values may help the orthopaedic surgeon to predict future hip displacement in children with CP.

Cite this article: Bone Joint J 2015;97-B:1291–5.

Aims

The goal of closed reduction (CR) in the treatment of developmental dysplasia of the hip (DDH) is to achieve and maintain concentricity of the femoral head in the acetabulum. However, concentric reduction is not immediately attainable in all hips and it remains controversial to what degree a non-concentric reduction is acceptable. This prospective study is aimed at investigating the dynamic evolution of the hip joint space after CR in DDH using MRI.

Untreated acetabular dysplasia following treatment for developmental dysplasia of the hip (DDH) leads to early degenerative joint disease. Clinicians must accurately and reliably recognise dysplasia in order to intervene appropriately with secondary acetabular or femoral procedures. This study sought early predictors of residual dysplasia in order to establish empirically-based indications for treatment. DDH treated by closed or open reduction alone was reviewed. Residual hip dysplasia was defined according to the Severin classification at skeletal maturity. Future hip replacement in a subset of these patients was compared with the Severin classification. Serial measurements of acetabular development and subluxation of the femoral head were collected, as were the age at reduction, type of reduction, and Tonnis grade prior to reduction. These variables were used to predict the Severin classification. The mean age at reduction in 72 hips was 16 months (1 to 46). On the final radiograph, 47 hips (65%) were classified as Severin I/II, and 25 as Severin III/IV (35%). At 40 years after reduction, five of 43 hips (21%) had had a total hip replacement (THR). The Severin grade was predictive for THR. Early measurements of the acetabular index (AI) were predictive for Severin grade. For example, an AI of 35° or more at two years after reduction was associated with an 80% probability of becoming a Severin grade III/IV hip. This study links early acetabular remodelling, residual dysplasia at skeletal maturity and the long-term risk of THR. It presents evidence describing the diagnostic value of early predictors of residual dysplasia, and therefore, of the long-term risk of degenerative change

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We aimed to determine hip-related quality of life and clinical findings following treatment for neonatal hip instability (NHI) compared with age- and sex-matched controls. We hypothesized that NHI would predispose to hip discomfort in long-term follow-up.

Aims

Open reduction is required following failed conservative treatment of developmental dysplasia of the hip (DDH). The Ludloff medial approach is commonly used, but poor results have been reported, with rates of the development of avascular necrosis (AVN) varying between 8% and 54%. This retrospective cohort study evaluates the long-term radiographic and clinical outcome of dislocated hips treated using this approach.