Aims. The purpose of this study was to analyze the incidence of the different ultrasound phenotypes of developmental dysplasia of the hip (DDH), and to determine their subsequent course. Patients and Methods. A consecutive series of 28 092 neonates was screened and classified according to the Graf method as part of a nationwide surveillance programme, and then followed prospectively. Abnormal hips were followed until they became normal (Graf type I). Type IIb hips and higher grades were treated by abduction in a Tübinger orthosis until normal. Dislocated hips underwent closed or open reduction. Results. Overall, 90.2% of hips were normal at birth. Type IIa hips (8.9%) became normal at a median of six weeks (interquartile range (IQR) 6 to 9). Type IIc and IId hips (0.67%) became normal after ten weeks (IQR 7 to 13). There were 19 type lll and eight type lV hips at baseline. There were 24 closed reductions and one open reduction. No late presentations of DDH were detected within the first five years of life. Conclusion. The incidence of DDH was eight per 1000 live births. The treatment rate was 1% (n = 273). The rate of first operations on the newborn hip was 0.86, and rate of open surgery was 0.04. The cumulative rate of open surgery was 0.07. The authors take the view that early identification and treatment in abduction of all dysplastic hips in early childhood reduces the rate of open reduction and secondary DDH-related surgery later in life. Cite this article: Bone Joint J 2018;100-B:1399–1404

The treatment of developmental dysplasia of the hip (DDH) in children remains controversial, we describe the clinical and radiological outcomes of 47 hips in 43 children treated with open surgery by one surgeon between 2004 and 2008 for DDH. The mean age at operation was 25 months (5 to 113) with a mean follow up of 89 months (22 to 169). 46 hips had an anterior open reduction, 1 had a medial approach performed and 16 had anterior open reductions only. 5 of the primary operations also had a pelvic osteotomy, 7 had a femoral osteotomy and 18 had a combined femoral and pelvic osteotomy. 7 (15%) of the hips required a second operation for dislocation, subluxation or dysplasia. At the latest follow up 40 of the 45 hips where Severin grades were recordable (89%) were graded as excellent or good, Severin class I or II. Clinically significant AVN (grade II to III according to the Kalamchi and MacEwen classification) was seen in 5 (11%) of the hips. We found a pelvic osteotomy to be a risk factor for AVN (p 0.02) and age at operation to be a risk factor for poor morphology at final follow up (p 0.03). We proceed to open surgery in patients over 12 months old or those with failed closed reduction. Over 18 months old a pelvic osteotomy should be performed in selective cases depending on intra-operative stability, but we will now consider doing this as a staged procedure and delaying the osteotomy for a period of time after open reduction to reduce the risk of AVN. We will also have a much lower threshold for performing a femoral shortening osteotomy in these patients as open reduction with Salters osteotomy alone tended to have a poorer outcome

Aims

Medial humeral epicondyle fractures (MHEFs) are common elbow fractures in children. Open reduction should be performed in patients with MHEF who have entrapped intra-articular fragments as well as displacement. However, following open reduction, transposition of the ulnar nerve is disputed. The aim of this study is to evaluate the need for ulnar nerve exploration and transposition.

The study was to ascertain if parents/carers could be effective screeners in the detection of infant hip dysplasia. Infants have been screened for developmental hip dysplasia (DDH) since the late 1960's. The recognition of the importance for early identification of the condition has been well documented. However, the changes to the national screening programme in 2008 have reduced the surveillance of DDH following the removal of the 8 month infant hip check, leaving only the 6–8 week hip check as standard. A self-check guide for DDH has been developed to enlist parents as screeners for the condition. The guide highlights common signs used to alert to the possibility of hip dysplasia or dislocation. The guide was disseminated by the Royal Berkshire Hospital NHS Trust between 2008 – 2013 within West Berkshire through the maternity services and Health Centres. The guide provided parents with information on classic signs associated with DDH which they were asked to check for. Of those infants referred to our specialist clinic as a result of parental screening, 73% were “abnormal” of these 33% went on to treatment with splintage. The mean age of these infants was 5.36 months. 20% of positive findings were in infants aged 7 month or over at the time seen. None went on to open surgery. These patients represented between 5 and 10% of our overall group of DDH positive patients. If left undiagnosed, they may have gone on to late presentation of hip dislocation requiring surgery as a child or undiagnosed acetabular dysplasia and possible surgical treatment in relatively early adult life. Therefore we concluded that given the right guidance parents/carers would be ideal screeners to assist in detecting possible later presenting DDH in their baby

Statement of Purpose. Our experience with Taylor Spatial Frame correction of complex foot deformities in children. Persistent foot deformity in congenital talipes equinovarus is a challenge. Open surgery is associated with complications including difficulty in achieving acute corrections in stiff, scarred feet. Gradual correction using the Ilizarov circular frame has been described as an alternative and we present the experience using a computer assisted hexapod gradual frame correction with the Taylor Spatial Frame (TSF). A retrospective audit of sequential patients treated by TSF was performed. Technique, outcome, complications and key learning points were recorded. 21 paediatric patients underwent 27 treatments with a Taylor Spatial frame for complex foot deformity correction. Average age 11 years with majority diagnosis of congenital talipes equinovarus. The deformities severity meant acute correction would result in either neurovascular or soft tissue compromise. Plantigrade feet with good function was achieved in 22 feet. 3 feet were deemed as failures. 2 feet have residual deformity but acceptable function. According to Paley's classification, there were 4 complications, 7 obstacles and 35 difficulties (pin tract infection and pain management). Complications did contribute to poorer outcomes. The key learning points were: protection of the ankle joint and distal tibial physis; staged osteotomy reduces swelling and complication rates; and consideration of further procedures at frame removal is important. Finally a thorough preoperative counselling programme should be instituted and patients warned of the time commitment and high difficulty rates associated with treatment. Managing patient expectation with goals is as important as meticulous surgery. Although complication rates were high, the majority of treatment goals were met, therefore the TSF is valid in the treatment of complex deformities in the foot. Most patients with severe deformity can achieve a plantigrade functional foot but residual stiffness and need for minor orthotics is almost universal

Aims

Extendible endoprostheses have been available for more than 30 years and have become more sophisticated with time. The latest generation is ‘non-invasive’ and can be lengthened with an external magnetic force. Early results have shown a worryingly high rate of complications such as infection. This study investigates the incidence of complications and the need for further surgery in a cohort of patients with a non-invasive growing endoprosthesis.

Supracondylar humeral fractures are common in children, but there are no classification systems or radiological parameters that predict the likelihood of having to perform an open reduction. In a retrospective case–control study we evaluated the use of the medial spike angle and fracture tip–skin distance to predict the mode of reduction (closed or open) and the operating time in fractures with posterolateral displacement. A total of 21 patients (4.35%) with a small medial spike angle (< 45°) were identified from a total of 494 patients, and 42 patients with a medial spike angle of > 45° were randomly selected as controls. The medial spike group had significantly smaller fracture tip–skin distances (p < 0.001), longer operating times (p = 0.004) and more complications (p = 0.033) than the control group. There was no significant difference in the mode of reduction and a composite outcome measure. After adjustments for age and gender, only fracture tip–skin distance remained significantly associated with the operating time (β = -0.724, p = 0.042) and composite outcome (OR 0.863 (95% confidence interval 0.746 to 0.998); p = 0.048).

Paediatric orthopaedic surgeons should have a lower threshold for open reduction when treating patients with a small medial spike angle and a small fracture tip–skin distance.

Cite this article: Bone Joint J 2013;95-B:1290–4.

We present our early experience of arthroscopic reduction of the dislocated hip in very young infants with developmental dysplasia of the hip (DDH).

Eight dislocated hips, which had failed attempts at closed reduction, were treated by arthroscopy of the hip in five children with a mean age of 5.8 months (4 to 7). A two-portal technique was used, with a medial sub-adductor portal for a 2.7 mm cannulated system with a 70° arthroscope and an anterolateral portal for the instruments. Following evaluation of the key intra-articular structures, the hypertrophic ligamentum teres and acetabular pulvinar were resected, and a limited release of the capsule was performed prior to reduction of the hip. All hips were reduced by a single arthroscopic procedure, the reduction being confirmed on MRI scan. None of the hips had an inverted labrum. The greatest obstacle to reduction was a constriction of the capsule. At a mean follow-up of 13.2 months (9 to 24), all eight hips remained stable. Three developed avascular necrosis. The mean acetabular index decreased from 35.5° (30° to 40°) pre-operatively to 23.3° (17° to 28°).

This study demonstrates that arthroscopic reduction is feasible using two standardised portals. Longer follow-up studies are necessary to evaluate the functional results.

We have modified the Ponseti casting technique by using a below-knee Softcast instead of an above-knee plaster of Paris cast. Treatment was initiated as soon as possible after birth and the Pirani score was recorded at each visit. Following the manipulation techniques of Ponseti, a below-knee Softcast was applied directly over a stockinette for a snug fit and particular attention was paid to creating a deep groove above the heel to prevent slippage. If necessary, a percutaneous Achilles tenotomy was performed and casting continued until the child was fitted with Denis Browne abduction boots.

Between April 2003 and May 2007 we treated 51 consecutive babies with 80 idiopathic club feet with a mean age at presentation of 4.5 weeks (4 days to 62 weeks). The initial mean Pirani score was 5.5 (3 to 6). It took a mean of 8.5 weeks (4 to 53) of weekly manipulation and casting to reach the stage of percutaneous Achilles tenotomy. A total of 20 feet (25%) did not require a tenotomy and for the 60 that did, the mean Pirani score at time of operation was 2.5 (0.5 to 3). Denis Browne boots were applied at a mean of 10 weeks (4 to 56) after presentation. The mean time from tenotomy to boots was 3.3 weeks (2 to 10). We experienced one case of cast-slippage during a period of non-attendance, which prolonged the casting process. One case of prolonged casting required repeated tenotomy, and three feet required repeated tenotomy and casting after relapsing while in Denis Browne boots.

We believe the use of a below-knee Softcast in conjunction with Ponseti manipulation techniques shows promising initial results which are comparable to those using above-knee plaster of Paris casts.

We report our initial experience of using the Ponseti method for the treatment of congenital idiopathic club foot.

Between November 2002 and November 2004 we treated 100 feet in 66 children by this method. The standard protocol described by Ponseti was used except that, when necessary, percutaneous tenotomy of tendo Achillis were performed under general anaesthesia in the operating theatre and not under local anaesthesia in the out-patient department. The Pirani score was used for assessment and the mean follow-up time was 18 months (6 to 30).

The results were also assessed in terms of the number of casts applied, the need for tenotomy of tendo Achillis and recurrence of the deformity. Tenotomy was required in 85 of the 100 feet. There was a failure to respond to the initial regimen in four feet which then required extensive soft-tissue release. Of the 96 feet which responded to initial casting, 31 (32%) had a recurrence, 16 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior. The remaining 15 required extensive soft-tissue release. Poor compliance with the foot-abduction orthoses (Denis Browne splint) was thought to be the main cause of failure in these patients.